Archives of Medical Research 50 (2019) 490e501

ORIGINAL ARTICLE
Anxiety and Fear-Related Disorders in the ICD-11: Results from a
Global Case-controlled Field Study
Tahilia J. Rebello,a Jared W. Keeley,b Cary S. Kogan,c Pratap Sharan,d Chihiro Matsumoto,e
Maya Kuligyna,f Tecelli Dom
ınguez-Mart
ınez,g Anne-Claire Stona,h Jean Grenier,i Jingjing Huang,j
Na Zhong,j Dan J. Stein,k Paul Emmelkamp,l Subho Chakrabarti,m Howard F. Andrews,n and
Geoffrey M. Reeda,o
a
Department of Psychiatry and WHO Collaborating Centre for Research and Capacity Building in Global Mental Health,
Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
b
Department of Psychology, Virginia Commonwealth University, Richmond, VA, USA
c
Department of Psychology, University of Ottawa, Ottawa, Canada
d
Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
e
ICD-11 Committee, Japanese Society of Psychiatry and Neurology, Tokyo, Japan
f
Instituto Nacional de Psiquiatr
ıa Ram
on de la Fuente Mu~niz, Ciudad de M
exico, M
exico
g
Alexeev Mental Clinic No 1, Moscow, Russian Federation
h
Lee Kong Chian School of Medicine, Nanyang Technological Univerity, Singapore
i
Institut du savoir Montfort, Montfort Hospital & University of Ottawa, Ottawa, Canada
j
Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, People’s Republic of China
k
SA MRC Unit of Risk and Resilience in Mental Disorders, Department of Psychiatry and Neuroscience Institute, University of Cape Town,
Cape Town, South Africa
l
Department of Clinical Psychology, University of Amsterdam, Amsterdam, the Netherlands
m
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
n
Departments of Biostatistics and Psychiatry and New York State Psychiatric Institute, Columbia University Medical Center, New York, NY, USA
o
Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland
Received for publication November 23, 2019; accepted December 17, 2019 (ARCMED_2019_1068).

Background. This article reports the results of one of a series of global field studies im-
plemented by the World Health Organization (WHO) to evaluate the accuracy, clinical
utility, and global applicability of the new diagnostic guidelines for Mental, Behavioural
and Neurological Disorders included in the next version of WHO’s International Classi-
fication of Diseases (ICD-11).
Aims of the study. The purpose of this study was to compare the diagnostic accuracy and
clinical utility ratings of global clinicians implementing the ICD-11 diagnostic guidelines
for Anxiety and Fear-Related Disorders, relative to those applying ICD-10 guidelines.
The study also aimed to identify elements of the guidelines that required further refine-
ment or clarification.
Methods. 1840 global mental health professionals registered with WHO’s Global Clin-
ical Practice Network completed the study in one of six study languages. Participants
were randomly assigned to apply either the ICD-11 or ICD-10 guidelines to diagnose
standardized case vignettes, and to rate the clinical utility of their assigned guidelines.
Results. ICD-11’s diagnostic accuracy and clinical utility were equivalent or superior to
that of ICD-10. Global clinicians were significantly more accurate in diagnosing Gener-
alized Anxiety Disorder, Specific Phobia and adult cases of Separation Anxiety Disorder
when using ICD-11 and provided high clinical utility ratings for these disorders. Clini-
cians also found the ICD-11 guidelines easy to use, clear, and a good fit to patients they
see in their clinical practice. However, clinicians had difficulty with distinguishing the

Surgeons, 1051 Riverside Drive, New York, NY 10032, USA; E-mail:

Address reprint requests to: Geoffrey M. Reed, PhD, Department of
gmr2142@cumc.columbia.edu
Psychiatry, Columbia University Vagelos College of Physicians and

0188-4409/$ - see front matter. Copyright Ó 2019 IMSS. Published by Elsevier Inc.
https://doi.org/10.1016/j.arcmed.2019.12.012
 A Global Field Study of Anxiety Disorders in the ICD-11 491

boundary between disorder and normality for subthreshold cases of anxiety, and also with
applying the new ICD-11 guidelines on panic attacks.
Conclusions. The new diagnostic guidelines for Anxiety Disorders in ICD-11 can be
applied in an acceptably consistent manner by global clinicians and perform as well or
better than the previous guidelines for ICD-10. Study findings also helped identify as-
pects of the ICD-11 guidelines that required refinement prior to their publication and
areas that should be emphasized in training programs. Ó 2019 IMSS. Published by
Elsevier Inc.
Key Words: Anxiety disorders, Anxiety and fear-related disorders, Mental disorders, International
Classification of Diseases (ICD), ICD-11, Diagnosis, Classification.

