Hence, the WPA is even reaching over its organizational limits by its website. The average number of visits per day was 328, and the average number of pages per visit was 3.32. The website is continuously visited by new people, with the proportion of new visitors being nearly 70%. This is also reflected in the fact that 67% of the visitors of the website reach it via “searchengines”, while 18% via “referring sites”, and 15% using “direct traffic”. It is interesting to check the days of the week that people prefer to visit the WPA website. During the first three days of the week (Monday through Wednesday), visits are more frequent than the other four days, with an increasing trend, while from Thursday to Sunday it decreases continuously. It seems the visitors start their week by visiting the pages of the WPA website.
IMPACT One of the widely used criteria to measure the impact of a website is “page rank check”, a free service provided by Google. The page rank value indicates the importance of a particular website/page. Being an objective measure of its citation significance, it also corresponds well with people’s subjective idea of importance.
Currently, the page rank of the WPA website is 7/10 (that is, the page rank value is 7 from 10 possible points), which reflects a high impact compared to many other similar websites.
FUTURE PERSPECTIVES Currently, the WPA website is a highly active electronic platform fulfilling two main functions at the same time: as an international “news channel” on psychiatry and mental health, and as an “archive” of training and educational materials, and basic reference documents. Considering its international character, these two functions could be improved to become more comprehensive and interactive. This is possible via advances in the relations with other international organizations in the fields of mental health and psychiatry. Giving high priority to international solidarity in psychiatry may enhance this process. In fact, a website is a highly flexible living platform, a work in progress where we can explore further improvements continuously. As the editor and the WPA Secretary General, I have been facilitating this process with the cooperation of the WPA Executive Committee members of 2008-2011 and of 2011-2014, and our past and current secretariat staff, Anna Engstrom, Francesca Sotgiu and
Pamela Atiase, and our IT staff at the Istanbul-based agency SaglikBahcesi. Their enthusiasm, support, and skilful efforts are highly appreciated. I hope the visitors of the WPA website will continue to support us in improving its quality by sending their contributions and comments.
References € ey L. The characteristics, content, per1. Ku formance, and impact of the WPA website (www.wpanet.org). World Psychiatry 2013;12:85-6. 2. Okasha T. WPA scientific meetings. World Psychiatry 2013;12:182-3. 3. Riba MB. WPA publications: opportunities to improve psychiatric research and inform clinical care and education. World Psychiatry 2013;12:279. 4. Javed A. WPA Scientific Sections. World Psychiatry 2013;12:278. 5. Belfort E. WPA educational activities. World Psychiatry 2013;12:181-2. 6. Bucci P. WPA partnership with the World Health Organization in the development of the ICD-11 chapter on mental disorders. World Psychiatry 2013;12:87-8. 7. Volpe U. WPA contribution to the development of the chapter on mental disorders of the ICD-11: an update. World Psychiatry 2013;12:183-4. 8. Bhugra D, on behalf of the Steering Group. The International Study on Career Choice in Psychiatry: a preliminary report. World Psychiatry 2013;12:181. DOI 10.1002/wps.20109
WPA NEWS
Following the development of ICD-11 through World Psychiatry (and other sources) VALERIA DEL VECCHIO Department of Psychiatry, University of Naples SUN, Naples, Italy
The World Health Organization (WHO) is developing the 11th edition of the International Classification of Diseases and Related Health Problems (ICD-11), whose publication is currently expected in the year 2015. The WPA is partnering with the WHO in the production of the chapter on 102
mental and behavioural disorders. The principles guiding the development of that chapter have been summarized by the International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders in a paper published in World Psychiatry in June 2011 (1). That paper emphasizes that the chapter is being produced in consultation with relevant stakeholders, including WHO member countries, several professional groups, and users
of mental health services and their families. Attention to the cultural framework is being a key element. The revision is seen as an opportunity to improve the classification’s clinical utility, particularly in primary care settings and in low- and middle-income countries (see also 2,3). The ICD-11 classification will remain based on descriptions of the prototypes of the various mental disorders rather than on operational diagnostic criteria. World Psychiatry 13:1 - February 2014
The advantages and possible limitations of this approach have been discussed in several World Psychiatry articles and commentaries (e.g., 4-11). A major argument in favour of this approach is that it is congruent with the spontaneous clinical process, which does not involve checking in a given patient whether each of a series of symptoms is present or not, but rather checking whether the characteristics of the patient match one of the templates of mental disorders that the clinician has built up in his/her mind through his/her training and clinical experience (see also 12). Moreover, some recent research focusing on various classes of mental disorders (i.e., personality, eating, anxiety and mood disorders) suggests that a diagnostic system based on refined prototypes may be as reliable as one based on operational criteria, while being more user friendly and having greater clinical utility (e.g., 13,14). Eleven Working and Consultation Groups have been appointed by the WHO for the development of the ICD11 chapter on mental and behavioural disorders. These groups include several WPA officers and experts among their chairpersons and members (see 15,16). Several of these groups have recently published background papers or preliminary reports on their activities. Highlights of the expected convergences and divergences between the ICD-11 and DSM-5 approaches to the classification of mood disorders have been presented in several papers in various journals (e.g., 17,18) and in a supplement to World Psychiatry (19). Among the convergences are the inclusion of activation/energy as a defining symptom for mania, and the acknowledgement that a manic/hypomanic syndrome emerging during antidepressant treatment, and persisting beyond the physiological effect of that treatment, qualifies for the diagnosis of manic/ hypomanic episode. Furthermore, the ICD-11, as the DSM-5, will allow the clinician to record the occurrence of a subsyndromal anxiety syndrome in a patient with a major depressive episode, by using a specifier. Bipolar II
