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On Monday World Organization Public Health published the eleventh edition of the International Classification of Diseases (ICD-11). It included 55 thousand diseases, injuries and disorders, including gambling addiction. There is also a section traditional medicine.
The International Classification of Diseases (ICD) is now used in more than 100 countries and has been translated into 43 languages. It allows data to be collated and shared around the world in a consistent and standardized way - across hospitals, regions and countries, and over specific time periods. This is convenient for collecting statistics on mortality and morbidity of the population, as well as for analyzing the prevalence of various diseases. The latest version of the ICD was adopted 27 years ago, in 1990. Now WHO has presented a new, eleventh edition, which has been in the works for more than a decade.
The new version of the ICD became fully electronic for the first time. More than one and a half thousand specialists were involved in its creation. Now the ICD-11 consists of 26 sections, which included a chapter on traditional medicine due to its wide distribution. In addition, there is a chapter on sexual health, which brings together illnesses and disorders that in the past belonged to other categories (for example, gender dysphoria was previously defined as a mental disorder) or described differently. The list of addiction-related disorders included gambling addiction - a pattern of persistent or repetitive behavior when playing online or offline games, which is accompanied by a violation of the control over the game (frequency, duration, and so on), the displacement of other hobbies and daily activities into the background , as well as the need to continue to play (including on the rise), despite the appearance of negative consequences. The disorder can be diagnosed if the individual's behavior entails disturbances in personal, family, social and other areas and has been observed for at least 12 months.
In addition, how the disease began to be defined and a dangerous passion for games (hazardous gaming). It is described as gambling, online or offline, that greatly increases the risk of harmful physical or mental consequences to the person or others. . It was included in the class of factors affecting the state of health of the population and appeals to health care institutions.
According to Vladimir Poznyak, member of the WHO department who proposed the new diagnosis, the organization is trying to follow the trends and innovations that occur both in society and in the professional environment. In his opinion, the inclusion of a gaming disorder in the list of diseases means that medical professionals and systems will be more “aware of the existence of this condition”, and at the same time increases the likelihood that “people who suffer from this disorder can receive appropriate help” .
The ICD-11 will be presented to the World Health Assembly in May 2019 for endorsement by WHO Member States. The new classification will come into force on January 1, 2022.
What WHO intends to include gambling addiction to the list of disorders, back in December 2017. Then the initiative caused a double attitude on the part of experts. While some studies point to positive effects, such as cognitive ability in the elderly, others point to negative effects, such as college students' suicidal tendencies.
Kristina Ulasovich
new international classification diseases (ICD-11). It contains about 55,000 unique codes for injuries, illnesses and causes of death. This classification forms a common language for physicians around the world.
“The ICD is a special pride of the WHO. It allows us to better understand the causes of disease and death, and to take action to prevent suffering and save lives,” says Dr Tedros Adhanom Ghebreyesus, WHO Director-General.
The ICD-11 has been in development for over ten years. Its updated version contains significant improvements over previous versions. For the first time it is presented completely in electronic form and has a much more convenient format. Many healthcare workers took part in its development and presented their proposals at conferences. Overall, the IBC team at WHO headquarters received more than 10,000 proposals to revise certain provisions.
The ICD-11 will be presented to the World Health Assembly in May 2019 for adoption by WHO Member States and will enter into force on 1 January 2022. This version is being published for preview, which should allow participating countries to make their own plans for its use, prepare its translations and train health professionals throughout the country.
The ICD is also used by insurance companies, since the amount of compensation depends on its codes. In addition, the ICD is used by national health program managers; data collectors; and those who track progress in global health and determine the allocation of resources for the health system.
The new version (ICD-11) also reflects advances in medicine and scientific advances. For example, codes related to antimicrobial resistance are more in line with the Global Antimicrobial Resistance Surveillance System (GLASS).
The ICD-11 will also help to better collect data on health safety, which means that it is possible to identify and reduce the impact of some factors that affect health status - for example, potentially some dangerous species organization of work in hospitals.
