Updates on status of ICD-11 and changes to other classification and terminology systems

World Health Assembly adopts ICD-11: When will member states start using the new edition?

June 17, 2019

Post #354 Shortlink: https://wp.me/pKrrB-4Sm

On May 25, 2019, the 72nd World Health Assembly voted unanimously to adopt the ICD-11, the next edition of the International Classification of Diseases (ICD).

Endorsement won’t come into effect until January 1, 2022, which is the earliest date that member states can begin using ICD-11 for reporting data.

A stable version of the ICD-11 MMS was released in June 2018 to enable member states to begin planning for implementation.

ICD-11 is an electronic classification containing over 55,000 codes and a considerably more complex product than ICD-10. It has been designed to incorporate or link with other ICD classifications, such as the International Classification of Functioning, Disability and Health (ICF), the WONCA* developed International Classification of Primary Care (ICPC), and with the SNOMED-CT and OrphaNet terminologies.

Even the earliest implementers will need several years to evaluate the new edition, determine how they will use ICD-11, complete translations, produce training and implementation materials and prepare their health systems for migration. Japan is understood to be well advanced with translations and planning.

There is no mandatory implementation date: member states will migrate to ICD-11 at their own pace and according to their countries’ needs and resources but there is an expectation that countries will start planning for transition. Some member states may need to develop clinical modifications of ICD-11 for country specific use. A few countries still use ICD-9.

Global implementation of the new edition will be a patchy and prolonged process and during the transition period, WHO will be accepting data reported using both ICD-10 and the new ICD-11 code sets until the majority of member states have transitioned to the new edition. WHO has said that the last update to ICD-10 will be Version 2019.

No member states have announced timeline projections but below is a round-up of ICD-11 transition planning activities already in progress:

*World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians


NHS England

NHS England mandates the use of ICD-10 in secondary care (currently using ICD-10 Version 2015).

As a WHO Collaborating Centre and designated UK Field Trial Centre, NHS Digital has taken part in ICD-11 Field Trials.

NHS Digital has said:

No decision has been made for the implementation of ICD-11 in England, however NHS Digital plan to undertake further testing of the latest release and supporting products that will inform a future decision.

NHS Digital Delen: ICD-11 resources page

Proposed Future Additions

Over the coming months, NHS Digital would like to engage and invite all users of ICD to participate and interact with the review process.

To support this, we are proposing to add the following information to our Delen site;

• A mechanism for questions, issues, concerns and errors relating to ICD-11 to be raised to us as the UK Field Trial Centre.
• A high-level overview of our future plans
• Presentations providing more information on ICD-11
• e-Learning materials to support familiarisation with ICD-11. Topics to include post coordination / cluster coding, chapter and code structure, chapter specific changes and notes, conventions etc
• Further testing – parallel coding in ICD-10 in real-time. If you would be interested in taking part in this please let us know by emailing icd-11@nhs.net

Until NHS England has implemented ICD-11, the mandatory classification system for use in the NHS remains ICD-10.

Since April 2018, SNOMED CT (which replaces the Read Codes/CTV3 clinical terminology) has been the mandatory terminology system for use in NHS primary care at the point of contact and forms an integral part of the electronic patient record (EPR).

SNOMED CT terminology system is already used in some secondary care settings but is planned to be implemented across all secondary care, acute care, mental health, community systems, dentistry and other systems used in direct patient care by April 2020.

SNOMED CT terminology system and clinical classifications, like ICD-10, work together to fulfil different needs:


Source: Presentation: NHS Digital: Clinical Coding for non coders – Overview of clinical coding, how ICD-10 and SNOMED CT work together, and the role of the Clinical Classifications Service.

For more information on the planning that will be required before ICD-11 can be implemented within the NHS, see BETA – Clinical Information Standards, section: ICD-11 and the new Procedure Based Classification (PBC).

Resources:

NHS Digital Delen Home Page

NHS Digital SNOMED CT resources

SNOMED CT UK Edition browser



Australia

Australia uses a modification of the WHO’s ICD-10, known as ICD-10-AM [1].

Australian classification standards and statistics agencies were well represented on the ICD-11 Joint Task Force, with 5 of the Joint Task Force’s 21 members representing Australia, plus co-chair (Dr James Harrison, Director, Research Centre for Injury Studies, Flinders University, Adelaide) and observer (Dr Richard Madden, Professor of Health Statistics and Director National Centre for Classification in Health, University of Sydney).

For comparison, the UK had only an observer on the Joint Task Force; the U.S. had 4 participants and an observer.

The Australian Institute of Health and Welfare (AIHW) has been conducting a review of ICD-11 to inform and assist decision-makers about the new edition and its potential for adoption in Australia, see Post: #349: Australia: Potential adoption of ICD-11: Pre-consultation for decision makers.

1 Australian Consortium for Classification Development



Canada

Canada uses a modification of the WHO’s ICD-10, known as ICD-10-CA, developed by Canadian Institute for Health Information (CIHI) [1].

CIHI is participating in the testing of ICD-11 and assessing the implications for potential implementation in Canada.

CIHI has said that no decision has been made for the implementation of ICD-11 in Canada and that they are currently working on a number of initiatives to better understand the differences between ICD-10-CA and ICD-11 to help inform the business and statistical implications of adoption.

1 Version 2018 ICD-10-CA/CCI, Canadian Coding Standards and related products



United States

The National Center for Health Statistics (NCHS) is the federal agency responsible for the use of ICD-10 in the United States.

ICD-10 has been used in the U.S. to code and classify mortality data from death certificates since January 1999. NCHS developed a clinical modification of ICD-10 for morbidity purposes (ICD-10-CM) which replaced ICD-9-CM on October 1, 2015.

Since its initial launch, in 2007, the U.S. has maintained high level participation in the ICD-11 development process and its ongoing update and improvement:

The U.S. provided representatives from professional and scientific organisations, academics and practitioners for the ICD-11 Topic Advisory Groups (TAGs) and sub working groups. Stanford Center for Biomedical Informatics Research developed the web based iCAT Collaborative Authoring Platform on which ICD-11 was developed.

The U.S. has representatives on the ICD-11 governance committees via the WHO-FIC Network; the Medical Scientific Advisory Committee (MSAC); the Classifications and Statistics Advisory Committee (CSAC); the Mortality and Morbidity (MbRF) Reference Groups; and the Functioning and Disability Reference Group, which have oversight for the annual updating and ongoing improvement of the global ICD-11 edition.

