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ICD-11: Schizophrenia or Other Primary Psychotic Disorders, Schemes and Mind Maps of Psychiatry

Primary Psychotic Disorders. ICD-10 Schizophrenia, Schizotypal and Delusional Disorders. Schizophrenia. Schizophrenia. Schizoaffective Disorder.

Typology: Schemes and Mind Maps

2021/2022

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Wolfgang Gaebel
Professor of Psychiatry and Psychotherapy
WHO Collaborating Centre for Quality Assurance and Empowerment
in Mental Health
LVR-Klinikum Düsseldorf
Dept. of Psychiatry
Heinrich-Heine-University
Düsseldorf
Germany
ICD-11: Schizophrenia or
Other Primary Psychotic Disorders
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Download ICD-11: Schizophrenia or Other Primary Psychotic Disorders and more Schemes and Mind Maps Psychiatry in PDF only on Docsity!

Wolfgang Gaebel

Professor of Psychiatry and Psychotherapy

WHO Collaborating Centre for Quality Assurance and Empowerment

in Mental Health

LVR-Klinikum Düsseldorf

Dept. of Psychiatry

Heinrich-Heine-University

Düsseldorf

Germany

ICD-11: Schizophrenia or

Other Primary Psychotic Disorders

  • Member of the APA DSM-5 working group on psychotic disorders
  • Chair of the WHO ICD-11 working group on psychotic disorders
  • Member of the WHO FSCG for MBND, the WHO-FIC MSAC and the WHO

Advisory Group on Training and Implementation for ICD-11 MBND

  • DGPPN Commissioner for ICD-11 MBND
  • Member of the German KKG / DIMDI / AWMF ICD-11 working group
  • Member of the Lundbeck International Neuroscience Foundation (LINF) Disclosure

ORIGINS OF THE CONCEPT OF SCHIZOPHRENIA ‘Dementia praecox’ (1893) ‘Group of Schizophrenias’ (1911)

  • Defining (mental) disease entities based on an "overall clinical picture“ of symptoms, course and outcome (with a postulated common underlying etiology) →Dementia praecox (vs. manic-depressive insanity):
    • (Early) Onset in adolescence or early adulthood
    • Chronic and deteriorating course
    • Poor outcome with permanent and pervasive impairment in mental functions
  • A group of disorders sharing a set of clinical features (with different etiology)
  • Fundamental symptoms (‘Grundsymptome’): loss of associations, inappropriate affect, ambivalence avolition, and autism
  • Accessory symptoms: hallucinations, delusions …
  • Primary and secondary symptoms
  • Variability in course and outcome [from Greek schizein ( splitting) and phren ( soul, spirit, mind)] ‘1st^ and 2nd^ rank symptoms’ (1938)
  • 1 st: hearing commenting or conversing voices, thoughts being inserted or withdrawn, delusions of being controlled …
  • 2 nd: other auditory hallucinations, visual hallucinations, delusional ideas … Emil Kraepelin *1856 † 1926 Eugen Bleuler *1857 † 1939 Kurt Schneider *1887 † 1967

The Evolution of the Schizophrenia Concept Tandon et al., Schizophrenia, “just the facts” 4. Clinical features and conceptualization Schiz Res 2009;110:1- 23

Status Report on ICD-11 Psychotic Disorders

Gaebel W, Zielasek J, Cleveland H-R. Classifying Psychosis – Challenges and Opportunities.

Int Rev Psychiatr 2012; 24(6): 538-548.

Gaebel W, Zielasek J, Cleveland H-R. Psychotic Disorders in ICD-11.

Asian J Psychiatry 2013; 6(3): 263-265.

Stein DJ, Szatmari P, Gaebel W, et al. Mental, behavioural and neurodevelopmental disorders in

the ICD-11: An international perspective on key changes and controversies. BMC Med 2020 ,18,21.

Etc.

