What is the DSM-5 classification and how does it differ from ICD-11?

What is DSM-5?

However, it is not the same classification as ICD-11, the eleventh revision of the International Classification of Diseases, developed by the World Health Organization and covering the whole of medicine rather than mental disorders alone. For this reason ICD has broader administrative, statistical, epidemiological and system-level applications, whereas DSM-5 remains a narrower tool.^[2]

In Poland, the basic classification used in medical records, reporting and reimbursement remains ICD. Although ICD-11 has been in force internationally since 1 January 2022, its implementation in national health-care systems is taking place gradually. Poland is in a transitional period (as of 2026), which means that the eleventh revision is already the international standard, while the national system still requires full organisational, IT, legal and training adjustment.^[3]

DSM-5 is a diagnostic manual published by the American Psychiatric Association. Its first version, DSM-I, was published in 1952. Subsequent editions reflected changes in psychiatry, clinical psychology, epidemiology and research on the reliability of diagnosis.^[4]

DSM-5 describes mental disorders only. Its structure includes, among others, neurodevelopmental disorders, the schizophrenia spectrum and other psychotic disorders, bipolar disorders, depressive disorders, anxiety disorders, obsessive-compulsive disorders, trauma- and stressor-related disorders, feeding and eating disorders, personality disorders, substance use disorders and neurocognitive disorders.^[1]

The most important feature of DSM-5 is its operational way of defining diagnoses. In most diagnostic categories the classification specifies a list of symptoms, the minimum number of symptoms required, the duration, exclusion criteria and the requirement of clinically significant distress or impairment in functioning. For example, a major depressive episode requires at least five of nine symptoms for a minimum of 2 weeks, with at least one symptom being depressed mood or loss of interest and the capacity to feel pleasure.^[1]

This approach increases the reproducibility of diagnosis between clinicians and facilitates scientific research. For this reason DSM-5 is very often used in clinical trials, meta-analyses, epidemiological studies and psychological and psychiatric publications. At the same time, its greater operationalisation also has limitations, because rigid numerical thresholds may not always capture the full complexity of a patient's clinical picture.

What is ICD-11?

ICD-11, the International Classification of Diseases, 11th Revision, is a WHO classification covering diseases, disorders, symptoms, causes of death, health-related conditions and reasons for contact with the health-care system. ICD-11 was adopted by the World Health Assembly in 2019 and came into effect as an international standard on 1 January 2022.^[2,3]

In the area of mental health, ICD-11 is complemented by the CDDR, the Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural and Neurodevelopmental Disorders. This is a clinical WHO manual published in 2024, designed to support accurate, consistent and globally applicable diagnosis of mental disorders.^[2]

Unlike DSM-5, ICD-11 relies to a greater extent on clinical descriptions and diagnostic requirements than on rigid symptom checklists. The CDDR indicates essential features, typical features, exclusion criteria, diagnostic boundaries and the most important elements of differentiation, while leaving the clinician greater scope for professional judgement. WHO adopted this approach deliberately, because the ICD classification has to be usable across very different health-care systems, cultures, languages and levels of access to specialist care.^[2,6]

The status of DSM-5 and ICD-11 in Poland

In Poland, DSM-5 is not the primary classification for coding diagnoses in medical records, settlements with the public payer or health statistics. In these areas the ICD classification is used. In practice this means that a diagnosis entered into the records should be coded in the ICD system, currently still largely as ICD-10 and ultimately as ICD-11 once the implementation process is complete.^[3,4]

DSM-5 may, however, be used as a supporting tool. It is helpful in differential diagnosis, scientific research, academic work, clinical training, the interpretation of foreign literature and the comparison of study results. Many clinicians know the DSM-5 criteria and use them as an additional point of reference, but within the formal Polish system the diagnosis must be translated into an ICD code.

ICD-11 has been in force as an international classification since 1 January 2022, yet each country implements it at its own pace. In Poland, projects on the implementation of ICD-11 are under way, including, among others, translation, adaptation of IT systems, code mapping, user preparation and the gradual incorporation of the classification into the health-care system.^[3,4] Therefore the correct way to describe the status of ICD-11 in Poland is: ICD-11 is the current WHO standard, but its full use in national records, reporting and reimbursement depends on the implementation process.

