Haravuori, Henna

Marttunen, Mauri

Helsingin yliopiston digitaalinen arkisto

                                                              9Haravuori et al.Psychiatria Fennica 2016;47:9-16Something old, something new:disorders specifically associatedwith stress in the ICD 11th revisionSomething old, something new: disorders specifically                                                                               thassociated with stress in the ICD 11   revisionHenna Haravuori, Mauri Marttunen   AbstractClassification of mental and behavioural disorders in World Health Organization’sInternational Classification of Diseases (ICD) is presently under revision. There is aproposal for a class of Disorders specifically associated with stress that includes,for example, post-traumatic stress disorder (PTSD) with revised criteria. There willbe new diagnoses of complex PTSD and prolonged grief disorder. In this article wereview main post-traumatic disorders as they are proposed to be in the forthcomingICD-11. There is some but limited literature on how the revision will affectepidemiology and clinical picture of the existing diagnoses. The introduction ofcomplex PTSD and prolonged grief disorder diagnoses facilitates recognition of theirspecific treatment needs.IntroductionThe 11th version of the International Classification of Diseases (ICD-11) is due by2018. With mental and behavioural disorders the focus has been on clinical utility inthe diagnostic criteria (1). Implementing a simple and limited set of symptoms shouldfacilitate identification and treatment of mental disorders by primary care orfront-line health workers globally.Reaction to severe stress and adjustment disorders class in ICD-10 has includeddisorders of acute stress reaction (ASR, F43.0), post-traumatic stress disorder (PTSD,F43.1), seven subtypes of adjustment disorders (AD, F43.2), and other or unspecifiedreactions to severe stress (F43.8, F43.9) (2). ICD-11 aims to integrate relevantsyndromes into a class of Disorders specifically associated with stress (3). The 10                             Haravuori et al.Psychiatria Fennica 2016;47:9-16Something old, something new:disorders specifically associatedwith stress in the ICD 11th revisionproposed class would include ASR, PTSD and AD, as well as complex PTSD, which is amodification of enduring personality change after traumatic experiences in ICD-10(F62.0), newcomer prolonged grief disorder, and childhood reactive attachment disorder(F94.1) and disinhibited social engagement disorder (F94.2).Overview of the post-traumatic conditions in ICD-11Acute stress reactionAcute stress reaction (ASR) should be considered as a transient normative reaction inrelation to the severity of the stressor that was extremely threatening or horrific(3). The symptoms are highly variable and do not meet criteria of any specific mentaldisorder. The proposed symptom list includes: being in a daze, confusion, sadness,anxiety, anger, despair, overactivity, inactivity, social withdrawal or stupor; andautonomic signs of anxiety: tachycardia, sweating or flushing. The onset of thesymptoms is within hours to days after the stressful experience yet symptoms shouldbegin to subside within a week. Functional recovery should be attained within aboutfour weeks.Post-traumatic stress disorderThe proposed ICD-11 criteria for post-traumatic stress disorder (PTSD) includeexposure to a threatening or horrific event or series of events followed by symptomsfrom each of the three core elements: re-experiencing of the traumatic event(s) in thepresent day with emotions of fear or horror; avoidance of traumatic reminders; senseof a current threat manifested as hypervigilance and/or an exaggerated startleresponse (Table 1) (3, 4). Symptoms should last for several weeks. Different from theICD-10, functional impairment is also required (2, 4).PTSD symptom factor structure. There are three symptom groups in the proposed ICD-11PTSD (re-experiencing, avoidance and hyperarousal), although the latent structure ofthe symptoms has not been scrutinized (5). Earlier studies indicate a very highcorrelation between re-experiencing and avoidance symptoms (6, 7). Forbes et al. (5)studied latent factor models of the ICD-11 PTSD: a three-factor model, where one outof two symptoms for each factor is required for the diagnosis; a two-factor model thatcombines re-experiencing and avoidance symptoms, where two out of four of these                                                             11Haravuori et al.Psychiatria Fennica 2016;47:9-16Something old, something new:disorders specifically associatedwith stress in the ICD 11th revisionsymptoms are required for the diagnosis; and finally a one-factor model. Confirmatoryfactor analysis showed that the two-factor model had at least an equivalent fit withthe three-factor model, and as a more parsimonious model, should be preferred (5). Tayet al. (8) and Hansen et al. (9) have