1. Disorders Specifically Related to Stress: Developments for ICD-11 Mark van Ommeren IASC RG meeting, Sep 2012

2. Disclaimer 'The material in this presentation reflects the draft recommendations of the WHO ICD-11 Working Group on the Classification of Disorders Specifically Associated with Stress. They have not been approved by the WHO International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders and do not represent the official policies or positions of the World Health Organization.

3. Members of the Working Group Christopher Brewin Richard Bryant Marylene Cloitre Asma Humayun Lynne Jones Ashraf Kagee Andreas Maercker (chair) Cecile Rousseau Dayanandan Somasundaram Yuriko Suzuki Simon Wessely Organizational representatives Augusto E. Llosa (Médecins Sans Frontières) Renato Olivero Souza (ICRC) Inka Weissbecker (Intern. Medical Corps) Mark van Ommeren (WHO)

4. DSM & ICD revisions From Stress-related disorder to Disorders Specifically Related to Stress: Developments for ICD-11

5. ICD-11 Lineare Structure of the category

6. Most frequently used diagnoses across ICD-10 Adjustment disorder PTSD WPA-WHO Survey of Psychiatrists’ use of ICD-10: Reed et al. (2011): 5000 clinicians in 44 countries

7. Literature search, source: PubMed (by July 2011) PTSD: 5424 Adjustment disorders: 292 Acute stress reaction: 236 Enduring personality change a. catast. exp.: 4 ____________________________ Prolonged (complicated) grief disorder: 211 Complex PTSD: 40 Developmental trauma disorder: 3

8. PTSD - Symptom pattern ICD-10: …repeated reliving of the trauma in intrusive memories (“flashbacks”) or dreams,... sense of numbness, anhedonia,... and avoidance Proposal for ICD-11: reexperiencing in the present... reexperiencing in the present, in which the event(s) are not just remembered but are sensed as occurring again in the here and now. deliberate avoidance … deliberate avoidance of reminders likely to produce reexperiencing of the traumatic event(s). hypervigilance... hypervigilance or enhanced startle reaction as a perception of heightened current threat.  tightening by removing non-specific symptoms and requiring impaired functioning

9. PTSD proposed in ICD 11 and DSM-5 Symptom pattern Intrusions Avoidance Hyperarousal Negative alterations in cognitions and mood eg, persistent negat. expectations about one‘s self pervasive emotional states... ICD-11:

10. Complex PTSD formerly: Enduring personality change after catastrophic experiences Trauma criterion extremely threatening or horrific nature... plus Exposure to a stressor … from which escape is difficult or impossible such as torture, concentration camps, slave trade, genocide campaigns and other forms of organized violence, domestic violence, and childhood sexual or physical abuse. Symptom pattern core symptoms of PTSD (re-experiencing in the present, avoidance, hyperarousal) plus persistent and pervasive impairments in – affective functioning: Affect dysregulation, heightened emotional reactivity, violent outbursts, tendency towards dissociative states when under stress – self functioning: Persistent beliefs about oneself as diminished, defeated or worthless; pervasive feelings of shame, guilt – relational functioning: Difficulties in sustaining relationships or feeling close to others.

11. Acute stress reaction Rational for change: Changed into Z-code: R AS R ends with R for ‘reaction’. Already in ICD 10 there was uncertainty whether this is a disorder. D DSM group in their articles debated if ‘their’ AS D (different time frame and PTSD like symptoms) is a disorder or not and stated that US insurance context was the key reason to maintain it in DSM-5. to define those who present as help seekers Clinical experience of humanitarian and relief sectors is that there is a need for a non- pathological category to define those who present as help seekers with a wide variety of transient emotional and somatic reactions in the immediate aftermath of acute stressful events. allows public health care workers to be trained Use of the Z code in ICD 11 for ASR allows public health care workers to be trained to recognize and assist those with such reactions, without on the other hand pathologising them. Poor predictive validity of ASR or ASD: Bryant (2011). Acute stress disorder as a predictor of posttraumatic stress disorder: a systematic review. J Clin Psychiatry, 72, 233-249.