Dr Geoffrey Reed (WHO, Geneva; Columbia University) is Senior Project Lead for the ICD-11 Mental Health chapter and a member of the MSAC; Steven Hyman, MD (former Director of the National Institute of Mental Health (NIMH) and former DSM-5 Task Force member) chaired the Topic Advisory Group for Mental Health; Michael B First, MD has served as a key external advisor to the Mental Health chapter.

Dr Christopher Chute (John Hopkins University) chaired the ICD-11 Revision Steering Committee, was a member of the Joint Task Force and now chairs the MSAC; Donna Pickett (Chief, Classifications and Public Health Data Standards, NCHS, Centers for Disease Control and Prevention, Head, Collaborating Center for the WHO-FIC in North America) co-chaired the Morbidity TAG, was a member of the Joint Task Force and is a member of the CSAC; Dr Robert Anderson (Chief, Mortality Statistics Branch Division of Vital Statistics, Centers for Disease Control and Prevention) was a member of the Joint Task Force and co-chaired the Mortality TAG; Cille Kennedy (ASPE) co-chaired the ICD-11 Functioning TAG; Sue Bowman (Senior Director of Coding Policy and Compliance, AHIMA) is a representative on the ICD-11 Morbidity Reference Group (MbRF).​

Around 25 member states have modified the ICD-10 for country specific use.

WHO is still formulating policies around the licensing of ICD-11 but it is understood that the intention is to limit development of national modifications.

See Presentation slides #36-38 for more information on licensing and the development of country modifications: Insights into the Next Revision: Like Texas, Everything is Bigger in ICD-11, Kathy Giannangelo, RHIA, CCS, CPHIMS, FHIMA, Texas Health Information Management Association.

It would be premature to speculate when the U.S. might be ready to migrate to ICD-11 for mortality (cause of death reporting) and whether ICD-11 will be adequate as a morbidity classification system for U.S. use or whether NCHS will need to develop a clinical modification, as it did for ICD-10.

It was put forward at the June 5-6, 2019 NCVHS meeting that the U.S. might potentially use ICD-11 unmodified if WHO were to incorporate some additional terms within the global ICD-11 edition.

NCVHS has initiated the process of planning for transition to ICD-11 at the federal level.

In February 2019, William W Stead, MD, Chair, NCVHS, sent a letter to the Secretary of Health and Human Services (HHS) recommending a simplified process for adopting future versions of ICD. The letter also recommended that HHS should invest now in an ICD-11 evaluation project and develop a plan to enable a smooth and transparent transition from ICD-10 to ICD-11 at the optimal time.



NCVHS meetings:

A National Committee on Vital and Health Statistics Full Committee Meeting was held on June 5-6, 2019.

Agenda: Full Committee Meeting-June 5-6, 2019

Presentations were given for Agenda item: ICD-11 Project:



Recording Mp3: Full Committee Meeting-June 5, 2019

Agenda item: ICD-11 Project: presentations and discussions starts 2hrs: 50 mins in from start; closes 5hrs 55mins from start.

Meeting summary: To follow

Transcript: To follow

Presentation slides: To follow



Forthcoming NCVHS meeting:

NCVHS Subcommittee on Standards is holding an ICD-11 Evaluation Expert Roundtable Meeting on August 6-7, 2019.

Location: U.S. Department of Health and Human Services, Hubert H. Humphrey Building, 200 Independence Avenue SW, Rm. 705-A, Washington, DC 20201.

Federal Register Notice: https://www.federalregister.gov/doc...mittee-on-vital-and-health-statistics-meeting

NCVHS Meeting page: https://ncvhs.hhs.gov/meetings/subc...-icd-11-evaluation-expert-roundtable-meeting/

Meeting Agenda: https://ncvhs.hhs.gov/wp-content/up...Expert-Roundtable-Meeting-August-6-7-2019.pdf




1 WHO Group Discusses ICD-11 Transition Planning report by Sue Bowman, MJ, RHIA, CCS, FAHIMA for Journal of AHIMA (American Health Information Management Association)

2 Presentation: Status on ICD-11: The WHO Launch National Committee on Vital and Health Statistics, July 18, 2018, Donna Pickett, Chief, Classifications and Public Health Data Standards, Head, Collaborating Center for the WHO-FIC in North America; Robert N. Anderson, PhD Chief, Mortality Statistics Branch Division of Vital Statistics

3 Presentation: Insights into the Next Revision: Like Texas, Everything is Bigger in ICD-11, Kathy Giannangelo, RHIA, CCS, CPHIMS, FHIMA, Texas Health Information Management Association


WHO-FIC Africa

WHO-FIC Africa Collaborating Centre has said:

ICD-10 is the current standard for Morbidity (cause of illness) and Mortality (cause of death (COD) coding.

The ongoing implementation and maintenance of ICD-10 for mortality and morbidity coding remain a core focus of the WHO-FIC Collaborating Centre (African region). Following the release of ICD-11 MMS in June 2018, there will be increasing focus on ICD-11 in the work plan of the collaborating centre. Inputs to the development of ICD-11 are essential to ensure that the classification meets regional needs.

WHO-FIC Africa News: WHO on the Implementation of ICD-11, November 2018:

https://www.youtube.com/watch?v=ilPhRkQqZTo

WHO-FIC collaborators met in Pretoria (South Africa) on 7 November 2018, discussing the implications for implementing ICD-11 and ICHI. We linked up with Nenad Kostanjsek from WHO (Geneva), who shared his thoughts about the preparation for implementation of ICD-11.

Download presentation slides



Other member states

This table from the eHealth DSI Semantic Knowledge Base project compiles information provided from a number of member states on their use of ICD (or a modification of ICD) and their plans regarding potential future implementation of ICD-11. Information provided by: Austria, Belgium, Croatia, Cyprus, Czech Republic, Estonia, France, Germany, Greece, Hungary, Ireland, Italy, Luxenbourg, Malta, Netherlands, Portugal, Slovenia and Spain.

Table: Current status of the use of ICD by eHDSI deploying countries (2018)


Resources:

ICD-11: The 11th Revision of the International Classification of Diseases – Site maintained by eHealth DSI Semantic Community providing resources for ICD-10, ICD-11, ICD derivative classifications and other classification and terminology systems

----------------

[Edited to insert Federal Register Notice and Agenda for NCVHS Subcommittee on Standards ICD-11 Evaluation Expert Roundtable Meeting on August 6-7, 2019.]