In Poland, the ICD code is mandatory for medical records, reporting and reimbursement with the public payer (NFZ). A diagnosis made according to DSM-5 criteria always has to be translated into the corresponding ICD code before being entered into the medical records.

The key difference: DSM-5 is more operational, ICD-11 more clinically descriptive

One of the most important differences between DSM-5 and ICD-11 is the way criteria are formulated. DSM-5 usually specifies concrete lists of symptoms, a minimum number of symptoms and a duration. ICD-11 more often describes the clinical picture of a disorder, indicating which features are required, which are typical and which argue against the diagnosis.^[1,2]

This does not mean that ICD-11 is less precise. It means rather that precision is achieved differently: not through numerical thresholds alone, but through a description of the clinical essence of the disorder, its diagnostic boundaries and differentiation. As a result, DSM-5 is often more convenient in scientific research and standardised recruitment of patients. ICD-11, in turn, is better suited to international practice, in which a diagnosis has to be applicable both in highly specialised centres and in less resourced health-care systems.^[2,6]

Differences in the classification of PTSD and complex PTSD

One of the most practical differences between ICD-11 and DSM-5 is the way trauma-related disorders are classified. ICD-11 contains two separate diagnoses: PTSD, that is post-traumatic stress disorder, and complex post-traumatic stress disorder, coded 6B41.^[2]

In ICD-11, PTSD comprises three core symptom clusters: re-experiencing the traumatic event in the present, avoidance of reminders associated with the trauma, and a persistent sense of current threat. Complex PTSD includes the same core PTSD symptoms but additionally involves disturbances in self-organisation, that is difficulties in emotion regulation, a negative self-concept and persistent relational difficulties.^[2,7,8]

DSM-5 does not single out complex PTSD as a separate diagnosis. Symptoms that in ICD-11 may lead to a diagnosis of cPTSD usually fall within the broader picture of PTSD, personality disorders, depressive disorders, dissociative disorders or other consequences of trauma in DSM-5. In practice this means that a patient with chronic trauma may be described differently depending on whether the clinician relies primarily on ICD-11 or DSM-5.^[7,8]

A practical difference: in ICD-11 a patient with chronic, repeated trauma can receive a separate diagnosis of complex PTSD (6B41). In DSM-5 the same symptoms fall within the broader definition of PTSD or within other diagnoses related to the consequences of trauma.

Personality disorders: the categorical DSM-5 model and the dimensional ICD-11 model

Another important difference concerns personality disorders. In the main part of the classification, DSM-5 retained the classical categorical model, comprising among others the paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent and obsessive-compulsive personalities. The alternative dimensional model of personality disorders is placed in DSM-5 in Section III, that is the part requiring further research and clinical application.^[1]

ICD-11 adopted a different solution. Instead of many separate personality types it introduced a single diagnosis of personality disorder, coded 6D10, with a severity rating: mild, moderate, severe or unspecified. The dominant trait domains can then be described, such as negative affectivity, detachment, dissociality, disinhibition and anankastia. ICD-11 also allows the addition of a borderline pattern qualifier, which is clinically important, because completely removing the reference to borderline could hinder diagnostic communication and treatment planning.^[2,9,10]

In practice, ICD-11 shifts the focus from the question “what personality type does the patient have?” to the questions “how severe is the impairment of personality functioning?”, “which areas of life are affected?” and “which trait profile best describes the patient's difficulties?”. This approach is more consistent with clinical observation, because many patients do not fit neatly into a single personality category, and the symptoms of different types often overlap.^[9,10]

Gaming disorder: a full diagnosis in ICD-11, a condition for further study in DSM-5

ICD-11 introduced gaming disorder as a full diagnosis, coded 6C51. The diagnosis concerns a persistent pattern of digital or video gaming in which there is impaired control over gaming, an increasing priority given to gaming over other activities, and continuation or escalation of gaming despite negative consequences. Significant impairment of personal, family, social, educational, occupational or other important areas of functioning is also required.^[2]

DSM-5 and DSM-5-TR frame a similar problem as internet gaming disorder, but not as a full diagnosis in the main part of the classification. It was placed in Section III as a condition requiring further study. This means that DSM-5 acknowledges the clinical importance of the problem but does not grant it the same status as ICD-11.^[1,11]

This difference has practical significance. In systems based on ICD-11, gaming disorder can be coded as a separate diagnosis. In the DSM-5 system it requires greater caution, because it formally remains a research category rather than a main diagnostic category.

