2nd November, 2010

Seminar on ICD-10: An Overview

LOGO :: Speaker ::
Dr. Santanu Ghosh
Postgraduate Student

:: Moderator ::
Dr. J. N. Das
Assistant Professor

Department of Psychiatry, Assam Medical College

1
 Layout of Presentation

• Introduction
• What is classification?
• Purpose of classification
• International classification criteria
• Problems of classification
• Evolution of ICD
• The basic structures & Principles of ICD
• ICD Multi-axial presentation
• ICD vs. DSM
• Problems with ICD 10
• Selected categories in the ICD-10
• Controversy regarding few sections
• Other versions of ICD 10
• ICD 11
• Conclusion
• Bibliography
2
 Introduction

The International Statistical Classification of Diseases and Related

Health Problems 10th Revision (ICD-10) is a coding of diseases and
signs, symptoms, abnormal findings, complaints, social circumstances
and external causes of injury or diseases, as classified by the WHO.
The code set allows more than 14,400 different codes and permits the
tracking of many new diagnoses. As of October 1998, W.H.O. had
authorized the publication of ICD-10 versions in 37 languages, with 30
countries having implemented ICD-10 for mortality and/or morbidity
applications
3
 What is Classification ???

Classification is a method of grouping of items

scientifically according to purpose and codifying them with

numerical (or alpha-numerical) identification according to

certain principles

4
Purpose Of Classification

Communication

• It enables users to communicate with each other about the disorders

with which they deal.

• This involves using names of categories as standard shorthand

ways of summarizing a great deal of information.

• When indicating that an individual has a particular disorder, this

confers information about the cluster of clinical features that the
individual is experiencing without listing all of the specific features
that together constitute the disorder.

5
 PURPOSES OF CLASSIFICATION contd…

Control
• It primarily refers to the prevention of their occurrence or the
modification of their course with treatment

• It refers to knowledge of the course of a condition, as this too is often

important in clinical management

Comprehension
• comprehension or understanding of the causes of mental disorders
and the processes involved in their development and maintenance

• usually leads to more effective treatment and prevention (i.e., better

control)

6
Criteria for International Classification :

BASIC ATTRIBUTES:

• It deals with a defined universe.

• It is designed for a specific purpose, which determines its scheme

of organization.

• It groups the objects, using as few groups as consistent with its

purpose. In public health and epidemiology, classifications are
designed primarily for compilation of statistics.

• It uses a schema that depends on the logic of its author

• It must accommodate all the objects in its universe and as a result

always has one or more categories termed other, which are often
called wastebasket categories. 7
Types of classification approaches

Categorical vs. dimensional

Descriptive vs. etiological

Syndrome vs. symptom

8
Criteria for good psychiatric classification

• Reliability: How far errors of measurement have been excluded

from assessment

• Validity: Actuality measures what it is supposed to measure

• Utility: Use, decision making process & clinical outcome

• Ease of use

• Applicability across settings & cultures

• Meet the needs of various user 9

Problems unique to of classifying Psychiatric
disorders
• Patient’s own subjective report of symptoms & the doctor’s
observation of patient behavior to arrive at a diagnosis

• Psychiatry lacks objective & independent criteria for sorting out

Psychiatric disorder

• Difficult to define normal human behavior

• Psychiatric symptoms are highly nonspecific & quite unstable over

time

10
Evolution of ICD

11
ICD-10: Development

 Work on the Tenth Revision of the ICD started in September 1983

when a Preparatory Meeting on ICD-10 was convened in Geneva.
 The programme of work was guided by regular meetings of Heads
of WHO Collaborating Centers for Classification of Diseases.
 Policy guidance was provided by a number of special meetings
including those of the Expert Committee on the International
Classification of Diseases
 Meeting for Tenth Revision was held in 1984 and 1987.
12
 Historical background

1853
●
● Brussels: First International Statistical Congress requested
William Farr (UK) & Marc d’Espine (Geneva) to
prepare “a uniform nomenclature of causes of death…”