Introduction statistical reporting, but also the development of the Clin-

ical Descriptions and Diagnostic Guidelines (CDDG) for
Anxiety disorders manifest across the lifespan and are char-
ICD-11 e a more comprehensive version that provides cli-
acterized by excessive symptoms of fear and anxiety over a
nicians with detailed clinical guidance for diagnosing
prolonged period of time, accompanied by behavioral
mental, behavioural and neurodevelopmental disorders in
changes and non-specific physiological arousal. They are
clinical settings (12e14). As part of CDDG development,
ubiquitous and widespread across the globe, with a lifetime
WHO’s Working Group for Mood and Anxiety Disorders
prevalence of 12.9% and with the highest 12 month preva-
was appointed to review the ICD-10 CDDG guidelines
lence rate of all mental disorders, affecting 1 in 15 persons
for anxiety, phobic, and related disorders, and to recom-
annually (1e4). Anxiety disorders result in significant
mend specific modifications to the diagnostic material
distress, functional impairment, disability, diminishment
based on the best available scientific and clinical data from
of educational and economic potential, and lowered quality
around the world (17,18). WHO’s priority was to provide
of life (3,4). The impact of these disorders extends beyond
member states and health professionals with a better tool
the individual and has major public health consequences,
for reducing the global disease burden of mental disorders
incurring substantial health, social, and economic costs
by enhancing the following implementation characteristics
for health systems, employers, governments and commu-
of the guidelines for Anxiety and Fear-Related Disorders
nities (3e6). Despite the presence of effective, evidence-
in the ICD-11: a) diagnostic accuracy and reliability; b)
based psychosocial and pharmacological interventions, a
clinical utility, or usefulness of the classification system
major gap in treatment exists (5,7e9). Over 70% of individ-
to clinicians working in varied clinical settings; and c)
uals with an Anxiety Disorder never receive any form of
applicability and acceptability of the system to clinicians
treatment, and up to 90% do not receive adequate treatment
worldwide (12e15).
(7,10). Moreover, a significant lag of up to 14 years may
A comprehensive discussion of the changes proposed in
exist between onset of the disorder and initiation of treat-
the ICD-11 CDDG for Anxiety and Fear-Related Disorders
ment (10); this treatment gap is in part associated with
and changes proposed by the WG has been provided by Ko-
the lack of early and accurate detection (8,10). Thus, initia-
gan et al. (18). Briefly, the overarching changes to this dis-
tives that enhance diagnosis of these conditions have the
order grouping include a reorganization of the categories
potential to significantly lower the global burden of disease
based on formative field studies (19e21) and a general clar-
associated with Anxiety Disorders.
ification of the guidelines relative to the ICD-10. First, the
For the clinical diagnosis of mental and behavioral dis-
distinction made in ICD-10 between Phobic anxiety disor-
orders, including Anxiety Disorders, the world’s most
ders and Other anxiety disorders is eliminated in ICD-11,
widely used classification system is the World Health Orga-
and all disorders with anxiety or fear as the primary clinical
nization’s (WHO) International Classification of Diseases
feature are brought together in a new and distinct grouping
(ICD) (11). In May 2019, WHO approved the most recent
titled Anxiety and Fear-Related Disorders (henceforth
version of the ICD for Mortality and Morbidity Statistics
referred to as ‘Anxiety Disorders’). Additionally, unlike
(ICD-11 MMS; https://icd.who.int/en). The ICD-11 now
ICD-10, the revised ICD-11 guidelines do not separate
serves as the official classification system for reporting of
childhood from adult disorders but instead recognize that
health information by all 194 WHO member countries
the same disorders may occur across the lifespan, although
and training and implementation processes are already
with developmentally distinct presentations. In ICD-11, the
underway.
focus of apprehensioneor the stimulus or situation that trig-
Development of the ICD-11 chapter on Mental, Behav-
gers the individual’s fear or anxietyeis used as the basis for
ioural and Neurodevelopmental Disorders was a decade-
distinguishing among the different Anxiety Disorders.
long revision process that was led by the WHO Department
Moreover, to enhance clinical utility, the ICD-11 guidelines
of Mental Health and Substance Abuse (12e16). This
systematically provide the following information for each
involved not only the development of the version for
492 Rebello et al./ Archives of Medical Research 50 (2019) 490e501
Anxiety Disorder: a) the focus of apprehension; b) a
description of characteristic behavioral manifestations of
the disorder; c) symptom duration requirements; d) guid-
ance on determining the boundaries with normality, and
other Mental and Behavioural Disorders/other relevant
health conditions with similar symptomology; e) and the
presence and extent of distress and impairment.
ICD-11 also includes clarification on the diagnostic sig-
nificance of panic attacks, by specifying that panic attacks
may occur in context of Panic Disorder, where they are a
key clinical feature and are unexpected and not restricted
to particular external stimuli or situations, or they may
occur in the context of other Anxiety Disorders. When
panic attacks occur in the context of other Anxiety Disor-
ders, they are generally expected, in the sense that they
are limited to stimuli and situations that are the focus of
apprehension of that particular Anxiety Disorder. However,
if panic attacks are limited to these situations then ICD-11
specifies that a separate Panic Disorder Diagnosis is not
warranted, and a ‘with panic attacks’ qualifier may be used.
If some panic attacks over the course of the disorder have
been unexpected and not exclusively in response to stimuli
associated with the focus of apprehension related to another
Anxiety Disorder, and all other essential features of Panic
Disorder are met, a co-occurring diagnosis of Panic Disor-
der may be assigned.
Key Changes to Specific Anxiety Disorders
The ICD-11 guidelines are conceptually similar to those of
the ICD-10 with some notable revisions. The ICD-11
Generalized Anxiety Disorder (GAD) has a more elabo-
rated set of essential features. General apprehensiveness,
which is an essential feature of GAD, has been expanded
to also include excessive worry about negative events
occurring in several different aspects of life. The guidelines
also provide clearer guidance for differentiating GAD from
normal reactions to life stressors and subthreshold worry or
apprehensiveness by including guidelines on symptom
duration (not transient, persisting for several months) and
severity (result in significant distress or functional
impairment).
Agoraphobia also no longer takes primacy over Panic
Disorder and the ICD-10 ‘with panic disorder’ or ‘without
panic disorder’ qualifiers for Agoraphobia have been elim-
inated. Co-occurrence of Agoraphobia and Panic Disorder
is permitted in ICD-11 only if all the essential features of
both disorders are met. In cases where panic attacks occur
only in response to agoraphobic situations (i.e., they are ex-
pected), a co-occurring Panic Disorder diagnosis is not war-
ranted and the ‘with panic attacks’ qualifier should be used
instead.
Specific Phobia in ICD-11 is conceptually similar to the
disorder in ICD-10, but ICD-11 indicates that as an alterna-
tive to active avoidance of the feared stimulus, which was
required in ICD-10, the feared object or situations may be
endured with intense fear or anxiety. In ICD 11, the diag-
nostic label of ‘Social Anxiety Disorder’ replaces the
ICD-10 diagnosis of ‘Social phobias’ but the guidelines
are similar. Finally, in line with ICD-11’s lifespan
approach, Separation Anxiety Disorder can be diagnosed
in adults as well as in children, whereas in ICD-10 the en-
tity was referred to as Separation Anxiety Disorder of