Prolonged grief: ICD-11 earlier, DSM-5-TR later

ICD-11 introduced prolonged grief disorder, coded 6B42. It concerns a persistent, intense grief reaction that exceeds cultural, religious or social norms and leads to significant distress or impairment in functioning.^[2]

DSM-5-TR also introduced prolonged grief as a new diagnosis, but only in the text revision of 2022. An important difference concerns the duration threshold. In ICD-11 the minimum period since the loss is at least 6 months, whereas in DSM-5-TR adults require at least a 12-month period since the death of a close person, and children and adolescents at least 6 months.^[1,2,12]

In practice this means that some people may meet the ICD-11 criteria earlier than the DSM-5-TR criteria. Therefore, when interpreting research, clinical records and diagnostic opinions, it is always worth checking which system was used to make the diagnosis.

Schizophrenia: a difference in the duration of symptoms

In the diagnosis of schizophrenia, one of the key differences between ICD-11 and DSM-5 is the required duration. ICD-11 requires the presence of characteristic symptoms for at least 1 month. DSM-5 requires a total duration of the disturbance of at least 6 months, of which at least 1 month must include active-phase symptoms.^[1,2]

This means that a person meeting the ICD-11 requirements for schizophrenia may not yet meet the full DSM-5 criteria for schizophrenia. This difference is important both clinically and for research, because it affects the comparison of prevalence, prognosis and treatment outcomes between diagnostic systems.^[13]

ICD-11 also abandoned the classical subtypes of schizophrenia known from ICD-10, such as paranoid, hebephrenic or catatonic schizophrenia. Instead, course specifiers and a dimensional rating of symptoms are used, covering positive, negative, depressive, manic, psychomotor and cognitive symptoms.^[2,6]

Note the duration threshold: ICD-11 requires symptoms for at least 1 month, whereas DSM-5 requires at least 6 months of total course (including a minimum of 1 month of the active phase). The same clinical presentation may therefore be classified differently in the two systems.

Substance use disorders

DSM-5 merged the former distinction between abuse and dependence into a single category: substance use disorder. The diagnosis is based on 11 criteria, and the severity is rated as mild, moderate or severe depending on the number of criteria met.^[1]

ICD-11 retains a more differentiated model. It distinguishes, among others, an episode of harmful use, a harmful pattern of use and dependence. This makes it possible to separate a single or episodic use of a substance with clear harm from an entrenched pattern of use and from the full dependence syndrome.^[2]

In practice, both systems describe a similar clinical area, but do so with different logic. DSM-5 frames the problem more on a continuum, through the number of criteria and the level of severity. ICD-11 more strongly differentiates the type of pattern of use and its health consequences.

ADHD and autism: greater convergence than in previous classifications

In the area of neurodevelopmental disorders, DSM-5 and ICD-11 are more closely aligned than earlier classifications. DSM-5 introduced a broad conception of autism spectrum disorders, abandoning separate categories such as childhood autism, Asperger's syndrome or pervasive developmental disorders not otherwise specified. ICD-11 adopted a similar structure, coding autism spectrum disorder as 6A02, with further specifiers regarding intellectual and language functioning.^[1,2]

Similarly, in the case of ADHD, ICD-11 moved closer to the DSM-5 conception. In ICD-10 the category of hyperkinetic disorders was narrower and more restrictive. ICD-11 uses the code 6A05 and frames ADHD as a neurodevelopmental disorder with presentations depending on the predominance of inattention, hyperactivity and impulsivity, or a combined picture.^[2,6]

This change has great practical significance, particularly in the diagnosis of adults. A broader and more developmental conception of ADHD and the autism spectrum better matches current clinical knowledge than the earlier, more rigid ICD-10 categories.

