Comparability between ICD-11 and DSM-5-TR

The differences between the ICD-11 and DSM- 5-TR (American Psychiatric Association, 2022) are intentional because they are directed toward different goals. This is because the former is the product of the collaborative work (non-profit) of experts from different professions (in addition to authorities) from 159 member states; while the latter configures a (commercial) franchise of the work of experts from a single profession and from a single country (Asociación Psiquiátrica Mexicana, 2022; ^{Columbia Psychiatry, 2022}). The DSM-5-TR has a more research-oriented (and less practice-oriented) approach because it has rigid diagnostic criteria (e. g., criteria A, B, etc.), which are expected to maximize the reliability of diagnostics in different environments (^{Appelbaum, 2017}; ^{Bach et al., 2022}; ^{Stein et al., 2020}). In contrast, the MBNDs of the ICD-11 have a more pragmatic approach because they incorporate flexible diagnostic guidelines (vignettes), considering in a deeper way the variability of diverse cultures and limitations of the different levels of health care, -even in low-resource settings- (^{Appelbaum, 2017}; ^{Bach et al., 2022}; ^{Stein et al., 2020}).

The chapter groups of the ICD-11 MBNDs are listed in Table 1, which also includes a comparison with the DSM-5-TR meta-structure; -for further details on the differences and similarities in diagnosis between ICD-11 MBNDs and DSM-5-TR consult ^{First et al. (2021}) and ^{O’Brien (2022})-. In general, the comparability of the structure of the two classifications can be considered a success of the harmonization efforts between the WHO and APA. Some structural differences reflect ICD-wide conventions related to residual categories and mental disorders associated with other underlying illnesses.

The discussions in which the WHO, the Advisory Group, and the various Working Groups took part resulted in other differences, such as those regarding the diagnosis and treatment of children with chronic irritability and anger, compulsive sexual behavior disorder, personality disorders, substance use/ substance dependence, and somatoform disorders. Another distinction is that the new chapters of the ICD-11 include the classification of «organic» and «non-organic» components of sleep-wake disorders, problems relating to sexual health, and gender identity in ways that are connected with the most recent research and clinical practice (^{O’Brien, 2022}).

^{Regier et al. (2020}) stated that one of the similarities between the two diagnostic systems is the incorporation of a dimensional approach for some disorders within their categorical system. The debate between the psychoanalyst’s approach to the dimensionality of mental disorders, and the discrete categorization of these conditions from the neo- Kraepelinian approach, can lead to a better understanding of the disorders through the description of the etiological factors, characteristics, and clinical course of the disease, supplemented with symptom scores. Accordingly, for some ICD-11 and DSM5- TR diagnoses, dimensional expansions regarding severity, course, and specific symptoms were added. Some examples of ICD-11 include autism spectrum disorders (ASD), personality disorder, depressive or bipolar disorders, and primary psychotic disorders (^{Alves et al., 2020}; ^{Gaebel et al., 2022}); while in the DSM-5 TR, they are autism spectrum disorders (ASD), attention deficit/hyperactivity disorder, bipolar disorder, and major depressive disorder (^{Regier et al., 2020}).

According to Michael B. First, co-chair and editor of DSM-5-TR, the differences between ICD-11 and DSM-5 TR provide four main advantages and disadvantages (as cited in ^{O’Brien, 2022}): (a) it enables classifications to be improved to satisfy user group needs; (b) it also supports growing clinical research validity over time; (c) it encourages frequent evaluation of the best nosological approaches; (d) finally, opportunities were created for those working on the development of diagnostic and measuring tools. However, these variations are disadvantageous because: (ii) they make it more difficult to gather and report health statistics in countries that use the DSM; (ii) they make it more difficult to compare the findings of studies that were assessed using various systems; (iii) they make it more difficult to evaluate and approve drugs for patients whose medical indications were prescribed using various systems; and (iv) they add to the workload for those who create diagnostic tools and measurements (O’Brien, 2022).

Table 1: Equivalence in the meta-structure of the MBNDs of the ICD-11 with other diagnostic systems 

Note: Elaborated from the integration of the works of some authors (see First et al., 2021; Gaebel et al., 2022). The Sleep-Wake Disorders, Sexual Dysfunctions, and Gender Incongruence groups have been moved to other ICD-11 groups (now considered diseases and not disorders) to reduce their stigma; since by themselves they do not explain the mental dysfunction (Baleige et al., 2022; Gozi, 2019; Graham, 2019). This is particularly favorable for Gender Incongruence; since transsexuality had a «double stigma», the religious moral rejection (even sexist) and the rejection of being considered a mental disorder (Asociación Psiquiátrica Mexicana, 2022; The Lancet Child & Adolescent Health, 2018).

