The “yes/no” item for this question was presented to all participants. For those who responded to this item (n=3193, 99.1%), 45.9% (n=1465) responded “yes.” A greater proportion of psychiatrists (n=972, 47.6%) than psychologists (n=493, 42.9%) responded “yes” to this question (χ2 (1)=3.9, p=.01), indicating that they considered at least one diagnostic category to be problematic.

Of those professionals who responded “yes,” 1301 (88.8%) provided an explanation for their response in the open-ended follow-up question and were included in the content analysis. The remaining 164 (11.2%) participants who responded “yes” were not included in this content analysis because they did not give an explanation for their previous affirmation of the existence of problematic categories or gave responses that were too vague to be coded (e.g., “I think that categories should be changed”2; “too many to give any answer”). A total of 99 specific diagnoses were described as problematic. In addition, two general (nonspecific) response groups were identified, including those who referred to all diagnoses or general aspects of diagnosis (e.g., “too many criteria to diagnosis”, “the whole concept is unsatisfying”) or unspecified diagnoses (e.g., “most of the criteria that have a NOS category - which ends up being used as a dustbin for any diagnosis we are unable to fit in anywhere else”). Diagnoses that were mentioned by fewer than 10 participants were excluded from analyses. In total, 24 specific diagnoses were considered to be problematic or unsatisfactory in regular clinical practice, in addition to the two previously defined general response groups. Table 2 shows the number and percentage of respondents who described any specific diagnostic categories as problematic.

Perceptions of problematic diagnoses may differ between professionals from different disciplines. To examine this possibility, we compared the frequency with which psychologists and psychiatrists identified specific diagnostic categories as problematic. The diagnostic categories that were mentioned by at least 30 participants (psychologists or psychiatrists) are presented in Figure 1. A total of 1187 observations were included and grouped in 13 specific diagnoses and one general group

Figure 1.

Diagnostic categories considered problematic by psychiatrists and psychologists.

(0.18MB).

There were some differences by profession in the diagnoses described as problematic. A higher percentage of psychologists considered posttraumatic stress disorder, pervasive developmental disorders, and attention-deficit (hyperactivity) disorders as problematic when compared to psychiatrists. More psychiatrists than psychologists perceived schizoaffective disorder and somatoform disorders as problematic (χ2 (13)=171.8, p<.001).

In about two-thirds of the responses (68.5%; n=813), participants went on to explain the reason why they considered the mentioned diagnoses as problematic. These open-ended explanations showed considerable variability in terms of content and level of detail provided. Through inductive content-analysis categorization, four major themes were identified for why a diagnosis was considered problematic: 1) Validity, where the diagnosis or the diagnostic requirements do not have adequate specificity or scientific foundation as they are currently formulated (e.g., “the criteria are too broad and the differences among patients with that diagnosis too big”); 2) Assessment, which includes dissatisfaction with the methods for evaluating diagnostic criteria, symptomatology, and severity (e.g., “a continuum based on severity would be better and more significant”); 3) Applicability, where important features of specific populations (e.g., based on gender, cultural background, or age) are not acknowledged by the diagnostic requirements (e.g., “this diagnosis is poorly fit into aged clinical population”); and 4) Exclusion, where the actual diagnostic requirements omit symptoms or areas relevant to the diagnosis (e.g., “neurocognitive deficits are an important aspect and so are social cognitive deficits but they are not included in the current diagnostic criteria”).

Validity was the main reason provided by psychologists (n=274, 75.3%) and psychiatrists (n=188, 41.9%) for why they considered any particular diagnosis to be problematic. The second and third most common reasons were related to Applicability (psychiatrists n=100, 22.3%; psychologists n=34, 9.3%) and Assessment (psychiatrists n=82, 18.3%; psychologists n=34, 9.3%). Psychiatrists (n=79, 17.6%) and psychologists (n=22, 6%) referred to Exclusion least often (χ2 (3)=92.6, p<.001). The percentage of responses for diagnostic categories most frequently identified as problematic for reasons of validity are presented in Table 3, along with prototypical examples of participants’ views that reference poor validity. For the general category of “all diagnoses,” the most common rationales related to Exclusion (n=23, 48.9%; e.g., “not so clear, from a clinical point of view insufficient description”).

When results were compared by geographical region, personality disorders were the diagnoses most reported as problematic in Europe (n=160, 22%), Asia (n=39, 23.4%) and Eastern Mediterranean (n=8, 18.2%). For Latin America and Africa, the report of all diagnoses as problematic was the most frequent (n=27, 24.8% and n=16, 36.4%, respectively), while bipolar disorder was the most cited diagnosis by participants in North America (n=19, 20%).