disorder is expected to be recognized as a distinct diagnostic entity in the ICD-11, while in ICD-10 it is just mentioned among “other bipolar affective disorders”. Expected divergences between the ICD-11 and the DSM-5 will include a different characterization of mixed states and schizoaffective disorders. Furthermore, the ICD-11 is going to exclude from the diagnosis of depressive episode, in line with the ICD10 but differently from the DSM-5, “normal bereavement reactions appropriate to the culture of the individual concerned” (see 20-26). Highlights of the expected convergences and divergences between the ICD-11 and the DSM-5 in the classification of stress-related disorders have been presented in a recent World Psychiatry paper (27). In the ICD-11, the proposed new grouping of “disorders specifically associated with stress” will include adjustment disorder (whose description will undergo a major revision, involving an increased specification of symptoms), post-traumatic stress disorder (PTSD) (whose diagnosis is going to be based on three wellidentified core symptoms), and complex PTSD (a new category marked by disturbance in the domains of affect, self-concept and relational functioning in addition to the three core features of PTSD). Acute stress reaction will be conceptualized as a normal reaction and thus classified in the chapter corresponding to ICD-10 “Factors influencing health status and contact with services” (while “acute stress disorder” is still included in the section on trauma- and stress-related disorders in the DSM-5). Proposals for the ICD-11 section on feeding and eating disorders have been summarized in another World Psychiatry article (28). These include a broadening of the category of anorexia nervosa through dropping the requirement for amenorrhoea, extending the weight criterion to any significant underweight, and extending the cognitive criterion to include developmentally and culturally relevant presentations. Furthermore, a severity qualifier “with dangerously low body weight” is expected to distinguish the
severe cases of anorexia nervosa that carry the riskiest prognosis. The bulimia nervosa category is likely to be extended to include subjective binge eating, and binge eating disorder will be included as a specific diagnostic category, in agreement with the DSM-5. The input of the ICD-11 Working Group on Intellectual Developmental Disorders has been presented in a paper published in World Psychiatry in 2011 (29) and is further discussed in this issue of the journal (30). Intellectual developmental disorders (a term replacing “mental retardation”) are proposed to be defined as “a group of developmental conditions characterized by significant impairment of cognitive functions, which are associated with limitations of learning, adaptive behaviour and skills”. The Working Group further advised that intellectual developmental disorders be incorporated in the larger grouping of neurodevelopmental disorders, that current subcategories based on clinical severity be maintained, and that problem behaviours be described as associated features. The Chairman of the ICD-11 Working Group on Psychotic Disorders recently reported (31) about the expected convergences and divergences in the ICD-11 and DSM-5 approaches to the classification of those disorders. In the ICD-11, as in the DSM-5, Schneider’s first-rank symptoms are going to be deemphasized in the description of schizophrenia, and the subtypes of the disorder are going to be omitted. These subtypes will be replaced by six symptom specifiers (positive symptoms, negative symptoms, depressive symptoms, manic symptoms, psychomotor symptoms, and cognitive impairment). Contrary to the DSM-5, the ICD-11 is expected to keep the one month duration criterion for the diagnosis of schizophrenia, and not to include functional impairment as a mandatory criterion. Preliminary reports about the development of the ICD-11 sections on mental disorders in children and adolescents (32), somatic distress and dissociative disorders (33) and personality 103
disorders (34) are also available in the recent literature. A more general discussion of diagnostic topics related to DSM-5 and ICD-11 classifications can be found in recent issues of World Psychiatry (35-45). Internet-based field testing of proposals for ICD-11 will be implemented through the Global Clinical Practice Network, currently consisting of more than 7,000 individual mental health and primary care practitioners (www. globalclinicalpractice.net).
References 1. International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders. A conceptual framework for the revision of the ICD-10 classification of mental and behavioural disorders. World Psychiatry 2011;10:86-92. 2. Reed GM. Toward ICD-11: improving the clinical utility of WHO’s International Classification of Mental Disorders. Prof Psychol Res Pract 2010;41:457-64. 3. Gureje O, Reed G. Revising the classification of mental disorders: do we really need to bother? Int Rev Psychiatry 2012; 24:511-3. 4. Maj M. Psychiatric diagnosis: pros and cons of prototypes vs. operational criteria. World Psychiatry 2011;10:81-2. 5. Westen D. Prototype diagnosis of psychiatric syndromes. World Psychiatry 2012; 11:16-21. 6. Jablensky A. Prototypes, syndromes and dimensions of psychopathology: an open agenda for research. World Psychiatry 2012;11:22-3. 7. First MB. A practical prototypic system for psychiatric diagnosis: the ICD-11 Clinical Descriptions and Diagnostic Guidelines. World Psychiatry 2012;11:24-5. 8. Frances A. Prototypal diagnosis: will this relic from the past become the wave of the future? World Psychiatry 2012;11:26. 9. Wakefield JC. Are you as smart as a 4th grader? Why the prototype-similarity approach to diagnosis is a step backward for a scientific psychiatry. World Psychiatry 2012;11:27-8. 10. Ayuso-Mateos JL. Prototype diagnosis of psychiatric syndromes and the ICD-11. World Psychiatry 2012;11:30-1. 11. Maj M. Adherence to psychiatric treatments and the public image of psychiatry. World Psychiatry 2013;12:185-6. 12. Ortigo KM, Bradley B, Westen D. An empirically based prototype diagnostic system for DSM-V and ICD-11. In: Millon T, Krueger RF, Simonsen E (eds). Contempo-
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DOI 10.1002/wps.20095
World Psychiatry 13:1 - February 2014