New horizons in classifications of MBNDs: The empirical strength of dimensional lenses

In recent years, three approaches have been introduced in psychiatric nosology: HiTOP, RDoC and SyNoPsis -see Figure 2 for more detail on the constructs of these approaches-. As ^{Gaebel et al. (2022}) mentioned, these frameworks were developed from a dimensional perspective to enable more accurate and nuanced knowledge of mental disorder assessment and diagnosis of mental conditions, rather than categorical descriptions that reduce the validity and reliability of mental disorders (^{Strik et al., 2017}). The first of them (HiTOP), designed by the HiTOP Consortium, seeks a classification based on the multivariate phenotype of clinical conditions; and the remaining two, -RDoC from the National Institute of Mental Health in the USA (NIMH) and SynoPsis from the Bern University Hospital of Psychiatry in Switzerland- an etiological explanation based on the neurobiology and pathophysiology of these conditions.

Currently, these three frameworks have deficits in terms of their global and clinical applicability (utility) because they are: complex for practice and culturally variable (^{Gaebel et al., 2022}; ^{Sharan & Keeley, 2018}), -mainly in the case of HiTOP-; and practically inaccessible and do not have convincing evidence of the neurobiology-psychopathology association (^{Gaebel et al., 2022}; ^{Regier et al., 2020}), -mainly in case of RDoC and SynoPsis-. In the future, if science demonstrates a harmonization of the RDoC or Synopsis units of analysis with syndromic manifestations, these neurobiological frameworks may be incorporated into future versions of the ICD; -only if they have evidence of acceptable diagnostic validity and are practical in routine settings (^{Gaebel et al., 2022})-. ^{Gaebel et al. (2022)} mention that HiTOP can be incorporated, but only in specialized mental health units; however, given its complexity, it will not be able to offer substantial changes in the classification of these systems. Recent preliminary evidence has rejected HiTOP as complex to use (see ^{Balling et al., 2023}); however, more study is still needed on this subject.

Extending categorical and dimensional diagnosis strengths: a stepwise approach

As mentioned by some authors, a potential problem with current categorical classification systems is that they were designed for global applicability in various settings, which could lead to the loss of construct validity (^{Gaebel et al., 2022}; ^{Maercker, 2022}). Complex frameworks such as RDoC or HiTOP are suitable for research purposes, while the categorical classification system in ICD-11 provides greater clinical utility (^{Gaebel et al., 2022}; ^{Regier et al., 2020}). For this reason, researchers often prefer detailed dimensional assessments; while primary care mental health professionals need diagnostic categories that are easy to understand and communicate (e. g., referrals and counter-referrals) (^{Gaebel et al., 2022}). However, the strengths of these dimensional frameworks can already be used by the member states, including Peru.

^{Gaebel et al. (2022}) emphasized that to ensure that future versions of the ICD meet the needs of different user groups, it is pertinent that a gradual procedure for diagnosis (i. e., a stepwise approach) be implemented. In this approach, each diagnostic step describes the patient’s psychopathology in greater detail. In step 1 of the diagnosis, a patient’s symptoms can be classified into broad diagnostic categories, as suggested in the primary care version of ICD-11, -e. g., for the identification and management of mental disorders in the first level of care of Peruvian health establishments (levels of care from I-1 to I-4 of the establishments of the Ministry of Health [MINSA])-. In this step, patients suffering from a degree of distress who require additional diagnostics and specialized interventions can be identified. In step 2, a more specific differential diagnosis can be made. The ICD-11 CDDR provides detailed descriptions of the core symptoms of disorders, boundaries with normality, and guidelines for differential diagnosis. This step can be performed in the second and third level of care (e. g., from II-1 to III-E of MINSA establishments). Once the disorder has been identified and differentiated, reassurance, brief cognitive interventions can be performed for a mild level of disorder severity.