ICD-11 Schizophrenia or Other Primary Psychotic Disorders ICD-10 Schizophrenia, Schizotypal and Delusional Disorders Schizophrenia Schizophrenia Schizoaffective Disorder Schizoaffective Disorder Acute and Transient Psychotic Disorder Acute and Transient Psychotic Disorder: 1 Acute Polymorphic Psychotic Disorder without Symptoms of Schizophrenia 2,3,4 see below Schizotypal Disorder Schizotypal Disorder Delusional Disorder Persistent Delusional Disorder Induced Delusional Disorder 4 Other Acute Predominantly Delusional Psychotic Disorder Other Primary Psychotic Disorder 3 Acute Schizophrenia-like Psychotic Disorder 2 Acute Polymorphic Psychotic Disorder with Symptoms of Schizophrenia

INTERNATIONAL ICD-11/10 VIGNETTE-BASED FIELD TRIAL

  • N = 928 Health Professionals from all WHO-Regions
  • Data collection via the WHO Global Practice Network
  • 10 case vignettes based on ICD-10 or ICD-11 mental disorders diagnostic guidelines
  • Assessment of diagnostic accuracy and perceived clinical utility Gaebel et al., Eur Arch Psychiatry Clin Neurosci 2019.

INTERNATIONAL ICD-11/10 VIGNETTE-BASED FIELD TRIAL DIAGNOSTIC ACCURACY Vignette n ICD- 11 % correct ICD- 10 % correct p Overall 928 71.9 53.2 <0. Schizophrenia 94 74.4 78.4 0. Schizoaffective Disorder 95 63.5 44.2 0. Bipolar Disorder Type II 90 68.4 9.6 <0. Recurrent Depressive Disorder 97 81.6 66.7 0. Moderate Personality Disorder 89 57.4 73.8 0. Adjustment Disorder 92 34.6 55.0 0. Complex PTSD 95 71.1 32.0 <0. Binge Eating Disorder 92 86.5 87.5 0. Bodily Distress Disorder 89 95.5 37.8 <0. Compulsive Sexual Behaviour Disorder 95 89.3 48.7 <0. Gaebel et al.,Eur Arch Psychiatry Clin Neurosci 2019.

ICD-10/11 PSYCHOTIC DISORDERS: OVERARCHING CHANGES  ICD-10 term ‘nonorganic’ psychotic disorders has been changed to ‘primary’ psychotic disorders to avoid suggesting these disorders are not brain-based  Acute and Transient Psychotic Disorder and Delusional Disorder substantially simplified  Course Qualifiers  Symptom Qualifiers and Severity Ratings

ICD-11 Schizophrenia - What is new?

  • De-emphasis of first-rank symptoms Due to a lack of clinical evidence that ‘first-rank’ symptoms are specific for schizophrenia
  • Omission of classical schizophrenia subtypes Due to a lack of clinical evidence for prospective value and clinical stability
  • Introduction of cognitive symptoms as symptoms of schizophrenia Due to compelling evidence that cognitive symptoms are closely related to clinically relevant functional impairments (especially important for rehabilitation services)
  • Introduction of new course qualifiers (for all primary psychotic disorders) To acknowledge the evidence that there are different types of disease courses and a need to differentiate between first and recurrent episodes emphasizing early diagnosis and treatment
  • Introduction of symptom qualifiers (for all primary psychotic disorders) To acknowledge the evidence that there is a spectrum of symptoms with time-variable clinical presentations and fuzzy borders to ‘normality’ and other mental disorders (‘dimensional concept’)

