SYMPOSIUM

NOSOLOGICAL ISSUES IN
RELATION TO
ICD 11

Dr. Amit Arya

Associate professor

Dr. Suyash
Junior Resident-III

DEPARTMENT OF PSYCHIATRY
KING GEORGE’S MEDICAL UNIVERSITY
LUCKNOW
 ICD- purpose and uses

 ICD is global standard and international public tool to

organize and classify information about health conditions.
 ICD defines the universe of diseases, disorders, injuries
and other related health conditions, listed in a
comprehensive, hierarchical fashion which allow us for
storage, retrieval and analysis for evidence based
decision making.
 It’s a language of communication across countries
 Provides standard for all clinical and research purpose.

Systematic recording, analysis, interpretation and comparison of mortality

and morbidity data collected in different countries and at different time
History of ICD

2018
Interval period of ICD revisions

28

15

1990 2018
What was lacking in ICD 10

 ICD 10 is a major change from ICD 9 but it

 Does not fully map on the neurobiology

 Does not given due importance Developmental

aspects

 Leads to so called “Death of phenomenology”

 ICD 11 : A STEP AHEAD

 updated for the 21st century

and reflects critical advances
in science and medicine.
 well integrated with electronic
health applications and
information systems.
 produced through a
transparent, collaborative
manner, the scope of which is
unprecedented
The International Classification of Diseases #ICD11 is now available
World Health Organization (WHO) Jun 18
Better health data means better # Health For All.
 WHO news release. JULY 21, 2018. Post #338 Shortlink: https://wp.me/pKrrB-4ni
The World Health Organization (WHO) released the next edition of the
International Classification of Diseases (ICD-11) on June 18.

This release is an advance preview

that will allow countries to plan how
to use the new version

We have to wait !
What is new in ICD 11?
The Foundation Component and the
Tabular Lists

 The Foundation Component is a multidimensional collection of all

ICD entities.
 Underlying data base content that holds all necessary information
to generate print versions of the tabular list
 contains also the necessary information to use the entities to build
a tabular list - a mono hierarchy in the style of a traditional
statistical classification
 Different tabular lists can be built
 The core tabular lists for international use are:
– Mortality and Morbidity Statistics (MMS)
– Primary care low resources settings (PCL)
– Primary care intermediate resources setting (PCM)
– Verbal Autopsy (VA)
– Simple Mortality List (SMoL)
 Linearization and Multiple parenting
Fit for a particular
purpose

represents the
entire universe
of ICD.
In a simple way,
the foundation
component
is similar to a
“store” of books
or songs

Entities can have more than one “parent” in the foundation component,
but only one “parent” in each linearization. Eg: lung cancer can be classified by site or by
etiology → it can be classified as a condition of the respiratory system and also as a
cancer under malignant neoplasms.
CODING SCHEME ICD 11

 The Chapter numbering is in Arabic numbers and not in Roman

numerals as before
 Categories have now 4 characters and there are 2 additional levels of
subcategories
 Codes have now a letter in the second position to differentiate them
from the codes in ICD-10
 When describing a casual relationship between conditions in a code title
the preferred term is 'due to'
 When describing the concurrence of two conditions in a code title the
preferred term is 'associated with'
 The terminal letter ‘Y’ is reserved for the residual category ‘other
specified’ (ICD 10 - .8)
 the terminal letter ‘Z’ is reserved for the residual category‘unspecified’
(ICD 10- .9)
Stem codes and Extension codes

Eg:
Neurodevelopmental
disorders

6A00 Disorders of
intellectual development

6A00.0 Disorder of
intellectual development,
mild

6A00.1 Disorder of
intellectual development,
moderate
New Methods of clustering

 Pre- and Post-Coordination, Cluster

 Stem codes hold all pertinent information in a pre-
combined fashion or pre-coordinated way,
 while when additional detail that refers to a single
condition is described by combining multiple codes,
this is called post-coordination.
 Cluster coding is the mechanism that shows which
codes are post-coordinated.
Sanctioning rules