Step 3 of the diagnosis enriches categorical diagnoses with dimensional assessments in research settings and specialized interventions to pin down psychopathology; -e. g., also at the second and third level of care (specialized care)-. Thus, the advantages of both approaches can be combined (e. g., for the diagnosis of schizophrenia or other primary psychotic disorders). Specifically, the result of each categorical diagnosis can be complemented with a symptom profile that provides specific information about the domains involved. In this step, users with moderate and severe personality disorder can be cared for. In moderate cases, brief cognitive interventions, less intensive structured psychotherapies are used; whereas, in severe cases structured intense psychotherapies and medications are used (^{Mulder, 2012}). Similarly, counter-referrals can be issued if mild or subclinical levels of the disorder are found. ^{Bach and Simonsen (2021}) mentioned that the disorder severity configures a decision tool for clinical management and the intensity of required treatment (involving the need to establish epistemic trust, level of support approach and strength of the therapeutic alliance).

Consequently, with the stepwise approach, prompt communication based on diagnostic categories is promoted; and dimensional assessments will provide more nuanced profiles for contexts where detailed dimensional information beyond the overall degree of severity is needed to inform treatment (e. g., psychotherapy) and research. The stepwise approach covers only some groups of disorders in ICD-11. However, there is great potential for enriching more categorical diagnoses with dimensional symptom profiles. For example, experts have recommended assessing all symptoms of substance use disorders in the DSM-5-TR on (at least) a 3-point scale; initiative which can be implemented in later versions of the ICD (^{Gaebel et al., 2022}).

Biological perspective

One should consider (a) genetic abnormalities, (b) brain dysfunction and neuronal plasticity, (c) hormonal and neurological abnormalities, (d) neurotransmitters in the brain or other parts of the central nervous system, and (e) temperament when examining biologically based abnormalities for potential diagnosis of any MBND ICD-11 (see ^{Hooley et al., 2021}). The ways in which the environment can influence the genotype (genotype-environment correlations), the ways in which the genotype can influence the phenotype, and the ways in which genetic vulnerabilities can influence the development of mental disorders (environment-genotype interactions) are some of the proposed objectives in the biological investigation of MBNDs (^{Hooley et al., 2021}; ^{Kring & Johnson, 2021}). Adoption, twin, and family history studies are all ways to examine how much genetic and environmental factors play a role. However, recent research has concentrated on employing linkage analysis and association studies to identify the precise position of genes that contribute to mental diseases (Hooley et al., 2021).

According to ^{Hooley et al. (2021}), the results of these studies showed that there are 1000 (distinct) genes that influence with a certain degree of vulnerability (diathesis) to schizophrenia; and some of these genes are also found in severe depressive disorder, 6A02 autism spectrum disorder (ASD), bipolar disorder and in 6A05 attention deficit hyperactivity disorder (ADHD). On the other hand, studies of neuronal plasticity have shown that the genetic makeup of brain development is not fixed as existing neural circuitry can be often modified based on experience. Additionally, various neurotransmitters (primarily serotonin, dopamine, norepinephrine, glutamate, and gamma aminobutyric acid) and hormonal abnormalities (primarily the hypothalamic-pituitary-adrenal, axis with activation of corticotrophin, adrenocorticotropic, epinephrine [adrenaline], and cortisol) contribute to the development of different mental disorders because of their effects on specific areas of the brain and body. Likewise, temperament -strongly influenced by genetics- configures the set of characteristics for reactions and self-regulation to environmental stimuli. Temperament also constitutes the basis of adult personality and influences vulnerability to various disorders (^{Hooley et al., 2021}).

Psychologists must consider these vulnerabilities mainly at the time of case conceptualization, and treatment planning. To control the associated acute symptoms of these vulnerabilities, immediate psychiatric care is crucial -e. g., the above- mentioned schizophrenia or ADHD, which are more strongly associated with alterations in biological domains as established by the organization of ICD-11 MBNDs through the lifetime approach-. Additionally, in specialty care health centers (e. g., hospitals), patients with life-threatening, degenerative, and/or chronic medical conditions (e. g., 2C61 Invasive breast carcinoma) may develop psychiatric conditions (e. g., 6E62.2 Secondary mood syndrome, with mixed symptoms). In these circumstances, multidisciplinary and coordinated work between doctors, nurses, psychologists, and clinical social workers is needed to achieve adequate knowledge of the disease and develop coping strategy and adherence to psychological and medical treatment (^{Semple & Smyth, 2019}).

