Diagnosis and classification of disorders specifically associated with stress: proposals for ICD-11
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The diagnostic concepts of post-traumatic stress disorder (PTSD) and other disorders specifically associated with stress have been intensively discussed among neuro- and social scientists, clinicians, epidemiologists, public health planners and humanitarian aid workers around the world. PTSD and adjustment disorder are among the most widely used diagnoses in mental health care worldwide. This paper describes proposals that aim to maximize clinical utility for the classification and grouping of disorders specifically associated with stress in the forthcoming 11th revision of the International Classification of Diseases (ICD-11). Proposals include a narrower concept for PTSD that does not allow the diagnosis to be made based entirely on non-specific symptoms; a new complex PTSD category that comprises three clusters of intra- and interpersonal symptoms in addition to core PTSD symptoms; a new diagnosis of prolonged grief disorder, used to describe patients that undergo an intensely painful, disabling, and abnormally persistent response to bereavement; a major revision of "adjustment disorder" involving increased specification of symptoms; and a conceptualization of "acute stress reaction" as a normal phenomenon that still may require clinical intervention. These proposals were developed with specific considerations given to clinical utility and global applicability in both low- and high-income countries.
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The ICD-11 proposal for complex PTSD was derived from the ICD-10 EPCACE diagnosis, but many aspects of its operationalization were based on the empirical literature that emerged from the DESNOS investigations.
“The ICD-11 proposal for complex PTSD 23 was derived from the ICD-10 EPCACE diagnosis, but many aspects of its operationalization were based on the empirical literature that emerged from the DESNOS investigations.”
From Emerging experience with selected new categories in the <scp>ICD</scp>‐11: complex <scp>PTSD</scp>, prolonged grief disorder, gaming disorder, and compulsive sexual behaviour disorder (2022) · cites this paper as [23]
The Complex PTSD section says the proposal replaces the overlapping ICD-10 diagnosis of enduring personality change after catastrophic experience. It also says the proposed symptoms draw on recent research, including a cited DESNOS study, but names other research and expert opinion as well; it does not establish that many aspects of operationalization came from DESNOS investigations. Page numbers were not available in our copy. (LLM, conf=0.83)
Experimental — accuracy not yet measuredSymptoms of PGD are associated with impairment of the bereaved person's familial, social, and occupational functioning to a similar extent as depression and post-traumatic stress disorder.
“Research have found symptoms of PGD to be associated with impairment of the bereaved person's famil ial, social, and occupational functioning to a similar extent as found for other mental disorders, e.g., depression and post-traumatic stress disorder (Jordan and Litz, 2014; Maercker et al., 2013; Prigerson et al., 2009; Shah and Meeks, 2012).”
From Prevalence of prolonged grief disorder in adult bereavement: A systematic review and meta-analysis (2017) · cites this paper as Maercker et al., 2013
The Prolonged grief disorder section says persistent severe grief is associated with significant impairment in general functioning and can make social activities difficult. It does not specify familial and occupational impairment or say that the impairment is similar in extent to that associated with depression or PTSD. (LLM, conf=0.88)
Experimental — accuracy not yet measuredThe grouping of disorders specifically associated with stress brings together disorders in which the experience of an identifiable stressor is a requirement (though not sufficient) for manifestation of the condition.
“The grouping of disorders specifically associated with stress brings together disorders in which the experience of an identifiable stressor is a requirement (though not sufficient) for manifestation of the condition.[48]”
From The Classification of Anxiety and Fear-Related Disorders in the ICD-11: Review: Anxiety and Fear-Related Disorders in ICD-11 (2016) · cites this paper as [48]
Based on its review of the evidence, the ICD-11 Working Group on Disorders Specifically Associated with Stress recommended inclusion of complex PTSD in the ICD-11.
“Based on its review of the evidence, the ICD-11 Working Group on Disorders Specifically Associated with Stress recommended inclusion of complex PTSD in the ICD-11 23 .”
PGD is included in the Appendix of DSM-5 and is expected to be included as a mental disorder in ICD-11.
“From a nosological perspective, expansions and alignment of this research seems crucial as PGD is included in the Appendix of DSM-5 and is expected to be included as a mental disorder in ICD-11 (Bryant, 2014; Maciejewski et al., 2016; Maercker et al., 2013; Rosner, 2015).”