performed confirmatory factor analyses on theICD-11 three-factor model that showed a good model fit, although neither studyanalysed alternative factor models. In a study with elderly victims of childhoodtrauma, a one-factor model provided the best fit for the long-lasting symptomatology(10). In our own study in a sample of adolescents and young adults and 16 monthsfollow-up after traumatic experience, the two-factor solution of PTSD was supported(11).Complex post-traumatic stress disorderIt has been proposed that ICD-11 would include a complex PTSD diagnosis with featuresof affect dysregulation, negative self-concept and interpersonal problems in additionto fulfilling regular PTSD criteria (12). Several studies are now arguing for thisseparate and devastating form of post-traumatic syndrome (13-17), although there isalso critical discussion for not seeing a separate diagnosis necessary (18).It is thought that complex PTSD develops after exposure to an event or series ofevents of an extreme and prolonged or repetitive nature that is experienced asextremely threatening or horrific and from which escape is difficult or impossible(e.g. prolonged interpersonal violence, repeated childhood sexual or physical abuse).As said, the core symptoms of PTSD should be present and all diagnostic requirementsfor PTSD should be met at some point during the course of the disorder. In addition,at least one symptom from each three classes is present: severe and pervasive problemsin affect regulation; persistent beliefs about oneself as diminished, defeated orworthless, accompanied by deep and pervasive feelings of shame, guilt or failurerelated to the stressor; and persistent difficulties in sustaining relationships andin feeling close to others (Table 1). The disturbance is persistent in nature andcauses significant and pervasive impairment in important areas of functioning.Interestingly, findings from the complex PTSD latent factor structure studies implythat complex PTSD is distinguishable from borderline personality disorder (14)although comorbidity should also be expected. 12                             Haravuori et al.Psychiatria Fennica 2016;47:9-16Something old, something new:disorders specifically associatedwith stress in the ICD 11th revision    Table 1. Overview of the diagnostic criteria for PTSD in ICD-10 and ICD-11,     and for the new complex PTSD in ICD-11.                                                 ICD-10          ICD-11          ICD-11                                                PTSD            PTSD            complex PTSD  Stressor criterion    Exposure to a traumatic event                   X               X             usually extreme,                                                                                prolonged,                                                                                cumulative or                                                                                complex  Re-experiencing                                 1/4             1/2              1/2  Distressing recollections                       X  Distressing dreams, nightmares                  X               X                X  Flashbacks                                      X               X                X  Psychological reactivity                        X  Avoidance                                       1/2             1/2              1/2  Avoiding internal reminders, thoughts           X               X                X  Avoiding external reminders, people,  places, activities                              X               X                X  Amnesia or Hyperarousal                         1/1 or 2/5       1/2              1/2  Specific amnesia                                X  Difficulty sleeping                             X  Irritable or aggressive behaviours              X  Difficulty concentrating                        X  Hypervigilance                                  X               X                X  Exaggerated startle response                    X               X                X  Severe and pervasive affect dysregulation                                     at least one                                                                                symptom  Heightened emotional reactivity, temper  outbursts, easily hurt feelings,  excessive crying, anhedonia,  selfdestructive behaviour, dissociation  or emotional numbing  Persistent negative self-concept                                              at least one                                                                                symptom  Beliefs about oneself as diminished,  defeated, inferior or worthless;  feelings of shame, guilt or failure  related to the stressor  Persistent interpersonal disturbances                                         at least one                                                                                symptom  Inability to build and sustain  relationships, difficulties