ICD-11

A critical article on the classification of personality disorder in the new edition of the psychiatric diagnostic manual, ICD-11. Why, the article asks, should patients be subject to the insistence that their problems are due to their personality when the evidence suggests otherwise.

Objective: The five personality disorder trait domains in the proposed International Classification of Diseases, 11th edition and the Diagnostic and Statistical Manual of Mental Disorders, 5th edition are comparable in terms of Negative Affectivity, Detachment, Antagonism/Dissociality and Disinhibition. However, the International Classification of Diseases, 11th edition model includes a separate domain of Anankastia, whereas the Diagnostic and Statistical Manual of Mental Disorders, 5th edition model includes an additional domain of Psychoticism. This study examined associations of International Classification of Diseases, 11th edition and Diagnostic and Statistical Manual of Mental Disorders, 5th edition trait domains, simultaneously, with categorical personality disorders.
Method: Psychiatric outpatients (N = 226) were administered the Structured Clinical Interview for DSM-IV Axis II Personality Disorders Interview and the Personality Inventory for DSM-5. International Classification of Diseases, 11th edition and Diagnostic and Statistical Manual of Mental Disorders, 5th edition trait domain scores were obtained using pertinent scoring algorithms for the Personality Inventory for DSM-5. Associations between categorical personality disorders and trait domains were examined using correlation and multiple regression analyses.
Results: Both the International Classification of Diseases, 11th edition and the Diagnostic and Statistical Manual of Mental Disorders, 5th edition domain models showed relevant continuity with categorical personality disorders and captured a substantial amount of their information. As expected, the International Classification of Diseases, 11th edition model was superior in capturing obsessive–compulsive personality disorder, whereas the Diagnostic and Statistical Manual of Mental Disorders, 5th edition model was superior in capturing schizotypal personality disorder.
Conclusion: These preliminary findings suggest that little information is ‘lost’ in a transition to trait domain models and potentially adds to narrowing the gap between Diagnostic and Statistical Manual of Mental Disorders, 5th edition and the proposed International Classification of Diseases, 11th edition model. Accordingly, the International Classification of Diseases, 11th edition and Diagnostic and Statistical Manual of Mental Disorders, 5th edition domain models may be used to delineate one another as well as features of familiar categorical personality disorder types. A preliminary category-to-domain ‘cross walk’ is provided in the article.

En m’inspirant du cadre théorique du dispositif de sexualité élaboré par Michel Foucault, je propose de mettre à l’épreuve le concept de « santé sexuelle », institutionnalisé par l’Organisation mondiale de la santé (OMS) dans les années 1970, et dont l’usage depuis les années 1990 dans les politiques de santé publique à travers le monde n’a cessé de croître, à la faveur notamment de la lutte contre le VIH/SIDA, et de la commercialisation de médicaments pour traiter certains troubles de l’érection. La question que je souhaite poser est celle-ci : le concept de « santé sexuelle » participe-t-il d’un dispositif de sexualité ? Constitue-t-il, dès lors, un outil de biopouvoir ? Les éléments qui me conduisent à poser cette question sont les suivants : le fait que la sexualité soit appréhendée à travers le prisme de la santé ; le fait que la notion de « santé sexuelle » ait pu être associée, à l’occasion, à l’idée de vertu sexuelle, et soit aujourd’hui parfois associée à celle de sexualité saine ; et enfin, le fait que l’institution promouvant le concept de « santé sexuelle » sur le plan international édite par ailleurs une classification des maladies qui comprend des paraphilies, c’est-à-dire ce que l’OMS appelait auparavant des « perversions sexuelles ».