The new ICD also includes new chapters on traditional medicine: despite the fact that millions of people around the world use traditional medicine, it has not yet been classified in this system. Another one new chapter- about sexual health - combines disorders that were previously classified in other ways (for example, gender incongruity was previously considered a mental disorder) or were described differently. Gambling disorder has been added to the section on addictive disorders.
“A key principle in the revision of the codes was to simplify the coding structure and electronic instrumentation, which will make it easier for health professionals to register disorders,” says Dr. Robert Jakob, Team Leader, WHO Classification Standards and Terminology.
Dr Lubna Alansari, WHO Assistant Director-General for Health System Measurement, says the ICD is the cornerstone of health information and ICD-11 will provide an updated version of the understanding of disease.
Center for Primary Immunodeficiencies in Adults
Primary immunodeficiencies (PID) are genetically determined diseases that lead to disruption of one or more parts of the immune system. Despite the fact that these diseases are associated with the "breakdown" of genes, not all of them manifest themselves from childhood. There are forms of primary immunodeficiency, the debut of which occurs at the age of over 18 years.
The immune system is involved in the implementation of the work of many organs and systems, so the symptoms of PID are diverse. For adults, the most common manifestations are recurrent severe infections of the upper and lower respiratory tract, abscesses of the skin and internal organs, persistent diarrhea, especially with weight loss, an increase in the size of lymphoid organs (lymph nodes and spleen), etc. Due to the low awareness of both patients and doctors about this pathology, the diagnosis is established with a great delay, when complications lead to irreversible changes in organs, reducing the quality and life expectancy of patients. While timely diagnosis and adequate therapy allows you to have a good quality of life, maintain working capacity and have healthy offspring.
PID is not AIDS, this disease is a birth defect and is not dangerous to others.
When should you consider having a PID? If you or your relative has 2 or more of the warning signs of PID, you should contact an immunologist to rule out this disease.
Warning signs of PID in adults:
- 1. Two or more otitis media per year
- 2. Two or more sinusitis per year
- 3. Two pneumonias in 1 year or 1 pneumonia for 2 or more consecutive years
- 4. Chronic diarrhea with weight loss
- 5. Recurrent viral infections(herpes, shingles, warts, warts)
- 6. The need for repeated courses of parenteral antibiotics to achieve infection control
- 7. Antibiotic therapy for 2 or more months with insufficient effect
- 8. Recurrent deep abscesses of the skin and internal organs
- 9. Persistent fungal infection of the skin and mucous membranes
- 10. Infection normally caused by non-pathogenic mycobacteria
- 11. Two or more episodes of severe generalized infection (meningitis, sepsis)
- 12. The presence of PID in relatives
“ICD is a product that WHO is rightly proud of,” said the WHO Director-General
Dr. Tedros Adhanom Ghebreyesus. “It enables us to understand the many reasons why people get sick and die, and to take action to prevent suffering and save lives.”
The ICD-11, which has been in preparation for over ten years, differs from previous versions in a number of important improvements. It is the first time it has been published in fully electronic form and has a much more reader-friendly format. In addition, an unprecedented number of health workers participated in the joint meetings and put forward their proposals as inputs. The ICD Group at WHO Headquarters has received over 10,000 proposals for changes to the Classification.
The ICD-11 will be submitted for adoption by Member States at the World Health Assembly in May 2019 and will enter into force on 1 January 2022. This release is preliminary and exploratory in nature and will allow countries to develop plans for the use new version, prepare its translations and conduct nationwide training for health professionals.
The ICD is also used by health insurance companies, which determine compensation payments based on the ICD codes; national health program managers; data collectors; and everyone who monitors trends in global health and makes decisions about the allocation of resources in this area.