William Farr: five groups: epidemic, constitutional, local

1855
●
●

developmental diseases and diseases due to violence

●
● D’Espine: divided based on nature of diseases.
●
● Adoption of compromise list of 138 categories

1864, 1874, 1880, ●

Revisions by Jacques Bertillon on the basis of
13
Farr’s classification in The International
Historical background contd…

Chicago: The Bertillon’s Classification of Causes of

1893
●

Death  Generalized diseases and Localized

diseases

1899 Recommendation to use the

●

classification for all statistical purposes

●
Paris: First international conference for revisions of
the International
14 Classification of Causes of
Historical background contd…

• ICD-2
1910

• ICD-3
1920

• ICD-4
1929

• ICD-5: Contained 200 titles, along with an intermediate

1938 list of 87 titles, and an abridged list of 44 titles.

15
 Historical background contd…

• ICD-6
• Renamed “Manual of the International Classification of
Diseases, Injuries, and causes of Death”.
• Jointly published by WHO, International Statistical Institute
1948 • Mental Disorders first included:10 psychosis, 9 psychoneurosis, 7
disorders of character, behavior & intelligence.
• Not accepted worldwide

• ICD-7
1955
• ICD-8
• with supplement on brief descriptions of the categories of Chapter V
1968
• In the 7th and 8th revision: basic structure maintained as ICD-6.
16
Historical background contd…

●
ICD-9
●
Emphasis on psychiatric illnesses
●
30 categories (290-319)
●
provisions to further sub classify using 4th or
fifth digit
●
Two additional segments introduced :
1975 ●
The ICD ‘family’ of classifications,
●
Classification of impairments and handicaps
●

●
Brief descriptions of the categories of
Chapter V within text.
●
First use of dagger (†) and asterisk (*) marks

17
Historical background contd…

●
ICD-10
●
8 Collaborating centers
worldwide
●
Effort coordinated by WHO unit
1979 but published in 1992
on Development of
Epidemiological and Health
statistical services.
●
Name changed to International
Classification of Diseases and
related health problems
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Revision of International List of Causes of Death

 In this conference held in Paris on 21 August 1900 adopted a

resolution for a detailed classification of causes of death consisting of
179 groups and an shortened classification of 35 groups.

 The First World Health Assembly was held in 1948 and endorsed the
Sixth Decennial Revision Conference marked the beginning of a new
era in international vital and health statistics. It recommended the
adoption of a comprehensive programme of international cooperation
in the field of vital and health statistics.
19
 ICD Revision Process

 Drafting

 Taxonomic Guidelines
 Definition, Diagnosis and Indexing / mapping guidelines

 Overall Structure
 Individual Chapters
 Overseeing the TOTAL ICD
• ALPHA Draft – structured comments
• BETA Draft – field testing

 Final Draft
World Health Assembly Approval
21
Why the long interval for ICD-11

Jablensky & Kendell proposed reasons:

• Frequent revision may undermine assimilation by clinicians, hamper

progress of research & damage credibility of our discipline

• Possibility of major research breakthroughs that may have significant

impact on nosology

• Satisfaction with performance of current systems

22
LANGUAGE VERSIONS of ICD-10

ICD-10 is available in the six official languages of WHO (Arabic,

Chinese, English, French, Russian and Spanish) as well as in 31 other

languages.

23
The basic structures & Principles

24
Structure of an ICD 10 code

• F20.00 Paranoid schizophrenia continuous course

• Mental and Behavioral disorder
2= Section of Schizophrenia & related disorder
0 = Schizophrenia
.0= Paranoid type
0 = Continuous course
5, 6th character – for specific purpose/research
“U” codes – unused codes
Addition of signs/symbols ( ), [ ], † , *, -
 Structure of ICD code

Identifies mental disorder Indicates type of course

chapter = Continuous

F 2 0 . 0 0

Section of Schizophrenia Indicates type of

& related disorder schizophrenia= Paranoid

Schizophrenia

26
 Volumes:

Volume 1 :
 Introduction
 Tabular list
 Morphology of neoplasms
 Special tabulation lists for mortality and morbidity
 Definitions
 Regulations