Personality disorders are common and ubiquitous in all medical settings, so every medical practitioner will encounter
them frequently. People with personality disorder have problems in interpersonal relationships but often attribute
them wrongly to others. No clear threshold exists between types and degrees of personality dysfunction and its
pathology is best classifi ed by a single dimension, ranging from normal personality at one extreme through to severe
personality disorder at the other. The description of personality disorders has been complicated over the years by
undue adherence to overlapping and unvalidated categories that represent specifi c characteristics rather than the core
components of personality disorder. Many people with personality disorder remain undetected in clinical practice and
might be given treatments that are ineff ective or harmful as a result. Comorbidity with other mental disorders is
common, and the presence of personality disorder often has a negative eff ect on course and treatment outcome.
Personality disorder is also associated with premature mortality and suicide, and needs to be identifi ed more often in
clinical practice than it is at present.

Deriving ICD-11 personality disorder domains from dsm-5 traits: initial attempt to harmonize two diagnostic systems. Objective: The personality disorder domains proposed for the ICD-11 comprise Negative Affectivity, Detachment, Dissociality, Disinhibition, and Anankastia, which are reasonably concordant with the higher-order trait domains in the Alternative DSM-5 Model for Personality Disorders 4. Method: We examined (i) whether designated DSM-5 trait facets can be used to describe the proposed ICD-11 trait domains, and (ii) how these ICD-11 trait features are hierarchically organized. A mixed Danish derivation sample (N = 1541) of 615 psychiatric outpatients and 925 community participants along with a US replication sample (N = 637) completed the Personality Inventory for DSM-5 (PID-5). Sixteen PID-5 traits were designated to cover features of the ICD-11 trait domains. Results: Exploratory structural equation modeling (ESEM) analyzes showed that the designated traits were meaningfully organized in the proposed ICD-11 five-domain structure as well as other recognizable higher-order models of personality and psychopathology. Model fits revealed that the five proposed ICD-11 personality disorder domains were satisfactorily resembled, and replicated in the independent US sample. Conclusion: The proposed ICD-11 personality disorder domains can be accurately described using designated traits from the DSM-5 personality trait system. A scoring algorithm for the ICD-11 personality disorder domains is provided in appendix. Significant outcomes • DSM-5 Section III personality disorder traits can be used for describing ICD-11 personality disorder domains (a scoring algorithm for Personality Inventory for DSM-5 is provided in Appendix 1). • The proposed ICD-11 personality disorder domains seem parsimonious and feasible for 'busy' practitioners across countries and clinical settings, while also aligning with the domains of the more comprehensive and informative DSM-5 Section III personality disorder trait system as well as other recognized models of personality and psychopathology.

In their Comment in The Lancet Healthy Longevity, Banerjee and colleagues proposed to exclude the code ‘Old age’ MG2A from the latest version of the International Classification of Diseases, ICD-11, claiming that equating old age to a disease could have the negative consequences of treating calendar age as a disease, raising concerns of ageism.
Yet, in fact, the ‘Old age’ code is not a new ICD addition, or one that should raise special concerns of ageism. The synonymic designation of ‘Senility’ or ‘Old age’ was carried over from ICD-10 as it has been a rather technical designation that allowed to establish the cause of death, when it was difficult or impossible to establish other causes. In contrast to the earlier versions, the ICD-11 allows for diverse synonymic interpretations, including those that can be highly useful for a clinician treating older persons, such as ‘Ageing’, ‘Senescence’, ‘Senile state’, ‘Frailty’, and ‘Senile dysfunction’, which refer to a state of health but not the number in the passport.
It is becoming increasingly clear that pathological processes of ageing are the major risk factors, and even major underlying causes of mortality and morbidity from non-communicable diseases, and, as we learn from the recent pandemics, also from infectious diseases. To address these ageing-related risk factors, there is a new wave of research and development that seeks to develop new therapies or repurpose older therapies, with the aim to slow and reverse the damage of ageing—ie, preventive, regenerative, and curative medicine. This research and development necessitates appropriate ICD coding.
In fact, WHO addressed this issue by including a new extension code XT9T ‘Ageing-related’ in the section aetiology. This code describes ageing-related conditions and can be helpful for research and clinical development. However, there is still a need for coding both the pathological biological ageing process as a whole and its advanced stage as well.
The new ICD-11 makes important steps toward that goal, as it provides a double focus for improving the health of older persons. First, by including the old age, senescence, and senile debility in the general symptoms category to target the state of ageing-related ill health, and second by including ‘Ageing-related’ code in the aetiology or causality category to target the pathogenic ageing processes.
Thus, far from discriminating against the rights of older persons and fostering neglect for their curative or preventive health care, the ICD-11 codes for old age and ageing-related causality do exactly the opposite: they draw the public and professional attention to the specific health problems of older persons and call to action to improve the prevention and cures specifically for older persons. Thus, these designations are the very opposite of ageism.
We advocate for a full therapeutic utilization of the new ICD-11 criteria for ageing-related ill health, by enhancing research and development of corresponding diagnostics and therapeutics to directly address the main risk factors for older persons—the degenerative ageing processes.

