DSM5 has changed the requirements for describing the clinical significance of a DSM category. Now there it is required that "impairment" criteria is specified in accordance with the ICF ( International Classification of Functioning Disability and Health ) and operationally measured with the WHODAS 2.0;

1. Clinical Significance:
ICF and WHODAS 2.0
Dr T. Bedirhan Üstün
Classifications, Terminologies and Standards
World Health Organization

2. Statement of Potential Conflicts of Interest
Clinical Significance:
ICF and WHODAS2.0
for measuring Disability
Relating to this presentation, the following relationships could be
perceived as potential conflict of interests:
• work at the World Health Organization
• Responsible for ICD, ICF
• Significantly involved in WHODAS2.0 development
• Believes in Science

3. ICD-10 B24 HIV disease B24 HIV disease
ICF activity limitations
performance restriction in:
Moving around (d455.44)
Washing (d510.33)
Education (d830.44)
…
Almost fully functional
moderate participation restriction in
Higher education (d830.03)

4. Separate Classification of
Disease and Disability
+ = case
Diagnosis Disability => better
formulation
of caseness

5. “Diagnosis” alone fails to predict:
 service needs (National Advisory Mental Health Council 1993)
 length of hospitalisation (McCrone and Phelan, 1994)
 level of care (Burns, 1991)
 outcome of hospitalization (Rabinowitz et al, 1994)
 receipt of disability benefits (Massel et al, 1990; Segal and Choi, 1991;
Basset and Regier)
 work performance (Gatchel et al, 1994; Massel et al, 1990)
 social integration (Ormel et al, 1993)

6. Dx + “Disability” can predict:
 health service utilization (Hoeper et al 1979; Regier et al, 1985;
Basset and Folstein, 1991; Von Korff et al,
1992; Ormel et al, 1993)
 Length of Hospitalization (Horn, 1990)
 Outcome after hospitalization (Rabinowitz et al, 1994)
 return to work (Hlatky et al, 1986)
 work performance (Massel et al, 1990)
 recovery of social integration (Tate, 1989)

7. Added Value of Disability Information
Predictive power
13%
8%
19%
28%
100%
100%
150%
123%
OR 1
OR 1
OR 1
OR 14
OR 4
OR 15
Functioning
Information

8. Operationalization of Diagnosis
ICD
A Specific phenomenology
B Signs and Symptoms
C ….
D Exclusion rules
DSM
A Specific phenomenology
B Signs and Symptoms
C DISABILITY & DISTRESS
D Exclusion rules

9. Recommendations
1. DSM 5 should adopt an unambiguous and
internationally harmonious terminology and
conceptual approach for functioning and
disability.
• Use ICF compatible terminology and definitions.
• Operationalize separate assessments of symptoms,
severity and disability.

10. ICF & WHODAS 2.0

11. What is ICF ?

12. What is WHODAS 2.0 ?
– A generic assessment instrument for measuring health and disability
– in clinical practice
– at population level
– captures the level of functioning in six domains of life
1: Cognition understanding and communicating
2: Mobility moving and getting around
3: Self-care hygiene, dressing, eating and staying alone
4: Getting along interacting with other people
5: Life activities domestic responsibilities, leisure, work and school
6: Participation joining in community activities, participating in society
– provides a disability profile and a summary measure
• that is reliable
• applicable across cultures, in all adult populations

13. Summing up different dimensions
combination of multiple vectors of functioning
Vision
Cognition
Hearing
Mobility
Social Activities
Work
Selfcare

14. Where is WHODAS 2.0
in the context of Health Status information?
Disease Status (ICD - DSM)
 Information about Illness, disorder, injury, trauma
Functional Status (ICF)
 Information about functioning
@ body level: IMPAIRMENTS
@ person level: ACTIVITIES
@ societal level: PARTICIPATION
impact of person’s ENVIRONMENT (barriers/facilitators)
Quality of Life
 Subjective well-being, satisfaction
WHODAS 2.0
WHOQoL

15. Why use WHODAS 2.0?
 Direct conceptual link to the
International Classification of
Functioning, Disability and
Health (ICF)
 Cross-cultural comparability
 Good Psychometric Properties
 Ease of use and availability

16. WHODAS 2.0
Development Centres
Seattle
Michigan
St. Louis New York
Mexico City Havana
Lima
Amsterdam
Luxembourg
Santander
Ibadan
London
Hamburg
Athens Ankara
Beijing Tokyo
Bangalore
Vienna
Delhi Madras
Santiago
Pitsburg
Moscow
Pnom Peng
Tmisora
Tunisia
Lebanon

