Editorial

Towards innovative internationalclassification and diagnostic systems: ICD-11and person-centered integrative diagnosis

A new cycle is starting in the development ofinternational classification and diagnostic systems.The World Health Organization (WHO) Depart-ment of Mental Health organized in January 2007the first meeting of an Advisory Committee for thepreparation of the Mental Disorders Chapter ofthe Eleventh Revision of the International Classi-fication of Diseases (ICD-11), to be consistent withthe overall ICD-11 plan coordinated by the WHOClassification Office. Of relevance, there has beenan active process of collaboration between theWorld Psychiatric Association (WPA) and WHOsince 2001 to explore new classification and diag-nostic paths. Also presently, the American Psychia-tric Association (APA) is preparing the bases forits Diagnostic and Statistical Manual of MentalDisorders, 5th Edition (DSM-V). Furthermore,other active national and regional psychiatricbodies such as the Chinese Society of Psychiatristsand the Latin American Psychiatric Associationare researching and refining, respectively, theirChinese Classification of Mental Disorders, 3rdEdition (CCMD-3) and Latin American Guide forPsychiatric Diagnosis (GLADP), which representICD adaptations to local realities and needs.As health professionals and institutions consider

and undertake these important activities on centraltopics for clinical care and public health, it may bewise to reflect carefully on their fundamentalpurposes so that their conceptualization can beoptimized. A full international revision of classifi-cation and diagnostic systems takes place onlyevery 10–20 years, and therefore this represents anopportunity as well as a responsibility not to bemissed to advance our field.

What is diagnosis?

The term diagnosis has a widely accepted centralposition in the process of medical care. Feinstein (1)has noted that diagnostic categories provide the

locations where clinicians store the observations ofclinical experience and the diagnostic taxonomyestablishes the patterns according to which clini-cians observe, think, remember and act.But, what is diagnosis? The eminent historian

and philosopher of medicine, Laın–Entralgo (2),has pointed out that �diagnosis is more thanidentifying a disorder (nosological diagnosis) ordistinguishing one disorder from another (differ-ential diagnosis); diagnosis is really understandingwhat is going on in the mind and body of theperson who presents for care�.In an attempt to delineate the nature and scope

of that �understanding� required to achieve aproper diagnosis, we may find the followingreflections helpful. As health professionals, ournatural area of concern is health. In Sanskrit, themother of all Indo-European languages, the termfor health is hal, meaning �wholeness�. AncientGreek philosophers pointed out that if the whole isnot well, it is impossible for the part to be well (3).Furthermore, WHO (4) has enshrined in its Con-stitution that �health is a state of complete physical,emotional, and social well being and not merely theabsence of disease�.As we know, medicine at large and psychiatry in

particular are professions committed to helpingpeople restore and promote their health. In fact,health promotion, in addition to health restoration(disease cure, alleviation or management), isincreasingly recognized as a proper and importanttask of clinical care (5, 6).From the above reflections, it should be possible

to accept that diagnosis would fulfill better itsfundamental role as informational basis for clinicalcare if it were to have a scope broad enough todescribe the overall health status of the personpresenting for care. And this means covering bothill health (or disease) and positive health, the latterinvolving domains such as functioning, personaland social values and resources, and quality of life (7).

Acta Psychiatr Scand 2007: 116: 1–5All rights reservedDOI: 10.1111/j.1600-0447.2007.01028.x

Copyright � 2007 The AuthorsJournal Compilation � 2007 Blackwell Munksgaard

ACTA PSYCHIATRICASCANDINAVICA

1

This also means bringing up to the front thehumanistic purpose of clinical care (8). Its targetand focus is the health of people who are notsimply carriers of disease, but human beings withhistory and aspirations, whose dignity is to berespected and promoted. In connection to this, itshould be recognized that diagnosis is not only aformulation, but an interactive process as conclu-ded by trialog forums of patients, families andhealth professionals (9).

