Tanı nın büyüsünü bozmak…

Dr. T. Bedirhan ÜstünDünya Sağlık Örgütü

Sınıflandırma Terimleme ve Standardlar Bölümü

“The world is hollow and I touched the sky ! ”

… BUILDING BLOCKS OF HEALTH INFORMATION …

CLASSIFICATIONS TERMINOLOGIES & standards

Diagnostic Statistical Manual

1952 DSM I 1968 DSM-II 1980 DSM-III 1987 DSM-III-R 1994 DSM-IV 2000 DSM-IV-TR 2013 DSM 5

ICD-6 ICD-8 ICD-9

ICD-10

ICD-11

International Classification ofDiseases

Beden – Zihin Ayrılığı Rene Descartes (1595-1650)

Discourse on Method (1637) Beden / zihin “dichotomy”

The Meditations ( 1641) Fiziksel / Ruhsal (mental) “dichotomy”

Fiziksel dünya maddeden kurulu

Bu aslında 'tek' bir maddedir

Ama her insan zihni kendine özgüdür

O zaman zihin ve beden ayrı ayrı maddelerden kurulu olmalıdır.

"Psychiatrists of Europe! Protect your sanctified diagnoses!”

Cartoon by Emil Kraepelin, "Bierzeitung", Heidelberg 1896

Death of the author

Birth of the reader ?

Am J Psychiatry 119:210-216, September 1962doi: 10.1176/appi.ajp.119.3.210© 1962

RELIABILITY OF PSYCHIATRIC DIAGNOSES : 1. A CRITIQUE OF SYSTEMATIC STUDIESAARON T. BECK M.D.1

1 Dept. of Psychiatry, University of Pennsylvania and the Philadelphia General Hospital.

Pertinent systematic studies of the reliability of psychiatric diagnosis were critically examined. It was pointed out that each of these studies presented certain methodological problems which made their findings inconclusive. An experimental design was presented to meet these problems and thus yield a more informative index of reliability. By systematically varying the important variables, such as the level of experience of the psychiatrists, the time interval between interviews, the use of ancillary information, and the degree of refinement of the nosological categories, it will be possible to determine their effects on reliability.

Roger Peele and Paul Luisada, in Washington, D.C., wrote a paper on “hysterical psychoses”

Spitzer went to meet them: During a forty-minute conversation, “hysterical psychoses” was divided into two disorders: Short episodes of delusion and hallucination would be

labelled “brief reactive psychosis,” The tendency to show up in an emergency room without

authentic cause would be called “factitious disorder Then Bob asked for a typewriter, and banged out

criteria sets for factitious disorder and for brief reactive psychosis

On the origins of BOGSAT

Operationalization

Hayali Bir Çin

Ansiklopedisinden AlıntıHayvanlar şu sınıflara ayrılırlar:

imparatora ait olanlar mumyalananlar evcilleştirilmiş olanlar süt domuzları deniz kızları kaf dağından gelenler başıboş köpekler bu sınıflandırmaya girenler kuduranlar sayılamayacak denli çok olanlar ince deve tüyünden yapılan fırça ile boyanmış olanlar ve saire su testisini kırmış olanlar uzaktan sineklere benziyenler Borges 1977

ICD – DSM ≈ Common Language ?

Pseudoconsensus ? Communication : ↑ ↓ Mutual data exchange ↔ Confusion

Research & Science : ↑ ↓ Common framework ↔ Straitjacket

Clinical utility : ↑ ↓ Reliable assessment ↔

Reductionism

Public Health : ↑ ↓ Guides decision making ↔

Conformism

Human Rights : ↑ ↓ Protection ↔ Discrimination and

stigma

World Mental Health Surveys: 12 month prevalence of MOOD disorders

Kessler & Üstün, 2008 CUP

United StatesUkraineFrance

NetherlandsColombiaLebanon

Belgium

Spain

MexicoItaly

GermanyJapan

PRC Beijing

PRC ShanghaiNigeria

Prevalence

Her insan yaşadığı dönemin ürünüdür

1950 ler psikoanaliz – beyinsiz bir psikiyati

1970 ler indirgemeci – zihinsiz bir psikiyatri

1990 ler beyin – beyin dönemi

decade of the brain

Ruhsal Bozuklukların ardında ne var ?