The “yes/no” item for this question was presented to all participants and 95.4% (n=3074) responded to it; 978 (31.8%) gave a “yes” response, indicating that additional diagnostic categories should be added to the classification. Of those who responded “yes,” 237 (26%) did not specify the diagnoses to be included or gave answers that were unclear or not related to the initial question (e.g., “of course we need these, that is why we sometimes diagnose patient as not otherwise specified”; “sometimes the clinical symptoms do not match criteria so it is not possible to label patient as mentally ill”). Thus, a total of 85 diagnoses that were reported by 741 respondents. Diagnoses that were suggested more than 10 times are shown in Table 4.

Frequencies for the most commonly mentioned diagnoses (by≥4% of the total sample, 330 total reports) were compared between psychiatrists and psychologists (Figure 2). Psychiatrists and psychologists recommended the inclusion of culture-related disorders at similar rates. Compared to psychologists, a higher percentage of psychiatrists suggested the addition of addiction as a specific diagnosis, attention deficit disorder in adults and culture-related disorders. On the other hand, more psychologists reported the need to include complex post-traumatic stress disorder and narcissistic personality disorder when compared to psychiatrists (χ2 (4)=53.2, p<.001).

Figure 2.

Diagnoses proposed by psychiatrists and psychologists to be added to mental disorders classifications.

(0.11MB).

Culture-related disorders and addiction as a specific diagnostic category were the two most frequently cited diagnoses to be added by participants from Latin America (n=17, 45.9% and n=14, 37.8%, respectively), Asia (n=26, 37.1% and n=31, 45.6%, respectively) and the Eastern Mediterranean (n=5, 45.1% each one). Among participants from Europe (n=82, 44.1%), Africa (n=6, 40%) and North America (n=7, 53.8%), complex post-traumatic stress disorder was the most frequently suggested diagnosis to be included in classification systems.

The “yes/no” item for this question was answered by 3115 (96.7%) of the participants. Of these, 27.2% (n=848) responded “yes,” indicating that the diagnostic system they used contained stigmatizing terminology. One-hundred and twelve answers were not included in the subsequent content analysis of this item as respondents gave nonspecific responses (e.g., “there are many examples; the medical context makes the person irrelevant and parts of body relevant; of course but that cannot preclude their use in a clinical setting. Any new term will become stigmatized if it refers to an unfavorable state”). A total of 42 specific diagnoses were described as stigmatizing. Diagnoses mentioned by more than five percent of the total sample are presented in Table 5. These diagnoses account for 74.3% of the total positive observations for this item.

The most frequently reported stigmatizing diagnoses were compared by profession (Figure 3). Psychiatrists were more likely to view schizophrenia as a stigmatizing diagnosis, while a higher percentage of psychologists viewed personality disorders as stigmatizing, particularly borderline personality disorder (χ2 (4)=39.7, p<.001).

Figure 3.

Diagnoses perceived as stigmatizing by psychiatrists and psychologists.

(0.09MB).

Reasons for stigmatization were given for only 24.7% (n=135) of the 546 reported instances of the most frequently reported stigmatizing diagnoses. Coding of the open-ended explanations for this item indicated four primary reasons that particular diagnoses were considered stigmatizing: 1) Lack of understanding or knowledge about the diagnosis among the general population (e.g., “most people don’t understand that schizophrenia doesn’t mean a total catastrophe for your life”; “are all words commonly used by non-professionals that make them have other meanings among common people”); 2) Negative meaning, where the diagnosis or diagnostic requirements are generally viewed as offensive, derogatory, or having other nonspecific negative associations (e.g., “the term gives the impression that the very essence of the persons being is wrong and pathologic”; “diagnosis is culturally pejorative”); 3) Violence, where the diagnosis is perceived to be associated with aggression, dangerousness and violent behavior (e.g., “schizophrenia is often connected to violence”; “understood in popular culture as describing multiple personality disorder of the Dr. Jekyll and Mr. Hyde kind”); and 4) Translation and cultural aspects, including instances where the adaptation of definitions to other languages and cultural settings leads to stigmatizing terms for specific societies (e.g., “in Chinese it means ‘Mad’ or ‘Loss of Mind’; “translation of the terms sounds awkward in our culture”).