Related international health and institutionaldevelopments

It is encouraging to note an array of recentnational and international developments and poli-cies in mental health that are quite consistent withthe above perspectives. A US Presidential Com-mission on Mental Health (10) has recommendedto place consumers and families as well as integ-ration of services at the center of an urgentlyneeded transformation of the health systems. Alsorelevant here are recent policy statement on value-based practice from the National Institute ofMental Health of England, and the French EtatsGeneraux de la Psychiatrie in June 2003 demandingattention to �complex clinical situations� throughcontextualized diagnosis and care. The WHOEuropean Ministerial Conference on MentalHealth (11) has spoken on the cruciality ofmental health and the need to empower peopleand to obtain patient- and carer-centered integra-tion of services.In connection to the historical aspirations noted

earlier and the above policy developments in theinternational health field, the WPA prepared andpublished in 2003 a set of International Guidelinesfor Diagnostic Assessment (IGDA) that pointed outthat a patient is more than a carrier of disease andproposed a comprehensive diagnostic model withstandardized and idiographic components thatreflect person-centered integrative perspectives.More recently, WPA approved at its 2005 GeneralAssembly an Institutional Program on Psychiatryfor the Person: from Clinical Care to Public Health(IPPP). It represents an initiative affirming thewhole person of the patient in context as the centerand goal of clinical care and health promotion, atboth individual and community levels. It involvesan articulation of science and humanism to opti-mize attention to the ill and positive health aspectsof the person. It includes four operational compo-nents: Conceptual Bases, Clinical Diagnosis, Cli-nical Care, and Public Health. The IPPP initiativefinds stimulating consistency on many points withsuch significant conceptual developments in the

field as the European Medicine de la Persone (12),the Value-based Practice Approach promoted bythe National Institute of Mental Health of England(8), and the Recovery Movement originating in theUnited States and now extending internationally(13, 14).In April 2006, WPA updated its formal position

concerning the development of ICD-11 and relateddiagnostic systems. This statement recognized thatWPA over the past several years, particularlythrough its Classification Section and in collabor-ation with WHO and national and regionalpsychiatric associations, has contributed signifi-cantly to setting the foundations of future interna-tional classification and diagnostic systems. Keyactivities have included a large InternationalSurvey on the Use of ICD-10, DSM-IV andRelated Diagnostic Systems, a number of WPA-WHO Symposia on International Classificationand Diagnosis at WPA Congresses and Confer-ences, which have led to three published mono-graphs and crucial advances in the field, and workcommissioned by WHO on the bases for thedevelopment of the ICD-11 mental health compo-nent presented at WHO meetings from 2003 to2005. It also noted that the process of ICD revisionhas recently entered a new phase with the WHOClassification Office directing the overall develop-mental process and the WHO Mental HealthDepartment directing the development of theMental Disorders Chapter. The position statementdeclared that WPA will offer its full collaborationto the World Health Organization for the prepar-ation of ICD-11 and related diagnostic systems,and that it will cooperate with its Member Soci-eties, including the American Psychiatric Associ-ation and other national and regional associations,concerning their own classification projects withthe expectation that they be as consistent aspossible with WHO’s ICD-11 and Family ofInternational Classifications. To ensure this, effect-ive interactive mechanisms for coordination andharmonization should be implemented.The position statement further indicated that

WPA will continue exploring through its variouscomponents, particularly its Section on Classifica-tion and Diagnostic Assessment and pertinentInstitutional Programs, and in collaboration withWHO and national and regional associations, themost promising approaches to fulfill etiopathoge-nic and clinical diagnostic validities and theaccomplishment of the following principal devel-opmental tasks:

i) striving for the best possible core internationalclassification of mental disorders, attending to

Editorial

2

the elucidation of optimal definitions andthresholds for the ascertainment of mentaldisorders, utilizing complementary dimen-sional approaches, and taking into considera-tion the most appropriate cultural frameworkfor classification and diagnosis, and

ii) working for the development of the mostuseful comprehensive and integrative diagnos-tic models to enhance clinical care and healthpromotion.