 

https://twitter.com/user/status/1141362465814585344



I will confirm again when CDC has posted the ICD-10-CM Tabular List and Index for FY 2020, which are due to be posted this month, that no new code for SEID has been added to ICD-10-CM Chapter 6.

But the AHIMA report and the .txt file and spreadsheet for Table 6A-New Diagnosis Codes

( https://www.cms.gov/Medicare/Medica...PPS/Downloads/FY2020-NPRM-Tables-6A-6K-6P.zip )

does appear to confirm.

 

The FY 2020 release of ICD-10-CM has been posted on the CDC site, today:

https://www.cdc.gov/nchs/icd/icd10cm.htm#FY 2020 release of ICD-10-CM

I can confirm there has been no change to the G93.3 coded terms and the R53.82 coded terms.

Either:

a) A decision was made by the NCHS Director not to approve either of the options presented at the September 2018 C & M meeting, or

b) No decision was arrived at and the topic has been left hanging, or

b) The topic is being carried forward for further discussion with potentially revised proposals at a future meeting of the C & M Committee.

Thank you to those who submitted comments during the public comment period following the Sept 2018 C & M meeting in opposition to the addition of the SEID term to Chapter 6 of ICD-10-CM.

 

The ICD-10-CM FY 2020 Tabular List, Index and associated documents are available at:

https://www.cdc.gov/nchs/icd/icd10cm.htm#FY 2020 release of ICD-10-CM

Not available yet are the documents:

Preface
ICD-10-CM FY2020 Guidelines
Conversion table FY2020

The Tabular List and Index are large PDFs included in a long list files. For ease of access, I have uploaded PDFs for the FY 2020 Tabular List and FY 2020 Index to my Dx Revision Watch files area. Note these are 28 MB and 40 MB files, respectively.


ICD-10-CM FY 2020 Tabular List:

https://dxrevisionwatch.files.wordpress.com/2019/06/icd10cm_tabular_2020.pdf

Shortlink: https://wp.me/aKrrB-4Wu

[28 MB]



ICD-10-CM FY 2020 Index:

https://dxrevisionwatch.files.wordpress.com/2019/06/icd10cm_index_2020.pdf

Shortlink: https://wp.me/aKrrB-4Wt

[40 MB]

 

The Resolutions approved at the 72nd World Health Assembly, in May, have now been added to the #WHA72 site:

http://apps.who.int/gb/e/e_wha72.html#resolutions

Resolution: WHA72.15 28 May 2019 Eleventh revision of the International Classification of Diseases:
http://apps.who.int/gb/ebwha/pdf_files/WHA72/A72_R15-en.pdf

 

ICD-11 Fibromyalgia:

a new proposal for a Change of Title, Change of Definition was submitted on June 26, 2019, via the ICD-11 Proposal Mechanism.

For ICD-11, Fibromyalgia has not been assigned a unique code. In May 2015, it was relocated from its legacy ICD-10 chapter location to a new category block in the Symptoms, signs chapter, as an Inclusion term under Chronic pain > Chronic widespread pain.

It is currently coded as an Inclusion term under MG30.01 Chronic widespread pain and it takes the MG30.01 code in the ICD-11 Mortality and Morbidity Statistics (MMS) Linearization.

The current description texts for Fibromyalgia can be accessed here, registration not required: https://icd.who.int/dev11/f/en#/http://id.who.int/icd/entity/236601102


New proposal submitted by Antonia Barke (member of the IASP NGO that collaborates with the WHO on the development of the ICD-11 Chronic pain disorders):

https://icd.who.int/dev11/proposals...lGroupId=2062ec5e-e674-4b1c-bd68-3e4cb2bf1bc3

Registration is required for access to the ICD-11 Proposal Mechanism. For ease of access, this PDF of the Proposal text is being provided by Dx Revision Watch. Permission is given to circulate:


Proposed Changes: Definition, Title. Antonia Barke 2019-Jun-26 - 15:19


Content Enhancement Proposal

(No Rationale or References are submitted in support of this proposal)


Proposed Change of Title to:

Fibromyalgia syndrome


Proposed change of Description text:


Short Definition

Fibromyalgia syndrome (FMS) is a form of chronic widespread pain, which is defined as diffuse pain in at least 4 of 5 body regions, that persists or recurs for longer than 3 months, and is associated with significant emotional distress (anxiety, anger/frustration or depressed mood) or functional disability (interference in daily life activities and reduced participation in social roles). CWP is multifactorial: biological, psychological and social factors contribute to the pain syndrome. FMS is in addition associated with sleep disorders, cognitive dysfunction and somatic symptoms. The symptoms have been present at a similar level for at least 3 months, and are not better accounted for by another specific diagnosis. Fibromyalgia is multifactorial: biological, psychological and social factors contribute to the pain syndrome.


Diagnostic Criteria:

Conditions A to D are fulfilled:

A. Chronic pain (persistent or recurrent for longer than 3 months) is present in at least 4 of 5 body regions
B. The pain is associated with at least one of the following:
B.1 Emotional distress due to pain is present.
B.2 The pain interferes with daily life activities and social participation.
C. The pain is associated with sleep disorders, cognitive dysfunction and somatic symptoms
D. The pain is not better accounted for by another chronic pain condition.

Comments
The body regions referred to are the four quadrants (upper left, upper right, lower left, lower right of the body) and axial (neck, back, chest and abdomen). [1]

The presence of pain, emotional distress and interference in daily activities due to pain should be established based on a thorough assessment procedure using standardized measures.

Detailed Definition

Fibromyalgia syndrome (FMS) is a form of chronic widespread pain, which is defined as diffuse pain in at least 4 of 5 body regions, that persists or recurs for longer than 3 months, and is associated with significant emotional distress (anxiety, anger/frustration or depressed mood) or functional disability (interference in daily life activities and reduced participation in social roles). CWP is multifactorial: biological, psychological and social factors contribute to the pain syndrome. FMS is in addition associated with sleep disorders, cognitive dysfunction and somatic symptoms. The symptoms have been present at a similar level for at least 3 months, and are not better accounted for by another specific diagnosis. Fibromyalgia is multifactorial: biological, psychological and social factors contribute to the pain syndrome. [2]

Definitions of FMS have been repeatedly revised since it was first recognized as a rheumatic disease by WHO in 1992. Some authorities prefer to reserve the term FMS for the more severe end/presentations of the spectrum encompassed in CWP/FMS, but this approach reflects a quantitative rather than a qualitative distinction that depends on criteria that have yet to be validated.