Schizophrenia was considered stigmatizing because of public lack of understanding of the condition (n=27, 42.9%; e.g., “I think the term ‘schizophrenia’ often is misunderstood be the larger public, for instance media, and in ways that may harm patients and create fear among common people”), as well as the public perception of its being linked to violence (n=8, 12.7%; e.g., “schizophrenia is often connected to violence”). The main reasons that specific personality disorders were considered stigmatizing related to negative connotations of the diagnoses (n=29, 74.4%; e.g., “all the personality disorders are used in a derogatory way”) followed by difficulties in translation and cultural aspects (n=8, 20.5%; e.g., “personality disorder/personlighetsforstyrrelse (Norwegian) refers to something very personal, as if the person is bad/wrong/broken”). For borderline personality disorder, negative connotations (e.g., “most of the borderline personality disorders description is far to judgmental and negative in wording”) and lack of understanding (e.g., “borderlines are often spoken about as if they are hopeless cases, making many who receive that diagnose feel stigmatized and lose any hope for getting help or becoming better”) were the main reasons cited for stigmatization (n=7, 63.6% and n=4, 36.4%, respectively). For mental retardation, negative connotations (n=11, 73.3%; e.g., “mental retardation makes people think of human vegetables”), difficulties in translation and cultural factors (n=2, 13.3%; e.g., “mental retardation - in Norwegian: psykisk utviklingshemming - is indeed a stigmatizing term”) and lack of understanding (n=2, 13.3%; e.g., “often people use this term disparagingly, calling someone a retard”) were the reasons described for stigmatization. Finally, for mental disorders in general, both negative connotations (n=5, 71.4%; e.g., “the word ‘mental’ itself is popularly believed to mean a typical disorganized person found on the streets and the same meaning is attached by public to all psychiatric symptoms and to the field of psychiatry”; “most terms are regarded as offensive”) and difficulties in translation and cultural factors (n=2, 28.6%; e.g., “the concept of ‘disorder’ is difficult to separate from cultural differences”) were the reasons cited for their being viewed as stigmatizing.

Schizophrenia was the most frequently identified stigmatizing diagnoses by participants in Asia (n=32, 54.2%), the Eastern Mediterranean region (n=14, 53.8%), Europe (n=151, 41%) and Latin America (n=25, 46.3%). Mental retardation was the most frequently identified stigmatizing diagnosis by participants in Africa (n=6, 42.9%) and borderline personality disorder in North America (n=11, 44%).

Ninety-seven percent of the participants (n=3,053) answered the “yes/no” item. Of these, 14.4% of participants (n=441) responded “yes” to this item, indicating a need for a national diagnostic classification system that is more than just a translation of the ICD.

A total of 324 (73.4%) of the participants provided specific explanations for their affirmation of the need for a national classification system. The main reasons were: 1) the classification needs to consider cultural and socio-historical differences of societies (n=194, 59.9%; e.g., “we have a unique culture and experience, so we need our own classification system”, “nations and cultures require diagnostic criteria that address the human in the context of culture”); 2) there is a different perception of what is and what is not pathological by country (n=56, 17.3%; e.g., “in some societies it is considered normal to fear witchcraft”; “the presentation of psychotic symptoms in a person may be viewed from a cultural perspective as a transition state to becoming a ‘traditional healer”’); 3) the inclusion of an additional national diagnostic system that would complement (rather than replace) current classifications (n=56, 17.3%; e.g., “may be some sort of complementary classification considering culture and language”; “perhaps adding extra criteria - relevant to our society - that would aid in making diagnoses”); and 4) to emphasize the national adaptation as a way to avoid using foreign classifications (n=18, 5.6%; e.g., “it is difficult to identify true etiologies when using foreign classifications”; “it is better to describe the reality with your own language”). Significant professional differences were found for two of the response categories: the third reason (national supplement for general classifications) was more frequently reported by psychiatrists than psychologists (21.2% vs. 10.7% respectively; χ2 (1)=5.77, p=.01), while the fourth reason (national adaptation to avoid using foreign classifications) was more frequently reported by psychologists than psychiatrists (9.9% vs. 3.0%; χ2 (1)=7.0, p=.008).

There were regional differences in the proportion of participants who identified a need for a national classification. US psychologists and European psychiatrists and psychologists were least likely to endorse the need for a national classification (5.8% and 4.4%, respectively), followed by the Eastern Mediterranean. Higher proportions of psychiatrists and psychologists from the Asian (23.9%), African (33.3%) and Latin American (33.7%) regions endorsed the need for a national classification.

The most problematic diagnostic group was specific personality disorders, especially among psychiatrists. Clinicians generally cited poor validity and a lack of specificity as their reasons for finding these categories to be inadequate. Nevertheless, the classification of personality disorders that has been included in DSM-5 (American Psychiatric Association, 2013) is unchanged from that in DSM-IV, though a very complicated dimensional alternative system was also included in an appendix. Findings suggest that, in order to improve clinical utility of the forthcoming ICD-11, a major revision of the guidelines for personality disorders should be undertaken, perhaps focusing on differential characteristics or a different conceptual system to reduce overlap among disorders. In fact, a major revision and simplification of the classification of personality disorders has been proposed for ICD-11 (Tyrer, Crawford, & Mulder, 2011), consistent with these findings. These data also suggest a need for training efforts related to this area of the ICD-11.