Volume 2 :
 Instruction manual

Volume 3 :
 Alphabetical indexes
27
 Chapters:
• Divided in to 21 chapters

• The first character of ICD code is a letter which is associated with a

particular chapter except for the letter
- D : used in both chapter II & III
- H : used in both chapter VII & VIII

• Four chapters use more than one letter (I,II, XIX & XX) in the first
position of their code

• Each chapter contains sufficient three- character categories to cover

its content

• All available codes were not used allowing space for future revision
& expansion 28
ICD 10 : Composition Of Chapters

Chapter number an designation Range of codes

I Certain infectious and parasitic diseases

II Neoplasms A00-B99
C00-D48
III Disease of the blood and blood forming organs and certain
D50-D89
disorders involving the immune mechanism
IV Endocrine, nutritional and metabolic diseases
E00-E90
V Mental and behavioral disorders F00-F99
VI Diseases of the nervous system G00-G99
VII Diseases of the eye and adnexa H00-H59
VIII Diseases of the ear and mastoid process H60-H95
IX Diseases of the circulatory system I00-I99
X Diseases of the respiratory system J00-J99
ICD 10 : COMPOSITION OF CHAPTERS contd…

Chapter number an designation Range of codes

XI Diseases of the digestive system K00-K93

XII Disease of the skin and subcutaneous tissue L00-L99
XIII Diseases of the musculo-skeletal system and M00-M99
connective tissue
XIV Disease of the genito-urinary system N00-N99
XV Pregnancy, childbirth and the puerperium O00-O99
XVI Certain conditions originating in the perinatal P00-P95
period
XVII Congenital malformations, deformations, and Q00-Q99
chromosomal abnormalities
ICD 10 : COMPOSITION OF CHAPTERS contd…

Chapter number and designation Range of codes

XVIII Symptoms, signs and abnormal clinical R00-R99

and laboratory findings, not elsewhere
classified

XIX Injury, poisoning and certain other S00-T98

consequences of external causes

XX External causes of morbidity and mortality

V01-Y98

XXI Factors influencing health status and

Z00-Z98
contact with health services
chapter xxi factors influencing health status and contact
with health services

Persons with potential health hazards related to socio economic

circumstances (Z55-Z65)

 Z55 Problems related to education and literacy

 Z55.3 Under achievement in school
 Z56 Problems related to employment and unemployment
 Z56.2 Threat of job loss
 Z60 Problems related to social environment
 Z60.3 Acculturation difficulty
 Z65 Problems related to other psychological circumstances
 Z65.4 Victim of crime and terrorism (Includes victim of torture)
 Contents of Chapter V

o Introduction
o Notes on selected categories

o List of categories (Including subcategories)

o Clinical descriptions and diagnostic guidelines
o Annexure : other conditions associated with mental and
behavioral disorders

33
Major Categories of Mental and Behavioral
Disorders in ICD-10

 F00-F09 Organic disorders

 F10-F19 Psychoactive substance use disorders
 F20-F29 Schizophrenia and other psychotic disorders

 F30-F39 Mood [affective] disorders

 F40-F49 Neurotic and stress-related disorders
 F50-F59 Physiological function disorders
 F60-F69 Adult personality disorders
 F70-F79 Mental retardation
 F80-F89 Psychological developmental disorders of childhood
 F90-F99 Behavioral and emotional disorders of childhood and adolescence

34
 Blocks of categories:
• Chapters subdivided in to homogeneous block of three categories

• Chapter:1- block title- two axes of classification: mode of transmission & infecting
organisms

• Chapter:2- the axis is behavior of neoplasm

• It uses either three or four character categories

• Supplementary subdivisions for the use of fifth & subsequent character level: found
in
Chap XIII: subdivisions of anatomical site
Chap XIX: open & closed #, intracranial, intrathoracic & intrabdominal injuries
Chap XX: type of activity being undertaken at the time of event

• The unused U code: U00- U49 for the new disease of uncertain etiology

35
 Additional nomenclature
 The Dagger (†) and the Asterix (*):
 †/* Dagger and asterisk used to designate the etiology code and the
manifestation code respectively, for terms subject to dual classification
 # Attached to certain terms in the list of sites under "Neoplasm" to refer the
coder to Notes 2 and 3, respectively, at the start of that list
 † indicates : primary disorder code and the supplementary code to which it may
be assigned is marked with an *
 For statistical reporting usually codes with † marks used
 ICD-10 allows dual diagnosis. 83 asterix categories at the 3-character level

36
 Additional nomenclature contd…

 NOS = Not otherwise specified.