Other chronic pain diagnoses to be considered are chronic cancer pain, chronic postsurgical or posttraumatic pain, chronic neuropathic pain, chronic visceral pain and chronic musculoskeletal pain.

Patients present with spontaneous or evoked pain in the affected regions, accompanied by allodynia and/or hyperalgesia and there may be features consistent with nociplastic pain. [1] Comorbid FMS can be found in many other conditions (8).

FMS is often associated with increased medical comorbidity. Patients with FMS often report increased disability [3], depressed and anxious mood [4-5]. Prevalence estimates of FMS range between 1% and 2%, usually higher in women than men, and higher in those more than 40 years of age [7]. Treatment should aim at the reduction of pain-related distress and disability.

Narrower Term

• Fibromyositis
  
• Fibrositis
  
• Myofibrositis

Body Site

• Connective tissue structure (body structure)
• Connective tissue (substance)
• Skeletal and/or smooth muscle structure (body structure)

Signs and Symptoms

• Pain (finding)

-------------------

For ease of access/circulation, I have put the above text into a PDF: https://dxrevisionwatch.files.wordp...-icd-11-proposal-mechanism-june-26-2019-2.pdf and in attachment.


The current Description and other texts for MG30.01 Chronic widespread pain under which Fibromyalgia is an Inclusion in the ICD-11 MMS, can be viewed here:

https://icd.who.int/dev11/l-m/en#/http://id.who.int/icd/entity/849253504

 

Thanks. Is there a particularly important implication to this for us to understand that I've missed, or are you just keeping people updated?

 

Hi Esther12, I'm not a stakeholder in, nor an advocate for Fibromyalgia.

I cannot say to what extent these proposed changes, submitted today, reflect international consensus criteria, or whether Fibromyalgia advocacy groups are comfortable with consensus criteria for Fibromyalgia, or would be comfortable with the term being changed to Fibromyalgia syndrome. Or whether they are comfortable with Fibromyalgia being classified as an Inclusion under Chronic widespread pain and no longer discretely coded for within ICD.

(To date, although they have been made aware of the change of chapter location in Mar 2015, the lack of a discrete code, and the degree of overlap between the characterization of Chronic widespread pain and the characterization of Bodily distress disorder, Fibromyalgia advocacy groups have not participated in submitting their own proposals or commenting on the WHO's proposals, via the Proposal Mechanism.)

Information on today's proposals for changes to the ICD-11 category Fibromyalgia, submitted on behalf of the IASP, is being provided here and on Twitter as part of my monitoring of ICD-11 and other classification and terminology systems.

 

The proposal above has been edited to include the following:

Rationale
This submission represents the consensus of the IASP Task Force Classification of Chronic Pain (Chairmen: Rolf-Detlef Treede and Winfried Rief).

References
[1] Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Hauser W, Katz RL, Mease PJ, Russell AS, Russell IJ, Walitt B. 2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria. Seminars in arthritis and rheumatism 2016;46(3):319-329.
[2] Lami MJ, Martinez MP, Miro E, Sanchez AI, Guzman MA. Catastrophizing, Acceptance, and Coping as Mediators Between Pain and Emotional Distress and Disability in Fibromyalgia. Journal of clinical psychology in medical settings 2018.
[3] Schweiger V, Del Balzo G, Raniero D, De Leo D, Martini A, Sarzi-Puttini P, Polati E. Current trends in disability claims due to fibromyalgia syndrome. Clinical and experimental rheumatology 2017;35 Suppl 105(3):119-126.
[4] Bateman L, Sarzi-Puttini P, Burbridge CL, Landen JW, Masters ET, Bhadra Brown P, Scavone JM, Emir B, Vissing RS, Clair AG, Pauer LR. Burden of illness in fibromyalgia patients with comorbid depression. Clinical and experimental rheumatology 2016;34(2 Suppl 96):S106-113.
[5] Janssens KA, Zijlema WL, Joustra ML, Rosmalen JG. Mood and Anxiety Disorders in Chronic Fatigue Syndrome, Fibromyalgia, and Irritable Bowel Syndrome: Results From the LifeLines Cohort Study. Psychosom Med 2015;77(4):449-457.
[6] Farin E, Ullrich A, Hauer J. Participation and social functioning in patients with fibromyalgia: development and testing of a new questionnaire. Health Qual Life Outcomes 2013;11:135.
[7] Walitt B, Nahin RL, Katz RS, Bergman MJ, Wolfe F. The Prevalence and Characteristics of Fibromyalgia in the 2012 National Health Interview Survey. PloS one 2015;10(9):e0138024.
[8] Fitzcharles MA, Perrot S, Häuser W. Comorbid fibromyalgia: A qualitative review of prevalence and importance. Eur J Pain. 2018;22(9):1565-1576.


I have added this Rationale and References text to the PDF.

The revised PDF is: https://dxrevisionwatch.files.wordp...icd-11-proposal-mechanism-june-26-2019-v2.pdf

also attached to this post.

-----------------------

I have left the following technical queries for the attention of Antonia Barke in response to the proposal:

https://icd.who.int/dev11/proposals...lGroupId=2062ec5e-e674-4b1c-bd68-3e4cb2bf1bc3

 

In what way has it been shown that "psychological and social factors" play a role in fibromyalgia? It's a long-held assumption but it has never actually been demonstrated beyond the level of "may" or "could". That's not a good basis for guidelines or classification. By that principle astrology "may" play a role in anything, it just very much likely doesn't.

Disappointing how pet hypotheses become policy. What to say about fool me 1M times?

 

It was pet hypotheses, also, that resulted in Somatic symptom disorder for DSM-5 and the very similar, Bodily distress disorder for the core ICD-11.

The current description text for Fibromyalgia also includes: "Fibromyalgia is characterised by chronic diffuse pain, intense fatigue and sleep disturbances often associated with anxiety or depression, and triggered by physical or psychological trauma."

The term is currently an inclusion under Chronic widespread pain and its description text includes: "CWP is multifactorial: biological, psychological and social factors contribute to the pain syndrome. The diagnosis is appropriate when the pain is not directly attributable to a nociceptive process in these regions and there are features consistent with nociplastic pain [2] and identified psychological and social contributors."