Complex post-traumatic stress disorder was the most frequent diagnosis suggested for inclusion in the classification of mental disorders, especially by psychologists. Participants reported that the diagnostic system needed to better account for the consequences of complex trauma and the differentiated processes that can arise when people experience extreme or prolonged traumatic stressful events from which escape is difficult or impossible. This is consistent with proposals for disorders specifically related to stress in ICD-11 (Maercker et al., 2013), which include the addition of complex post-traumatic stress disorder, characterized by the core symptoms of PTSD as well as difficulties in emotion regulation, beliefs about oneself as diminished, defeated or worthless, and difficulties in sustaining relationships. This category was not added to the DSM-5 (American Psychiatric Association, 2013).

Some other categories recommended for inclusion by clinicians are already a part of the proposed content of ICD-11. These include bipolar type II disorder (Strakowski, 2012) and Binge eating disorder (Al-Adawi et al., 2013), both of which are also in DSM-5, as well as prolonged grief disorder (Maercker et al., 2013), none of which were included in DSM-5. Lewy body dementia is proposed for inclusion in the chapter on Diseases of the Nervous System. Other suggests reflect some lack of clarity about the contents of ICD-10. Attention deficit disorder is called hyperkinetic disorder in ICD-10, and diagnosis in adults is specifically permitted, though a key characteristic of the disorder is its early onset. Proposals for ICD-11 include changing the name of these disorders to attention deficit disorders. The proposed revision for ICD-11 also permits their diagnosis in adults, though continues to describe them as characterized by onset in early life (childhood or adolescence). Unlike DSM-5, proposals for ICD-11 include a category of attention deficit disorder without hyperactivity. Some of the other categories recommended by clinicians were considered by ICD-11 Working Groups but not recommended for inclusion in ICD-11. A complete list of categories proposed for inclusion in ICD-11 can accessed at http://apps.who.int/classifications/icd11/browse/l-m/en, and will be modified based on an extensive review and comment process and the results of field studies.

In terms of diagnoses that clinicians considered to be stigmatizing, as was hypothesized and in line with previous research (Nunnally, 1961; Pescosolido et al., 1999), schizophrenia was the diagnosis most frequently identified, mainly due to lack of public understanding or knowledge about the diagnosis. Further contributing to the stigma, the diagnostic term is used inaccurately in common language within the general population and is often (incorrectly) associated with aggression, dangerousness, and violent behavior. In response to these factors, the Japanese Society of Psychiatry and Neurology decided to change the Japanese term for schizophrenia from “seishin bunretsu byo” (“mind-split-disease”) to “togo shitcho sho” (“integration disorder”), in an effort to reduce the stigma related to schizophrenia and to improve clinical practice in the management of the disorder (Sato, 2006).

Indeed, proposed modifications in the names of specific stigmatized diagnoses as a part of the development of ICD-11 involve complex and sensitive social issues (e.g., Drescher, Cohen-Kettenis, & Winter, 2012). Also, participants in the present study reported problems regarding the translation of terms to other languages and cultural settings were reported. According to clinicians, translation issues could lead to stigmatizing terms for specific societies. Better translation of diagnostic terminology into different languages may help to support WHO's goal of reducing the stigma of mental disorders in order to increase access to care (World Health Organization, 2012).

The specificity of the sample and the non-probabilistic method for recruiting participants suggests some that a degree of caution in generalizing the results is warranted, even to all English- and Spanish-speaking psychiatrists and psychologists. Thus, the present findings should not be interpreted as representing all clinicians or all countries, but rather as providing suggestions and rationales based on a very large sample of English- and Spanish-speaking psychiatrists and psychologists in diverse contexts in 35 countries. Another limitation is that it was not possible for the purposes of the present study to examined open-ended responses in the languages other than English and Spanish in which the original surveys were administered: a total of 17 additional languages for the WHO-WPA survey, and three additional languages for the WHO-IUPsyS survey, limiting the global richness of the present analysis.

Moreover, the open-ended responses that were analyzed in the present study were in response to structured “yes/no” questions that focused on specific issues. If psychologists and psychiatrists had been asked in a more open-ended way about what aspects of current classification systems they found problematic or how they thought that classification systems could be improved, a variety of other themes would likely have emerged. Some of these issues, such as the importance of incorporating a dimensional perspective and role of functional impairment in diagnosis, were the focus of closed-ended questions in the original surveys (see Evans et al., 2012; Reed et al., 2011), but were not follow up with open-ended questions. A more systematic examination of clinicians’ open-ended suggestions for how classification systems might be improved would clearly be possible. Such studies could also address the aspects of existing classifications that clinicians find helpful and satisfactory, as a way to gain additional insight into what kinds of descriptors, heuristics, or content should be included in potential diagnostic categories.

Another important area for further research would be more systematic assessments of the experiences of health care providers who are not mental health specialists. WHO (2012) has indicated that the develop the capacity of these professionals to identify individuals who need mental health services and to provide basic treatment will be a critical aspect of addressing the global gap between treatment needs and available services, especially in low- and middle-income countries.