Developing the best possible classification of mentaldisorders

This is widely regarded as an important task.Obtaining an improved nosology of mental disor-ders would respond to the well-established expec-tations of clinicians, researchers, educators andpublic health planners for a tool long considered ascrucial for their work. The assignment rules relatedto the definitions of the classified disorders wouldallow health professionals to identify them in theclinic and the community in a reasonably reliablemanner for their pertinent professional purposes.In the Laın-Entralgo (2) terminology outlinedearlier, this disorder identification process corres-ponds to nosological diagnosis.Of relevance to this critical task, WHO following

its constitutional responsibilities is launching thedevelopment of the 11th Revision of the Interna-tional Classification of Diseases. This work iscoordinated at the whole system level by theWHO Classification Office and at the mentaldisorders chapter level by the WHO MentalHealth Department. At this more specific level,the work is expected to include discussions on howthis chapter will fit within the whole system, theparticular uses of the classification in the mentalhealth field, the definition of mental disorders, theconceptualization of broad and narrow categories,the use of dimensionality, the presentation of theclassification for research and for clinical care inspecialized and primary care settings, the organ-ization of workgroups for major disorder categor-ies and cross-cutting themes, the harmonization ofthe ICD classification with those developed bynational and regional associations, and the engage-ment of world-wide scientific and stake holdercontributions. It is hoped that the development ofthe mental disorders chapter, through alpha andbeta versions, be completed around 2012, with apossible approval of the whole ICD-11 in 2014.WPA, which has a substantial record of collabor-ation with WHO on the matter (15, 16), willparticipate actively throughout this developmental

process, at the various levels of work and throughthe engagement of national psychiatric societiesand classification groups.The American Psychiatric Association, which

has contributed richly to the field through thepreparation and publication of path-opening edi-tions of its Diagnostic and Statistical Manual ofMental Disorders, particularly DSM-III and DSM-IV, is working intensively towards the preparationof a DSM-V (17). It is presently holding a series ofresearch conferences on psychopathological andmethodological aspects of the classification. It hasincluded WHO and WPA representatives in theiradvisory committees for DSM-V.There are also other national and regional

psychiatric associations which have developedsubstantial adaptations of the International Clas-sification of Mental Disorders to their particularcircumstances and purposes. Specially notable arethe Chinese Classification of Mental Disorders, 3rdEdition (CCMD-3) published by the ChineseSociety of Psychiatry (18), the French Classifica-tion of Child and Adolescent Mental Disordersprepared by the French Federation of Psychiatry(19), the Third Cuban Glossary of Psychiatry(GC-3) (20), and the Latin American Guide ofPsychiatric Diagnosis produced by the LatinAmerican Psychiatric Association (21). All theseassociations, among others, are expected tocontribute to the development of ICD-11 in coordi-nation with the World Psychiatric Association.Along with all this activity, a consensus is

emerging towards ICD-11 as a single internationalreference for the classification of mental disorders,with national and regional versions representingadaptations, annotations or extensions of the ICDcore classification.

Developing a Person-centered Integrative DiagnosticModel and Guide

The plan for the development of a Person-centeredIntegrative Diagnosis (PID) as a theoretical modelas well as a practical guide is an initiative of theWorld Psychiatric Association through its Institu-tional Program on Psychiatry for the Person(IPPP). Collaboration for this development isbeing arranged with WPA’s scientific sections andmember societies and their national diagnosis andclassification groups as well as with WHO. Thegrowth of the World Psychiatric Association inrecent years, in terms of the enlargement andstrengthening of the WPA family of nationalpsychiatric societies, its wide array of scientificsections, and active publications program is

Editorial

3

bolstering the position of WPA to undertake majorglobal initiatives such as PID.A key starting point for the development of PID

would be the schema combining standardizedmultiaxial and personalized idiographic formula-tions at the core of the WPA International Guide-lines for Diagnostic Assessment (IGDA) (22). Alsoinformative to this process would be the recentEvaluation of the DSM Multiaxial System, whichhas documented the value of such a system andoffered recommendations for its further develop-ment and implementation (23).At the heart of Person-centered Integrative

Diagnosis (PID) is a concept of diagnosis differentfrom the more conventional notion of just identi-fying and differentiating disorders. In PID, diag-nosis is tentatively defined as the description of thepositive and negative aspects of health, interact-ively, within the person’s life context. PID wouldinclude the best possible classification of mentaland general health disorders (expectedly the ICD-11 classification of diseases and its national andregional adaptations) as well as the description ofother health-related problems, and positive aspectsof health (adaptive functioning, protective factors,quality of life, etc.), attending to the totality of theperson (including his/her dignity, values, andaspirations). The approach would employ categor-ical, dimensional, and narrative descriptiveapproaches as needed, to be formulated andapplied interactively by clinicians, patients, andfamilies. It appears that PID comes close to Laın-Entralgo’s (2) concept of real diagnosis.The proposed phases for the development of