CWP is part of the Chronic primary pain category block, which has considerable conceptual overlap with Bodily distress disorder. The IASP would like BDD secondary parented to Chronic primary pain. (WHO has not acted on this request, but it was not submitted by Antonia Barke, as a formal proposal.)

In August 2015, I reported via my site and elsewhere on the proposed changes:

...But I urge stakeholder patient organizations, the clinicians who advise them, allied health professionals, occupational therapists and disability lawyers to scrutinize the IASP Task Force paper, the Beta draft rationale and proposals documents, proposed definitions and other descriptive content and to register with the Beta draft to submit comments and make formal suggestions for improvements via the Proposal Mechanism, (supported with references, where possible).

There is a considerable amount of psychosomatics in the Detailed Proposals document for Primary chronic pain. There is disorder description and criteria overlap with ICD-11’s proposed Bodily distress disorder; with DSM-5 Somatic symptom disorder “Predominate pain” specifier; with Somatoform pain disorder and the German ICD-10-GM: F45.41: Chronic pain disorder with somatic and psychological factors – a classification which Prof Winfried Rief was instrumental in getting inserted into the German ICD-10-GM, in 2009...​

The change of chapter location for Fibromyalgia had taken place in May 2015, but Fibromyalgia advocacy orgs and their clinician and researcher allies have not taken the opportunity to submit comments or suggest revisions to the description texts - at least not via the prescribed channel (the Proposal Mechanism). I contacted several Fibro orgs in 2015/16 to advise of the change of chapter and the issue of Fibromyalgia losing its discrete code for ICD-11 and being rolled up as an inclusion under CWP in the MMS Linearization. I think only one org responded.

Last year, I discussed these issues with several Fibro org reps via Twitter and provided simple instructions on how to submit comments - they appeared keen to prepare submissions - but nothing was submitted. Yesterday, I put this most recent proposal out on Twitter and one org has said they plan to comment; that they consider that a discrete code would be helpful and consider the term "Fibromyalgia syndrome" to be a legacy term.

But I don't know what orgs, internationally, think about including Fibro under the term CWP; whether they welcome this or whether they think this could be seen as a move by WHO towards eventual deprecation of the term "Fibromyalgia" in favour of the term "Chronic widespread pain"; or what they think about the emphasis within the current ICD-11 description texts (and in the text of this recent new proposal) on the role that psychological and social factors are assumed to play in both FM (or FMS, as is now being proposed) and in CWP.

The IASP's Chronic pain Task Force has worked closely with the WHO on the structuring of this new category block and the conceptualization of the numerous new categories that have been created within it; it may be that there is limited room for negotiation and input from stakeholder groups.

The IASP is currently running a stakeholder feedback exercise on the new ICD-11 Chronic pain and Chronic primary pain categories via a German university, but again, I don't know how many Fibro orgs might be planning to submit feedback. And it seems like shutting the door after the horse has bolted - why did the IASP not run a public consultation before ICD-11 went to WHA for approval, in May?

Fibro orgs have certainly left it very late in the day to start submitting comments on ICD-11 proposals.

[Edited for clarity]

 

[insert emoji and/or whatever conveys the feeling of the world's longest sigh ever recorded]

Sometimes it feels like the "duty" part of duty of care is mostly carried by its scatalogical definition. What a freaking mess. Everything that can't be structured in objective standard measurements is just as silly and random as it ever was, almost all the way back to the stone age, just people bickering over whatever they feel is right.

I need a drink, or ten. Possibly more.

 

The US ICD-10-CM took an analagous approach with CFS and it has had a negative impact as below. I expect FM would be similarly impacted.

When ICD-10-CM was implemented here, CFS was equated to the symptom of chronic fatigue, and as a result, the same code is inserted in the medical records regardless of whether the doctor entered CFS or chronic fatigue.

Because most US doctors diagnose CFS and not ME, this has a significant impact on tracking since the CFS diagnoses are lumped in with the diagnoses of chronic fatigue in the medical records. Big impact on any efforts to use medical records in retrospective analyses. It also likely reinforces any negative perceptions of doctors about the disease and negatively impacts insurance reimbursement.

These guys just make shit up but pretend its all scientific and "evidence based." Drinking sometimes helps.

 

https://twitter.com/user/status/1143836852706848768

 

As I've probably mentioned earlier in this thread, the original IASP Task Force position paper describes Chronic primary pain as (my emphasis):

2.1. Chronic primary pain
Chronic primary pain is pain in 1 or more anatomic regions that persists or recurs for longer than 3 months and is associated with significant emotional distress or significant functional disability (interference with activities of daily life and participation in social roles) and that cannot be better explained by another chronic pain condition. This is a new phenomenological definition, created because the etiology is unknown for many forms of chronic pain. Common conditions such as, eg, back pain that is neither identified as musculoskeletal or neuropathic pain, chronic widespread pain, fibromyalgia, and irritable bowel syndrome will be found in this section and biological findings contributing to the pain problem may or may not be present. The term “primary pain” was chosen in close liaison with the ICD-11 revision committee, who felt this was the most widely acceptable term, in particular, from a nonspecialist perspective.
​

(But the Task Force did not obtain approval of relocating IBS under Chronic primary pain, nor secondary parenting IBS to this new parent class and IBS remains in its legacy chapter, with an exclusion for BDD.)


and (under 2.7. Chronic musculoskeletal pain):

…Well-described apparent musculoskeletal conditions for which the causes are incompletely understood, such as nonspecific back pain or chronic widespread pain, will be included in the section on chronic primary pain.​

Extract from my August 2015 report: Proposals for the classification of Chronic pain in ICD-11: Part 1:

Under two new terms: Mono-site primary chronic pains syndromes [term since revised] and Multi-site primary chronic pains syndromes [term since revised] the IASP working group proposes to locate irritable bowel syndrome; chronic nonspecific back pain; chronic pelvic pain; chronic widespread pain; fibromyalgia, and potentially some other conditions where chronic pain is a feature.

This "new phenomenological definition" appears to be an umbrella diagnosis for a number of the so-called, "functional somatic syndromes."