 NEC = Not elsewhere classified

 Added after terms classified to residual or unspecific categories

 Terms in themselves ill defined as a warning that specified forms of the

conditions are classified differently.

 If the medical record includes more precise information the coding should be
modified accordingly
 Provisional : for future information which is yet to be added
 Tentative : if further chance of information is unlikely

37
 Multi-axial presentation

 Published in 1997
 Comprises of three axes:
Axis I : Clinical diagnosis
Axis II : Disability
Axis III : Contextual factors

38
Multi-axial presentation for Children and
Adolescent
 Published in 1996.
 It comprises of six axes:
 Axis I : Clinical Psychiatric Syndrome.
 Axis II : Specific disorders of psychological development.
 Axis III : Intellectual level.
 Axis IV : Medical conditions.
 Axis V : Associated abnormal psychosocial situations.
 Axis VI : Global assessment of psychosocial disability

39
Integrate ICD & DSM

 Research version of ICD & primary care version of DSM are hardly
used.

 Best option - drop them

 This would have helped in integration of DSM & ICD.

 Ideal situation- one international classification

 It is early in the process, with critical decisions on most issues yet to

be determined.

40
 ICD-10 vs. DSM IV

ICD-10 DSM-IV

International classification National classification

Several versions and languages Single version & language

Alphanumerical coding Numerical coding

10 major categories 17 major categories

It includes disorders of all medical Only mental disorders
specialties
Multi axial presentation: 3 axes(adult) Multi axial presentation: 5
: 6 axes axes
(children)

41
Problem encountered with ICD-10

• Developmental aspects not given due importance

• Gaps in classification
• Death of phenomenology
• Difficulty of use in diverse populations & settings

42
Selected categories in the ICD-10

43
F00 – F09: Organic, including symptomatic mental
disorders

o All disorders having an organic etiology are grouped in this

section.

o Dementia: duration 6 months added.

o F08 remains unassigned.

o Further classification in four character level can be specified

in most of the disorders

44
F20 – F29: Schizophrenia, Schizotypal and Delusional
Disorders

o Main contents of this subchapter are Schizophrenia, Acute and transient

psychotic disorders, Schizoaffective disorders, delusional disorders, and other
non-organic psychotic disorders.
o Schizophrenia  1 month duration unlike DSM IV.
 4th character  subtypes
 5th character  course specifier
o Acute and transient psychotic disorder

 4th character  subtypes

 5th character  with/ without stress
o F26 and F27 are unassigned.
45
 F20 – F29 (Contd..)

Simple schizophrenia (F20.6)

 Retained because of its continued use
 because of the uncertainty about its nature and its relationships to
schizoid personality

Schizoaffective disorders (F25.-)

 Controversy exists whether it is related to mood disorders other
psychosis or third psychosis. The final decision after field trial is
to keep under F20-F29

46
F30 – F39: Mood (affective) disorders

 F35 – F37  unassigned.

 All mood disorders are combined in this subchapter.

 Neurotic Depression (ICD-9) omitted.

 Recurrent manic  Bipolar Disorders.

47
F40 – F48: Neurotic, Stress related and somatoform Disorders

 Term “neurosis” used

 No differentiation between Dissociative states and conversion

 The term “hysteria” is dropped
 Mixed anxiety and depressive disorder retained

 Disorders are subdivided into a large number of categories. e.g.

Dissociative disorders have 7 subcategories.
 Somatoform disorders : New category introduced
 Neurasthenia is retained

48
F50 – F59: Behavioral Syndromes associated with
physiological disturbances and physical factors

 Contains eating disorders, non-organic sleep disorders, sexual dysfunction,

and abuse of non-dependence producing substances.