Hypersensitivity diseases are not adequately coded in the International Coding of Diseases (ICD)-10 resulting in misclassification, leading to low visibility of these conditions and general accuracy of official statistics. To call attention to the inadequacy of the ICD-10 in relation to allergic and hypersensitivity diseases and to contribute to improvements to be made in the forthcoming revision of ICD, a web-based global survey of healthcare professionals' attitudes toward allergic disorders classification was proposed to the members of European Academy of Allergy and Clinical Immunology (EAACI) (individuals) and World Allergy Organization (WAO) (representative responding on behalf of the national society), launched via internet and circulated for 6 week. As a result, we had 612 members of 144 countries from all six World Health Organization (WHO) global regions who answered the survey. ICD-10 is the most used classification worldwide, but it was not considered appropriate in clinical practice by the majority of participants. The majority indicated the EAACI–WAO classification as being easier and more accurate in the daily practice. They saw the need for a diagnostic system useful for nonallergists and endorsed the possibility of a global, cross-culturally applicable classification system of allergic disorders. This first and most broadly international survey ever conducted of health professionals' attitudes toward allergic disorders classification supports the need to update the current classifications of allergic diseases and can be useful to the WHO in improving the clinical utility of the classification and its global acceptability for the revised ICD-11.

Jack Drescher, MD, is an American psychiatrist and psychoanalyst known for his work on the history of theorising about, diagnosing, treating and mistreating sexual minorities. Dr Drescher was a member of the American Psychiatric Association’s DSM-5 expert working group on Sexual and Gender Identity Disorders, which revised the DSM- IV-TR diagnosis of gender identity disorder to the DSM-5 diagnosis of ‘gender dysphoria’. He was also a member of the World Health Organization expert working group that recommended replacing ICD-10’s gender identity disorder with ‘gender incongruence’, as well as moving the diagnosis out of the mental disorders section of the latest International Classification of Diseases (ICD-11). Dr Drescher is also an expert on sexual orientation change efforts (SOCE) and served on the American Psychological Association’s Task Force on Appropriate Therapeutic Responses to Sexual Orientation. He has published a number of books in the field including Psychoanalytic Therapy and the Gay Man (Drescher, 1998a) and Sexual Conversion Therapy: Ethical, clinical and research perspectives (Shidlo et al., 2001). In February 2020, I interviewed him about his role in the recent ICD-11 revisions and his views on tackling the practice of conversion therapy. What follows is an edited version of our conversation. (Adam Jowett, Chair of the Psychology of Sexualities Section)