Childhood and listed in a separate grouping of ‘‘Emotional
disorders with onset specific to childhood’’ (22).
A key feature of the development of the classification of
mental disorders for ICD-11 has been a rigorous scientific
program of field studies designed to evaluate these features
of the ICD-11 (23e31). The results of the field studies have
been used to further to refine the diagnostic guidelines
based on how clinicians actually applied them. The present
article reports the results of one of a series of studies that
compared the application by clinicians of the new ICD-11
CDDG to similar guidelines published for the ICD-10
(32) to standardized case material in the form of written vi-
gnettes, referred to as case-controlled studies due to their
systematically controlling and varying specific features of
the case description to examine their influence on clinical
decision making (23,31). The purpose of this study was
to assess the impact of these changes in the diagnostic
guidelines for Anxiety Disorders from the ICD-10 to the
ICD-11 on diagnostic accuracy, clinical utility, and global
applicability. This was a vignette-based case-controlled
field study was developed and implemented via the
Internet, to members of the Global Clinical Practice
Network (GCPN, https://gcp.network/en/) (33). The GCPN
is an online network of more than 15,000 mental health pro-
fessionals from over 150 countries who volunteered to
collaborate in the development of the ICD-11 classification
of mental disorders by participating in these field studies.
Materials and Methods
Procedures
The field study was developed and implemented via the
internet using Qualtrics survey software (https://www.
qualtrics.com, Provo, USA). The study was conducted in
Chinese, English, French, Japanese, Spanish and Russian.
Study materials were initially developed in English, fol-
lowed by rigorous forward and back-translation processes
as previously described (23,31). Each participant received
an individualized link to the study. Upon entry to the study,
participants were randomly assigned to one of two condi-
tions in which they were presented with either the ICD-
10 or ICD-11 diagnostic guidelines for Anxiety Disorders.
Participants were blind to their assigned condition,
although it is likely that users of the ICD-10 who were pre-
sented with them recognized the ICD-10 guidelines. Partic-
ipants were asked to review the guidelines for their
 A Global Field Study of Anxiety Disorders in the ICD-11
assigned diagnostic system, and were then randomly pre-
sented with two of eleven possible clinical case vignettes
(Table 2).
Vignettes were developed by members of the WHO
ICD-11 WG on Mood and Anxiety Disorders and other
content experts, after which a vignette validation process
was undertaken. Validation was conducted by an indepen-
dent group of international content experts that assessed
whether the vignettes fit the diagnostic guidelines for the
conditions they were intended to depict, to confirm the cor-
rect diagnosis for the person in the vignette, and to assess
the ecological validity (i.e., whether they were similar to
real-life cases) and global applicability of each case.
Vignette development and validation processes have been
described in detail elsewhere (23,31).
After presentation of the vignette, participants were asked
to select a diagnosis from the list of possible Anxiety Disor-
ders in their assigned diagnostic system. Participants were
able to pick an Anxiety Disorder on its own, or as part of a
co-occurring diagnosis with Panic Disorder (e.g., ‘Agora-
phobia’ or ‘Agoraphobia and Panic Disorder’). Participants
could also choose to select no diagnosis for the case, or could
indicate a different diagnosis was warranted, in which case
they were asked to type in their selection. Participants could
refer to both the vignette and their assigned diagnostic guide-
lines while making their diagnostic decision. After selecting
a diagnosis, the participant was shown the essential features
for the selected diagnosis in a stepwise fashion and asked to
indicate whether each essential feature for that disorder was
present in the vignette using a dropdown menu (choices: Yes;
No; Not sure; Does not apply). Participants were able to view
the vignette when answering these questions after which they
had the option of changing their diagnosis. If the participant
chose an incorrect diagnosis for the vignette, they were asked
to provide a rationale for their selection, though the partici-
pant was not explicitly informed that they selected an incor-
rect diagnosis.
After each vignette, participants were asked a set of
supplementary questions to rate the clinical utility of the
guidelines using four-point Likert scales, including their
ease of use (Not at all to Extremely easy to use), goodness
of fit (Not at all to Extremely accurate), and clarity (Not
at all to Extremely clear). Participants were also asked to
rate the severity of the symptoms (Not to Extremely se-
vere) and the level of impairment (No to Complete
impairment) of the person in the vignette using five-
point Likert scales. Participants also indicated how
frequently they encountered patients with their selected
diagnosis (Never to Very frequently: multiple times a
week; 5 point scale) and the similarity of the symptoms
of the patients they see with their selected diagnosis rela-
tive to the person described in the vignette (Not at all to
Extremely similar; 4 point scale). Participants were then
shown a second randomly assigned vignette and the above
procedures were repeated.
493
The study protocol was exempted from review by the
Human Subjects Committee of the University of Kansas,
where the servers hosting the data collection were located,
and by the Research Ethics Review Committee of the
World Health Organization. Even so, each participant was
asked to indicate informed consent to participate in the
study and told that they could exit the study at any time.
Participants
Participants were recruited from WHO’s GCPN, an online
network of mental health and primary care professionals
from across the globe who have registered to participate
in the ICD-11 field studies. At the time of study implemen-
tation, all GCPN members who met the following criteria
were invited to participate: a) either directly providing clin-
ical services or were engaged in direct clinical supervision,
and b) self-identified as proficient or fluent in one of the six
study languages. Eligible participants were sent a study
invitation e-mail containing their individualized link, fol-
lowed by reminder e-mails ten days and twenty days
following the initial invitation. For each language, data
was collected for a 2 month period.
Statistical Analysis
We used c2 analyses to examine differences between ICD-
11 and ICD-10 on diagnostic accuracy for each vignette.
For clinical utility variables, because the response metric
was ordinal, we also used c2 analyses to examine differ-
ences in the response pattern across ICD-11 and ICD-10.
In instances where we compared severity and impairment
ratings for the vignettes, we used independent samples t-
tests to examine differences across the two diagnostic
systems.
Results
9915 individuals were invited to participate in the study
2408 (24.3%) people started the survey and 1840 of them
(76.4%) completed enough of the study to be included in
the present analysis. Demographic information for partici-
pants is provided in Table 1. Slightly more than half of par-
ticipants completed the study in English (52.3%), with the
remainder divided among Chinese (7.1%), French (7.9%),
Japanese (10.8%), Russian (8.6%) and Spanish (13.3%).
Participants were from 86 countries with the highest repre-
sentation from Mexico (n 5 413), Spain (n 5 237) and
Japan (n 5 193). All global regions were represented with
the highest proportion from Europe (40.7%), the Americas
(23.4%) and the Western Pacific region (21.6%). 58.9% of
participants identified as male and 41.1% as female. Mean
age was 47.1 years old (SD 5 11.2 years). The majority of
participants were physicians, mostly psychiatrists (55.4%),
about a third were psychologists (30.7%), and the rest
494 Rebello et al./ Archives of Medical Research 50 (2019) 490e501