The new ICD-11 reflects the progress in medicine and the achievements of scientific thought. For example, antimicrobial resistance codes are now more in line with the Global Antimicrobial Resistance Surveillance System (GLASS) criteria. ICD-11 also makes it possible to more effectively record health safety data and, accordingly, to identify and prevent undesirable events that may be harmful to health, such as unsafe practices in hospitals.
The new ICD also includes new chapters, in particular on folk (traditional) medicine: although the methods of traditional medicine are used by millions of people around the world, it has not yet been included in this classification system. Another new chapter on sexual health brings together disorders that were previously classified in other categories (for example, gender incongruity was listed in the category of mental disorders) or described differently. Gaming disorder has been added to the Addictive Disorders section.
“A key principle of this revision was to simplify the structure of codes and electronic instruments so that health professionals can more easily and comprehensively record different diseases,” said Dr Robert Jakob, Team Leader, WHO Classifications, Terminology and Standards .
According to Dr. Lubna A. Al-Ansary, assistant Director General on metrics and statistical measurements, "The ICD is the cornerstone of health information, and ICD-11 will provide an updated look at the typology of diseases."
The history of the study of personality and its disorders has about two millennia. The first attempt to find out what predetermines individual differences in people's behavior was made by Hippocrates, and during this time, of course, much has changed.
For more than a hundred years, psychiatry has been using an established paradigm, the foundations of which were laid by Emil Kraepelin. In 1904, he describes 7 types of "psychopathic personality", which were named according to the similarity with the manifestations of major mental disorders: Schizoid - reminiscent of schizophrenia, cycloid - echoes the iconic manifestations of manic-depressive psychosis, and so on. Later, Kurt Schneider develops this idea, voicing one of the main signs of a psychopathic personality: the inability to form and maintain relationships with people. He distinguishes 9 types of personality disorders, based on his extensive clinical practice, and most of them are still present in one form or another in the classifications of disorders to this day.
But any paradigm is sooner or later questioned, and, apparently, with the advent of DSM-5 and ICD-11, the time has come for personality disorders (PD). The latest classifications offer a new approach that eliminates all specific categories of PD except for one: the very fact of having a personality disorder.
Why all this?
Many psychiatrists will ask this question, because the system works. But the developers of the new international classification of diseases do not think so. For example, half of patients who meet the criteria for one personality disorder also show signs of other personality disorders. Part of the PD are too rare, at the same time, a significant cohort of people with serious personality disorders do not fit into the criteria for any of the existing personality disorders. Patients with the same diagnosis can be strikingly different from each other, both in personal qualities and in the severity of their condition. In addition, there is currently a dichotomous division of the population into people with and without PD in the ICD. In fact, there is an intermediate category of “character accentuations”, which, although it was singled out a long time ago, had no place in the classification of diseases before. This makes it impossible for psychiatrists to reliably record subsyndromal changes.
But most main reason so global change is that the ICD-10 and DSM-IV RLs are based primarily on anecdotal clinical experience with little to no evidence-based evidence supporting their existence as discrete categories. The available descriptions of PD ignore the main personality traits that are currently established and have a consistent structure, regardless of the presence or absence of a personality disorder.
Now in order. What to do with it?
Step one.
And the lightest. Because at this stage there are practically no changes. The first step is to determine whether the patient meets the general definition of a personality disorder. In theory new classification this diagnosis can be made by both a psychiatrist and a doctor of the primary network, since the approach to the definition does not have serious differences from the ICD-10. Using the following criteria, without going into categories, the specialist establishes Availability personality disorder:
- the presence of progressive disturbances in how a person thinks and feels about himself, others and the world, which manifests itself in inadequate ways of cognition, behavior, emotional experiences and reactions;
- the identified maladaptive patterns are relatively rigid and are associated with severe problems in psychosocial functioning, which is most noticeable in interpersonal relationships;
- the impairment manifests itself in a variety of interpersonal and social situations (i.e., not limited to specific relationships or situations);
- the disturbance is relatively stable over time and has a long duration. Most often, a personality disorder first manifests itself in childhood and manifests itself clearly in adolescence.