Psychological perspective

The ICD-11 stems from the medical model, where the disorder is identified solely through its symptoms, and the typical treatment is to eliminate them through medication, without the need to identify and treat its causes. If only this approach is used, mainly for severe levels of the disorder, it is possible that the patient develops dependence on the medication and the symptoms reappear once it is discontinued (^{Kielkiewicz, 2019}). For example, a meta-analysis showed that a combination of psychotherapy and pharmacotherapy produces more effective outcomes against major depressive disorder than each of these treatments applied individually (i. e., monotherapy; ^{Kamenov et al., 2017}). Although there is some interpretation bias, another umbrella review also demonstrated the superiority of combined treatment in cases of ADHD, complex post-traumatic stress disorder (PTSD) and Social Anxiety compared to monotherapy (Leichsenring et al., 2022). Given this, the psychological interpretation of the patient’s condition, through psychological theories, is important for the psychotherapeutic approach (^{Peterson, 2009}).

Certainly, science cannot find replicability of the results to identify genetic and environmental agents, or their degree of influence in the development of a mental condition; consequently, these cannot be generalized. However, based on the individual psychological evaluation, conceptualization of the case, psychodynamic definition of the problem, functional analysis and other strategies used by the psychologist, it is possible to find the causal components (or at least the most influential central components in the deterioration) for the development, maintenance, and exacerbation of other symptoms or signs of the disorder(s) (^{Kielkiewicz, 2019}). Intervening in these causal agents from the individual intervention, and progressively with group therapies, pharmacological treatment can be enhanced, and eventually discontinued without fear of relapse.

A psychologist, unlike a psychiatrist -as is traditional- must delve deeper into the patient’s problem. Psychiatrists often have a high demand for patients (often continuators) and therefore, reduce their attention time (^{Evans et al., 2013}; ^{Guggenheim, 2013}); which probably also affects rapport (Patel et al., 2017). Additionally, patients may feel less stigmatized and better understood in a psychological consultation because psychologists, unlike psychiatrists, assign fewer diagnostic categories to a patient (^{Evans et al., 2013}). According to Evans et al. (2013), these different perspectives on the patient’s mental condition lie in main issues such as: theoretical perspectives, training, professional activities, the services provided, the served patient populations, and health policies. The stigma must certainly be of particular interest and care for psychologists to address and reduce its effects on patient care.

Although both types of mental health practitioners are responsible for treating patients with compassion, empathy, and dignity, psychological care produces more relief than psychiatric consultation because of the emotional and therapeutic link that is created. Moreover, in psychological care, people are not usually labeled as «depressed» or «schizophrenic», and active listening and other interview techniques based on emotional reflection are used. Also, a feedback based on psychological theories is carried out to obtain an understandable, assertive, and compassionate message of the psychiatric condition.

Psychologists are aware of two fundamental problems: (a) Psychiatric diseases are severe forms of internal experience and behavior, due to sadness, rage, and anxiety; which are common human emotions; (b) unlike other medical conditions (illnesses), mental disorders generate more prejudiced and derogatory assumptions than other types of medical conditions (^{Miles, 2018}). The patient is not to blame for having a disorder (^{Corrigan et al., 2014}), and probably does not deserve to be objectified with these adjectives.

Considering the role of the psychologist for the management of diagnostic categories of the ICD- MBNDs (see Figure 1), prevention would mainly lie in the adequate detection (presumptive diagnosis) of the MBNDs, their subclinical levels and the psychosocial factors present that affect the patient; this is followed by a brief CBT approach or referral as appropriate. For this, the psychologist and health professionals at the first level of care must receive training for proper management of step 1 of the stepwise approach (categorical diagnosis) using the ICD-11-PHC and ICD-11 MMS as a guide.

At the second level of care where confirmation of the clinical condition is required in a precise and refined manner (steps 2 and 3 of the stepwise approach), the psychiatrist must assign the definitive diagnosis of the ICD-11 MBNDs after a multidisciplinary evaluation with the psychologist and/ or a nursing professional specialized in mental health issues. This diagnosis must be complemented with a case formulation that includes the anamnesis, current behavior, presentation of symptoms, subjective experience of the user and social functioning. After that, the psychologist will be able to establish the most appropriate therapeutic regimen for the case (see e. g., ^{Kramer, Eubanks, et al., 2022}); being able to predict the estimated time of therapy, possible complications -e. g., abandonment of therapy, usual in patients with 6D11.5 Borderline pattern (^{Arntz et al., 2022}; ^{Iliakis et al., 2021}); or refusal of therapy, typical in patients with 6D11.2 dissociality in personality disorder or personality difficulty (Herpertz et al., 2022)-, possible acute episodes and comorbidities with other conditions and/or mortality outcomes. These predictions will also provide psychologists with possible treatment/approach alternatives to initiate a change in the proposed therapeutic scheme and improve the therapeutic alliance (^{Kramer, Ranjbar, et al., 2022}).