Table 1. Participant demographics

Chinese, English, French, Japanese, Russian, Spanish, Total,

Study language n (%) n (%) n (%) n (%) n (%) n (%) n (%)

Region
Africa 0 53 (5.5) 12 (8.2) 0 0 0 65 (3.5)
Americas-North 0 216 (22.4) 7 (4.8) 0 0 0 223 (12.1)
Americas-South 0 40 (4.2) 0 0 0 168 (68.6) 208 (11.3)
Eastern Mediterranean 0 44 (4.6) 15 (10.3) 0 0 0 59 (3.2)
Europe 0 402 (41.7) 112 (76.7) 0 158 (100) 77 (31.4) 749 (40.7)
South-East Asia 0 139 (14.4) 0 0 0 0 139 (7.6)
Western Pacific-Asia 130 (100) 8 (0.8) 0 198 (100) 0 0 336 (18.3)
Western Pacific-Oceania 0 61 (6.3) 0 0 0 0 61 (3.3)
Gender
Male 80 (61.5) 522 (54.2) 84 (57.5) 167 (84.3) 93 (58.9) 119 (48.6) 1065 (57.9)
Female 50 (38.5) 439 (45.6) 62 (42.5) 31 (15.7) 65 (41.1) 125 (51.0) 772 (42.0)
Discipline
Counseling 3 (2.3) 65 (6.7) 2 (1.4) 2 (1.0) 2 (1.3) 2 (0.8) 76 (4.1)
Medicine 120 (92.3) 434 (45.1) 86 (58.9) 166 (83.8) 127 (80.4) 86 (35.1) 1019 (55.4)
Nursing 0 18 (1.9) 7 (4.8) 1 (0.5) 0 1 (0.4) 27 (1.5)
Psychology 5 (3.8) 321 (33.3) 50 (34.2) 26 (13.1) 24 (15.2) 138 (56.3) 564 (30.7)
Social work 0 61 (6.3) 0 0 1 (0.6) 2 (0.8) 64 (3.5)
Occupational Therapy 0 32 (3.3) 1 (0.7) 0 0 1 (0.4) 34 (1.8)
Certified Peer Support Worker 0 6 (0.6) 0 0 0 0 6 (0.3)
Other 2 (1.5) 26 (2.7) 0 3 (1.5) 4 (2.5) 15 (6.1) 50 (2.7)
Age 41.02 (8.5) 48.39 (11.2) 46.95 (12.3) 46.88 (9.7) 44.03 (11.3) 47.23 (11.4) 47.06 (11.2)
Years of Experience 11.10 (7.6) 16.04 (10.3) 16.66 (10.7) 15.36 (9.9) 17.75 (10.7) 17.49 (10.3) 16.01 (10.3)
Total N 130 (7.1) 963 (52.3) 146 (7.9) 198 (10.8) 158 (8.6) 245 (13.3) 1840

represented various other mental health professions. Mean
years of experience was 16.0 years (SD 5 10.3 years).
Diagnostic Accuracy
Table 2 shows the diagnostic accuracies of clinicians
applying ICD-11 or ICD-10 guidelines to Anxiety Disorder
case vignettes.
Generalized anxiety disorder (GAD). Diagnostic accuracy
for GAD was assessed based on clinicians who responded
to vignette 1 which depicted a case presenting with all of
the essential features of GAD. Diagnostic accuracy was
significantly higher for clinicians applying ICD-11
guidelines (93.9% of clinicians accurately selected GAD
vs. any other diagnosis or no diagnosis) than for those
applying ICD-10 (85.5% accuracy).
To test the accuracy with which clinicians could differ-
entiate the boundary between GAD and normality, diag-
nostic responses to a subclinical case of an individual
with worries in multiple areas but without significant
distress or impairment (vignette 2) were analyzed. The ma-
jority of clinicians correctly indicated that vignette 2 should
have no diagnosis, with no statistical differences between
the two diagnostic systems (ICD-11: 55.8% accurately
selected no diagnosis vs. GAD or any other diagnosis;
ICD-10: 55.6% accuracy). However, a fair proportion of
participants inaccurately selected a GAD diagnosis (ICD-

Table 2. Diagnostic accuracy of clinicians applying either ICD-11 or ICD-10 Anxiety Disorder guidelines

Vignette
number Clinical case ICD-11 Accuracy % (n) ICD-10 Accuracy % (n) Statistical comparison

1 Generalized Anxiety Disorder 93.9% (n 5 154) 85.5% (n 5 148) c2 (2) 5 6.38, p !0.05
2 Subthreshold worry 55.8% (n 5 96) 55.6% (n 5 89) c2 (2) 5 0.82, ns
3 Panic Disorder 86.0% (n 5 141) 88.4% (n 5 152) c2 (1) 5 0.43, ns
4 Agoraphobia 75.3% (n 5 113) 82.3% (n 5 153) c2 (1) 5 2.14, ns
5 Agoraphobia (with cued panic attacks) 40.2% (n 5 70) 44.4% (n 5 67) c2 (3) 5 1.23, ns
6 Specific Phobia 85.2% (n 5 144) 85.1% (n 5 137) c2 (1) ! 0.01, ns
7 Social Anxiety Disorder 84.2% (n 5 133) 77.7% (n 5 136) c2 (1) 5 2.23, ns
8 Social Anxiety Disorder (with cued panic attacks) 63.4% (n 5 109) 56.8% (n 5 92) c2 (2) 5 1.80, ns
9 Subthreshold social anxiety 28.9% (n 5 94) 17.8% (n 5 111) c2 (2) 5 5.84, p 5 0.054
10 Separation Anxiety Disorder (child case) 94.2% (n 5 161) 94.6% (n 5 158) c2 (1) 5 0.03, ns
11 Separation Anxiety Disorder (adult case) 74.4% (n 5 119) 20.6% (n 5 32) c2 (1) 5 91.07, p !0.0001