Person-centered Integrative Diagnosis, including itstheoretical model and its practical guide or manual,in terms of main activities and outcomes, follow.

i) Design of the Person-centered Integrative Diag-nostic (PID) Model. This would encompass areview of the pertinent background (includingthe monographs listed above) aimed at eval-uating critically the status of the diagnosticfield, its fundamental limitations to provide anadequate basis for clinical care and publichealth actions, and the most suitable andpromising domains and structures for thediagnosis of a person’s health. Possibledomains include illnesses, disabilities/func-tioning, risk and protective factors (resilience,resources, supports) and quality of life. Poss-ible structures may include multilevel schemasencompassing standardized (categories anddimensions) and idiographic/narrative infor-mation. This work would include literatureresearch conducted and discussed by members

of the IPPP Clinical Diagnosis Componentthrough the internet and face to face meetings,with input from WPA components and per-tinent health stakeholders. The timeline forthis phase would be calendar year 2007.

ii) Development of the Person-centered IntegrativeDiagnostic (PID) Guide. The sub-phases ofthe PID Guide development would include thefollowing:a)Preparation of the PID Guide draft. This

would include the schemas, instruments andprocedures to evaluate real persons accord-ing to each of the domains of the PID. Thiswork would include literature research andintense interactive discussions conducted bymembers of the IPPP Clinical DiagnosisComponent through the internet and face toface meetings, with input from WPA com-ponents and pertinent health stakeholders.This draft is hoped to be ready by the end of2008.

b)Evaluation of the PID Guide draft. Thisevaluation would be conducted by the IPPPClinical Diagnosis Workgroup in collabor-ation with the WPA Global Consortium ofClassification and Diagnosis Sectionsthrough clinical and epidemiological studiesusing reliability, validity, and feasibilitycriteria. This work is hoped to be completedby the end of 2009.

c)Preparation and publication of the finalversion of the PID Guide. This work will bebased on the results of the evaluative phaseoutlined above, expert discussions andhealth stakeholders input. This is hoped tobe accomplished by the end of 2010.

iii) Person-centered Integrative Diagnosis Guidetranslations, implementation, and training.This work would include, first, the translationof the PID Guide to prominent world lan-guages; second, the promotion and facilitationof the implementation of the PID Guideacross the world; and third, the developmentof training curricula and programs at gradu-ate, post-graduate and continuing professionaleducation levels both for specialty and pri-mary care arenas. The work would be con-ducted by the IPPP Clinical DiagnosisWorkgroup in collaboration with partnerorganizations in the year 2011 and thereafter.

Concluding remarks

The upcoming work on the development of thebest possible classification of mental disorders

Editorial

4

(through WHO’s ICD-11 and related versionsfrom the APA and other national and regionalpsychiatric associations) as well as that of aPerson-centered Integrative Diagnosis brings asense of excitement and historical responsibilityto the many institutions and individuals involved.It will be certainly a world-wide effort. In contem-plating this scenario from the pages of ActaPsychiatrica Scandinavica it is necessary to reflecton the enormous contributions from NordicEuropean colleagues to the foundations of thesedevelopments. We are celebrating this year the300th birthday of Carolus Linnaeus, who asprofessor of biology and medicine at UppsalaUniversity set key principles for systematization inthe life sciences. We must also recognize thecontributions of Stengel (24) to the internationalclassification of mental disorders and of Essen-Moeller and Wohlfahrt (25) to the original con-ceptualization of multiaxial diagnosis. Last, butnot least, we would like to thank Otto Steenfeldt-Foss (26), who has argued cogently that psychi-atry and medicine being based on science andhumanism must be personalized in diagnosis andcare.