in feeling  close to others, feelings being isolated  or disconnected from other people; may  manifest as avoiding or having little  interest in relationships and social  engagement  Impairment                                    not required       X                X  Minimum duration of symptoms                  not stated      at least        persistent                                                                several                                                                weeks                                                             13Haravuori et al.Psychiatria Fennica 2016;47:9-16Something old, something new:disorders specifically associatedwith stress in the ICD 11th revisionProlonged grief disorderProlonged grief disorder emerges after (often traumatic) death of a partner, parent,child or other close person to the bereaved. There is pervasive yearning orpreoccupation with the deceased that is associated with intense emotional pain such assadness, guilt, anger, denial, blame, difficulty accepting the death, feeling one haslost a part of one’s self, an inability to experience positive mood, emotionalnumbness or difficulty in engaging with social or other activities (3). The intensegrieving persists atypically long, at least six months. The disturbance causessignificant impairment in important areas of functioning. Treatment of this disordershould be specific for (traumatic) grief and not merely standard treatment ofdepression (4).Clinical implications of the changes in the diagnostic systemsChanges in classification systems may have implications on the prevalence estimates ofdisorders, changes in clinical features such as comorbidity, functioning, as well astreatment provision and treatment outcomes. For example, the proposed ICD-11 PTSDcriteria have identified a fewer (or less frequently equal) number of cases comparedto ICD-10, DSM-IV or DSM-5 in adult studies (8, 9, 13, 19-21). However, ICD-11identified more cases with PTSD in one child sample when compared to DSM-IV andDSM-5 (22). In our study with adolescents and young adults ICD-11 criteria identifiedmore PTSD cases than DSM-IV and far less than ICD-10 (11).Diagnostic agreement on PTSD between classification systems also varies. In one adultsample of 510 injury patients followed 72 months after hospitalization, PTSD wasdiagnosed simultaneously in 64% of the cases with both ICD-10 and the proposed ICD-11criteria, and in 42% of the cases with both the proposed ICD-11 and DSM-5 criteriaamong those meeting at least one PTSD criterion (20). Similarly, ICD-10 and DSM-IVwere only at a moderate level of diagnostic agreement with the ICD-11 PTSD criteria inan adolescent and young adult sample (11). If the ICD-10 diagnostic criteria werecomplemented with the impairment criterion, the diagnostic agreement changed to begood with ICD-11. 14                             Haravuori et al.Psychiatria Fennica 2016;47:9-16Something old, something new:disorders specifically associatedwith stress in the ICD 11th revisionConclusionThe 11th revision of ICD is intended to serve primary care settings where relevantdiagnostics and a proper treatment plan can be generated. Using the very core symptomsof each disorder should enable differentiation between the disorders while"artificial" comorbidity decreases. On the other hand, this may underestimate themultitude of symptoms that we observe in our patients requiring specialized levels ofcare. As the ICD-11 is implemented into clinical practice, the statistics on primaryand specialized health care will probably change to some degree as well as clinicalpicture of the patients in treatment. Those involved in academic research will have toput up with coexisting and unharmonized DSM-5 and ICD-11. The proposed Disorders specifically associated with stress class in ICD-11 brings complex PTSD and prolongedtraumatic grief "onto stage" and legitimizes their specific treatment needs.References1. Reed GM. Toward ICD-11: improving the clinical utility of WHO’s international classification of mentaldisorders. Prof Psychol Res Pr 2010; 41: 457-464. 2. World Health Organization. The ICD-10 classification of mental and behavioural disorders: clinicaldescriptions and diagnostic guidelines. Geneva: World Health Organization; 1992. 3. World Health Organization. ICD-11 beta draft: joint linearization for mortality and morbidity statistics.Geneva: World Health Organization; 2016. http://apps.who.int/classifications/icd11/browse/l-m/en [Accessed 29May 2016]. 4. Maercker A, Brewin CR, Bryant RA, Cloitre M, Reed GM, van Ommeren M, Humayun A, Jones LM, Kagee A,Llosa AE, Rousseau C, Somasundaram DJ, Souza R, Suzuki Y, Weissbecker I, Wessely SC, First MB, Saxena S.Proposals for mental disorders specifically associated with stress in the ICD-11. Lancet 2013; 381: 1683-1685. 