 Disorders associated with puerperium should be used only when cannot

classified elsewhere

 Psychosomatic disorders (F54) used for somatic diagnosis.

 Gender identity disorders and disorders of sexual preferences are not

included in this section.

 Culture-specific disorders were included

49
F60 – F69: Disorders of adult personality and
behavior

 Include a variety of severe problems, whose solution requires information

that can come only from extensive and time-consuming investigations.
 Borderline personality disorder (F60.31) is a subcategory of emotionally
unstable personality disorder (F60.3)
 Specific personality disorders except Cyclothymic personality disorder are
included here.
 Factitious disorders, Enduring personality changes after catastrophic
experience / psychiatric illness (F62) are new addition.

50
F70 – F79: Mental Retardation

 Describes mental retardation classification according to severity

 Fourth character : degree of impairment of behaviour.

 F74 - F77 : unassigned.

51
F80 – F89: Disorders of psychological development

 24 disorders : onset specific to childhood.

 The major disorders include Specific developmental disorders of

speech and language, Disorders of scholastic skills, Dysfunction of
motor function and PDD.

 Oppositional Defiant Disorder : new category introduced

 Rette and Asperger disorders are included.

 F85 to F87 remain unassigned.

52
F90-F98: Behavioural and emotional disorders with
onset usually occurring in childhood and
adolescence

 Many important disorders are described in this block

 Hyperkinetic disorders, Conduct disorders, Attachment disorders ,

Elective mutism, Tic disorders and Tourette's syndrome, Nonorganic

enuresis, Nonorganic encopresis, Feeding disorder etc.

53
Unspecified mental disorder (F99)

 Last category : F99

 Left for "unspecified mental disorder" when required.

54
 Controversy
regarding few sections

55
 OCD Spectrum Disorders

 OCD is currently conceptualized as an anxiety disorder.

 Many disorders have similar phenomenology and psychobiology,
and sometimes respond to similar treatments, raise the question of
whether to create a new category of OCD spectrum disorders in
DSM-V and ICD-11.
 The construct of an OCD spectrum has significant heuristic appeal,
in sofar as it encourages clinicians to screen for a range of neglected
disorders, and to consider the use of potentially effective treatments
that are also often ignored.
56
 OCD Spectrum Disorders

 There is a good deal of evidence that OCD is characterized by

disruptions in striatally and serotonergically mediated control
processes.

 Such a view can potentially integrate a range of findings about

compulsive and impulsive phenomena in OCD and related disorders,
as well as about their underlying neurobiology.

 In OCD, one cluster of co-morbid OC spectrum disorders comprises

intermittent explosive disorder, kleptomanias, eating disorders, and
stereotypic self-injurious behaviours.

 In this view, compulsivity and impulsivity are not diametrically

opposed, but rather may lie on orthogonal planes.

57
OCD Spectrum Disorders

 Future work of cognitive-affective processes relevant to OCD may

ultimately result in a reconfiguration of the way in which we
currently view the OCD spectrum of disorders.

 There is currently a good deal of excitement about advances in

understanding reward processes, and the possibility that these may
ultimately lead to a better way of conceptualizing and treatment of
these conditions.

58
Schizophrenia & other Psychotic Disorders

 The use of endophenotypes with specific neurocognitive,

neurophysiological or neuroanatomical foundations as a more useful
way of categorizing psychotic disorders than the current clinical
classifications.

 The genetic deconstruction of psychosis: broadening the phenotype of

schizophrenia to include most non-affective psychotic disorders better
fits genetic factors than more restrictive phenotypes.

 The addition of a class to capture cases in prodromal phases will

surely be an interesting challenge.

59
Other versions of ICD 10

60
 Other versions of ICD10

 ICD-10-DCR: Diagnostic Criteria for Research

 Published in 1996.
 Strict criteria suitable for research.
 Derived from Chapter V of ICD 10.
 Text contain General criteria ‘G’, Obligatory criteria A, B, C…., and non-essential
criteria a, b, c…. or 1, 2, 3
 Exclusion criteria provided to clarify.
 Psychosocial dysfunction are included as diagnostic criteria only if unavoidable e.g.
childhood disorders or personality disorders

61
 Other versions of ICD10 contd…

 Diagnostic and Management guidelines for mental disorders in

primary care:

 Suitable for busy PHC doctors.