If the disorder is first detected in adulthood, the "late onset" qualifier may be used. This specifier should be used in cases where there is no clear evidence of detectable impairment at an earlier age in history.
It is very important to determine the area of detected violations. Problems in interpersonal interaction in personality disorders are characterized by general disturbances in relationships with people that interfere with mutual understanding. This must be understood, since most mental disorders are somehow related to social dysfunction. Thus, the difficulty in completing tasks, organizing life responsibilities, free time, maintaining adequate relationships at work, as well as the lack of harmony in the family, are very different from the violations associated with the inability to get along with the rest of the population. human race which is exactly what is observed in personality disorders. A person whose life is turned upside down by a family feud does not necessarily have a personality disorder. The diagnosis should only be made if there is clear evidence of widespread deterioration in relationships with everyone around.
Step two: determining the severity of RL.
Currently, personality disorders are an exclusively qualitative category, which often leads to the fact that two patients with the same diagnosis can be strikingly different from each other. ICD-11 offers 3 degrees of severity of personality changes (see tab. 1), each of which may include one or more pathological signs. Severity ranking allows for the fact that although PD is assumed to be a lifelong diagnosis, its severity may change over time.
Tab. 1 The severity of personality disorders in the ICD-11
| Severity | Main characteristics |
| Mild personality disorders | - there are pronounced difficulties in constructing a significant part interpersonal relationships and in fulfilling expected professional and social roles; The ability to perform certain social or professional roles, maintain part of the relationship is preserved; Not associated with causing significant harm to self or others. |
| The average severity of personality disorders | - serious problems are observed in most interpersonal relationships and in the performance of expected professional and social roles; These problems are found in a wide range of situations, most of which are compromised to some extent; Often associated with past and expected future harm to self or others, but NOT to a degree that could result in long-term harm or life threatening. |
| Severe severity of personality disorders | - serious problems in interpersonal functioning, affecting all spheres of life; The general social dysfunction of a person becomes deep, and the ability and / or willingness to perform the expected professional and social roles missing or seriously compromised; Often associated with a history of and expected future infliction of severe harm to oneself or others, to a degree that can lead to long-term damage or threaten life. |
In addition, a subthreshold level of disorder is distinguished, which corresponds to the familiar concept of “personality accentuations” and is designated as “personality difficulty” (complex / difficult personality) (see tab. 2) . “Personality difficulty” will not be a diagnosis, and, in essence, will correspond to the existing Z code in the ICD-10. Registration of accentuations is necessary, since its presence increases the risk of needing medical intervention in certain conditions, for example, under stress or under certain conditions environment. At the same time, it must be understood that some cases of mild personality disorders may not require specialist supervision. According to modern epidemiological estimates, 1 out of 14 people in the population suffers from a personality disorder, and treatment of each, firstly, is not necessary, and secondly, incurs huge economic costs. The presence of ranking by severity will allow a more professional approach to the selection of indications for therapeutic interventions.
Tab. 2 Dimensional system for classifying personality disorders according to severity.
| Severity | Name | Main characteristics |
| 0 | Lack of RL | There are no personality disorders |
| 1 | Personality difficulty(accentuation) | There are some violations that appear in limited range of situations, but not always |
| 2 | Disorder personalities |
The presence of a distinct personal disorders manifested in a wide range situations |
| 3 | Complex RL | multiple domains and appearing in all situations |
| 4 | Severe RL | The presence of significant problems affecting (usually) multiple domains and appearing in all situations resulting in significant risk to self or others |
Eliminated difficult to understand comorbidity various types PD, which may lead to a decrease in the number of patients with unspecified/mixed personality disorder. The designation of "complex personality disorder" reflects the universal finding in research on this topic that as the problem becomes more pronounced, the diagnostic boundaries between different personality disorders blur.
Step three.