Background: Researchers and clinicians within the field of trauma have to choose between different diagnostic descriptions of posttraumatic stress disorder (PTSD) in the DSM-5 and the proposed ICD-11. Several studies support different competing models of the PTSD structure according to both diagnostic systems; however, findings show that the choice of diagnostic systems can affect the estimated prevalence rates. Objectives: The present study aimed to investigate the potential impact of using a large (i.e. the DSM-5) compared to a small (i.e. the ICD-11) diagnostic description of PTSD. In other words, does the size of PTSD really matter? Methods: The aim was investigated by examining differences in diagnostic rates between the two diagnostic systems and independently examining the model fit of the competing DSM-5 and ICD-11 models of PTSD across three trauma samples: university students (N = 4213), chronic pain patients (N = 573), and military personnel (N = 118). Results: Diagnostic rates of PTSD were significantly lower according to the proposed ICD-11 criteria in the university sample, but no significant differences were found for chronic pain patients and military personnel. The proposed ICD-11 three-factor model provided the best fit of the tested ICD-11 models across all samples, whereas the DSM-5 seven-factor Hybrid model provided the best fit in the university and pain samples, and the DSM-5 six-factor Anhedonia model provided the best fit in the military sample of the tested DSM-5 models. Conclusions: The advantages and disadvantages of using a broad or narrow set of symptoms for PTSD can be debated, however, this study demonstrated that choice of diagnostic system may influence the estimated PTSD rates both qualitatively and quantitatively. In the current described diagnostic criteria only the ICD-11 model can reflect the configuration of symptoms satisfactorily. Thus, size does matter when assessing PTSD.

For more than a decade, research studies on the various personality disorders have been carried out at an ever-expanding pace (Blashfield and McElroy, 1987; Gorton and Akhar, 1990). Factors promoting this research have  included the establishment within the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) of a separate axis for the diagnosis of personality disorders, the enumeration within DSM-III of diagnostic criteria for these conditions, and the development of standardized interviews for the assessment of personality disorders.  Innovations such as these are expected to advance the scientific stature of personality disorder research.

La propuesta oficial de establecer una “incongruencia de género en la infancia” amenaza como último bastión de la patologización de las infancias trans* y también, me atrevo a decir, de una expresión de género que atañe a cientos de miles de chonguitas y mariconcitos –por mencionar recientes contranarrativas de memorias de la infancia– que viven y experimentan sus vidas en los márgenes coercitivos de la diferencias sexual y su compulsión hetero-centrada. ¿Estamos ante una nueva re-patologización de la orientación sexual y expresión de género?


Theumer Emmanuel, “ICD 11:HA61. Luchas abiertas por la despatologización” en Elena Victoria Acevedo de Bomba; Silvio Alexis Lucena (comp.) Educación y política: en el camino hacia un nuevo humanismo, San Miguel de Tucumán : Editorial Humanitas-Universidad Nacional de Tucumán, 2020. pp. 105-112. ISBN 978-987-754-236-3

ICD and the Clinical Description and Diagnostic Guidelines (CDDG) has undergone the ‘first major revision of the world’s foremost classification of mental disorders in nearly 30 years’. The revision process was rigorous and beginning from January 1, 2022, our country has to report the health statistics to the WHO using the ICD-11.  There is substantial changes in the revision and for effective implementation, the clinical psychologists have to get trained with the changes in ICD-11. On a priority basis, Tamil Nadu Association of Clinical Psychologists have to 1. conduct Continuing Professional Development programs on the substantial changes for the professional clinical psychologists, 2. Conduct Continuing Professional Development programs on changes for the teachers who teach clinical psychology and 3. Develop collaborative efforts with other professionals to improve on the quality of training.  The scope for devising and incorporating psychometric tools along with diagnostic categories can be a boon for researchers. Using artificial intelligence and working in collaboration with technology experts can help improve on the accuracy of diagnosis, ease in recording and analysis of the big data.

US psychiatric classification arose in the mid 1800’s from a Federal need to collect statistical information about mental disorders. Data, initially collected across mental hospitals, was broadened after WW-II to accommodate outpatient servicemen/veterans. Concurrently, WHO’s 6th Edition of its ICD for the first time included mental disorders, with categories substantially influenced by VA nomenclature. In turn, APsychiatricA in 1952 developed DSM as a variant on ICD-6.  Subsequent revisions were conservative, and DSM-III was to follow ICD-9.