Acta Psychiatrica ScandinavicaJuan E. Mezzich, Ihsan M. Salloum

Invited Guest Editors

References

1. Feinstein AR. Clinical judgment. Huntington, NY: RobertE. Krieger, 1967.

2. Laın-Entralgo P. El Diagnostico Medico: Historia y Te-orıa. Barcelona: Salvat, 1982.

3. Christodoulou GN (ed). Psychosomatic medicine. NewYork: Plenum Press, 1987

4. World Health Organization. WHO constitution. Geneva:WHO, 1946.

5. Herrman H, Saxena S, Moodie R. Promoting mental health:concepts, emerging evidence, practice. Geneva: WHO,2005.

6. Schmolke M, Lecic-Tosevski D (eds.) Health promotion: anintegral component of effective clinical care. DynamicPsychiatry 2003;36:221–319.

7. Mezzich JE. Positive health: conceptual place, dimensionsand implications. Psychopathology 2005;38:177–179.

8. Fulford KWM, Dickenson D, Murray TH. (eds.). Health-care ethics and human values: an introductory text withreadings and case studies. Malden: Blackwell, 2002.

9. Amering M. Trialog on Psychiatric Diagnosis. WPA Clas-sification Section Newsletter, August 2003 http://www.wpanet.org.

10. US Presidential Commission on Mental Health. Achievingthe promise: transforming mental health care in America.Final Report. DHHS Pub N: SMA-03-3832. Rockville,MD: US Department of Health and Human Services,2003.

11 WHO European Ministerial Conference on Mental Health.Mental health action plan for Europe: facing the chal-lenges, building solutions. Helsinki, Finland, 12–15 Janu-ary 2005. EUR/04/5047810/7, 2005.

12. Cox J, Campbell A, Fulford KWM. Medicine of the person.London: Kingsley Publishers, 2006.

13. Anthony W. Recovery from mental illness. The guidingvision of the mental health service systems in the 1990s.Psychosoc Rehabil J 1993;16:11–23.

14. Amering M, Schmolke M. Recovery–Das Ende der Un-heilbarkeit. Psychiatrie-Verlag, Bonn, 2007.

15. Mezzich JE, Ustun TB. International classification anddiagnosis: critical experience and future directions. Psy-chopathology 2002;35(Special Issue, March–June).

16. Banzato CEM, Mezzich JE, Berganza CE. Philosophicaland methodological foundations of psychiatric diagnosis.Psychopathology 2005;38:(Special Issue, July–August).

17. Kupfer DJ, First MB, Regier D (eds). A research agendafor DSM-V. Washington, DC: American PsychiatricAssociation, 2002.

18. Chinese Society of Psychiatry. Chinese classification ofmental disorders, Third Edition (CCMD-3). Author, Jin-an, 2002.

19. Mises R, Quemada N, Botbol M et al. French classificationfor child and adolescent mental disorders. Psychopathol-ogy 2002;35:176–180.

20. Otero AA. (ed.). Glosario Cubano de Psiquiatrıa (GC-3).Cuba: Hospital Psiquiatrico de La Habana, 2003.

21. APAL. Guıa Latinoamericana de Diagnostico Psiquiat-rico (Latin American Guide of Psychiatric Diagno-sis)(GLADP). Mexico: Editorial de la Universidad deGuadalajara, 2004

22. WPA2003. Essentials of the World Psychiatric Associ-ation’s International Guidelines for Diagnostic Assessment(IGDA). Br J Psychiatry 2003;182(suppl. 45):37–66.

23. Mezzich JE, Banzato CEM, Cohen P et al. Report of theAmerican Psychiatric Association Committee to Evaluatethe DSM Multiaxial System. Presented to the APAAssembly, Atlanta, May 21, 2005.

24. Stengel E. Classification of mental disorders. Bull WorldHealth Organization 1959;21:601–663.

25. Essen-Moeller E, Wohlfahrt S. Suggestions for theamendment of the official Swedish classification of mentaldisorders. Acta Psychiatr Scand 1947;suppl. 47:551–555.

26. Steenfeldt-Foss O. Patient- and Human-Rights and Bio-psychosocial Development in Psychiatry. Cairo: Jean De-lay Prize Lecture, WPA XIII World Congress ofPsychiatry, September 10–15, 2005.

Editorial

5