5. Forbes D, Lockwood E, Creamer M, Bryant RA, McFarlane AC, Silove D, Nickerson A, O’Donnell M. Latentstructure of the proposed ICD-11 post-traumatic stress disorder symptoms: implications for the diagnosticalgorithm. Br J Psychiatry 2015; 206: 245-251. 6. Elhai JD, Miller ME, Ford JD, Biehn TL, Palmieri PA, Frueh BC. Posttraumatic stress disorder in DSM-5:estimates of prevalence and symptom structure in a nonclinical sample of college students. J Anxiety Disord2012; 26: 58-64. 7. Miller MW, Wolf EJ, Kilpatrick D, Resnick H, Holowka BP, Keane DW, Rosen RC, Friedman MJ. The prevalenceand latent structure of proposed DSM-5 posttraumatic stress disorder symptoms in U.S. national and veteransamples. Psychol Trauma 2013; 5: 501-502.                                                             15Haravuori et al.Psychiatria Fennica 2016;47:9-16Something old, something new:disorders specifically associatedwith stress in the ICD 11th revision 8. Tay AK, Rees S, Chen J, Kareth M, Silove D. The structure of post-traumatic stress disorder and complexpost-traumatic stress disorder amongst West Papuan refugees. BMC Psychiatry 2015; 15: 111. 9. Hansen M, Hyland P, Armour C, Shevlin M, Elklit A. Less is more? Assessing the validity of the ICD-11 modelof PTSD across multiple trauma samples. Eur J Psychotraumatol 2015; 6: 28766. 10. Glück TM, Knefel M, Tran US, Lueger-Schuster B. PTSD in ICD-10 and proposed ICD-11 in elderly withchildhood trauma: prevalence, factor structure, and symptom profiles. Eur J Psychotraumatol 2016; 7: 29700. 11. Haravuori H, Kiviruusu O, Suomalainen L, Marttunen M. An evaluation of ICD-11 posttraumatic stressdisorder criteria in two samples of adolescents and young adults exposed to mass shootings: factor analysisand comparisons to ICD-10 and DSM-IV. BMC Psychiatry 2016; 16: 140. 12. Cloitre M, Garvert DW, Brewin CR, Bryant RA, Maercker A. Evidence for proposed ICD-11 PTSD and complexPTSD: a latent profile analysis. Eur J Psychotraumatol 2013; 4: 20706. 13. Knefel M, Lueger-Schuster B. An evaluation of ICD-11 PTSD and complex PTSD criteria in a sample of adultsurvivors of childhood institutional abuse. Eur J Psychotraumatol 2013; 4: 22608. 14. Cloitre M, Garvert DW, Weiss B, Carlson EB, Bryant RA. Distinguishing PTSD, complex PTSD, and borderlinepersonality disorder: a latent class analysis. Eur J Psychotraumatol 2014; 5: 25097. 15. Perkonigg A, Höfler M, Cloitre M, Wittchen H-U, Trautmann S, Maercker A. Evidence for two different ICD-11posttraumatic stress disorders in a community sample of adolescents and young adults. Eur Arch Psychiatry ClinNeurosci 2016; 266: 317-328. 16. Elklit A, Hyland P, Shevlin M. Evidence of symptom profiles consistent with posttraumatic stress disorderand complex posttraumatic stress disorder in different trauma samples. Eur J Psychotraumatol 2014; 5: 24221. 17. Knefel M, Garvert DW, Cloitre M, Lueger-Schuster B. Update to an evaluation of ICD-11 PTSD and complexPTSD criteria in a sample of adult survivors of childhood institutional abuse by Knefel & Lueger-Schuster(2013): a latent profile analysis. Eur J Psychotraumatol 2015; 6: 25290. 18. Resick PA, Bovin MJ, Calloway AL, Dick AM, King MW, Mitchell KS, Suvak MK, Wells SY, Stirman SW,Wolf EJ. A critical evaluation of the complex PTSD literature: implications for DSM-5. J Trauma Stress 2012;25: 241-251. 19. Morina N, van Emmerik AAP, Andrews B, Brewin CR. Comparison of DSM-IV and proposed ICD-11 formulationsof PTSD among civilian survivors of war and war veterans. J Trauma Stress 2014; 27: 647-654. 20. O’Donnell ML, Alkemade N, Nickerson A, Creamer M, McFarlane AC, Silove D, Bryant RA, Forbes D. Impact ofthe diagnostic changes to post-traumatic stress disorder for DSM-5 and the proposed changes to ICD-11. Br JPsychiatry 2014; 205: 230-235. 21. Stammel N, Abbing EM, Heeke C, Knaevelsrud C. Applicability of the ICD-11 proposal for PTSD: a comparisonof prevalence and comorbidity rates with the DSM-IV PTSD classification in two post-conflict samples. Eur JPsychotraumatol 2015; 6: 27070. 22. Danzi B, La Greca A. DSM-IV, DSM-5, and ICD-11: how well do diagnostic criteria for PTSD fit childrenafter disasters? ISTSS 30th annual meeting poster abstracts, abstract #182. 2014.https://www.istss.org/ISTSS_Main/media/Documents/2014PosterAbstracts.pdf [Accessed 29 Mar 2016]. 16                             Haravuori et al.Psychiatria Fennica 2016;47:9-16Something old, something new:disorders specifically associatedwith stress in the ICD 11th revisionHenna Haravuori, MD, PhDMental Health Unit, Department of Health, National Institute for Health and WelfareAdolescent Psychiatry, University of Helsinki and Helsinki University HospitalMauri Marttunen, MD, PhD, professorMental Health Unit, Department of Health, National Institute for Health and WelfareAdolescent Psychiatry, University of Helsinki and Helsinki University HospitalCorrespondence:henna.haravuori@thl.fi

Something Old, Something New – Disorders specifically associated with stress in the ICD 11th Revision

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