17. WHO DAS CENTRES
T. Kugener Austria
K. Hourn Cambodia
G. Yao China
J. Saiz Cuba
V. Mavreas Greece
S. Murthy India
H. Pal India
R. Thara India
U. Nocentini Italy
M. Tazaki Japan
E. Karam Lebanon
C. Pull Luxembourg
H. Hoek Netherlands
B. Odejide Nigeria
J. Segura Garcia Peru
R. Vrasti Romania
D. Veltischev Russia
J.-L. Vazquez-Barquero Spain
N.Glozier UK
P. Doyle USA
D. Hasin USA
WHODAS 2.0
Development TEAM
TASK FORCE MEMBERS:
M. von Korff USA (HSR TF Chair)
C. Pull Luxembourg (AI TF Chair)
E. Badley Canada
K. Ritchie France
D. Wiersma Netherlands
M. Prince U.K.
R. Kessler USA
R. Trotter USA
NIH Staff
D. Regier, C. Kennedy, K. Magruder NIMH
B. Grant NIAAA
J. Blaine NIDA
WHO STAFF
T.B. Ustun , N. Kostansjek
S. Chatterji, J. Rehm

18.  Conceptual equivalence of
Disability Assessment
– Language
– Norms, Values , beliefs
– Classification differences
– Context differences
 Translatability
 Usability
 Cross-population
comparability

19. Structure of WHODAS 2.0
 Full version (36-item)
– provides most detail
– allows to compute overall and 6 domain specific functioning scores
– available as interviewer-, self- and proxy-administered forms
– average interview time: 20 min.
 Short version (12-item)
– useful for brief assessments of overall functioning in surveys or health-outcome studies
– allows to compute overall functioning scores
– explains 81% of the variance of the 36-item version
– available as interviewer-, self- and proxy-administered forms
– average interview time: 5 min.
 Hybrid Versions (12+24-item)
– uses 12 items to screen for problematic domains of functioning.
– Based on positive responses to the initial 12 items, respondents may be given up to
24 additional questions.
– can only be administered by interview or computer-adaptive testing (CAT)

20. WHODAS 2.0 factor structure

21. WHODAS 2.0 reliability:
test–retest summary

22. WHODAS 2.0
Meaningful distinctions among subgroups

23. WHODAS 2.0
Concurrent Validity Summary
SF QOL LHS FIM
1 Cognition -.56 -.48
2 Mobility -.82/-.59 -.60/-.68 -.70 -.80
3 Self Care -.58/-.76 -.47 -.69
4 Interpersonal -.54 -.36/-.57 -.62 -.37
5 Work & Home -.54/-.46 -.51
6 Participation -.69 -.39

24. WHODAS 2.0
relationship with work disability
WHODAS 2.0 Score
Days with reduced
household tasks
Days missed work for
half day or more
Cognition .28 .15
Mobility .42 .31
Self Care .48 .40
Interpersonal .33 .28
Work & Household .68 .58
Participation .53 .49
TOTAL
.63
.52

25. WHODAS 2.0
Responsiveness in depressed subjects
0 0.2 0.4 0.6 0.8 1 1.2 1.4
0.8
1.07
0.44
0.74
0.81
0.72
1.32
N = 100
SF-36 (MCS)
0.23
Effect size
( mean/ SD)
Outpatient care
(Mexico City)
Outpatient care
(Ibadan, Nigeria)
Outpatient care of
elderly (London, UK)
Primary health care
(Seattle, USA)
N = 60
LHS
N = 40
LHS
N = 73
SF-36 (MCS)
WHODAS 2.0 Comparator

26. WHO DAS II
Responsiveness in schizophrenia subjects
0 0.2 0.4 0.6 0.8 1 1.2 1.4
1.03
1.38
0.65
0.86
Outpatient care
(Cuba)
Outpatient care -
newly treated
(Beijing, China)
WHODAS 2.0 Comparator
Effect size
( mean/ SD)
N = 50
SF-12 (MCS)
N = 50
LHS

27. WHODAS 2.0
Responsiveness in other conditions
0 0.2 0.4 0.6 0.8 1 1.2 1.4
1.25
0.77
0.59
1.19
0.58
0.42
Alcohol dependence
rehab. (Romania)
Hip / knee
arthoplasty
(London, UK)
Primary care of low
back pain (Seattle,
US)
WHODAS 2.0 Comparator
Effect size
( mean/ SD)
N = 80
LHS
N = 72
LHS
N = 76
SF-12 (PCS)