Diagnostic codes: DSM-5 has no coding system of its own

A common misconception is the belief that DSM-5 has its own independent coding system. In reality, DSM-5 uses ICD codes, primarily ICD-10-CM in the United States. This means that DSM-5 describes diagnostic criteria but, for administrative and reimbursement purposes, uses codes derived from the ICD system.^[1]

ICD-11, by contrast, has its own alphanumeric code structure. In the chapter on mental, behavioural and neurodevelopmental disorders, the codes range from 6A00 to 6E6Z. For example, schizophrenia has the code 6A20, single-episode depressive disorder 6A70, recurrent depressive disorder 6A71, generalised anxiety disorder 6B00, PTSD 6B40, complex PTSD 6B41, prolonged grief 6B42, gaming disorder 6C51, personality disorder 6D10, ADHD 6A05, and autism spectrum disorder 6A02.^[2,3]

Example mapping of ICD-10, DSM-5 and ICD-11

In many areas DSM-5 and ICD-11 are clinically congruent, but they differ in coding structure, the details of the criteria and the specifiers.

Depression. ICD-10 used the codes F32 for a depressive episode and F33 for recurrent depressive disorder. In DSM-5 these correspond mainly to major depressive disorder. In ICD-11, a single depressive episode is coded 6A70 and recurrent depressive disorder 6A71.^[1,2]

Anxiety disorders. In ICD-10, generalised anxiety was coded F41.1 and panic disorder F41.0. In ICD-11, generalised anxiety disorder has the code 6B00, panic disorder 6B01, agoraphobia 6B02, specific phobia 6B03 and social anxiety disorder 6B04.^[2]

ADHD. In ICD-10, ADHD was captured within hyperkinetic disorders, mainly the code F90. In DSM-5 it functions as attention-deficit/hyperactivity disorder. In ICD-11 it corresponds to the code 6A05, with presentations depending on the predominant symptom profile.^[1,2]

Autism spectrum. ICD-10 separated childhood autism, Asperger's syndrome and other pervasive developmental disorders. DSM-5 and ICD-11 capture them within a single spectrum. In ICD-11, autism spectrum disorder is coded 6A02, with additional specifiers regarding intellectual and language functioning.^[1,2]

Schizophrenia. ICD-10 used the code F20 and subtypes of schizophrenia. DSM-5 abandons the classical subtypes, and ICD-11 also moves away from using them. In ICD-11, schizophrenia is coded 6A20, with the option of specifying the course and the current symptomatic state.^[1,2]

Criticism of DSM-5 and ICD-11

DSM-5 is sometimes criticised for the risk of excessive medicalisation, for categorical cut-offs in disorders that are dimensional in clinical practice, and for being strongly rooted in the American system of psychiatry and health insurance. Critics point out that lowering diagnostic thresholds or introducing new categories may increase the number of diagnoses without always translating into better care.^[14]

ICD-11, in turn, is sometimes criticised for the lower operationalisation of some criteria. Because the CDDR more often describes the clinical essence of a disorder than a rigid list of symptoms, the experience of the clinician matters more. This may increase flexibility and usefulness in practice, but at the same time it requires good diagnostic training and may lead to differences in interpretation between diagnosticians.^[2,6]

In practice, the two systems are increasingly converging. DSM-5 and ICD-11 frame the autism spectrum, ADHD and many mood and anxiety disorders in a similar way. The greatest differences, however, remain in areas such as complex PTSD, personality disorders, gaming disorder, prolonged grief, psychotic disorders and the way substance use is described.

Which classification should be used in practice?

In Polish medical records, reporting and reimbursement, ICD should be used in accordance with the current requirements of the health-care system. At present national practice is still largely based on ICD-10, while ICD-11 is being implemented gradually as the current WHO standard.^[3,4]

DSM-5 is worth treating as a supporting tool. It is particularly useful in academic work, reading English-language literature, conducting research, comparing clinical results and learning operational diagnosis. It should not, however, replace ICD coding wherever this is required by regulations, records or the reimbursement system.

The most practical approach is to know both classifications. ICD-11 is crucial from a system-level, international and, ultimately, national perspective. DSM-5 remains very important from the perspective of scientific research, publications and international clinical communication. For a diagnostician in Poland, the key skill is therefore the ability to understand the DSM-5 criteria while coding and documenting diagnoses in accordance with ICD.

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