Likewise, the forecast extracted from the case conceptualization will serve to establish distance between the dates of home visits, or phone call tracking of the users. For example, continuous (weekly) tracking is preferable in patients with severe levels of a condition and suicidal intent -e. g., in cases of patients with 6A71.4 recurrent depressive disorder, current episode severe, with psychotic symptoms / 6B41 Complex post-traumatic stress disorder / 6D11.5 Borderline pattern (^{Gelezelyte et al., 2022})-, than in patients with mild levels or with psychosocial problems derived from judicial instances. Finally, in the third level of care where the rehabilitation of patients with severe and chronic conditions prevails, the psychologist repeats clinical management of the second level of care and accompanies and guides scientific practice of the ICD-11 MBNDs. To do this, it involves a multidisciplinary team in regional and national studies at all levels of care, designs and evaluates the health care programs and protocols of the MBNDs taking the ICD-11 as a framework and a comprehensive and inclusive perspective.

Traditionally, the psychological approach involves different frameworks to treat clinical manifestations of a disorder. For example, from the ICD-11 model, for a patient with 6C40.2 alcohol dependence, a psychologist using the psychodynamic framework may interpret the condition as her attempt to reduce intrapsychic conflict and anxiety through repeated alcohol use; and that the person when making catharsis and realizing this dynamic can find a corrective emotional experience. On the other hand, from the behavioral framework, the same professional can interpret the disorder as the patient learning inadequate habits to reduce social stress; and the approach to it is precisely aimed at modifying this learning through conditioning factors (^{Hooley et al., 2021}).

As ^{Hooley et al. (2021}) stated, from the cognitive- behavioral framework, the same psychologist can interpret said psychopathology as the irrational thought that the patient has about his excessive alcohol consumption as a way to reduce social stress; and his approach is based upon guidelines to modify these irrational thoughts. Likewise, from a humanistic framework, the psychologist interprets the exaggerated consumption of alcohol as a blockage or distortion of the natural growth of the individual person. In addition, the psychiatric condition can be overshadowed if the «client» promotes his virtues and achieves self-realization. Finally, from the existentialist framework, alcohol dependence is interpreted as a failure for the constructive management of the «client» in the face of despair and frustration, of his own existence; and that the disorder can be dealt with by promoting its values, but also by managing the adverse obstacles it may encounter.

Evidence-based psychological interventions for specific diagnostic categories are known to be effective, but only if they perfectly fit the patient’s clinical manifestations; situations that are more pragmatic but unfortunately not very common in clinical practice (^{The Psychology Practice, 2021}). Thus, current practice of psychologists, at least in specialized care, requires comprehensive management of various psychotherapeutic techniques that have shown evidence for addressing specific symptomatic domains (^{Livesley, 2018}; ^{Tyrer & Mulder, 2022}). This ensures personalized therapeutic attention to individual needs of the user. This, in turn, generates greater efficiency within a shorter intervention time (^{Tyrer & Mulder, 2022}). On the other hand, in primary care where anxious and depressive disorders predominate (i. e., with symptoms that represent common alterations in the somatic and emotional domains), the progressive approach with the behavioral and cognitive- behavioral approach is more effective and practical. However, for more complex cases, -such as the chronic emptiness presented by a patient with a borderline pattern, in which alterations in the volitional domain predominate-, it will be necessary to integrate these approaches with others such as the psychodynamic, humanistic, or existential ones, according to the needs of the patient.

With this, the complexity of multiple domains can be better addressed, which in ordered sequence are biological, somatic, emotional, behavioral, cognitive and volitional ones involved in the patient’s disorders. Certainly, in the domains closest to biological components, it is simpler to assign a diagnosis and a brief and effective pharmacological and psychological approach (cure/treatment). However, as the complexity of the condition progresses owing to the influence of social and cultural factors, a complex, comprehensive, and multidisciplinary approach is necessary. In fact, this perspective of sequential diagnosis and intervention has been considered for the organization of ICD-11 MBNDs through the lifetime approach; which, similar to human development, clearly represents how clinical manifestations deviate dimensionally (quantitatively) from normality; and they become more complex as human subjectivity increases with personal experience. From this perspective, the evaluation and diagnosis with the ICD-11 must be constant since most mental disorders by themselves are not chronic; and they depend a lot on inadequate social functioning strategies that make the condition last over time, creating and maintaining disability.

