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Classification Systems: DSM-5-TR & ICD-11

A Comprehensive 30-Slide Presentation

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SLIDE 1 — Title Slide

Diagnostic and Statistical Manual of Mental Disorders, 5th Edition – Text Revision (DSM-5-TR) International Classification of Diseases, 11th Revision (ICD-11)

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SLIDE 2 — Outline of Presentation

1. Definition / Introduction
2. Epidemiology
3. Etiology
   • Biological
   • Psychodynamic Factors
   • Psychosocial Factors
4. Diagnosis (DSM-5-TR)
5. Differential Diagnoses
6. Course and Prognosis
7. Treatment
   • Pharmacotherapy
   • Psychotherapy
   • Other Interventions

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SLIDE 3 — Definition & Introduction (I)

• A classification system is a standardized framework used to categorize, name, and define mental disorders based on observable signs, symptoms, and clinical criteria
• Provides a common language among clinicians, researchers, educators, and policymakers
• Enables consistent diagnosis, treatment planning, and epidemiological tracking
• Two dominant systems worldwide:
  • DSM-5-TR (American Psychiatric Association, USA-centric)
  • ICD-11 (World Health Organization, international standard)

Both systems are "purely descriptive and emphasize clinical pragmatism" — Harrison's Principles of Internal Medicine, 21st Ed., p. 12849

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SLIDE 4 — Definition & Introduction (II): DSM-5-TR

• Published by the American Psychiatric Association (APA) in 2022 (original DSM-5: 2013)
• The Text Revision updated:
  • Diagnostic criteria for some disorders
  • Symptom codes (ICD-10-CM codes integrated)
  • Cultural formulation and culturally relevant content
  • Addition of Prolonged Grief Disorder as a new diagnosis
• Organized around 20 diagnostic chapters based on symptom clustering and shared pathophysiology
• Uses categorical and dimensional assessment approaches
• No longer uses a multi-axial system (Axes I–V abolished in DSM-5)

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SLIDE 5 — Definition & Introduction (III): ICD-11

• Published by the World Health Organization (WHO) in 2018, adopted for global use from January 2022
• Covers ALL diseases — Chapter 06 is dedicated to Mental, Behavioural, or Neurodevelopmental Disorders
• Replaces ICD-10 (used since 1990)
• Key features:
  • Available as a digital, freely accessible system
  • Uses a hierarchical, alphanumeric coding system (e.g., 6A00, 6B41)
  • Includes clinical descriptions and diagnostic requirements (CDDR)
  • Introduces Prototype Matching for some personality disorders
  • Global applicability — designed for use in low- and middle-income countries (LMICs)

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SLIDE 6 — Historical Context & Evolution

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SLIDE 7 — Key Structural Differences: DSM-5-TR vs ICD-11

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SLIDE 8 — Epidemiology (I): Global Burden

• Mental and substance use disorders are the leading cause of years lived with disability (YLDs) globally
• Affect >1 billion people worldwide (approximately 1 in 8 people) — WHO 2022
• The Global Burden of Disease Study (2019) confirmed mental disorders are the "major cause of life-years lost to disability among all medical illnesses" (Harrison's, p. 12849)
• Lifetime prevalence of any mental disorder: ~29–46% (varies by country)
• Point prevalence: ~17.6% globally

1. Depressive disorders
2. Anxiety disorders
3. Schizophrenia spectrum disorders
4. Bipolar disorders
5. Alcohol and drug use disorders

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SLIDE 9 — Epidemiology (II): Diagnostic System Usage

• DSM-5-TR: Predominantly used in the USA, Canada, and for research worldwide
• ICD-11: Adopted by WHO member states (~194 countries), including Europe, Asia, Africa, Latin America
• Many countries (including UK, Germany, Australia) use ICD for official statistics but DSM for clinical practice

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SLIDE 10 — Etiology: Biological Factors (I)

• Mental disorders result from complex gene-environment interactions — no single cause
• Genetic heritability is substantial for major disorders:
  • Schizophrenia: ~80%
  • Bipolar disorder: ~75–80%
  • Major Depressive Disorder: ~40–50%
  • ADHD: ~70–80%
• Polygenic risk scores now used in research (not yet routine clinical practice)
• Epigenetic mechanisms: early adversity alters gene expression without changing DNA sequence (methylation, histone modification)