However, far from clinical practice – in courtrooms – a growing US problem called for radical revision.  Primitively conceived psychiatric classification invited trouble. Given “Not guilty by reason of insanity,” the “right diagnosis” could mean the difference between conviction or acquittal. And given Freudian, Jungian, eclectic and biological psychiatrists, the diagnosis often said more about the psychiatrist than the patient. Ennis and Litwack’s 1974 manuscript expresses the dilemma: “Psychiatry and the Presumption of Expertise: Flipping Coins in the Courtroom.”

To resolve this crisis, Hempel’s then preeminent logical empiricist philosophy of science provided an answer, and APA’s DSM-III a methodology for psychiatric classification that persists to today. With valid psychiatric entities “not here yet,” uniform lists of reliable operationalized diagnostic criteria could still delineate reliable disorders.  These entities could be studied and in time achieve validity. Ongoing revolutions in neuroscience and genetics would assure this.

In short – the problem is simple -- reliable entities need never achieve validity. But is there an alternative?

This presentation will argue “yes.” Psychiatric disorders – forms of abnormal psychology -- are real. But the only conceptual coherence is at the methodological level. As complex emergent phenomena, mental disorders can sometimes be typified. And they can be approached variously and in combination as diseases, dimensions, behaviors, life stories, and diversity. The remainder of this presentation will spell out this framework.

Background: The WHO International Classification of Diseases, 11th version (ICD-11), includes a trauma-related diagnosis of complex posttraumatic stress disorder (CPTSD) distinct from posttraumatic stress disorder (PTSD). Results from previous studies support the validity of this distinction. However, no studies to date have evaluated the ICD-11 model of PTSD and CPTSD in treatment-seeking military veterans. Objective: To determine if the distribution of symptoms in treatment-seeking Danish veterans was consistent with the ICD-11 PTSD and CPTSD symptom profiles. Based on previous studies, we hypothesized that separate classes representing PTSD and CPTSD would be found that membership of a potential CPTSD-class would be predicted by a larger number of childhood traumas, and that a potential distinction between PTSD and CPTSD would be supported by differences in sociodemographic and functional outcomes. Method: Participants (N = 1,541) were formerly deployed Danish soldiers who completed proxy measures of ICD-11 PTSD and disturbances in self-organization (DSO) symptoms, along with self-report measures of traumatic life events, prior to starting treatment at the Military Psychology Department of the Danish Defence. Results: All hypotheses were supported. Latent profile analysis (LPA) revealed separate classes representing PTSD and CPTSD. In comparison to the PTSD-class, membership of the CPTSD-class was predicted by more childhood traumatic experiences, and members of this class were more likely being single/divorced/widowed and more likely to use psycho-tropic medication. Besides a PTSD-class and a CPTSD-class, LPA revealed a Low Symptoms-class, a Moderate DSO-class, a Hyperarousal-class, and a High DSO-class, with clear differences in functional outcomes between classes. Conclusion: Findings replicate previous studies supporting the distinction between ICD-11 PTSD and CPTSD. In addition, there seem to be groups of treatment-seeking military veterans that do not fulfil full criteria for a trauma-related disorder. Further research should explore subsyndromal PTSD and CPTSD profiles in veterans and other populations.