Ruhsal bozukluklar Beyin Hastalığı mıdır?

İşlev bozukluğu hastalık ilişkisi Her islev bozukluğunda

hastalık ortaya çıkıyor mu?

Her hastalık tablosunda aynı işlev bozukluğu görülüyor mu?

Understanding Mood DisordersThe Biological Perspective

Brain Disorders: Scale & Scope

Disorders of the Human Connectome

A.  A behavioral or psychological syndrome or pattern that occurs in an individual B.  That reflects an underlying psychological dysfunction C.  The consequences of which are clinically significant distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) D.  Must not be merely an expectable response to common stressors and losses (for example, the loss of a loved one) or a culturally sanctioned response to a particular event (for example, trance states in religious rituals) E.  That is not primarily a result of social deviance or conflicts with society   

Definition of a Mental Disorder(DSM 5 proposal, 2010)

Psikiyatri ... TIP

Robins and Guze clinical description laboratory studies delimitation from others disorders

follow-up studies (stability for diagnosis)

family studies

DSM 5 Validity Criteria

Bedensel Hastalıklar

He

ritab

ility

BreastCancer

Hyper-tension

IschemicHeart

Disease

RheumatoidArthritis

0.8

0.6

0.4

0.2

0

Ruhsal Hastalıklar

He

ritab

ility

Depression ADHD Schizo-phrenia

Bipolar

0.8

0.6

0.4

0.2

0Autism

The Meaning of the Human GenomeProject for Neuropsychiatric Disorders

Steven E. HymanProvost, Harvard University and Professor of Neurobiology,

Harvard Medical School Boston, MA, USA

Gen-Davranış Pathway(Ustun, 2005)

Genotypes Endophenotypes Phenotypes

N1

N2

N3

G1

G2

G3

G4

P1

P2

P3

P4

B1

B2

B3

GeneticNeuro-physiological Psychological Behavioural

Units of analysis Genes Molecules Cells Neural Circuits Physiology Behaviours Self Reports (Paradigms)

Research Domain Criteria NIMHDimensions of Observable neurobiological measures

RDoC Constructs

Schizophrenia as a brain disease

Source: Thompson et al. 2001

A Developmental Brain Model For Schizophrenia

Lieberman, Insel Issue Joint Statement About DSM-5 and RDoC - 14 May 2013

.. they acknowledged that along with the International Classification of Diseases, DSM "represents the best information currently available for clinical diagnosis of mental disorders" and that the two publications "remain the contemporary consensus standard to how mental disorders are diagnosed and treated." … mental illness will be best understood as disorders of brain structure and function that implicate specific domains of cognition, emotion, and behavior," which is the focus of the RDoC initiative

Psikiyatrinin Genel Tıp içinde yer alışı: son dönem

1964 International Pilot Study on

Schizophrenia

1972-75 Diagnostic Criteria for Research

1980 DSM-III

1993 ICD-10 - DSM-IV

2001 ICF

Ruhsal Bozuklukların Tanısı

ICDASpecific

phenomenologyBSigns and

SymptomsC….

DExclusion rules

DSMASpecific

phenomenologyBSigns and

SymptomsCDISABILITY &

DISTRESS

DExclusion rules

Hastalık ve Yetiyitimi ayrı ayrı ele alınması

+ = olgu

Tanı Yetiyitimi = olgu

Definition of Disease (ICD)a set of dysfunction(s) in any of the body systems

including:

with a known pattern of signs, symptoms & findings symptomatology - manifestations

probably with an underlying explanatory mechanism etiology

a distinct pattern of development over time course and outcome

a known pattern of response to interventions treatment response

with linkage to underlying genetic factors genotypes, phenotypes and endophenotypes

with linkage to interacting environmental factors

Ontology (philosophy)– the Organization of Reality

!!!

Ontology (computer science) – the explicit – operational

description of the

conceptualization of a domain:Concepts: entity and quality

(properties and attributes)

An ontology defines:– a common vocabulary a

shared understanding/exchange:among people

among software agents

between people and software– to reuse data - information– to introduce standards to allow

interoperability

What is Ontology?