• Dopamine: implicated in psychosis (excess) and reward/motivation
• Serotonin: mood regulation, anxiety, sleep
• Norepinephrine: arousal, stress response
• GABA/Glutamate imbalance: anxiety, psychosis, mood disorders

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SLIDE 11 — Etiology: Biological Factors (II)

• Structural MRI findings:
  • Reduced prefrontal cortex volume (MDD, PTSD, ADHD)
  • Enlarged lateral ventricles (schizophrenia)
  • Reduced hippocampal volume (PTSD, MDD)
• Functional imaging (fMRI, PET):
  • Hyperactive amygdala (anxiety, PTSD, MDD)
  • Reduced prefrontal-limbic connectivity
  • Dopamine D2 receptor abnormalities (schizophrenia)

• Prenatal infections (influenza, rubella → schizophrenia risk)
• Obstetric complications (hypoxia, prematurity)
• Maternal stress during pregnancy
• Immune dysregulation and neuroinflammation

• Chronic stress → cortisol hypersecretion → hippocampal damage
• Central to depression, anxiety, PTSD

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SLIDE 12 — Etiology: Psychodynamic Factors

• Rooted in Freudian theory and later developments (Ego Psychology, Object Relations, Self Psychology, Attachment Theory)

• Early object loss (death, abandonment) → vulnerability to depression (Melanie Klein, Bowlby)
• Insecure attachment styles (anxious, avoidant, disorganized) predict psychopathology in adulthood
• DSM-5-TR and ICD-11 are atheoretical — do not endorse specific etiological theories, but psychodynamic concepts inform psychotherapy

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SLIDE 13 — Etiology: Psychosocial Factors

• Adverse Childhood Experiences (ACEs): abuse (physical, sexual, emotional), neglect, household dysfunction → dose-response relationship with virtually all mental disorders
• Trauma and PTSD: single-incident vs. complex/developmental trauma
• Socioeconomic deprivation: poverty, unemployment, food insecurity → 2–3× higher rates of mental disorders
• Social isolation and loneliness: strong predictor of depression, anxiety, cognitive decline
• Migration and acculturation stress: refugee populations, diaspora communities
• Discrimination and racism: racial trauma, microaggressions → chronic stress burden
• Urban living: higher rates of psychosis, anxiety (noise, crowding, reduced green space)
• Life events (bereavement, divorce, job loss): precipitate episodes in vulnerable individuals

• Strong social support networks
• Secure attachment
• High socioeconomic status and education
• Sense of purpose and belonging
• Access to mental healthcare

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SLIDE 14 — DSM-5-TR: Core Diagnostic Framework

• A mental disorder is defined as:

  "A syndrome characterized by clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning."

• Must cause clinically significant distress or impairment in social, occupational, or other areas
• Must not be better explained by:
  • Normal bereavement/grief responses
  • Culturally expected responses
  • Direct effects of a substance or medical condition

1. Neurodevelopmental Disorders
2. Schizophrenia Spectrum & Other Psychotic Disorders
3. Bipolar & Related Disorders
4. Depressive Disorders
5. Anxiety Disorders
6. OCD & Related Disorders
7. Trauma & Stressor-Related Disorders
8. Dissociative Disorders
9. Somatic Symptom & Related Disorders
10. Feeding & Eating Disorders (continues →)

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SLIDE 15 — DSM-5-TR: Diagnostic Chapters (Continued)

• Prolonged Grief Disorder — added as a formal diagnosis
• Updated cultural formulation sections throughout
• Revised coding aligned with ICD-10-CM
• Enhanced suicidality and self-harm guidance

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SLIDE 16 — DSM-5-TR: Dimensional Assessment

• DSM-5-TR uses specifiers to capture clinical nuance:
  • Severity (mild / moderate / severe)
  • Course (in partial remission / full remission)
  • Episode features (with psychotic features, with anxious distress, with mixed features, etc.)