ICD- 11 Schizophrenia: Replacement of subtypes with symptom qualifiers

Rationale: Cluster analytic and other approaches to identify taxonic schizophrenia subtypes consistently fail to identify the DSM-IV subtypes. Picardi et al., Psychiatry Res. 2012;198, 386–394. A review of 24 publications describing 38 analyses of 28 participant cohorts found no support for classic schizophrenia subtypes. Linscott et al., Schizophr Bull 2010; 36: 811- 829 Subtypes continue to be found to exhibit poor diagnostic stability over time, do not cluster in families, and have limited prognostic value. Tandon et al., Schizophr Res 2009, 110: 1- 23 Except for the paranoid and undifferentiated subtypes, the other subtypes are rarely utilized in most mental health care settings across the world. Tandon et al., Schizophrenia Research 2013;150 :3– 10

ICD-11 Schizophrenia: Cognitive impairment in the clinical description

  • Relevant for prognosis and management of schizophrenia
  • Helps clinicians and families to anticipate the degree of problems in work, school, social functioning, or rehabilitation
  • Helps explain difficulties people with schizophrenia encounter and reduce unrealistic expectations

Neurocognitive impairments and negative symptoms are related to poorer psychosocial

outcome in first-episode schizophrenia

Green et al., Schizophr Res 2004;72:41-51; Milev et al., Am J Psychiatr 2005;162:495- 506 Neurocognitive factors predict 52% of the variance in return to work or school in schizophrenia Nuechterlein et al., Schizophr Bull 2011; 37 (Suppl. 2):S33-S Cognitive remediation and cognitive behavioral therapy are effective in reducing negative symptoms in schizophrenia Klingberg et al., Schizophr Bull 2011; 37 (Suppl. 2):S98-S Cognitive training improves the outcome of vocational rehabilitation therapy in schizophrenia McGurk et al., Schizophr Bull 2009;35:319-335; Tan & King, Austr N Z J Psychiatr 2013;47:1068- 1080 Rationale:

SYMPTOM QUALIFIER RATINGS (POST-COORDINATED)

 Replace subtypes  Rate each individual with any primary psychotic disorder on all six domains:  Positive Symptoms  Negative Symptoms  Depressive Mood Symptoms  Manic Mood Symptoms  Psychomotor Symptoms  Cognitive Symptoms

Symptom Qualifier Severity Rating

Scale

0 = Not Present

1 = Present but mild

2 = Present and moderate

3 = Present and severe

9 = Unable to make a rating based

upon available information

QUALIFIER SCALES (GENERIC SEVERITY OPERATIONALIZATIONS) FOR SYMPTOMATIC MANIFESTATIONS OF PRIMARY PSYCHOTIC DISORDERS

The contribution of each of the symptom domains can be recorded in the form of qualifiers, which can be rated as mild, moderate,

or severe , using the guidelines provided in the table below. As many symptom qualifiers should be applied as necessary to accurately

describe the current clinical presentation. The ratings should be made based on the severity of the symptoms corresponding to that

domain during the past week.

SEVERITY ANCHOR POINTS

Present and mild Symptoms in the domain have been present during the past week, but these are minimal in number or do not have a substantial degree of impact. Everyday functioning is not affected by these symptoms, or is affected only minimally. No significant negative social or personal consequences have occurred as a consequence of the symptoms. The symptoms may be intermittent and show fluctuations in severity, and there may be periods during which the symptoms are absent. Compared to other individuals with similar symptoms, the severity of symptoms in the domain is in the mildest third. Present and moderate A greater number of symptoms in the domain have been present during the past week or a smaller number of symptoms that have a substantial degree of impact. Everyday functioning may be moderately affected by the symptoms. There are negative social or personal consequences of the symptoms, but these are not severe. Most of the symptoms are present the majority of the time. Compared to other individuals with similar symptoms, the severity of symptoms in the domain is in the middle third. Present and severe Many symptoms in the domain have been present during the past week, or a smaller number that have a severe or pervasive degree of impact (i.e., they are intense and frequent or constant). Everyday functioning is persistently impaired due to the symptoms. There are serious negative social or personal consequences. Compared to other individuals with similar symptoms, the severity of symptoms in the domain is in the most severe third. Unspecified For example, unable to make a current severity rating based on the available information.