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

Comparative Strengths and Weaknesses of DSM-5-TR and ICD-11 for Diagnosing Dissociative Identity Disorder

Both DSM-5-TR and ICD-11 provide clinically useful categorical frameworks for diagnosing DID, but both systems share fundamental weaknesses: they remain purely symptom-based without neurobiological grounding, rely on categorical rather than dimensional approaches, and lack validated structured diagnostic interviews specific to dissociative disorders.

Strengths of DSM-5-TR for DID Diagnosis

Enhanced Phenomenological Accuracy

• DSM-5 revised criteria more accurately capture the actual symptom profile of DID patients by removing the requirement that alternate identities must regularly "take control" of behavior, which was overly restrictive in DSM-IV-TR 1
• The DSM-5 explicitly includes possession experiences within the definition of identity disruption, recognizing cross-cultural manifestations of the disorder 2
• DSM-5 emphasizes the disruptive nature of dissociation and amnesia for everyday events (not just traumatic events), which better reflects the chronic functional impairment patients experience 2

High Diagnostic Accuracy in Clinical Practice

• In a study of 169 clinicians diagnosing DID, 95.27% accurately assigned the diagnosis when patient symptoms were matched against DSM criteria 1
• The DSM-5 criteria changes slightly increased the number of individuals meeting diagnostic criteria (6.21% of accurately diagnosed cases met only DSM-5 criteria, not DSM-IV-TR) 1

Inclusion of Depersonalization/Derealization

• DSM-5 appropriately expanded Depersonalization Disorder to include derealization symptoms, recognizing these commonly co-occur 2

Weaknesses of DSM-5-TR for DID Diagnosis

Absence of Neurobiological Validation

• DSM-5-TR remains entirely symptom-based, relying solely on self-reported or clinically observable symptoms rather than incorporating neurobiological dimensions or underlying pathophysiology 3, 4
• This categorical approach produces diagnostically heterogeneous groups that cannot guide biologically-targeted treatment selection 4
• Despite growing neurobiological evidence demonstrating differences between dissociative identities within DID patients and between DID patients and controls, none of this is incorporated into diagnostic criteria 5

Lack of Validated Structured Diagnostic Instruments

• No empirically validated structured diagnostic interview exists specifically for DID, forcing clinicians to rely on clinical judgment alone 4
• Self-report scales have minimal usefulness in dissociative disorders due to patients' impaired insight and memory fragmentation 6

Potential for Idiomatic Misinterpretation

• The negative wording of DSM-5 exclusionary criteria may lead to idiomatic response errors that artificially inflate the appearance that DSM-IV-TR criteria fit better 1

Persistent Categorical Limitations

• DSM-5-TR maintains a purely categorical classification that does not capture the dimensional nature of dissociative symptoms or severity gradations 3, 4

Strengths of ICD-11 for DID Diagnosis

Improved Usability and Clinical Utility

• Field studies involving 928 clinicians from all WHO regions found 82.5%–83.9% rated ICD-11 as quite or extremely easy to use, accurate, clear, and understandable compared to ICD-10 4
• ICD-11 underwent the largest participative revision in classification history, with demonstrated higher reliability compared to ICD-10 3

Expanded Classification Framework

• ICD-11 expanded from 11 to 21 disorder groupings in the mental, behavioral, and neurodevelopmental disorders chapter, providing more granular classification options 3, 4

Explicit Differential Diagnosis Guidance

• ICD-11 provides explicit guidance on distinguishing dissociative disorders from similar behavioral features in other conditions 3

Weaknesses of ICD-11 for DID Diagnosis

Identical Neurobiological Limitations as DSM-5-TR

• ICD-11 similarly lacks any neurobiological dimensions, remaining entirely symptom-based without biological grounding 4
• The transition from ICD-10 to ICD-11 involved only modest changes with no paradigm shift toward biologically informed classification 3, 4

Less Specific Phenomenological Detail for DID

• ICD-11 does not include insight specifiers or specific subtypes (such as possession-form presentations) that are present in DSM-5-TR 4
• This reduced granularity may overlook clinically important DID subtypes

Methodological Concerns About Field Study Evidence

• Selection bias likely inflated ICD-11 performance metrics because clinicians favorable toward ICD-11 were more likely to participate in field studies 3, 4
• Vignette-based field studies used prototypical cases that do not reflect real-world diagnostic complexity 3, 4
• Participants' awareness of being studied may have altered their diagnostic behavior, meaning results may not reflect routine clinical conditions 4

Critical Common Pitfalls in Both Systems

Failure to Address Biological Heterogeneity

• Neither system adequately addresses the biological heterogeneity within the DID diagnostic category, limiting treatment selection based on mechanisms 3
• Both systems would benefit from incorporating Research Domain Criteria (RDoC) framework elements to provide biologically informed understanding, though RDoC alone is too complex for clinical practice 3

Ongoing Diagnostic Controversy

• Despite robust neurobiological and cognitive evidence establishing DID as an empirically valid chronic psychiatric disorder based on non-integration in response to unbearable stress, some critics continue to attribute the condition to iatrogenic influences 7, 5
• This controversy persists partly because neither diagnostic system incorporates the substantial neurobiological validation that exists 5

Need for Multi-Informant Assessment

• Both systems require gathering information from multiple sources using varied developmentally sensitive techniques, as confirmation from multiple informants is necessary due to potential discrepancies in self-reporting 6
• Informant discrepancies should be expected and evaluated systematically, as they do not invalidate the diagnosis 6