• Self-rated and clinician-rated tools
• Assess domains: depression, anxiety, anger, mania, somatic symptoms, sleep, substance use, suicidality, dissociation, memory, psychosis

• Recommended for rating overall disability
• Replaces former GAF (Global Assessment of Functioning) from DSM-IV

• 16-question structured interview
• Assesses cultural context of illness presentation and help-seeking

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SLIDE 17 — ICD-11: Core Structure and Chapter 06

• Chapter 06: Mental, Behavioural, or Neurodevelopmental Disorders
• Coding format: alphanumeric (e.g., 6A00 = Autism, 6A40 = Major Depressive Disorder)

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SLIDE 18 — ICD-11: Key Innovations

1. Complex PTSD (CPTSD) — formally recognized as distinct from PTSD
   • Adds disturbances in affect regulation, self-concept, and relational functioning
2. Personality Disorder Reformulation — dimensional model
   • Severity specifiers (mild, moderate, severe)
   • Five trait domain qualifiers (negative affectivity, detachment, dissociality, disinhibition, anankastia)
   • Borderline pattern qualifier retained
3. Gaming Disorder — included under addictive behaviors
4. Prolonged Grief Disorder — also included (parallel with DSM-5-TR)
5. Catatonia — independent grouping with cross-diagnostic application
6. Bodily Distress Disorder replaces somatization disorder and hypochondriasis
7. Premenstrual Dysphoric Disorder (PMDD) — included
8. Elimination of "organic" vs "functional" distinction — removed stigmatizing language

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SLIDE 19 — Differential Diagnoses: Conceptual Challenges

• Most patients meet criteria for >1 disorder simultaneously
• ~45–50% of those with one disorder have at least one other disorder
• High comorbidity between depression & anxiety, substance use & mood disorders, ADHD & conduct disorder

• Psychiatric conditions lie on spectra — arbitrary cut-offs create artificial boundaries
• Example: MDD vs. persistent depressive disorder (dysthymia) vs. adjustment disorder

• Always exclude organic causes before assigning a primary psychiatric diagnosis:
  • Hypothyroidism → depression
  • Hyperthyroidism / pheochromocytoma → anxiety
  • CNS tumors / epilepsy → psychosis, personality change
  • Autoimmune encephalitis → psychosis, mood disorders
  • Substance intoxication/withdrawal → virtually any psychiatric syndrome

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SLIDE 20 — Differential Diagnoses: Cross-Diagnostic Considerations

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SLIDE 21 — Course and Prognosis (I): General Principles

• Acute onset (vs. insidious)
• Later age of onset
• Absence of premorbid psychopathology
• Good premorbid social/occupational functioning
• Strong social support
• Absence of comorbid substance use or personality disorder
• Early treatment initiation
• Good medication adherence

• Childhood/early adolescent onset
• Insidious onset
• Comorbid substance use
• Chronic course with multiple episodes
• Psychotic features
• Poor insight
• Limited social support
• Socioeconomic deprivation
• Inadequate or delayed treatment

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SLIDE 22 — Course and Prognosis (II): By Diagnostic Group

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SLIDE 23 — Treatment: Pharmacotherapy (I)

• SSRIs (fluoxetine, sertraline, escitalopram): First-line for MDD, anxiety, OCD, PTSD, eating disorders
• SNRIs (venlafaxine, duloxetine): MDD, anxiety, pain comorbidity
• TCAs (amitriptyline, imipramine): Refractory depression, chronic pain
• MAOIs (phenelzine): Treatment-resistant depression, atypical depression
• Bupropion: MDD, smoking cessation, ADHD adjunct
• Mirtazapine: MDD, appetite stimulation, insomnia

• Lithium: Gold standard for bipolar disorder; also reduces suicidality
• Valproate: Bipolar disorder, especially rapid cycling
• Lamotrigine: Bipolar depression maintenance
• Carbamazepine/Oxcarbazepine: Bipolar disorder

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SLIDE 24 — Treatment: Pharmacotherapy (II)

• First-generation (FGAs / typical): Haloperidol, chlorpromazine — positive symptoms; higher EPS risk
• Second-generation (SGAs / atypical): Olanzapine, risperidone, quetiapine, aripiprazole, clozapine — positive and negative symptoms; metabolic side effects
• Clozapine: Treatment-resistant schizophrenia; reduces suicidality

• Benzodiazepines (diazepam, lorazepam): Short-term anxiety, alcohol withdrawal; risk of dependence
• Buspirone: Generalized anxiety disorder; non-addictive
• Z-drugs (zolpidem, zopiclone): Short-term insomnia

• Methylphenidate, amphetamine salts — first-line for ADHD
• Atomoxetine, guanfacine — non-stimulant alternatives

• Naltrexone / Acamprosate / Disulfiram: Alcohol use disorder
• Methadone / Buprenorphine: Opioid use disorder
• Prazosin: PTSD nightmares