Zusammenfassung Die Deutsche Gesellschaft für Psychiatrie, Psychotherapie, Psychosomatik und Nervenheilkunde (DGPPN) hat federführend (Projektleitung WG) in Kooperation mit vier weiteren medizinischen Fachgesellschaften (DGPM, DGPPR, DeGPT, DGfS) * eine von elf der vom Bundesministerium für Gesundheit geförderten Validierungsstudien zur Unterstützung der WHO-Revision der ICD-10 zur ICD-11 durchgeführt. Die internetbasierte Feldstudie hatte zum Ziel, für ausgewählte Kategorien aus dem Bereich psychischer Erkrankungen (Betadraft, Kapitel 6 und 17) die Konsistenz (Reliabilität) der Diagnosestellung (Teilprojekt TP 1) sowie der Zuweisung diagnostischer Codes (TP 2) nach ICD-11 im Vergleich zur ICD-10 zu überprüfen sowie Anwendereinschätzungen zur Praktikabilität und Nutzerfreundlichkeit zu erheben. TP 1 untersuchte in randomisiertem Design die Konsistenz der Diagnosestellung anhand von zehn Fallvignetten mittels klinischer Diagnoseleitlinien über die WHO GCPN-Plattform ** mit Hilfe von 319 rekrutierten Mitgliedern der beteiligten Fachgesellschaften. Hypothesenkonform war die Konsistenz für ICD-11 signifikant höher als für ICD-10 (p = 0,02). Zusätzlich waren Zeitdauer der Diagnosestellung kürzer (p = 0,01) und Anwenderbeurteilungen positiver für ICD-11 hinsichtlich Nutzerfreundlichkeit (p = 0,047) und Passgenauigkeit (p < 0,001). Ebenfalls randomisiert wurde in TP 2 die Konsistenz der Kodierung für 25 explizite Diagnosen mit kurzen epikritischen Fallbeschreibungen für ICD-11 und ICD-10 mittels WHO FiT-Tool *** erfasst (n = 531 Kodierungen von 120 Teilnehmenden). Entgegen der Hypothese fand sich eine unterlegene Konsistenz korrekter Kodierung für ICD-11 vs. ICD-10 (71 % vs. 82 %; p < 0,001) sowie ein höherer Zeitbedarf für ICD-11 (p < 0,001). Hingegen war die Nutzerbewertung für ICD-11 erneut überlegen (p < 0,005). Zusammenfassend weist die ICD-11 in der diagnostischen Güte bessere, in der Kodierleistung schlechtere Konsistenzergebnisse auf als ICD-10. Die Ergebnisse belegen, dass die revidierten diagnostischen Leitlinien die Qualität des diagnostischen Prozesses günstig beeinflussen, was durch die zeitlichen Leistungsmaße und Nutzerbeurteilungen gestützt wird. Demgegenüber fallen die Kodierleistungen für die ICD-11 noch zurück, was sowohl auf die mögliche höhere Kodierkomplexität (z. B. Komplex-Codes mit sog. „post-coordination“) als auch auf den ungeübten Umgang mit dem neuen Kodiertool für ICD-11 zurückzuführen sein dürfte. Dennoch wird der neue Kodierprozess aufgrund erweiterter und systematischerer Kodieroptionen günstiger beurteilt als für ICD-10. In den Verläufen der zeitlichen Leistungsmaße zeichnen sich überdies Lernerfolge für ICD-11 ab, die darauf hinweisen, dass eingehende Schulungs- und Trainingsmaßnahmen im Rahmen der künftigen Praxisimplementierung von ICD-11 nicht nur erforderlich, sondern auch erfolgreich sein dürften. Die über Diagnosekategorien hinweg variablen Konsistenzergebnisse weisen allerdings auch darauf hin, dass es in der gegenwärtigen Entwurfsfassung der ICD-11 noch Verbesserungspotenziale für Diagnostik und Kodierung gibt, die in abschließenden und kontinuierlichen Revisionsmaßnahmen i. S. eines „living document“ zu berücksichtigen sind.

In his essay titled: Are Mental States a Useful Concept? Neurophilosophical Influences on Phenomenology and Psychopathology, Paul Harrison (1991) considers whether the recently emerging field of neurophilosophy, and in particular its "eliminative materialist" branch, will eventually undermine the clinical psychiatric disciplines of descriptive psychopathology and phenomenology. Eliminative materialists classify common sense assumptions and explanations concerning mental life as "folk psychology"; additionally, they consider phenomenological descriptions of normal mental life as a merely more complex version of folk psychology.  Moreover, "the eliminative materialists not only see [folk psychology] theories as largely false, but believe the whole level of explanation to be unnecessary and a hindrance to progress  in understanding the basis of mental processes" (Harrison, 1991). Harrison goes on to clarify that descriptive psychopathology and abnormal phenomenology also qualify as folk psychology. As a result, if eliminative materialists are correct, psychiatrists and psychopathologists must at the very least "reconfigure" (radically alter?) their approaches to abnormal mental events.