There is a considerable amount of psychosomatics in the Detailed Proposals document for Primary chronic pain [sic]. It is unclear whether the intention is to add discrete categories for irritable bowel syndrome; chronic nonspecific back pain; chronic widespread pain, and other diagnoses proposed to be aggregated under the Chronic primary pain term. But at the time of compiling this report, Fibromyalgia is the only term to have been inserted.​

Back in 2012, Chronic pain Task Force co-chair, Prof Winfried Rief, had presented tentative ideas for potential frameworks for a new ICD-11 chapter or section for pain conditions:

Presentation slides: 2012 SIP Symposium Workshop presentation: IASP and the Classification of Pain in ICD-11

Note in Slides #12-15, a number of the so-called, functional somatic syndromes, and in Slide #15, "Chronic Fatigue Syndrome, Neurasthenia" [sic], had been floated by Rief, in 2012, as potential partners in any proposed new chapter or section for chronic pain in ICD-11.

If Rief had had his way, there would have been a BDS-like section within ICD-11 under which many of the various so-called functional somatic syndromes could have been aggregated - instead, ICD-11 has this "new phenomenological definition" Chronic primary pain category block (minus IBS, but there is a Chronic primary visceral pain within this category block which can potentially capture IBS):

"...Chronic primary visceral pain includes pain in the head/neck viscera of the digestive system (e.g., burning mouth syndrome); in the thoracic region (e.g., Achalasia, non-cardiac chest pain, jackhammer pain, diffuse oesophageal spasm); in the abdominal region arising from the abdominal viscera of the digestive system (e.g., epigastric pain syndrome, irritable bowel syndrome, functional abdominal pain, biliary dyskinesia) and in the pelvic region due to involvement of the pelvic viscera of the digestive, urinary and genital systems (e.g., interstitial cystitis*, anal spasm, chronic pelvic pain, chronic testicular pain)..."
​

*Interstitial cystitis is primary parented in Chapter 16 Diseases of the genitourinary system.

​

 

To demonstrate how expansive this new Chronic primary pain category block has become, I've pasted screenshots, below, of all the categories that are "children" under the Chronic primary pain parent block (ie all the terms that display in the Foundation Component hierarchies when all the grey arrows are opened - these extend down to the blue line).

Note that not all of these terms are included and individually coded for in the MMS but will point to a specific code when searched for in the Coding Tool/Index. Some terms, for example the headache categories, are primary parented under Diseases of the nervous system's Headache block and secondary parented under Chronic primary pain in the MMS - these terms display as grey entries (known as "grey children") in the MMS to indicate they are primary parented in another location.

​

​

So if you have a problem with persistent pain, if BDD doesn't capture, then one of the above might.

(Only 3 more days of this...)

 

New post on my site:

Clinical Descriptions and Diagnostic Guidelines (CDDG) for ICD‐11 Mental, Behavioural and Neurodevelopmental Disorders

June 28, 2019

https://dxrevisionwatch.com/2019/06...behavioural-and-neurodevelopmental-disorders/

The ICD-10 “Blue Book” and “Green Book”

In the World Health Organization’s ICD-10 Tabular List there are no disease or disorder descriptions, criteria or diagnostic guidelines in any chapters other than the brief description texts for disorders coded within Chapter V Mental and behavioural disorders.

The WHO describes these brief description texts as suitable for use by coders or clerical workers and to serve as a reference point for compatibility with other classifications. These brief texts are not recommended for use by mental health professionals.

Two companion publications were developed for use with ICD-10’s Chapter V which expand on these brief texts and provide clinical descriptions and diagnostic guidelines. These publications are available as license free downloads:

The ICD-10 Classification of Mental and Behavioural Disorders: Clinical descriptions and diagnostic guidelines (aka the “Blue Book”):

https://www.who.int/classifications/icd/en/bluebook.pdf

intended for mental health professionals for general clinical, educational and service use.



The ICD-10 Diagnostic criteria for research (aka the “Green Book”):

https://www.who.int/classifications/icd/en/GRNBOOK.pdf

produced for research purposes and designed to be used in conjunction with the Clinical descriptions and diagnostic guidelines “Blue Book.”​

A survey of nearly 5,000 psychiatrists in 44 countries sponsored by the WHO and the World Psychiatric Association found that 70% of respondents mostly used the ICD-10 classification system in their daily clinical work compared to 23% of practitioners primarily using the American Psychiatric Association’s DSM-IV [1].


ICD-11 and the CDDG

For ICD-11, the WHO Department of Mental Health and Substance Abuse has developed the “Clinical Descriptions and Diagnostic Guidelines (CDDG) for ICD‐11 Mental, Behavioural and Neurodevelopmental Disorders.”

The CDDG provides expanded clinical descriptions, essential (required) features, boundaries with other disorders and normality, differential diagnoses, additional features, culture-related features and codes for all mental and behavioural disorders commonly encountered in clinical psychiatry; it is intended for mental health professionals and for general clinical, educational and service use.

The CDDG does not provide diagnostic criteria. The essential features are less rigid than DSM-5’s criteria sets and allow practitioners more flexibility to use clinical discretion when making a diagnosis.


CDDG review process

The CDDG review process has been undertaken via the Global Clinical Practice Network.

Qualified clinicians who signed up to participate in the CDDG guideline review process have been able to review and provide feedback on the draft content. No draft texts have been made available for public stakeholder scrutiny and comment and I have not had access, for example, to the most recent draft for the clinical descriptions and diagnostic guidelines for ICD-11’s Bodily distress disorder.

This paper in the February 2019 edition of World Psychiatry (Innovations and changes in the ICD-11 classification of mental, behavioural and neurodevelopmental disorders) describes major changes to the structure of the ICD‐11 classification of mental disorders as compared to ICD‐10; discusses new categories added for ICD‐11 and presents rationales for their inclusion; and describes important changes that have been made in each ICD‐11 disorder grouping [2].

What the paper does not give is a firm release date for the CDDG — stating only that the WHO will publish the CDDG as soon as possible following approval of the overall system by the World Health Assembly (WHA).

Member states approved the draft resolution to adopt ICD-11 at the 72nd World Health Assembly, in May 2019. Endorsement takes effect from January 01, 2022, which is the earliest date from which member states can begin reporting data using the new ICD-11 code sets.

Continued in next post

 

Continued from previous post:

Extract from Innovations and changes in the ICD-11 classification of mental, behavioural and neurodevelopmental disorders:

Disorders of bodily distress and bodily experience

ICD‐11 disorders of bodily distress and bodily experience encompass two disorders: bodily distress disorder and body integrity dysphoria. ICD‐11 bodily distress disorder replaces ICD‐10 somatoform disorders and also includes the concept of ICD‐10 neurasthenia. ICD‐10 hypochondriasis is not included and instead is reassigned to the OCRD [Ed: Obsessive‐compulsive and related disorders] grouping.