 The use of multiple codes (post-coordination) risks the creation of

meaningless expressions that combine stem codes with
inappropriate qualifiers.
 To prevent that from happening, "sanctioning rules" that define
legal combinations is done by crowdsourcing method.
 SNOMED CT (Systematized Nomenclature of Medicine - Clinical
Terms), is the most comprehensive, multi-lingual medical
terminology in the world. It is emerging as the standard clinical
terminology for use in the Electronic Health Record (EHR).
New Chapters in ICD 11

 Chapter 3: Diseases of blood and blood forming

Organs.
 Chapter 4: Disorder of immune system.
 Chapter 5: Conditions related to sexual health.
 Chapter 8: Sleep-wake disorder.
 Chapter 25: Code for special purpose.
 Chapter 26: Traditional Medicine condition.
 V: Supplementary section for functioning assessment
 X: Extension Codes
Chapter 26: Traditional Medicine
condition

 Mental and emotional disorders (TM1)

 SD80 Lily disorder (TM1)
 SD81 Manic disorder (TM1)
 SD82 Depression disorder (TM1)
 SD83 Uneasiness disorder (TM1)
 SD84 Insomnia disorder (TM1)
 SD85 Somnolence disorder (TM1)
 SD86 Dementia disorder (TM1)
 SD87 Repressed fire disorder (TM1)
 SD8Y Other specified mental and emotional disorders (TM1)
 SD8Z Mental and emotional disorders (TM1), unspecified
ICD 11 : WHATS IN STORE FOR US?
06 Mental, behavioural or neurodevelopmental
disorders

 Neurodevelopmental disorders
 Schizophrenia or other primary psychotic disorders
 Catatonia
 Mood disorders
 Anxiety or fear-related disorders
 Obsessive-compulsive or related disorders
 Disorders specifically associated with stress
 Dissociative disorders
 Feeding or eating disorders
 Elimination disorders
 Disorders of bodily distress or bodily experience
 Disorders due to substance use or addictive behaviours
 Impulse control disorders
 Disruptive behaviour or dissocial disorders
 Personality disorders and related traits
 Paraphilic disorders
 Factitious disorders
 Neurocognitive disorders
 Mental or behavioural disorders associated with pregnancy, childbirth and the puerperium
6A00 Neurodevelopmental Disorders

 Disorder of Intellectual development (ICD 10- MR)

 Developmental speech or language disorders
 Developmental learning
 Stereotyped movement
 ADHD included here (ICD 10 - Hyperkinetic disorder)
 ASD (ICD 10 – Pervasive Developmental Disorder)
 Tic disorder coded in disorder of nervous system(08)
6A20 Schizophrenia, psychotic
disorders and 6A40 Catatonia

 Subtypes of schizophrenia removed Postcoordination

Code:
 Supplementary or additional codes for 6A20.00/6A25.5&XS25
6A20.00 Schizophrenia, first
episode, currently
symptomatic manifestations symptomatic
Has manifestation
 Acute and transient psychotic 6A25.5 Cognitive symptoms
in primary psychotic disorders
disorder(6A23) multiple episodes remove postcoordination
value
 ( No provision for recurrent psychosis in Has severity
XS25 Severe
XS5W
10th) Mild
XS0T
 Catatonia given a separate category Moderate
XS25
Severe
6A60 Mood disorders

 Bipolartype I and II separate

 Cyclothymia under bipolar and related disorder
 Dysthymia under depressive disorders

(ICD 10- both under persistent mood disorders)

 Moderate depression with psychotic symptoms
 Supplementary codes for symptomatic and course
presentations for mood episodes
 Premenstrual dysphoric disorder is now in disease of
genitourinary system (GA34.41)
6B00 Anxiety/fear-related
6B20 Obsessive-compulsive and related
disorders

 Separation anxiety disorder and Selective Mutism are

sifted (ICD-10 – F93 emotional disorder with onset in
childhood)

 OCD sub classified in term of insight

 Body dysmorphic disorder, Olfactory reference
disorder, Hypochondriasis, Hoarding disorder
and Body-focused repetitive behaviour disorders
(Trichotillomania, Excoriation disorder) given as
separate categories under OC and related disorders
6B Disorders specifically associated
with stress