Purpose – The 11th revision of the International Classification of diseases which sets global standards for defining, reporting and managing health conditions is under way. The International Classification of Diseases (ICD) underpinning principle of clinical utility is currently poor for persons with Disorders of Intellectual
Development (DID) and mental disorders. This impedes access to healthcare resources; services and social inclusion thereby further aggravating their vulnerability. The purpose of this paper is to present a critical overview and evidence informed recommendations within the context of an international collaborative programme, undertaken by the Faculty of Psychiatry of Intellectual Disability, Royal College of Psychiatrists, UK with support from the World Health Organisation (WHO).

Design/methodology/approach – The authors carried out: first, a systematic review (SR) of literature, using PRISMA guidelines regarding the reliability, validity and utility of the ICD-10/Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic criteria in people with DID (PWDID); second, a national and international consultation exercise with partners, stakeholders and experts; third, a multicentric survey of
problem behaviours in PWDID; and finally, information dissemination/dialogues including presentations and
workshops at key scientific events, consultation networking, data gathering and consensus building.

Findings – The SR revealed a dearth of robust studies – most consisting of weak research methodologies.
Significant difficulties were highlighted regarding the application of diagnostic criteria in the current classificatory systems – particularly in people with severe/moderate DID. Recommendations supported the introduction of modifications based on observed phenomena (signs) in PWDID in lieu of reported symptoms to facilitate DIAGNOSIS AND better access to healthcare and the community. Heterogeneity precluded quantitative pooling and meta-analysis. The consensus building exercise globally revealed that problem behaviours were the commonest reasons for referral to healthcare services with
significant numbers without a diagnosed mental disorder being prescribed psychoactive medication.

Research limitations/implications – The consensus gathering exercise WAS SELECTIVE AND did not cover all of the 194 member states of WHO due to resource and time constraints and this constitutes the
main limitation of our study. Based on the SR and expert consensus, the authors submitted evidence
informed pragmatic proposals to the WHO aimed at addressing the shortcomings of the ICD-10. The key recommendations focused on improving clinical utility within the context of epistemic iteration which would consolidate and strengthen the future evidence base. It was also recommended that self-injurious behaviour should form a standalone sub category in view of its relevance for healthcare services and resources which underpin clinical utility.

Practical implications – The ICD-11 is a global, multidisciplinary and multilingual development for public health benefit with 70 per cent of the world’s health expenditures assigned using this system for resource allocation. Currently mental disorders in PWDID can be misinterpreted, unrecognised and under reported resulting in barriers to access to treatment and healthcare resources. Conversely disorders may be over diagnosed when the inherent discrepancies between the chronological age and the developmental level of functioning are not considered.

Conclusions and recommendations from this study will result in better diagnosis of mental disorders and healthcare resources in this population.

Social implications – PWDID are a vulnerable sector of the population with an increased prevalence of mental health problems who are marginalised and discriminated by society. Early detection, treatment and management of these conditions will prevent further decompensation and stigmatisation.

Originality/value – To the best of the authors knowledge this is the first comprehensive, large-scale study which evaluates the ICD classificatory system within the context of clinical utility for PWDID, including experts and stakeholders from both lower/middle- and high-income countries. The international consultation/consensus building process culminating in the formulation of evidence informed recommendations, aimed at improving the clinical utility of the ICD-11 for this population, has the potential to improve access to appropriate healthcare and treatment and consequent enhancement of their quality of life.