Figure 1: Tentative Role of the Psychologist for the Care of MBNDs with the ICD-11 in the Peruvian Health System 

Social perspective

(a)Early deprivation or trauma (classified in ICD-11 as QE82 personal history of maltreatment) is a common cause of social vulnerability. Being raised in inadequate children’s shelters after parental abandonment and to experience abandonment and/ or physical or sexual abuse at home by a close family member produces «emotional wounds» difficult to heal; facts like these can result in the development of inadequate attachment patterns, avoidance, reactive anger, and other behaviors like these. (b) Problems with parenting style (which can be categorized as QE52.0 caregiver-child relationship / QE70.Z problems related to primary support group, including family circumstances, unspecified) include the psychopathology of the parents, since primary caregivers have depression, personality disorder, among others. This leads to a dysfunctional coexistence characterized by pain, helplessness, and despair for all the family, where children are often the most vulnerable. Likewise, authoritarian, authoritative, permissive, and neglectful parenting styles also generate insecure attachment, an increase in maladaptive personality characteristics and syndromic manifestations of various mental disorders. (c) Marital discord and divorce (classified as QE70.1 disruption of family by separation or divorce) that causes harm to both parents and children; and low socioeconomic status and unemployment (classified as QD51 low income and QD80 problem associated with unemployment, respectively). It also generates stress that can affect the development of some physical or mental illness. (d) Maladaptive relationships with peers such as bullying, bullying and harassment at work (classified as QE50.1 relationships with teachers or classmates / QD85 burnout / QD82 problem associated with threat of job loss) can also be configured as triggers for mental problems. For example, burnout syndrome (QD85 Burnout) has greatly increased as a result of the pandemics currently affecting the world population and the health professionals who deal with them (^{Menon et al., 2022}; ^{Taylor, 2022}; Ulfa et al., 2022). This is particularly relevant since it has been seen that (uninformed) society does not only discriminate people for having a disadvantaged mental condition. Certainly, discrimination based on gender, race, ethnicity, or others may generate stress and influence the presentation and exacerbation of mental disorders (^{Hooley et al., 2021}).

Since women frequently exhibit more internalizing disorders and males more externalizing and thinking disorders, gender also plays a significant effect in how mental problems appear (see Figure 2, for an adequate identification of these disorders and their equivalence in the ICD-11). Even though the ICD- 11 does not code gender as a risk factor, it should be considered because it helps identify the diagnosis. For example, a large part of Peruvian women evidences a higher suicidal risk (i. e., symptom of 6A70.3 Single episode depressive disorder, severe, without psychotic symptoms) and a large part of the country’s males have a tendency towards aggression (i. e., characteristic of 6D11.2 dissociality in personality disorder or personality difficulty) (Instituto Nacional de Salud Mental, 2019). With this evidence, it could be more certain to assign a diagnosis of severe depression to Peruvian women and a diagnosis of PD with prominent externalizing characteristics to men in the country.

The rejection of immigrants by members of the new culture of the current region or nation in which they dwell is known as acculturation, a term frequently employed in the field of mental health. This social risk factor is codified in the ICD-11 as QE04 target of perceived adverse discrimination or persecution. For example, in secular societies or states, marginalized groups -such as immigrants (WHO, 2021), the gay community (^{File & Marlay, 2022}), the Peruvian Andean rural community (^{Hualparuca-Olivera, 2022}; Instituto Nacional de Salud Mental, 2019)- can show a greater degree of anxiety and depression due to constant violence (rejection) they experience.

In addition, it is common to observe cases in which legal procedures produce distress, and if such an association is detected, the psychologist can code the current problem as QE40 problem associated with conviction in civil or criminal proceedings without imprisonment. Often in primary and specialized care, a Peruvian psychologist is in charge of reporting judicial cases and acts of violence in MINSA records. This serves as epidemiological support to make decisions on budget management for infrastructure and human resources in the fight against violence and the promotion of a culture of peace. If these cases are not registered, it is possible that efforts and investments would be allocated to other activities in the executive agenda of the governments.

