Earlier this month, Spencer Evans and colleagues published data from their field study comparing the ICD-11 with ICD-10 and DSM-5 in terms of their classifications of irritability and oppositionality in youth. In this study, 196 clinicians from 48 countries were randomly assigned to review one of the three diagnostic systems and to use it to assess validated vignettes describing youths referred for clinical services. Then, the study authors evaluated how well the clinicians identified chronic irritability versus non-irritable oppositionality, episodic bipolar disorder, dysthymic depression and normative irritability, according to their assigned diagnostic system. We asked Dr. Evans, the study’s lead author, to explain and provide his opinion on the study findings:
“This study was not about understanding the true nature of psychopathology or evaluating how well a diagnostic system corresponds to that nature. Instead, our focus was on clinical utility”, he says. “We found that, compared to ICD-10 and DSM-5, the ICD-11’s approach to classifying youth oppositionality and irritability may lead to overall more accurate diagnosis of disruptive mood and behaviour problems in youth.” He went on to explain that clinicians who were randomly assigned to use DSM-5 generally did not apply the Disruptive Mood Dysregulation Disorder (DMDD) diagnosis when it was appropriate, and they tended to over-assign mental disorder diagnoses to a case with developmentally normative irritability.
“In terms of implications, I think these findings lend support for the clinical utility of the ICD-11 formulation of irritability and oppositionality, as described in its section on Disruptive Behaviour and Dissocial Disorders”, proposes Evans. “Our results also suggest that mental health professionals may tend to conceptualize Oppositional Defiant Disorder as such, whether it is accompanied by chronic irritability or not, and irrespective of the diagnostic system being used”.
Going forward, the researchers consider that data generated using various different methodologies, such as epidemiological, clinical, behavioural, neuroscientiﬁc, and genetic approaches, are now required to better understand and evaluate the ICD-11 formulations of oppositionality and irritability compared to alternatives.
Evans, S.C., Roberts, M.C., Keeley, J.W., Rebello, T.J., de la Peña , F., Lochman, J.E., Burke, J.D., Fite, P.J., Ezpeleta, L., Matthys, W., Youngstrom, E.A., Matsumoto, C., Andrews, H.F., Medina-Mora, M.E., Ayuso-Mateos, J.L., Khoury, B., Kulygina, M., Robles, R., Sharan, P., Zhao, M. & Reed, G.M. (2020), Diagnostic classification of irritability and oppositionality in youth: a global field study comparing ICD‐11 with ICD‐10 and DSM‐5. J. Child Psychol. Psychiatr. doi: 10.1111/jcpp.13244.
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th edn). Arlington, VA: Author.
Evans, S. C., Burke, J. D., Roberts, M. C., Fite, P. J., Lochman, J. E., de la Peña, F. R., & Reed, G. M. (2017). Irritability in child and adolescent psychopathology: An integrative review for ICD-11. Clinical Psychology Review, 53, 29-45.
World Health Organization (1992). The ICD-10 classiﬁcation of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines. Available here
World Health Organization (2020). International classiﬁcation of diseases (10th and 11th revisions). Available here
Disruptive Mood Dysregulation Disorder (DMDD): The Basics. From the National Institute of Mental Health. NIH Publication No. 20-MH-8119. Available here
Disruptive Mood Dysregulation Disorder (DMDD): According to the National Institute of Mental Health, DMDD presents as a childhood condition of extreme irritability, anger, and frequent, intense temper outbursts. Children with DMDD experience severe impairment that requires clinical attention.
Oppositional Defiant Disorder (ODD): A childhood disorder characterised by a pattern of hostile, disobedient, and defiant behaviours directed at adults or other authority figures. Many children might display angry and irritable moods, and are often argumentative and engage in vindictive behaviours.