Where you need to forget everything you knew before. The usual classification for us implies that personality disorders are discrete and qualitatively different syndromes and, at their core, work according to the scheme of all or nothing. The changes that have affected the problem of personality disorders in the ICD-11 indicate that PDs are maladaptive variants of personal qualities that can imperceptibly pass into normal ones, or one into another, being a kind of continuum without any strict distinctions.
The new approach was based on the line started by G. Allport, G. Eysenck and R. Cattell, about the dispositional (from the English disposition - predisposition) model of a person's personality or the so-called "Big Five". The essence of this model is that the levels of dominance of the described personality traits form the individuality of a person and, in turn, predetermine the ability to adapt this personality. Empirically, using scales, questionnaires and expert assessments five properties were identified (see tab. 3).
Tab. 3 Comparative characteristics Big Five domains and RDOCs
The same idea was picked up by the developers of the alternative RDOC classification. The features identified by these researchers can fully prove the legitimacy of the big five and domain theories used in the ICD-11 (see tab. 4) and DSM 5.
Tab. 4 ICD-11 Personality trait domains.
| ICD-11 domain | Characteristics |
| negative affective features signs of negative affectivity (neuroticism in big five) |
Has a tendency to show wide range anxious emotions, including anxiety, anger, self-loathing, irritability, vulnerability, depression, and other negative emotional states, often in response to even relatively minor actual or perceived stressors. |
| Dissociation features dissocial signs (antagonism - opposed goodwill in big five) |
The core of the domain of dissocial traits is the disregard for social obligations and agreements, as well as the rights and feelings of others; traits in this area include: callousness, lack of empathy, hostility and aggression, ruthlessness, and an inability or unwillingness to maintain prosocial behavior, often manifested as an overly positive view of oneself and a tendency to manipulate and exploit others. |
| Features of disinhibition disinhibitory signs (impulsiveness - opposed good faith in big five) |
The disinhibitory trait domain is characterized by a persistent tendency to act impulsively in response to immediate internal or external stimuli without consideration of long-term consequences; traits in this area include: irresponsibility, impulsiveness without regard to risks or consequences, distractibility, and recklessness. |
| Anankastic features anancaste signs (conservatism - opposed openness to experience big five) |
This domain is characterized by having a narrow focus on controlling and regulating one's own behavior and the behavior of others to ensure that things conform to one's ideal; traits in this area include: perfectionism, perseveration, emotional and behavioral limitation, stubbornness, conscientiousness, orderliness, adherence to rules and obligations. |
| Features of detachment signs of isolation (low level extraversion in big five) |
Emotional and interpersonal distance, manifested in a noticeable social isolation and / or indifferent attitude towards people; isolation with very little or no attachment, including the avoidance of not only intimate relationships but also close friends; features of this domain include: aloofness or coldness towards other people, reserve, passivity and lack of self-confidence, as well as reduced experience in experiencing and expressing emotions (especially positive ones), to the point of weakening the ability to experience pleasure. |
The DSM has a similar domain model: negative affective, dissocial, disinhibited, and also detached domain traits; and instead of anancaste, the domain of psychotism, which is absent in ICD-11.
Each of the domains can occur both in apparently healthy members of the population and among patients with a personality disorder, but in patients with PD they indicate a focus in which the disorder is manifested to a greater extent. For the diagnostician, it will be necessary to isolate the signs of domains in a particular patient, even if the clinical picture reveals phenomena characteristic of all five domains. The proposed innovations will make it possible to get rid of the temptation to make a diagnosis bypassing a comprehensive personality assessment. There is no need for such a vague diagnosis as "mixed personality disorder". Modern research, studying this approach, identify specific therapies that can be effective when the signs of individual domains predominate. For example, the domain of disinhibitory signs requires structured psychological intervention, patients with signs of the negative affectivity domain respond well to cognitive-behavioral therapy, and patients with dissocial signs are resistant to therapeutic interventions and rather require social changes.
Prepared by: Chesnokova O.I.
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