From Prevalence of prolonged grief disorder in adult bereavement: A systematic review and meta-analysis (2017) · cites this paper as Maercker et al., 2013
CPTSD is intended to describe more pervasive post-traumatic reactions that, in addition to core PTSD symptoms, also include development of persistent symptoms of affect dysregulation, negative self-concept, and difficulties in relationships.
“CPTSD is intended to describe more pervasive post-traumatic reactions that, in addition to the core PTSD symptoms, also include the development of persistent symptoms of affect dysregulation, negative self-concept, and difficulties in relationships 58,59 .”
From An organization‐ and category‐level comparison of diagnostic requirements for mental disorders in <scp>ICD</scp> ‐11 and <scp>DSM</scp> ‐5 (2021) · cites this paper as [58]
The ICD-11 CDDG PTSD diagnosis is narrower than the ICD-10 diagnosis and requires here-and-now re-experiencing of intrusive symptoms and functional impairment.
“The ICD-11 CDDG for post-traumatic stress disorder diagnosis are conceptually narrower than the ICD-10 ones, and now require the presence of re-experiencing of intrusive symptoms in the “here and now”, as opposed to only experiencing intrusive memories of the traumatic event, as well as the presence of functional impairment 5 .”
The ICD-11 CDDG removed adjustment disorder subtypes because evidence for their validity or clinical utility was lacking.
“Similarly, the subtypes of adjustment disorder have been eliminated from ICD-11 CDDG because they lacked evidence for validity or clinical utility 5 .”
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The Adjustment Disorder–New Module 20 as a Screening Instrument: Cluster Analysis and Cut-off Values
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“The ICD-11 puts forward substantial revisions, guided by key organising principles regarding cross-cultural validity and clinical utility (see Maercker et al., 2013).”
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- Authors
- Maercker, A., Brewin, C. R., Bryant, R. A., Cloitre, M., van Ommeren, M., Jones, L. M., Humayan, A., Kagee, A., Llosa, A. E., Rousseau, C., Somasundaram, D. J., Souza, R., Suzuki, Y., Weissbecker, I., Wessely, S. C., First, M. B., & Reed, G. M.
- Affiliations
- Department of Psychology; Division of Psychopathology; University of Zurich; Switzerland
- University College London (GB)
- UNSW Sydney (AU)
- Division of Dissemination and Training; National Center for PTSD; Menlo Park; CA; USA
- Department of Mental Health and Substance Abuse; World Health Organization; Geneva; Switzerland
- Harvard University (US)
- Benazir Bhutto Hospital (PK)
- Stellenbosch University (ZA)
- Epicentre (FR)
- McGill University Health Centre (CA)
- University of Jaffna (LK)
- International Committee of the Red Cross (CH)
- National Center of Neurology and Psychiatry (JP)
- International Medical Corps (US)
- King's College London (GB)
- Columbia University Irving Medical Center (US)
- World Health Organization (CH)
- ORCID
- Venue
- World Psychiatry
- Publisher
- Wiley
- Published
- 2013-10
- Volume
- 12
- Issue
- 3
- Pages
- 198-206
- ISSN
- 1723-8617 (ISSN-L)
- PMC
- PMC3799241
- OpenAlex
- W1986344781
- Cited by
- 762
- References
- 41
- Citations by year
- 2026: 36 · 2025: 46 · 2024: 54 · 2023: 58 · 2022: 72 · 2021: 58 · 2020: 89 · 2019: 58 · 2018: 83 · 2017: 80 · 2016: 50 · 2015: 47 · 2014: 20 · 2013: 6 · 2012: 1
- FWCI
- 45.62
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- World Psychiatry (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Research Portal (King's College London) (publishedVersion, other-oa)
- Zurich Open Repository and Archive (University of Zurich) (acceptedVersion, other-oa)
- UCL Discovery (University College London) (submittedVersion)
- Zurich Open Repository and Archive (University of Zurich) (submittedVersion, other-oa)
- Zurich Open Repository and Archive (University of Zurich)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Posttraumatic Stress Disorder Research
- Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
- Social Sciences › Arts and Humanities › Philosophy › Mental Health and Psychiatry
- Keywords
- post-traumatic stress disorder, ICD-11, complex PTSD, prolonged grief disorder, adjustment disorder, acute stress response, diagnostic classification, bereavement, clinical utility, high- and low-income countries
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