ns, nonsignificant.
 A Global Field Study of Anxiety Disorders in the ICD-11
11: 24.7%; ICD-10: 20.6%), a different Anxiety Disorder
(ICD-11: 13.2%, ICD-10: 15.0%), or a different diagnosis
(ICD-11: 6.9%, ICD-10: 8.8%) for this vignette. Incorrect
selections of clinicians using ICD-11 were overall more
unitary than those using ICD-10 whose selections spanned
a wider range of incorrect diagnoses. Clinicians using the
ICD-11 who incorrectly selected GAD also rated the symp-
tom severity and functional impairment of the person in the
vignette as higher (severity: M 5 2.86, SD 5 0.59; impair-
ment: M 5 2.59, SD 5 0.60) than participants who gave the
correct option of no diagnosis (severity: M 5 1.91,
SD 5 0.48, t [131] 5 9.66, p !0.001; impairment:
M 5 1.63, SD 5 0.51, t [131] 5 9.38, p !0.001). The ma-
jority of participants assigned to ICD-11 who incorrectly
selected GAD indicated that they identified the presence
of the essential features of GAD in the vignette (Table 3).
Of the 18 participants who provided written responses to
the question regarding why they had selected GAD instead
of no diagnosis, nearly all stated that the person seeking
clinical services indicated sufficient impairment to qualify
for a GAD diagnosis.
Panic disorder. Clinicians applying either ICD-11 or ICD-
10 guidelines to vignette 3, a Panic Disorder case, were
highly accurate in selecting the correct diagnosis (ICD-
11: 86.0%; ICD-10: 88.4%), with no statistical difference
between the two systems. If responses in which the partic-
ipant selected a co-occurring diagnosis of Panic Disorder
and another Anxiety Disorder are included in this figure,
96.3% of the participants in the ICD-11 condition and
95.3% of the participants in the ICD-10 condition correctly
identified the presence of panic disorder, even though some
were inaccurately identifying that another disorder was pre-
sent as well.
Agoraphobia. Clinicians applying both diagnostic systems
to vignette 4, which depicted a case of Agoraphobia, did so
with a fairly high degree accuracy (ICD-11: 75.3%; ICD-
10: 82.3%), with no significant difference between ICD-
11 and ICD-10. Vignette 5 tested whether clinicians were
able to correctly diagnose a case of a person with Agora-
phobia who also experienced expected panic attacks in
the context or anticipation of agoraphobic situations such
as crowds or public spaces. For this case, the correct
Table 3. Endorsement of essential features for GAD in ICD-11 on vignette 2 (subthreshold worry)
Yes % (n)
General apprehensiveness or worry 89.5 (34)
Additional required symptoms 78.9 (30)
Present for several months 89.5 (34)
Distress or impairment 68.4 (26)
Normal stress reaction 36.8 (14)
Results for each endorsement are based on 38 out of 41 clinicians who were shown this vignette, incorrectly selected GAD, were assigned to use the ICD-11
diagnostic guidelines, and responded to this question.
495
diagnosis according to the ICD-11 guidelines is Agora-
phobia without a co-occurring Panic Disorder diagnosis
given the cued nature of the panic attacks. Clinicians ex-
hibited comparably low diagnostic accuracy with only
40.2% of clinicians using ICD-11 and 44.4% of those using
ICD-10 (not significantly different) assigning the correct
response of Agoraphobia alone. An almost equal proportion
of participants incorrectly selected the Agoraphobia and co-
occurring Panic Disorder diagnosis (ICD-11; 45.4%; ICD-
10: 41.7%), while a small percentage selected Panic Disor-
der alone (ICD-11: 5.2%; ICD-10: 6.6%). Clinicians who
were assigned to apply the ICD-11 guidelines to this
vignette and incorrectly selected a comorbid Panic Disorder
diagnosis, or Panic Disorder alone were asked whether each
of the essential features of Panic Disorder were exhibited
by the person in vignette 5 (Table 4). Almost all of these
clinicians endorsed that the person experienced unexpected
panic attacks (91.9%) and that their panic attacks were not
better accounted for by another disorder despite the fact
that person met the requirements for an Agoraphobia diag-
nosis and the vignette clearly indicated that the attacks were
situationally bound. Narrative responses regarding why cli-
nicians added a diagnosis of Panic Disorder to Agoraphobia
focused on the salience of the panic attacks in the case and/
or that they occurred prior to the symptoms of Agora-
phobia. None acknowledged that the attacks were situation-
ally bound or provided a rebuttal to the exclusionary
diagnostic guideline specifying that cued or expected panic
attacks in the context of another Anxiety Disorder do not
warrant a comorbid Panic Disorder diagnosis.
Specific Phobia. For Vignette 6, a case of a person meeting
the essential features for Specific Phobia, clinicians using
both ICD-11 and ICD-10 accurately selected the correct
diagnosis (ICD-11: 85.2%; ICD-10: 85.1%), with no signif-
icant difference between diagnostic systems.
Social anxiety disorder. Clinicians in both the ICD-11 and
ICD-10 group performed well when diagnosing a case of
Social Anxiety Disorder (vignette 7; ICD-11: 84.2%;
ICD-10 77.7%), with no significant difference between
the groups. Vignette 8 depicted a person who met the guide-
lines for a Social Anxiety Disorder diagnosis, but also expe-
rienced situationally specific panic attacks associated with,
No % (n) Not sure or does not apply % (n)
5.3 (2) 5.3 (2)
13.2 (5) 7.9 (3)
10.5 (4) 0 (0)
13.2 (5) 18.4 (7)
44.7 (17) 18.4 (7)
496 Rebello et al./ Archives of Medical Research 50 (2019) 490e501

Table 4. Endorsement of essential features for Panic Disorder in ICD-11 on vignette 5 (Agoraphobia, with cued panic attacks)

Yes % (n) No % (n) Not sure or does not apply % (n)

Unexpected panic attacks 91.0 (71) 7.7 (6) 1.3 (1)

Attacks occur only in the context of another Anxiety disorder 33.3 (26) 52.6 (41) 14.1 (11)
Different from normal anxiety 80.8 (63) 16.7 (13) 2.6 (2)
Better captured by another disorder 11.5 (9) 82.1 (64) 6.4 (5)
Concern about future attacks 98.7 (77) 0 (0) 1.3 (1)
Impairment 97.4 (76) 0 (0) 2.6 (2)

Results for each endorsement are based on 77 out of 174 clinicians who were shown this vignette, incorrectly selected Panic Disorder, were assigned to use
the ICD-11 diagnostic guidelines, and responded to this question.

or in anticipation of, anxiogenic social situations. Re-
sponses to this vignette were used to assess whether clini-
cians could correctly diagnose this person with Social
Anxiety Disorder versus with a comorbid Panic Disorder.
Clinicians in the ICD-11 and ICD-10 group had compa-
rably moderate accuracy (ICD-11: 63.4%; ICD-
10 5 56.8%) in selecting Social Anxiety Disorder alone
(or Social phobia alone, for ICD-10). However, a sizeable
proportion made an incorrect comorbid Panic Disorder
diagnosis even though the panic attacks were situationally
bound and related to the Social Anxiety Disorder diagnosis
(ICD-11: 22%; ICD-10: 24%). About three quarters of the
clinicians assigned to ICD-11 who incorrectly selected a
comorbid Panic Disorder diagnosis indicated the presence
of unexpected panic attacks even though the vignette
clearly depicted that the attacks were bound specifically
to socially anxious situations (Table 5). These clinicians
incorrectly made a Panic Disorder diagnosis despite
78.9% of them acknowledging that the panic attacks occur
only in the context of another Anxiety Disorder. Of clini-
cians who selected the incorrect comorbid diagnosis and re-
sponded to the open-ended question regarding why they did
not select Social Anxiety Disorder alone, most correctly
recognized that the panic was situationally specific but indi-
cated that they still selected the comorbid diagnosis
because of the severity of the symptoms, or based on the
fact that the two disorders are commonly comorbid.
The boundary between Social Anxiety Disorder and sub-
threshold social anxiety was also tested using vignette 9.
This vignette depicted a shy person who exhibited symptoms
of social anxiety but did not meet the requirements for Social
Anxiety Disorder nor any other diagnosis. Clinicians
assigned to apply both ICD-11 and ICD-10 had low diag-
nostic accuracy for this vignette (ICD-11: 28.9%; ICD-10:
17.8%). The difference between the groups approached sig-
nificance with ICD-11 guidelines resulting in slightly higher
diagnostic accuracy (Table 2). A substantial proportion of
clinicians in both groups were tempted to give a diagnosis
of Social Anxiety Disorder to this case, even though it did
not meet the required level of impairment, with 56.6% of cli-
nicians using ICD-11 and 65.7% of those using ICD-10
incorrectly providing this diagnosis. This is despite the fact
that clinicians’ average severity and impairment ratings were
lower for this vignette compared to vignettes 7 and 8. Clini-
cians using ICD-11 who gave a diagnosis of Social Anxiety
Disorder (56.6%) and completed the step-by-step review of
the essential features generally indicated that the person’s
fear was excessive beyond the bounds of cultural norms
and resulted in significant distress and impairment
(Table 6). Open-ended responses provided by 94 clinicians
who made this diagnostic selection indicated that help
seeking by the individual was enough to justify the diag-
nosis. They also considered the person putting off a public
speaking course to be sufficient evidence of avoidance.
Several mentioned prioritizing the person’s need for treat-
ment as a justification for selecting a diagnosis.
Separation anxiety disorder. Clinician responses to two vi-
gnettes (10 and 11) were used to assess the accuracy with
which clinicians applied the assigned guidelines for this
disorder. For vignette 10, which represented a child case
of Separation Anxiety Disorder, participants applying either
ICD-11 or ICD-10 did so with high accuracy (ICD-11:
94.2%; ICD-10: 94.6%), with no statistically significant