 Corresponding codes for international report

 Only 24 categories without any subdivision

 Flow charts and educational materials

62
 ICD-10 Primary Health Care List of
Categories
Organic Disorders (F0)
Dementia F00
Delirium F05 Physiological disorders (F5)
Psychoactive substance abuse (F1) Eating disorders F50
Alcohol use disorders F10 Sexual disorders F52
Drug use disorders F11 Sleep Problems F51
Tobacco use disorders F17.1 Mental retardation (F7)
Psychotic disorders (F2)
Mental retardation F70
Acute psychotic disorders F23
Childhood and adolescence (F9)
Chronic psychotic disorders F20
Mood, stress-related, and anxiety
Hyperkinetic disorder F90
disorders (F3 and F4) Conduct disorders of childhood F91
Bipolar disorder F31 Enuresis F98
Depression F32
Phobic disorders F40
Panic disorders F41.0
Generalized anxiety F41.1
Mixed anxiety and depression F41.2
Adjustment disorder F43
Dissociative (conversion) disorders F44
Unexplained somatic complaints F45
Neurasthenia F48.0

63
 Other versions of ICD10 contd…

 ICD-10-CM : Clinical modification of the WHO’s ICD-10,

which consists of a diagnostic system

 Consists of three to seven characters

 First digit is alpha
 All letters used except U
 Second and third digits are numeric
 Fourth, fifth, sixth, and seventh digits can be alpha or numeric
 Decimal placed after the first three characters

64
ICD-11

65
ICD-11 Revision

Goals
 Evolve an ontologically coherent classification
 Linked logically to underpinning terminologies
 Rubrics “defined” by aggregation logics
 Explicit language definitions
 Incorporate genomic disease definitions
 Longitudinal consistency

66
 ICD-11

The WHO is undergoing the 11th revision of the International Classification of

Diseases! This development of international health information standards is in
accordance with its constitution.

Mission:
To produce an international disease classification that is ready for electronic health
records that will serve as a standard for scientific comparability and communication.
Deliverables:
ICD-11 alpha draft process began September 2009
ICD-11 beta draft process will begin in 2011
ICD final draft will be submitted to WHA by 2014
67
Future proposals:

ICD-11 is supposed to incorporate major paradigm shift in the

thinking related to classification.

o It will be more etiology based.

o It will incorporate more developmental and life cycle issues.
o Personality disorder and relational disorder will come to axis-I.

o Obsession will include spectrum disorder.

o Some change in Schizophrenia & Other Psychotic Disorders may
come.

68
Future proposals contd…

o Child psychiatry section will be reorganized.

o Somatoform disorder will become somatic symptom disorder.
o Understanding of sexual dysfunction will improve.
o Dimensional issues will be included to assist categorical classification
system.
o Issues related to sub threshold psychiatry will retain its place.

69
 Conclusion

Jasper was prophetic when he remarked, “ When we design a

diagnostic schema, we can only do so if we forego something at the
outset ... And in the face of facts we have to draw the line where none
exists …A classification has only provisional value. It is a fiction which
will discharge its function if it proves to be the most appropriate for the
time”. His words hold true even today and will continue to do so for all
subsequent classification in the future.

70
 Bibliography
 Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 8th Edition ,
2005,p1004-13

 The International Statistical Classification of Diseases and related Health

problems:1992: Tenth Revision; Vol: I – III

 The ICD-10 Classification of Mental and Behavioural Disorders; First Indian

Edition 2004 Diagnostic Criteria for Research

 The ICD-10 Classification of Mental and Behavioural Disorders: Clinical

Descriptions and Diagnostic Guidelines. 2002
 N. Sartorius; Understanding the ICD-10 Clasification of Mental Disorders, A
Pocket Manual; 2nd edition, 2002
 www.wikipedia.org
 www.indianpsychiatryj.org 71
Thank you

72