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SLIDE 25 — Treatment: Psychotherapy (I)

• Strongest evidence base across anxiety disorders, MDD, OCD, eating disorders, PTSD, insomnia
• Targets maladaptive thought patterns (cognitive distortions) and behaviors (avoidance)
• Variants: Trauma-focused CBT (TF-CBT), CBT-E (eating disorders), CBT-I (insomnia)

• Developed by Marsha Linehan for Borderline Personality Disorder
• Four modules: mindfulness, distress tolerance, emotional regulation, interpersonal effectiveness
• Highly effective for BPD, self-harm, suicidality

• PTSD first-line treatment (WHO & APA guidelines)
• Bilateral stimulation facilitates reprocessing of traumatic memories

• PTSD: systematic confrontation with trauma memories and triggers
• Highly effective; supported by VA/DoD, APA, NICE guidelines

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SLIDE 26 — Treatment: Psychotherapy (II)

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SLIDE 27 — Treatment: Other Interventions (I)

• Indications: Severe/refractory MDD, severe bipolar depression, catatonia, treatment-resistant schizophrenia
• Gold standard for life-threatening depression (with psychosis, severe suicidality, refusal to eat)
• Response rate: ~70–90% in suitable candidates
• Side effects: transient short-term memory impairment, post-ictal confusion

• FDA-approved for treatment-resistant MDD, OCD, smoking cessation
• Non-invasive; repetitive magnetic pulses to prefrontal cortex
• Response rate: ~30–50%; well tolerated; no anesthesia required

• Emerging evidence in depression, cognitive enhancement
• Not yet standard of care

• Investigational for severe, refractory OCD and MDD
• Targets subcallosal cingulate (Area 25) for depression

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SLIDE 28 — Treatment: Other Interventions (II)

• Intensive community-based care for severe mental illness
• Reduces hospitalization; improves social functioning

• Individual Placement and Support — competitive employment for SMI
• Strong evidence base; significantly improves outcomes

• Lived-experience workers embedded in care teams
• Enhances engagement, reduces stigma, promotes recovery

• Exercise: Meta-analyses show effects comparable to antidepressants for mild-moderate MDD
• Sleep hygiene/CBT-I: Critical for anxiety and mood disorders
• Nutrition: Mediterranean diet associated with 30% reduced depression risk
• Mindfulness-Based Cognitive Therapy (MBCT): Reduces depression relapse by ~43%

• Smartphone apps (mental health apps, mood tracking)
• Telepsychiatry — expanded access post-COVID-19
• AI-assisted diagnostic support tools

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SLIDE 29 — Comparing DSM-5-TR and ICD-11: Clinical Implications

"Considerable effort has been expended to provide an operational translation between the two nosologies." — Harrison's, p. 12849

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SLIDE 30 — Summary and Key Takeaways

1. DSM-5-TR and ICD-11 are the two dominant, complementary classification systems — both descriptive, atheoretical, and evidence-informed
2. Mental disorders are defined by clinically significant disturbances in cognition, emotion, and behavior causing distress or impairment
3. Epidemiologically, mental disorders affect >1 billion people globally and represent the leading cause of disability-adjusted life years
4. Etiology is biopsychosocial — genetic vulnerability + neurobiological dysfunction + psychodynamic factors + psychosocial stressors
5. Diagnosis requires systematic exclusion of medical/organic causes and consideration of cultural context
6. Course and prognosis vary widely but are significantly improved by early, adequate treatment
7. Treatment is multimodal: pharmacotherapy + psychotherapy + psychosocial rehabilitation represent the gold standard
8. ICD-11 innovations (Complex PTSD, dimensional personality, gaming disorder) represent paradigm shifts aligned with evolving science
9. Both systems are iterative — classification will continue to evolve as neuroscience and global data mature

"None of these diagnostic systems has as yet achieved adequate validation." — Harrison's Principles, p. 12849 — humility in classification remains essential

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• American Psychiatric Association. DSM-5-TR. Washington DC: APA Press, 2022
• World Health Organization. ICD-11 for Mortality and Morbidity Statistics. Geneva: WHO, 2019/2022
• Harrison's Principles of Internal Medicine, 21st Edition, p. 12849
• Global Burden of Disease Study 2019 — Lancet 2020
• Sadock BJ, Sadock VA, Ruiz P. Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 10th Ed.