Table 5. Endorsement of essential features for Panic Disorder in ICD-11 on vignette 8 (Social Anxiety Disorder, with cued panic attacks)

Yes % (n) No % (n) Not sure or does not apply % (n)

Unexpected panic attacks 73.7 (28) 23.7 (9) 2.6 (1)

Attacks occur only in the context of another Anxiety Disorder 78.9 (30) 15.8 (6) 5.3 (2)
Different from normal anxiety 81.6 (31) 13.2 (5) 5.3 (2)
Better captured by another disorder 21.1 (8) 63.2 (24) 15.8 (6)
Concern about future attacks 76.3 (29) 15.8 (6) 7.9 (3)
Impairment 86.8 (33) 5.3 (2) 7.9 (3)

Results for each endorsement are based on 38 out of 172 clinicians who were shown this Vignette, incorrectly selected Panic Disorder, were assigned to use
the ICD-11 diagnostic guidelines, and responded to this question.
 A Global Field Study of Anxiety Disorders in the ICD-11 497

Table 6. Endorsement of essential features for Social Anxiety Disorder in ICD-11 on Vignette 9

Not sure or does not apply

Yes % (n) No % (n) % (n)

Excessive fear of social 90.4 (85) 7.4 (7) 2.1 (2)

situations
Concern of negative 59.6 (56) 13.8 (13) 26.6 (250)
evaluation
Social situations avoided or 85.1 (80) 7.4 (7) 7.4 (7)
endured
Present at least several 90.4 (85) 6.4 (6) 3.2 (3)
months
Significant distress or 69.1 (65) 18.1 (17) 12.8 (12)
impairment
Symptoms are part of normal 12.8 (12) 75.5 (71) 11.7 (11)
development
Symptoms in excess of 83.0 (78) 8.5 (8) 8.5 (8)
cultural norms
Better characterized by 1.1 (1) 90.4 (85) 8.5 (8)
another mental disorder

Note: Results for each endorsement are based on 94 out of 166 clinicians who were shown this Vignette, incorrectly selected Social Anxiety Disorder, were
assigned to use the ICD-11 diagnostic guidelines, and responded to this question.

difference between the two diagnostic systems. For vignette
11, which represented an adult case of the disorder as per
ICD-11 guidelines, 74.4% of clinicians applying the ICD-
11 to this vignette selected Separation Anxiety Disorder.
For those applying ICD-10 only 20.6% of clinicians
applying ICD-10 selected the correct diagnosis as per this
diagnostic system, which would be either ‘Other Anxiety
Disorder’ or ‘Unspecified Anxiety Disorder’.
Clinical Utility
Clinical utility of the guidelines was assessed based on
clinician ratings of the ease of use, goodness of fit, and
clarity of the diagnostic material. In addition, clinicians
provided ratings of the similarity of the cases presented
in the vignettes to cases they see in their practice, the fre-
quency with which they see cases with the diagnosis they
selected, and their confidence in their selected diagnosis.
For most diagnoses, across these variables, there was no
appreciable difference between ICD-10 and ICD-11. How-
ever, differences were present for GAD, Specific Phobia,
and Separation Anxiety Disorder:
GAD. Participants percieved the ICD-11 guidelines to be
easier to use, a better fit, and clearer relative to the ICD-
10 guidelines (Table 7). Clinicians using the ICD-11

Table 7. Clinicians’ perceived clinical utility of GAD guidelines

Not at all Somewhat Quite Extremely Statistical comparison

Ease of Use
ICD-11 0 22 100 86 c2 (3) 5 16.40, p !0.001
0.0% 10.6% 48.1% 41.3%
ICD-10 3 38 128 56
1.3% 16.9% 56.9% 24.9%
Goodness of Fit
ICD-11 0 25 102 81 c2 (3) 5 13.58, p !0.01
0.0% 12.0% 49.0% 38.9%
ICD-10 3 36 132 54
1.3% 16.0% 58.7% 24.0%
Clarity
ICD-11 0 9 111 80 c2 (3) 5 13.88, p !0.01
0.0% 4.5% 55.5% 40.0%
ICD-10 0 28 131 59
0.0% 12.8% 60.1% 27.1%
Confidence
ICD-11 0 15 95 90 c2 (3) 5 11.97, p !0.01
0.0% 7.5% 47.5% 45.0%
ICD-10 0 28 126 64
0.0% 12.8% 57.8% 29.4%
498 Rebello et al./ Archives of Medical Research 50 (2019) 490e501

