What are the changes in the diagnosis of Anxiety Disorder Due to Another Medical Condition across the Diagnostic and Statistical Manual of Mental Disorders (DSM) versions III, III‑TR (Text Revision), IV, V, and V‑TR (Text Revision), and the International Classification of Diseases (ICD) versions X and XI?

Evolution of Anxiety Disorder Due to Another Medical Condition Across DSM and ICD Versions

The diagnosis "Anxiety Disorder Due to Another Medical Condition" has remained remarkably stable across DSM-III through DSM-5-TR with minimal substantive changes to core diagnostic criteria, while ICD-11 introduced dimensional severity ratings that represent the most significant evolution in how this condition can be characterized. 1

DSM Evolution (DSM-III through DSM-5-TR)

Core Diagnostic Stability

• The fundamental requirement that anxiety symptoms must be the direct physiological consequence of a general medical condition has persisted unchanged across all DSM versions since DSM-III 1
• The diagnosis maintained its categorical structure throughout all DSM revisions, with no major reconceptualization of the disorder itself 1
• DSM-IV through DSM-5-TR retained identical core criteria: marked anxiety, panic attacks, or obsessions/compulsions that are judged to be the direct physiological consequence of a medical condition 1

Terminology and Classification Changes

• The disorder grouping name evolved from "Anxiety Disorders" in DSM-III/IV to remain within anxiety disorders in DSM-5, despite discussions about reclassifying certain anxiety-related conditions 2
• DSM-5 maintained the ICD-10 code F06.4 for this diagnosis, ensuring cross-system compatibility 1
• The push for reliability since DSM-III came at the expense of validity, with overly rigid symptom-based criteria potentially missing culturally variant presentations 3

Diagnostic Criterion Refinements

• Minor wording changes occurred across versions to improve clarity, such as replacing "anxiety" with "fear" in specific contexts to better reflect acute fear responses versus anxious anticipation 1
• The requirement for "clinically significant distress or impairment" became more explicitly operationalized in later versions 4
• Exclusion criteria were refined to better differentiate this diagnosis from substance-induced anxiety disorder and primary anxiety disorders 1

ICD Evolution (ICD-10 to ICD-11)

Revolutionary Dimensional Approach

• ICD-11 introduced dimensional symptom specifiers that rate current severity across six domains on a 4-point scale (not present to present and severe): positive symptoms, negative symptoms, depressive symptoms, manic symptoms, psychomotor symptoms, and cognitive symptoms 1
• This dimensional framework can be applied to anxiety disorder due to another medical condition, allowing clinicians to document partial or atypical presentations that categorical diagnosis misses 5
• Field studies with 928 clinicians demonstrated that 82.5% to 83.9% rated ICD-11 as quite or extremely easy to use, accurate, clear, and understandable 1

Structural and Organizational Changes

• ICD-11 reorganized the chapter structure from 11 disorder groupings in ICD-10 to 21 disorder groupings, with principles based on shared etiology, pathophysiology, and phenomenology 1
• The separate grouping for disorders with onset in childhood/adolescence was eliminated, highlighting developmental continuity across the lifespan 1
• ICD-11 harmonized its structure with DSM-5 while maintaining the F06.4 code for anxiety disorder due to another medical condition 1

Reliability and Clinical Utility Improvements

• Interrater reliability for ICD-11 was higher compared with ICD-10 estimates, though reliability for anxiety and fear-related disorders remained only small to moderate in some field studies 1
• Diagnostic accuracy and perceived clinical utility (ease of use, goodness of fit, clarity) were more favorable for ICD-11 compared with ICD-10, though advantages were largely limited to new diagnostic categories 1
• The time required to reach a diagnosis was reduced with ICD-11 compared to ICD-10 1

Critical Diagnostic Considerations

Establishing Medical Causation

• Document the temporal relationship between medical condition onset and anxiety symptoms—symptoms must develop during or shortly after the medical condition begins 6
• Verify that anxiety symptoms improve when the underlying medical condition is treated, as this supports the diagnosis of secondary rather than primary anxiety 6
• Thyroid dysfunction specifically shows 9-39% prevalence in patients with anxiety symptoms, making thyroid screening essential before assuming primary psychiatric disorder 6

Cultural and Contextual Limitations

• Nearly 60% of anxiety disorder cases in Chinese populations fall into "Not Otherwise Specified" categories, suggesting DSM/ICD criteria fail to capture non-Western manifestations 3
• The prioritization of psychological over somatic symptoms inadvertently excludes patients whose anxiety manifests primarily somatically, resulting in artificially low disorder rates in Asian and African populations 3
• Inadequate neurobiological markers and treatment response data have been collected across cultural groups, preventing validation of universal applicability 3

Optimal Diagnostic Strategy

• Use ICD-11's dimensional framework to document symptom severity across all six domains at each assessment, while maintaining DSM-5-TR's categorical distinction for insurance reimbursement and treatment justification 5
• Never rely solely on categorical diagnosis when medical conditions are present, as this misses partial and atypical presentations that dimensional assessment captures 5
• Avoid making definitive distinctions between primary and secondary anxiety at initial presentation—longitudinal reassessment is necessary to determine whether symptoms persist independently of the medical condition 5

Common Pitfalls to Avoid

• Never delay treatment of the underlying medical condition while pursuing psychiatric diagnosis, as untreated medical illness can prevent anxiety symptom resolution regardless of psychotropic medication 6
• Do not assume DSM/ICD criteria have equivalent validity across cultural groups—actively assess whether symptom presentation matches expected patterns or represents culturally-specific manifestations 3
• Expand assessment beyond psychological symptoms to include somatic manifestations, particularly for patients from non-Western backgrounds where somatic presentation predominates 3
• Schedule reassessment after 3-6 months of medical treatment optimization to determine whether anxiety symptoms represent primary disorders or secondary manifestations 6