What are the strengths and weaknesses of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) and the International Classification of Diseases, Eleventh Revision (ICD-11) in diagnosing Other Specified Anxiety Disorder?

Diagnostic Strengths and Weaknesses of DSM-5-TR and ICD-11 for Other Specified Anxiety Disorder

Critical Limitation: Both Systems Systematically Miss Atypical Presentations

The fundamental weakness shared by DSM-5-TR and ICD-11 is that their rigid symptom specifications inadvertently exclude culturally variant and atypical anxiety presentations, forcing approximately 60% of anxiety disorder cases into "Not Otherwise Specified" or "Other Specified" categories when presentations do not conform to exact Western-derived criteria. 1

This over-specification problem stems from the post-DSM-III emphasis on symptom-based reliability at the expense of validity, creating diagnostic instruments that miss related but somewhat different presentations of the same underlying disorder. 1

DSM-5-TR Strengths

• Administrative efficiency: The categorical framework streamlines insurance authorization, billing, and treatment justification, making DSM-5-TR the preferred system when reimbursement is the primary concern. 2, 3

• Reliable case identification: Standardized symptom thresholds enable consistent diagnosis across clinical settings when presentations match specified criteria sets. 3

• Clinical familiarity: Most mental health professionals (68.1%) routinely use diagnostic classifications for administrative purposes, with DSM maintaining dominant market position in many healthcare systems. 4

DSM-5-TR Weaknesses

• Cultural insensitivity: The prioritization of psychological over somatic anxiety symptoms systematically excludes individuals whose anxiety manifests primarily through physical sensations—a presentation common in non-Western populations. 1, 3

• Contextual blindness: The manual provides no framework for distinguishing pathological anxiety from appropriate responses to genuine environmental threats, risking false-positive diagnoses when symptoms represent rational fear (e.g., undocumented immigrants' worry after immigration raids). 3

• Lack of biological validation: DSM-5-TR does not incorporate neurobiological markers, genetic risk factors, or treatment-response data, creating biologically heterogeneous diagnostic groups that cannot guide mechanism-based treatment selection. 2

• Limited guidance for clinical judgment: The constructs of "excessive" and "uncontrollable" anxiety lack cross-cultural validation and operational definitions, requiring substantial clinical expertise that may not be uniformly available. 3

• High residual category usage: Approximately 12% of clinicians routinely use "other specified" or "unspecified" categories, most commonly when clinical presentations do not conform to specific diagnostic criteria or when insufficient information exists. 4

ICD-11 Strengths

• Dimensional flexibility: ICD-11 allows severity rating across multiple symptom domains at each encounter, supporting flexible treatment planning without rigid temporal symptom counts. 2, 3

• Longitudinal tracking: The system permits coding of episodicity and current status, enabling clinicians to track anxiety patterns beyond a single categorical label. 2, 3

• Superior clinical utility: In field studies of 873 clinicians, 82.5%–83.9% rated ICD-11 as "quite" or "extremely" easy to use, accurate, clear, and understandable—significantly higher than ratings for ICD-10. 2

• Captures partial presentations: The dimensional framework identifies atypical and incomplete anxiety presentations that categorical systems miss, potentially reducing the proportion of cases relegated to residual categories. 3

ICD-11 Weaknesses

• Selection bias in validation studies: Field-study participants were self-selected online volunteers, introducing bias toward practitioners already favorable to the new system. 2, 3

• Limited real-world validation: Study vignettes used prototypic cases lacking the complexity of actual clinical presentations (comorbidities, mixed symptomatology), limiting generalizability of reported accuracy advantages. 2, 3

• No significant advantage for established categories: When newly introduced diagnostic categories were excluded, ICD-11 showed no statistically significant advantage over ICD-10 in diagnostic accuracy, goodness-of-fit, or clarity. 2, 3

• Absence of biological grounding: Like DSM-5-TR, ICD-11 remains symptom-based without neurobiological validation, restricting its ability to guide mechanism-based treatment selection. 3, 5

• Higher residual category usage: Approximately 19% of DSM users (which includes ICD-11 users in some contexts) employ residual categories often or routinely, suggesting dimensional approaches have not eliminated the need for "other specified" diagnoses. 4

Practical Implications for Other Specified Anxiety Disorder

• Recognize the category as a system failure indicator: The high prevalence of "other specified" diagnoses reflects inadequate capture of valid anxiety presentations rather than patient pathology. 1

• Employ structured screening instruments: Use validated tools rather than unstructured interviews to reduce cultural bias and improve reliability across diverse populations. 3

• Assess both psychological and somatic symptoms: Explicitly evaluate physical manifestations (gastrointestinal distress, palpitations, dizziness, breathing difficulty, sweating) to capture culturally variant presentations. 3

• Document contextual factors: Before labeling anxiety as pathological, evaluate whether symptoms represent appropriate responses to genuine environmental threats, considering cultural background, immigration status, socioeconomic stressors, and community context. 3

• Collect multi-informant data: Obtain collateral information from family members or other observers, as patients may have limited insight into the pervasiveness of their anxiety. 3, 5

System Selection Algorithm

Choose DSM-5-TR when:

• Insurance billing and treatment authorization are primary concerns 2, 3
• Administrative documentation requirements dominate clinical workflow 4
• The healthcare system mandates DSM coding 3

Choose ICD-11 when:

• Dimensional symptom tracking is essential for treatment planning 2, 3
• Longitudinal monitoring across multiple encounters is required 2
• International clinical communication is necessary 3
• The presentation is atypical but clinically significant 3

Common Pitfalls to Avoid

• Forcing categorical diagnoses: When presentations do not meet full criteria but cause significant distress or impairment, use "other specified" categories rather than inappropriately assigning a specific anxiety disorder diagnosis. 3

• Ignoring measurement equivalence: Standard diagnostic instruments may yield false-negative results when patients' subjective experiences diverge from Western assumptions embedded in the tools. 1

• Overlooking somatic presentations: Anxiety manifesting primarily through physical symptoms is clinically valid but systematically missed by psychological-symptom-focused criteria. 1, 3