28. CLASSIFICATIONS … BUILDING BLOCKS OF HEALTH INFORMATION …

29. Population distribution of IRT-based scores for
WHODAS 2.0 – Full version

30. Mobility Vignettes
 Paul: active athlete who runs long distance races of 20 kilometres
 Mary: has no problems with moving around or using her hands, arms and
legs. She jogs 4 kilometres twice a week
 Rob: is able to walk distances of up to 200 metres without any problems
but feels breathless after walking one km.
 Margaret: feels chest pain and gets breathless after walking distances of
up to 200 metres, but is able to do so without assistance. Bending and
lifting objects such as groceries produces pain.
 Louis: is able to move his arms and legs, but requires assistance in
standing up from a chair or walking around the house. Any bending is
painful and lifting is impossible.
 David: paralysed from the neck down; is confined to bed and must be fed
and bathed by somebody else

31. Calibration Tests
 Mobility: variation of standard PosturoLocomotor Test.
 Vision: a standard vision chart (Snellen)
 Cognition:
– simple memory: 10 objects given, immediate recall & 20mn recall
– cancellation test: a combined test of attention, task execution
– fluency: naming as many as animals in 1 minute.

32. Applications of WHODAS 2.0:
Population surveys
 Multi-country studies/applications
– WHO Multi Country Survey Study (MCSS)
– World Mental Health Survey (WMHS)
– Global Study on Aging (SAGE)
– Tsunami Recovery Impact Assessment and Monitoring System (TRIAMS)
– WHO/UNESCAP project on disability statistics
 Country studies
– Ireland’s National Physical and Sensory Disability Database (NPSDD)
– National Health Performance Assessment Survey (Mexico)
– First National Study on Disability (Chile)
– US VA Twin Registry

33. Clinical applications of WHODAS 2.0
 Disease specific validation studies / health outcome assessment
– inflammatory arthritis
– stroke
– systemic sclerosis
– anxiety disorders
– hearing loss
– psychotic disorders
– schizophrenia
– HIV/AIDS
– depression
– low back pain
– ankylosing spondylitis
– Injuries
– …
 Setting specific validation studies / health outcome assessment
– General practitioners
– Clinical rehabilitation
– Community based care for the elderly
– …

34. Recommendations
1. DSM 5 should adopt an unambiguous and
internationally harmonious terminology and
conceptual approach for functioning and disability.
• Use ICF compatible terminology and definitions.
• Operationalize separate assessments of symptoms,
severity and disability.

35. ICD11 βeta
 http://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

36. THE CONTENT MODEL
Any Category in ICD is represented by:
1. ICD Concept Title
1.1. Fully Specified Name
2. Classification Properties
2.1. Parents
2.2 Type
2.3. Use and Linearization(s)
3. Textual Definition(s)
4. Terms
4.1. Base Index Terms
4.2. Inclusion Terms
4.3. Exclusions
5. Body Structure Description
5.1. Body System(s)
5.2. Body Part(s) [Anatomical Site(s)]
5.3. Morphological Properties
6. Manifestation Properties
6.1. Signs & Symptoms
6.2. Investigation findings
7. Causal Properties
7.1. Etiology Type
7.2. Causal Properties - Agents
7.3. Causal Properties - Causal Mechanisms
7.4. Genomic Linkages
7.5. Risk Factors
8. Temporal Properties
8.1. Age of Occurrence & Occurrence Frequency
8.2. Development Course/Stage
9. Severity of Subtypes Properties
10. Functioning Properties
10.1. Impact on Activities and Participation
10.2. Contextual factors
10.3. Body functions
11. Specific Condition Properties
11.1 Biological Sex
11.2. Life-Cycle Properties
12.Treatment Properties
13. Diagnostic Criteria

37. Mental Health and Rest of Medicine
• Parity
– Common Information Model
– Disease definition:
• Dimensions – Categories - Thresholds
– Formulation of Disability
– Use in electronic health records

38. John NASH: “A Brilliant Mind”
1996 WPA Congress
My irrational “dreams”,
as I call them,
and my mathematical thoughts both
came from the same place,
same source …
In time, I kind of created
my own thought police
in my mind,
I then came to recognize my own irrationality

39. Additional Information
 International Classification of Functioning, Disability and
Health
http://www.who.int/classifications/icf/en/
 World Health Organization Disability Assessment
Schedule 2 http://www.who.int/icf/whodasii/index.html
 Developing the World Health Organization Disability
Assessment Schedule 2.0
http://www.who.int/bulletin/volumes/88/11/09-067231.pdf