Although some authors refer that those adverse factors experienced during infancy and early childhood, including those related to primary caregivers, are the ones that have the greatest influence on the onset of a mental disorder, the truth is that the accumulation (quantity) of social risk factors, more than what they are, contribute to the appearance of mental conditions. Psychologists may decide if a patient’s diagnosed disorder is accompanied by some social risk factor or diagnose only one or more symptoms (e. g., MB26. A suicidal ideation and/or QC4B personal history of self- harm) rather than diagnosis of a more complex entity (e. g., 6A71.1 recurrent depressive disorder, current episode moderate, without psychotic symptoms) accompanied by social risk factors (e. g., QE51 problem associated with interactions with spouse or partner) if the current problem is better explained by social circumstances, rather than a psychiatric disorder.

In the same way, it is important to mention that the approach to social risk factors requires multidisciplinary and intersectoral work, the generation of government regulations and investments, health promotion at different levels of care, and the prevention in primary care. A collaborative work structure is needed between authorities, health technicians and professionals, educators, among others, to reduce these risk factors.

Figure 2: Systems and Classification Frameworks for Mental Disorders 

Cultural perspective

The way in which a social group experiences each of the adverse biopsychosocial factors in a certain culture of a region also influences the manifestation of psychopathology (^{Gureje et al., 2020}). The ICD-11 MBNDs working groups have collected information on cultural variants in order to: (a) identify cultural concepts of distress syndrome (causes/explanations, idioms) in various cultural groups, (b) assess the impact of culture on the manifestation of disorders and their dynamics, (c) identify the differences in the prevalence of various disorders considering the dynamics and cultural factors (^{Sharan & Hans, 2021}). The result is mainly reflected for some of the ICD-11 MBNDs. For example, 6B83 avoidant-restrictive food intake disorder is diagnosed mostly in populations of low and middle- income countries (LMICs) who avoid food intake for fear of generating somatization (^{Sharan & Hans, 2021}; ^{Sharan & Keeley, 2018}). Likewise, category 6B04 social anxiety disorder has a marked cultural variant in Asian countries (e. g., Japan and South Korea) as fear of offending others; more than the fear of being evaluated (offended or mocked) socially (^{Sharan & Hans, 2021}).

An applied example of this variability in Peru is found in the distress symptoms of 6B43 Adjustment disorder; which in Quechua-speaking communities is referred to as «sunquymi llakisqa kachkan» which can be translated as «my heart is sad» since the patient attributes to a part of her body -in this case, her heart- feeling worried about an adverse situation and not knowing what to do, which generates impotence and sadness (^{Paniagua, 2018}; ^{Sharan & Hans, 2021}). Spanish-speaking patients, who are native Quechua speakers, frequently use the term «mi cuerpo hizo razz» to describe somatic anxiety -as a Peruvian expression of «ataque de nervios» (see ^{Paniagua, 2018}) in 6B01 panic disorder- in the form of muscle contractions that cause the skin to stand on end. Another common attribution in these Spanish- speaking Peruvian Andean communities (with Quechua as their mother tongue), -specifically in relatives who attend consultation together with the patient having psychotic symptoms-, is the phrase «su cabeza está débil» since they think that hearing voices is a product of undernutrition, and consequently the weakness manifests itself in their head (as an Andean folkloric explanation of this condition; Quiroz-Valdivia et al., 1997).

In the same way, habits and behaviors that may appear to be signs of detachment traits of a personality disorder (PD) are common behavior in remote communities of Andean areas whose main economic activity is mining. In these places, where intense cold is experienced, and with an institutionalized mining economy, -which means that social contact is scarce-, normal behavior can appear to be perceived as a sign of mental alteration if the psychologist who evaluates them is a foreigner (^{Hualparuca-Olivera, 2022}). Moreover, it is common for patients to attribute the cause of a mental disorder to witchcraft. This cultural group certainly does not have sufficient terms to report a mental disorder and often refers to external entities to confirm its possible cause. This leads this community to seek the service of sorcerers and healers who recommend them to perform mystical rituals instead of seeking help from mental health professionals.

Other disorders, in which there is cultural variability in the prevalence and subjective experience of certain symptoms, more than others, are those manifested in: depression, adjustment disorder. Unlike its previous version and the DSM-5-TR, in the ICD-11 CDDR it has been decided to eliminate culture-specific diagnostic categories, and sections have been created to explain possible cultural variations for each disorder (^{Sharan & Hans, 2021}). This change still generates debate both for the practice and for the research of the ICD-11 MBNDs, which mainly argues for two opposing reasons: (a) the designation of vignettes, instead of criteria, facilitates the cultural adaptation of diagnostic categories in clinical practice (^{Bach et al., 2022}); b) the designation of vignettes reflects the lack of interest from the WHO in compiling exhaustive information on culture as the priority of scientists is to find biological markers (^{Seligman, 2019}), rather than cultural markers in their desire to universalize the diagnostic system (^{Sharan & Hans, 2021}).