guidelines who made this diagnosis also had significantly
more confidence in their diagnostic selection, relative to
those using ICD-10 (c2 [3] 5 11.97, p !0.01).
Specific Phobia. The ICD-11 Specific Phobia guidelines
were also rated as significantly easier to use, a better fit
to the case, and clearer relative to the ICD-10 guidelines.
Clinicians also felt more confident about making this selec-
tion when using the ICD-11 compared to the ICD-10
(Table 8).
Separation anxiety disorder. Clinicians applying the ICD-
11 guidelines indicated that they more frequently saw pa-
tients in their practice with this diagnosis than those using
ICD-10, with a significant difference between groups (c2
[4] 5 12.90, p !0.05). For the child case (vignette 10),
there were no differences in similarity ratings between
ICD-11 and ICD-10. For the adult case (vignette 11), how-
ever, there was a significant difference with clinicians using
the ICD-11 indicating that the vignette was more similar to
cases they saw in their clinical practice than those using the
ICD-10 (ICD-11: M 5 2.71, SD 5 0.66; ICD-10:
M 5 2.41, SD 5 0.80; t [282] 5 ‒3.40, p !0.001).
Discussion
This article reports findings from a global, multilingual
field study implemented by WHO to assess the accuracy
and clinical utility of the ICD-11 guidelines for Anxiety
Disorders. For all disorders tested, clinicians implementing
the ICD-11 guidelines made equally or more accurate diag-
nostic selections than those using ICD-10. The general
comparability of diagnostic accuracy between ICD-11 and
ICD-10 is unsurprising given the relatively modest concep-
tual changes made in the guidelines for most Anxiety
Disorders.
For three disorders: Generalized Anxiety Disorder
(GAD), Specific Phobia, and Separation Anxiety Disorder,
ICD-11 outperformed ICD-10 in terms of diagnostic accu-
racy. In the case of GAD, the higher diagnostic accuracy
may be attributable to the more detailed and elaborated
set of guidelines presented for this disorder in ICD-11
(e.g., inclusion of worry about multiple areas of life as an
alternative to apprehension, addition of physiological
symptoms of anxiety as part of the essential features, symp-
tom duration requirements). In this way, GAD in ICD-11 is
much more clearly defined, making it a distinct diagnostic
entity rather than a residual disorder.
The ICD-11 guidelines for Specific Phobia were also
more accurately applied to the case vignette than the
ICD-10 guidelines. Though the ICD-11 guidelines for this
disorder are conceptually similar to those in ICD-10,
ICD-11 provides a much more comprehensive and detailed
description of Specific Phobia with an expanded set of
essential features as well as information on important addi-
tional clinical features. The differential diagnosis section of
the ICD-11 is also more detailed and descriptive than ICD-
10, providing guidance not only on the boundary with
normality, but also on boundaries with other disorders
and conditions. These more elaborate and structured ICD-
11 Specific Phobia guidelines may enhance clinicians’ abil-
ity to apply them accurately to clinical cases.
For Separation Anxiety Disorder, clinicians using the
ICD-11 guidelines performed better than those using
ICD-10, specifically when assessing an adult case of this