 PTSD and Complex PTSD (affect

regulation; beliefs about oneself as
diminished, defeated or worthless,
shame, guilt or failure, difficulties in
sustaining relationships)
 Acute stress reaction removed
 Prolonged grief disorder separate
from Adjustment disorder
 Reactive attachment disorder and
Disinhibited social engagement
disorder included
6B Dissociative disorders

 Dissociative neurological symptom disorder

 Depersonalization-Derealization disorder

 Dissociative identity and partial identity

 Trance and Possession trance separate

 Dissociative fugue and stupor removed

6B Feeding or eating disorders

 Anorexia Nervosa classified as per body weight

 Binge eating disorder included
 Avoidant-restrictive food intake disorder- abnormal eating or
feeding behaviours that result in the intake of an insufficient quantity or variety of
food to meet adequate energy or nutritional requirements.

 Pica

 Rumination-regurgitation disorder
 Vomiting associated with other psychological disturbance removed
6C Disorders of bodily distress or
bodily experience

 Bodily distress disorder

 Body integrity dysphoria (intense and persistent desire to

become physically disabled in a significant way). There was
debate about including it in the DSM-5 and it was not included

 Replaces all of ICD‐10 categories within the group

of somatoform disorders (Hypochondriasis excluded)
and neurotic disorder, Neurasthenia
6C Disorders due to substance use or
addictive behaviours

 New categories to include newer psychoactive

substances
 Stimulants including amphetamines,
methamphetamine or methcathinone
 Synthetic cathinones ("bath salts," are human-made
stimulants)
 MDMA or related drugs, including MDA
 Dissociative drugs including ketamine and
phencyclidine [PCP]
6C Disorders due to substance use or
addictive behaviours

 Gambling disorder included here (ICD 10 -impulse

control disorder)

 Gaming disorder : a new entity

6C Impulse control disorders

 Compulsive sexual behaviour disorder added

 Intermittent explosive disorder as separate category
 Gambling and trichotillomania (ICD 11- body
focussed repetitive behaviour) removed
6D Personality disorders and related
traits

 Subtypeas per severity (mild, moderate and severe)

Post coordination as per traits and pattern
6D Paraphilic disorders and Factitious
disorders

 Fetishism and Fetishistic transvestism removed

 Other paraphilic disorder involving non-consenting
individuals
 Paraphilic disorder involving solitary behaviour or
consenting individuals

 Factitious disorder imposed on self

 Factitious disorder imposed on another
Mental or behavioural disorders associated with
pregnancy, childbirth and the puerperium

 Classified on the basis of presence or absence of

psychotic symptoms
 ICD 10 – mild and severe
 Post coordination with causing conditions
Has causing condition
 6E62 Secondary mood syndrome
 Bipolar or related disorders
 Depressive disorders
 Substance-induced mood disorders
 6B43 Adjustment disorder
21 MB 21-29 Symptoms, signs or clinical
findings, not elsewhere classified

 Mental or behavioural symptoms, signs or clinical

findings
 MB20 Symptoms, signs or clinical findings involving
consciousness
 MB21 Symptoms, signs or clinical findings involving
cognition
 MB22 Symptoms or signs involving motivation or
energy
 MB23 Symptoms or signs involving appearance or
behaviour
ICD – 11 : WHAT WE LOSE

 Sleep-wake disorders a separate chapter (07)

 Conditions related to sexual health – separate
chapter (17)
 Gender incongruence included above
ICD 11 : how it affects us

 Ease of electronic record keeping

 Integration with SNOMED

 International multilingual reference

 More exhaustive

 Ease across different specialities

 ICD 11 : Verdict ?

 New era of classification after a long and detailed

process of its development

 More comprehensive use by clinicians is required for

its clinical implications

 Welcome change as well as a fresh challenge

Dr Lubna Alansari, WHO’s Assistant Director-General for Health Metrics and

Measurement, says: “ICD is a cornerstone of health information and ICD-11 will deliver
an up-to-date view of the patterns of disease.”