Bodily distress disorder is characterized by the presence of bodily symptoms that are distressing to the individual and an excessive attention directed toward the symptoms, which may be manifest by repeated contact with health care providers69. The disorder is conceptualized as existing on a continuum of severity and can be qualified accordingly (mild, moderate or severe) depending on the impact on functioning. Importantly, bodily distress disorder is defined according to the presence of essential features, such as distress and excessive thoughts and behaviours, rather than on the basis of absent medical explanations for bothersome symptoms, as in ICD‐10 somatoform disorders.​

*Embedded links to the ICD-11 Orange Maintenance Platform disorder descriptions are not included in the paper.

DSM-5’s Somatic symptom disorder is listed under Synonyms to ICD-11’s Bodily distress disorder and indexed to 6C20.Z Bodily distress disorder, unspecified.

The CDDG is expected to be published as a licence free download. When the WHO has released the CDDG, I will update this post.


This Letter to the Editor published in the June 2019 edition of World Psychiatry (Public stakeholders’ comments on ICD-11 chapters related to mental and sexual health) summarizes common themes of the submissions for the mental disorder categories that generated the greatest response [3].

Extract:

A majority of submissions regarding bodily distress disorder were critical, but were often made by the same individuals (N=8). Criticism mainly focused on conceptualization (48%; κ=0.64) and the disorder name (43%; κ=0.91). Use of a diagnostic term that is closely associated with the differently conceptualized bodily distress syndrome5 was seen as problematic. One criticism was that the definition relies too heavily on the subjective clinical decision that patients’ attention directed towards bodily symptoms is “excessive”. A number of comments (17%; κ=0.62) expressed concern that this would lead to patients being classified as mentally disordered and preclude them from receiving appropriate biologically-oriented care. Some contributors submitted proposals for changes to the definition (30%; κ=0.89). Others opposed inclusion of the disorder altogether (26%; κ=0.88), while no submission (κ=1) expressed support for inclusion. The WHO decided to retain bodily distress disorder as a diagnostic category6 and addressed concerns by requiring in the CDDG the presence of additional features, such as significant functional impairment.​

Note: “Use of a diagnostic term that is closely associated with the differently conceptualized bodily distress syndrome5 was seen as problematic.”

Whilst it is welcomed that this specific concern has been acknowledged within this Letter to the Editor, I have drawn to the authors’ attention that WHO/ICD Revision has repeatedly failed to respond to requests to provide a rationale for its re-purposing of a diagnostic term that is already strongly associated with the Fink et al (2010) Bodily distress syndrome*, despite provision of examples from the literature clearly demonstrating that these two terms have been used interchangeably by researchers and practitioners, since 2007 [4].

The potential for confusion and conflation of these differently conceptualized disorder constructs was acknowledged by the WHO’s Dr Geoffrey Reed, in 2015. However, there has been no discussion of this potential in any of the S3DWG working group’s progress reports and field trial evaluations. If the WHO is not willing to reconsider and remedy this problem, there is the expectation that a rationale for going forward with the Bodily distress disorder term is provided for clinical and public stakeholders.

*Operationalized in Denmark and beyond, BDS is differently conceptualized to ICD-11’s BDD diagnostic construct: BDS has very different criteria/essential features, based on physical symptom patterns or clusters from organ systems; psychobehavioural responses to symptoms do not form part of the BDS criteria; BDS requires the symptoms to be “medically unexplained”; is inclusive of a different patient population to ICD-11’s BDD, and crucially, is considered by its authors to capture myalgic encephalomyelitis, chronic fatigue syndrome, IBS and fibromyalgia patients under a single, unifying BDS diagnosis.

As an unprocessed proposal is currently under review with the CSAC/MSAC committees I have requested that earlier submissions, which were marked as rejected in February 2019 with no adequate rationale for dismissing the concerns raised within them, are reconsidered and that the WHO responds to three specific concerns:

a) its re-purposing of a disorder term already in use interchangeably for a differently conceptualized disorder construct;

b) the potential difficulties of maintaining disorder construct integrity within and beyond ICD-11 and the implications for clinical utility, data reporting and statistical analysis;

c) the requirement for adding exclusions under BDD for Concept Title 8E49 Postviral fatigue syndrome and its inclusion terms, to mitigate confusion/conflation with the Fink et al (2007, 2010) Bodily distress syndrome.

Continued in next post

 

Continued from previous post


Bodily distress disorder in SNOMED CT

The SNOMED CT Concept term SCTID: 723916001: Bodily distress disorder was added to the July 2017 release of the SNOMED CT International Edition.

SNOMED International’s classification leads confirmed that the term had been added by the team working on the SNOMED CT and ICD-11 MMS Mapping Project as “an exact match for the ICD-11 term, Bodily distress disorder.”

In ICD-11, Bodily distress disorder has specifiers for three degrees of severity: Mild BDD; Moderate BDD; and Severe BDD, which are each assigned a unique code and a discrete description/characterization text.

It was submitted that including the three ICD-11 BDD severities might help clinicians and coders distinguish between the SNOMED CT/ICD-11 Bodily distress disorder concept term and the similarly named, but differently conceptualized, Bodily distress syndrome (Fink et al 2010), which has two severities.

A request for addition of the three BDD severities was submitted and approved in early 2018 and Mild BDD; Moderate BDD; and Severe BDD were added as three discretely coded for Children concepts for the July 2018 release of the International Edition and subsequently absorbed into the various national editions.



ICD-11 PHC

The ICD-11 CDDG should not be confused with the ICD-11 PHC.

Since 2012, I have been reporting on the parallel development of the ICD-11 Primary Health Care (PHC) Guidelines for Diagnosis and Management of Mental Disorders (ICD-11 PHC).

The ICD-11 PHC is a revision of the Diagnostic and Management Guidelines for Mental Disorders in Primary Care: ICD-10 Chapter V Primary Care Version. 1996.

ICD-11 PHC is a clinical tool written in simpler language to assist non-mental health specialists in primary care settings and non medically trained health workers, and also intended for use in low resource settings and in low- to middle-income countries.

It comprises 27 mental disorders considered to be most clinically relevant in primary care and low resource settings. (It is a misnomer to refer to the ICD-11 PHC as the “Primary Care version of ICD-11” since it contains just 27 mental disorders and no general medical diseases or conditions.)