43

Content Model

• A structured framework• captures the knowledge that underpins the definition of an

ICD entity• Represents ICD entities in a standard way• Allows computerization

• Each ICD entity is defined by “parameters” representing different dimensions

• A parameter is expressed using standard terminologies “value set”

44

THE CONTENT MODELAny Category in ICD is represented by:

1. ICD Concept Title1.1. Fully Specified Name

2. Classification Properties2.1. Parents2.2 Type2.3. Use and Linearization(s)

3. Textual Definition(s)

4. Terms4.1. Base Index Terms4.2. Inclusion Terms4.3. Exclusions

5. Body Structure Description 5.1. Body System(s) 5.2. Body Part(s) [Anatomical Site(s)]5.3. Morphological Properties

6. Manifestation Properties6.1. Signs & Symptoms 6.2. Investigation findings

7. Causal Properties7.1. Etiology Type7.2. Causal Properties - Agents7.3. Causal Properties - Causal Mechanisms 7.4. Genomic Linkages7.5. Risk Factors

8. Temporal Properties8.1. Age of Occurrence & Occurrence Frequency8.2. Development Course/Stage

9. Severity of Subtypes Properties

10. Functioning Properties10.1. Impact on Activities and

Participation10.2. Contextual factors10.3. Body functions

11. Specific Condition Properties11.1 Biological Sex11.2. Life-Cycle Properties

12.Treatment Properties

13. Diagnostic Criteria

ICD Revision

ICD11 βetahttp://www.who.int/classifications/icd/revision

Beta – Browser & Print 10 look & feel

+ descriptions – code structure !

• ICD-11 Beta draft is NOT FINAL

• updated on a daily basis

•NOT TO BE USED for CODING except for agreed FIELD TRIALS

βeta

ICD-11

Comments Proposals Field Trials Review Mechanism

48

ICD-11 Features

Internet Based Platform

Content Model

Multi Lingual Representations

Definitions

Input from all Stakeholders

Arabic لعربية 官话 ChineseEnglish EnglishFrançais FrenchРусский язык Russian Español Spanish Deutsch German Português Portuguese

Field Trials for Use Cases

Electronic Health Record Ready

Rewriting ICD Using SNOMEDexample of Depressive Disorder

F32.0

A. Low mood {41006004}

Loss of interest {417523004 }

Low energy {248274002}

1. Appetite (decrease, increase) {64379006, 72405004}

2. Body weight (decrease, increase) {89362005, 8943002}

3. Sleep (decrease, increase) {59050008, 77692006}

4. Psychomotor (decrease, increase) {398991009, 47295007}

5. Libido loss {8357008}

6. Low self esteem {286647002, 162220005}

7. Guilt, self blame {7571003}

8. Thoughts of death …

9. Suicide Ideation {102911000, 6471006}

B.

ICD11 Field Trials Basic aims

To test the “fitness of ICD-11 for multiple purposes” Mortality coding Morbidity coding Quality & Safety Other use cases

To ensure the comparability between ICD-10 and ICD-11 To increase consistency, identify improvement paths, and reduce errors

.

Key Assessments:

Applicability – feasibility easy to use

Reliability - consistency gives same results in the hands of all

Utility - added value renders useful information

Inter-rater reliability The Case information

live medical record

Coded using ICD11 by at least

two different people

Agreement rates measured

Incentives for Participants

Phenomenology

Psychopathology

Syndromes

Clinical Intuition

Expert Consensus

Phenotypes

Neuroscience

Physiology

Epidemiologica

l Val idation

Evidence base

ICD Revision: Change of Paradigm

Son sözlerBilim Kuramı

1. Dünya bir sahneShakespeare

2. Dünya bir kütüphane Borges

3. Dünya bir göstergeler evreni Umberto Eco

4. Dünya bir ağ: …. Herşey birbiriyle bağıntılı Semantic Web

Son sözlerTıp Bilimleri

Genel bir hastalık kuramı sınıflandırma

• Tanım• Boyutlar• genler – devreler - eşikler

• Yetiyitiminin ayrışımı

Son sözlerFelsefe – Politik – Pratik

Ruh Sağlığı Genel Sağlık • Denklik• Birliktelik

Descartes huzur içinde yatsın ! ….

Soru & Yorumlar

ustunb@who.int

@ustunb