How do international clinicians apply DSM‑5 and ICD‑11 dissociative criteria differently in low‑resource settings?
Executive summary
International clinicians in low-resource settings tend to prefer the ICD-11’s streamlined, clinically oriented dissociative guidelines because WHO designers explicitly prioritized simplicity, clinical utility and feasibility for global implementation [1] [2] [3], while the DSM‑5’s more granular, often research‑driven criteria—such as the DSM requirement for dissociative amnesia in some Dissociative Identity Disorder formulations—can be harder to apply where time, training and ancillary assessment tools are scarce [4] APADSMChanges_from_DSM-IV-TR-toDSM-5.pdf" target="_blank" rel="noopener noreferrer">[5].
1. How the manuals actually differ on dissociation — practical cut points versus detailed rules
The ICD‑11 reorganized and simplified the dissociative disorders chapter to emphasize the essential clinical features and what a clinician should expect to find, a design choice explicitly intended to enhance clinical utility across diverse settings [2] [3]; by contrast DSM‑5 retains more detailed, historically accrued criteria and specifiers (for example changes to DID and depersonalization/derealization across editions) that can require more probing and structured interviews to apply consistently [5] [6].
2. Concrete diagnostic divergences that matter in clinic rooms with limited resources
At the diagnostic item level, ICD‑11 does not require dissociative amnesia for a diagnosis of DID or partial DID whereas DSM‑5 specifies recurrent gaps in recall as part of its DID criteria—this single divergence can shift which cases meet thresholds when clinicians lack time or collateral history to establish amnesia reliably [4] [7]. Similarly, what DSM‑5 calls Functional Neurological Symptom Disorder appears in ICD‑11 as Dissociative Neurological Symptom Disorder and is placed within the dissociative grouping, a reclassification that steers clinical reasoning toward dissociation rather than somatic framing in settings without neurologic workups [4] [2].
3. Why ICD‑11’s simplicity is pitched as an advantage in low‑resource contexts
WHO working groups explicitly aimed for a “simple and efficient” system usable in most clinical settings worldwide, citing the need to reduce complexity that would otherwise impede implementation in low‑resource environments; clinician ratings from field testing reported the ICD‑11 clinical descriptions as easy to use and no more time‑consuming than standard practice in multiple countries [8] [3]. The ICD‑11’s orientation toward essential features rather than exhaustive checklists was therefore an intentional tradeoff favoring feasibility and global applicability [2].
4. How clinicians actually apply the rules in the field — adaptations and heuristics
Evidence in the provided material indicates clinicians value the ICD‑11’s “goodness of fit” and ease of use in practice, suggesting that in busy or under‑resourced clinics practitioners adopt the ICD‑11 as a pragmatic heuristic to guide treatment prioritization; where DSM‑5 is used, clinicians may rely on wider differential frameworks and structured interviews—approaches that can be ideal but time‑ and training‑intensive [3] [9]. Direct comparative field data on diagnostic yields for dissociative disorders in low‑resource settings are not supplied in the sources, so exact rates of misclassification or missed cases under each manual cannot be asserted from this reporting [9].
5. Competing incentives, professional agendas and the limits of harmonization
The ICD‑DSM Harmonization Group achieved near‑complete harmonization through the dissociative chapter, but deliberate differences remain—WHO’s emphasis on simplicity for global use versus APA’s more detailed, research‑oriented criteria reflect different institutional missions and audiences, an implicit agenda that shapes which manual clinicians in a given country prefer or are mandated to use [4] [7] [10]. Where national coding and billing rely on ICD codes, clinicians may pragmatically adopt ICD‑11 descriptors even if local training emphasizes DSM constructs [11].
6. Practical implications for patient care and research gaps
Clinicians in low‑resource settings are likely to favor ICD‑11 because it lowers thresholds for reliable bedside diagnosis and supports triage and treatment planning without extensive testing, but this may also compress clinical nuance that DSM‑5 attempts to capture—potentially affecting longitudinal characterization and research comparability; the sources do not provide empirical outcome studies comparing patient trajectories when diagnosed by ICD‑11 versus DSM‑5 in low‑resource settings, a key evidence gap [2] [9].