It is important to note that like the ICD-10 PHC, this revised diagnostic and management guideline won’t be mandatory for use by member states, although the WHO hopes this revised edition will have greater clinical utility than the ICD-10 PHC (1996).

The WHO intends to make the ICD-11 PHC publication, once completed, free to download by anyone. There is currently no date available for its projected finalization or release.

The revision is the responsibility of the WHO Department of Mental Health and Substance Abuseadvised by an external advisory group — the Primary Care Consultation Group (PCCG) which is chaired by Prof Sir David Goldberg*; Vice-chairs: Dr Michael Klinkman and WHO’s, Dr Geoffrey Reed.

*Prof Sir David Goldberg also chaired the working group for the development of ICD-10 PHC (1996). Dr Michael Klinkman is a GP who represents WONCA (World Organization of Family Doctors) and current convenor of WONCA’s International Classification Committee (WICC) that is responsible for the development and update of the WHO endorsed, ICPC-2 (International Classification of Primary Care).

The full draft texts for the 27 mental disorder categories proposed for inclusion in the ICD-11 PHC have not been made available for public scrutiny, but a number of progress papers, field trial evaluations and presentations have been published since 2010 [5-8].

25 of the 27 mental disorder categories proposed for inclusion in the ICD-11 PHC have equivalence with mental disorder classes within the core ICD-11’s Chapter 06.

ICD-11 PHC is proposed to include a disorder category called “Bodily stress syndrome (BSS)” which replaces ICD-10 PHC’s “F45 Unexplained somatic complaints/medically unexplained symptoms” and “F48 Neurasthenia” categories.

This proposed “Bodily stress syndrome (BSS)” diagnosis has been adapted from the Fink et al (2010) Bodily distress syndrome (BDS). “Bodily stress syndrome (BSS)” does not have direct equivalence to a diagnostic construct in the core ICD-11.

The ICD-11 PHC’s “Bodily stress syndrome (BSS)” requires at least 3 persistent, medically unexplained symptoms, over time, of cardio-respiratory, gastrointestinal, musculoskeletal, or general symptoms of tiredness and exhaustion, that result in significant distress or impairment.

Under exclusions and differential diagnoses for BSS, certain psychiatric and general medical diagnoses have to be excluded but CFS, ME; IBS; and FM appear not to be specified as exclusions. So this (non mandatory) 27 mental disorder guideline needs very close scrutiny.

For the mandatory core ICD-11 classification, the WHO is going forward with the differently conceptualized, Bodily distress disorder (BDD), which has close alignment with DSM-5’s Somatic symptom disorder.*

*See: Comparison of SSD, BDD, BDS, BSS in classification systems, Chapman & Dimmock, July 2018.


If ICD-11 PHC goes forward with its proposed BSS category, there will be all these diagnostic constructs in play:

Somatic symptom disorder (DSM-5; under Synonyms to BDD in the core ICD-11)
Bodily distress disorder (core ICD-11; SNOMED CT)
Bodily stress syndrome (ICD-11 PHC guideline for 27 mental disorders)
Bodily distress syndrome (Fink et al 2010, operationalized in Denmark and beyond)

plus the existing ICD-10 and SNOMED CT Somatoform disorders categories and their equivalents in ICPC-2.



References:

1 Reed GM, Correia J, Esparza P, Saxena S, Maj M (2011). The WPA-WHO global survey of psychiatrists’ attitudes towards mental disorders classification. World Psychiatry, 10, 118–131. https://onlinelibrary.wiley.com/doi/full/10.1002/j.2051-5545.2011.tb00034.x

2 Reed GM, First MB, Kogan CS, et al. Innovations and changes in the ICD-11 classification of mental, behavioural and neurodevelopmental disorders. World Psychiatry, 2019;18(1):3–19. doi:10.1002/wps.20611
Html: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6313247/
PDF: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6313247/pdf/WPS-18-3.pdf

3 Fuss J, Lemay K, Stein DJ, Briken P, Jakob R, Reed GM and Kogan CS. (2019). Public stakeholders’ comments on ICD‐11 chapters related to mental and sexual health. World Psychiatry, 18: 233-235. https://onlinelibrary.wiley.com/doi/full/10.1002/wps.20635

4 Chapman S. Proposal and rationale for Deletion of the Entity Bodily distress disorder. Proposal submitted via ICD-11 Beta draft Proposal Mechanism, March 02, 2017.

5 T P Lam, D P Goldberg, A C Dowell, S Fortes, J K Mbatia, F A Minhas, M S Klinkman. Proposed new diagnoses of anxious depression and bodily stress syndrome in ICD-11-PHC: an international focus group study, Family Practice, Volume 30, Issue 1, February 2013, Pages 76–87, https://doi.org/10.1093/fampra/cms037

6 MASTER PROTOCOL Depression, Anxiety and Somatic Symptoms in Global Primary Care Settings: A Field Study for the ICD-11-PHC Version 2 for WHO Research Ethics Review Committee.
http://www.psychiatryresearchtrust.co.uk/protocols/WorldHealth14.pdf[/SIZE]

7 Fortes, Sandra, Ziebold, Carolina, Reed, Geoffrey M, Robles-Garcia, Rebeca, Campos, Monica R, Reisdorfer, Emilene, Prado, Ricardo, Goldberg, David, Gask, Linda, & Mari, Jair J.. (2019). Studying ICD-11 Primary Health Care bodily stress syndrome in Brazil: do many functional disorders represent just one syndrome? Brazilian Journal of Psychiatry, 41(1), 15-21. Epub October 11, 2018.
Html: https://dx.doi.org/10.1590/1516-4446-2018-0003
PDF: http://www.scielo.br/pdf/rbp/v41n1/1516-4446-rbp-1516444620180003.pdf

8 Presentation: Rosendale, M (2017). MUS becomes Bodily Stress Syndrome in the ICD-11 for primary care



Resources:

Comparison of Classification and Terminology Systems, Chapman & Dimmock, July 2018

Comparison of SSD, BDD, BDS, BSS in classification systems, Chapman & Dimmock, July 2018

[Ends]

 

Too bad this is always skipped and never actually happens as indicated. It's literally impossible with available tools and techniques to make that distinction. May as well rely on the confirmation of a unanimous decision from a panel of fairies for all that this description matters.

And who determines distress? It's an extreme state: "extreme anxiety, sorrow, or pain". You can't test for that either and indistinguishable from any serious health problems.

Amateurs. Fools and amateurs.