Although the first statement has been continually supported by the ICD-11 MBNDs working group in its research, it is also true that most of this has been done in high-income countries (HICs). Although they were conducted in LMICs, most of these studies have been conducted in major urban cities, rather than in remote rural communities, which represents both a weakness and an opportunity for the research and practice of the psychologist and other professionals dedicated to mental health.

Implications of ICD-11 MBNDs in public health and its policies

Classification systems have been criticized for medicalizing common problems (^{Stein et al., 2020}); however, the psychopathology subthreshold that is addressed is relevant for early recognition of future psychiatric disorders -that is, with a focus on primary care (^{Krasnov, 2021})-. With the most accurate identification of MBNDs in a country, the availability of assistance services can be evaluated and plans to implement them can be structured (^{Reed, 2021}). Furthermore, when combining well-targeted treatment and prevention programs in the field of mental health; and in general, public strategies, it would be possible to: (a) avoid years lived with disability and deaths, (b) reduce the stigma associated with mental disorders, (c) substantially increase social capital, (d) reduce poverty and promote development of a country (^{Saxena et al., 2012}). When determining what will be financed with a certain number of resources, the general objective must be to guarantee that health interventions maximize the benefits for society. For this, evidence- based prevention programs must be applied to improve positive mental health (^{Messias, 2020}; ^{Peseschkian & Remmers,} 2020; ^{Sarý & Schlechter, 2020}; Smirnova & Parks, 2018), physical health and generate economic and social benefits. In order to favor decision-making in public policies, some issues to be considered are presented below.

Training

With the arrival of ICD-11, it is expected that governments, in coordination with the WHO, or with its regional entities such as the Pan American Health Organization, academic societies, non-governmental organizations would create bridges of communication with state leaders to establish strategies in order to train each health professionals, administrators and managers on the use of the ICD-11 (^{Krasnov, 2021}; ^{Stein et al., 2020}). Likewise, state leaders and their ministers should organize working groups to adapt ICD-11 to local laws, policies, health systems and infrastructures, and subsequently design various multilevel actions and train mental health practitioners (^{Fiorillo & Falkai, 2021}). Although educational resources are available online, the implementation and training of health professionals (by the Peruvian authorities) has not yet started; and it will take time (R. Valle [Psychiatrist of the National Institute of Mental Health ‘Honorio Delgado-Hideyo Noguchi’], personal communication, December 1, 2022). Even epidemiological studies on mental health in the country are being carried out under the ICD-10 framework. Everything suggests that the implementation of the ICD-11 in Peru will begin, at least, in a future five-year period.

Furthermore, since the education of health professionals represents one of the most essential steps to implement and disseminate the new classification system in routine care, the WHO International Advisory Group led by Geoffrey M. Reed has organized training courses for professionals on the use of the ICD-11 MBNDs chapter through the GCP Network platform. Likewise, psychiatric associations, mainly centralized in Europe and the USA, have provided educational activities through interactive virtual formats, including online courses with the active participation of students through the application of the new guidelines to clinical cases and discussion of diagnostic dilemmas (^{Reed, 2021}). Certainly, these trainings have focused on psychiatrists and at the moment have left aside other mental health professionals or those who work on mental health issues.

Because ICD-11 will represent an important change in global clinical practice, it is urgent to promote educational activities to improve the dissemination of this innovative classification approach and contribute to the continuing education of mental health and related professionals. Also, The WHO Collaborating Centre voor de Familie van Internationale Classificaties in Nederland (WHO-FIC Netwerk; 2019) established a roadmap for the Americas that can be adapted for mental health issues when implementing ICD-11. The promotion and dissemination stage, for example, mainly involves (a) designing and strengthening committees, councils or inter-institutional health information centers (health statistics, social security and civil registration); (b) developing a transition plan and implementation of ICD-10 to ICD-11 aligned with the country’s health information improvement plan; and (c) develop attractive materials in different formats and use social networks to spread ICD-11 innovations (^{Fiorillo & Falkai, 2021}).