Table 8. Clinicians’ perceived clinical utility of Specific Phobia guidelines

Not at all Somewhat Quite Extremely Statistical comparison

Ease of Use
ICD-11 0 9 82 69 c2 (3) 5 14.46, p !0.01
0.0% 5.6% 51.3% 43.1%
ICD-10 2 29 101 54
1.1% 15.6% 54.3% 29.0%
Goodness of Fit
ICD-11 1 8 87 64 c2 (3) 5 21.34, p !0.001
0.6% 5.0% 54.4% 40.0%
ICD-10 3 35 104 44
1.6% 18.8% 55.9% 23.7%
Clarity
ICD-11 1 11 83 70 c2 (3) 5 16.54, p !0.001
0.6% 6.7% 50.3% 42.4%
ICD-10 1 29 112 45
0.5% 15.5% 59.9% 24.1%
Confidence
ICD-11 1 11 80 73 c2 (3) 5 19.24, p !0.01
0.6% 6.7% 48.5% 44.2%
ICD-10 5 34 98 50
2.7% 18.2% 52.4% 26.7%
 A Global Field Study of Anxiety Disorders in the ICD-11
disorder. This is unsurprising given the lifespan approach of
ICD-11 which allows for Separation Anxiety Disorder to be
diagnosed across the developmental spectrum, albeit with
developmentally distinct presentations. This is in contrast
to ICD-10 in which this disorder was limited to childhood
cases (as indicated by its former name: Separation anxiety
disorder of childhood), and was included in a separate diag-
nostic grouping entitled ‘Emotional disorders with onset
specific to childhood’. For this reason, clinicians applying
the ICD-10 guidelines, had much lower accuracy and
selected a wide range of alternate diagnoses for the adult
case of this disorder in an attempt to account for the fea-
tures of separation anxiety in adulthood. The findings from
this field study thus validate that the ICD-11 guidelines
more accurately capture Separation Anxiety Disorder in
adults and help clarify the diagnostic landscape for adult
cases.
Although clinicians using ICD-11 were equally or more
accurate in making Anxiety Disorder diagnoses than those
using ICD-10 they had difficulty applying the ICD-11 diag-
nostic guidance on determining the boundary between dis-
order and normality. Clinicians who were asked to diagnose
two subthreshold vignettes (vignette 2: subthreshold worry,
and vignette 9: subthreshold social anxiety) did so with low
accuracy when applying either the ICD-11 or the ICD-10
(Table 2). For vignette 2, 24.7% of clinicians applying
ICD-11 to this vignette incorrectly selected a GAD diag-
nosis rather than no diagnosis. For vignette 9, a majority
(56.6%) of clinicians using ICD-11 incorrectly selected So-
cial Anxiety Disorder rather than no diagnosis. These vi-
gnettes had both been developed and validated by a
global expert panel so that the cases described did not meet
the diagnostic requirements for GAD or Social Anxiety
Disorder, respectively.
For both vignettes, clinicians who provided written jus-
tifications for their diagnosis indicated that the fact that the
individual was presenting for mental health services was a
sufficient basis for assigning the diagnosis. This is not in
line with guidance provided by ICD-11 which clearly states
that, in addition to the presence of the essential features
related to presenting symptoms, duration and severity, the
symptoms must result in significant distress or impairment
in personal, family, social, educational, occupational or
other important areas of functioning. This over-diagnosis
is, however, consistent with the demand characteristics of
most clinical situations (e.g., for the purpose of reimburse-
ment in some settings). Similarly, clinicians may be influ-
enced by the design and focus of the study to be more
willing to assign a diagnosis than not. These findings sug-
gest that additional clarity should be provided as a part of
the guidelines regarding the extent and level of distress
and impairment that would be considered an essential or
required feature for the diagnosis of an Anxiety Disorder.
Clinicians also struggled to apply the ICD-11 guidelines
to the presence of panic attacks in the context of other
499
Anxiety Disorders. This was evident from clinician re-
sponses to vignettes 5 (Agoraphobia with cued panic at-
tacks) and vignette 8 (Social Anxiety Disorder with cued
panic attacks). For vignette 5, almost half (45.4%) of clini-
cians using ICD-11 incorrectly provided a co-occurring
Panic Disorder diagnosis, and almost a quarter (22%) did
so for vignette 8. This does not fit with the guidance pro-
vided by ICD-11 which requires the presence of recurrent,
unexpected panic attacks that are not restricted to particular
external stimuli in order to make a Panic Disorder diag-
nosis. In both vignettes, the panic attacks were exclusively
situationally-bound and occurred solely in the context or
anticipation of the focus of apprehension for Agoraphobia
(in which attacks are triggered specifically by agoraphobic
stimuli) or Social Anxiety Disorder (attacks triggered by
anxiogenic social situations). Thus, clinicians had difficulty
differentiating expected (cued) panic attacks explained by
other Anxiety Disorders and unexpected panic attacks,
which would provide a basis for an ICD-11 diagnosis of
Panic Disorder, particularly for Agoraphobia with cued
panic attack (vignette 5). This may be related to lack of
clinician training regarding this distinction. Though these
clinicians were assigned to use the ICD-11 in this study,
many were users of the ICD-10 guidelines in clinical prac-
tice, and may therefore have provided a diagnosis more in
line with ICD-10, in which Agoraphobia is diagnosed as
either with or without Panic Disorder. Clinicians likely also
noticed the salience of the panic attacks as a part the pre-
senting symptomatology of vignettes 5 and 8, and recog-
nized them to be an important clinical feature, but were
provided with no way to indicate this other than by assign-
ing a co-occurring Panic Disorder diagnosis.
As a direct result of the above findings, the ICD-11
guidelines were refined to clarify the distinction between
expected (cued) and unexpected panic attacks. In addition,
a ‘with panic attacks’ qualifier was included so that a differ-
entation can be made between unexpected panic attacks
that occur in the context of a Panic Disorder, and cued
panic attacks, which are understood as a marker of severity,
that occur in the context of another Anxiety Disorder. This
distinction has implications for clinical practice given that
cued panic attacks that occur as a part of another Anxiety
Disorder should be considered in clinical management,
such as in the selection of the pace and type of exposure
therapy (34). Treatment strategies for unexpected panic at-
tacks in the context of Panic Disorder would be more likely
to focus on interoceptive exposure, helping the individual to
learn that the symptoms of anxiety are not dangerous (35).
Based on the findings from this study, the ICD-11 guide-
lines have been modified to provide more specific informa-
tion about this distinction for each Anxiety Disorder, and
particularly for Agoraphobia. Clinical training materials
on the ICD-11 being developed by WHO also address this
important point providing clinicians with additional guid-
ance on implementing the ICD-11 guidelines.
500 Rebello et al./ Archives of Medical Research 50 (2019) 490e501
In addition to ICD-11 guidelines performing well in
terms of diagnostic accuracy, clinicians’ ratings of the clin-
ical utility of the ICD-11 guidelines were equal or superior
to those ratings for ICD-10. In particular, clinicians rated
the clinical utility of the ICD-11 GAD and Specific Phobia
guidelines as significantly higher than ICD-10, indicating
that the ICD-11 guidelines were easier to use, a better fit
to the patients they saw in their clinical practice, and signif-
icantly clearer and more understandable (Tables 7 and 8).
These strong clinical utility ratings may be, in part, associ-
ated with the empirically-based overarching changes made
to the ICD-11 based on formative field studies of global cli-
nicians (19e21) which resulted in the reorganization of the
categories, consolidation of anxiety and phobic disorders,
and the more developmental approach to disorder clustering
(i.e., no longer separating childhood and adult disorders).
The changes made in structure and content of the guidelines
for the individual disorders such as GAD and Specific
Phobia (e.g., elaboration of the guidelines, provision of ex-
amples for clarification, standardized presentation of essen-
tial features that clearly delineate the symptoms, severity,
impairment and duration requirements, more comprehen-
sive differential diagnosis section) may also be responsible
for the enhanced clinical utility of ICD-11 (18).
ICD-11’s lifespan approach may also improve the case-
ness and fit of some Anxiety Disorders such as Separation
Anxiety Disorder especially in adult cases. This is captured
in part by clinicians indicating that they more frequently
saw patients with this disorder in their practice when
applying the ICD-11, suggesting that the ICD-11 guidelines
may facilitate clinicians detecting this disorder in their own
adult patients. Clinicians also indicated that the adult case
was more similar to the patients they see in their clinical
practice, relative to those using ICD-10, again indicating
that ICD-11 is better capturing the clinical presentations
of adult cases of this Anxiety Disorder (22). Both of these
findings may also simply reflect a response bias based on
participants using the ICD-11 being informed about this
disorder.
Strengths of this study include its large sample, adminis-
tration in six languages, and broad international participa-
tion. Small differences among languages did occur, but
none impacted the overall pattern of results presented here.
However, the GCPN is not a representative sample of all
mental health professionals. Rather, participants in the
GCPN are specifically interested in contributing to the
improvement of mental health diagnosis through participa-
tion in ICD-11 field studies. Therefore, these results may
not generalize to all clinicians, situations, contexts, or lan-
guages. Moreover, while a vignette-based methodology
can provide a valid indication of how the ICD-11 diagnostic
guidelines will be used in clinical settings (31), it cannot
address all questions relevant to their application to real clin-
ical cases. It is reassuring, therefore, that findings to date
have been similar in our clinic-based field studies.
Specifically, we have found that reliability for the subset of
ICD-11 Anxiety Disorders diagnoses examined was good
to excellent when applied to real patients; there was evidence
of some confusion in applying the diagnoses of Panic Disor-
der, but otherwise reliability was superior to ICD-10.
Conclusion
The general conclusion of this study is that the new diag-
nostic guidelines for Anxiety Disorders in ICD-11 can be
applied in an acceptably consistent manner by global clini-
cians and perform as well or better than the previous guide-
lines for ICD-10. Similarly, they are seen as equally or
more clinically useful than the previous guidelines. In addi-
tion, a major strength of this study was its ability to high-
light aspects of the changes introduced in the ICD-11 that
may be difficult for practicing clinicians when applying
the guidelines. In this study, these difficulties had particu-
larly to do with: 1) identifying the threshold between Anx-
iety Disorders and subthreshold variation in worries and
social anxiety; and 2) distinguishing between panic attacks
that occurred specifically in response to exposure or antic-
ipation of the focus of apprehension in the relevant Anxiety
Disorder (e.g., public speaking in Social Anxiety Disorder,
crowded public places in Agoraphobia) and panic attacks
that occurred in an unexpected or uncued manner. These
findings have provided an important opportunity to clarify
these aspects of the diagnostic guidelines prior to their
finalization and dissemination for use in clinical settings.
The findings also help to identify areas on which a partic-
ular emphasis should be placed in training programs as a
part of ICD-11 implementation.
Acknowledgments
The authors of this article are members of or associated with the
Field Study Coordination Group, International Advisory Group
for the Revision of ICD-10 Mental and Behavioural Disorders
(TJR, JWK, CSK, PS, CM, RR, MK, TD, A-CS, JG, NZ, HM,
DJS, HFA) and/or members of the ICD-11 Working Group on
the Classification of Mood and Anxiety Disorders (DJS, PE,
SC), or members of the WHO Secretariat, Department of Mental
Health and Substance Abuse (GMR). The authors are grateful to
the following individuals for their assistance with development,
translation, and testing of the study materials: Sherin Asiimwe,
St
ephane Bouchard, Samantha Burns, Jacky Chan, Erina Doi,
Amruta Houde, Takeshi Inoue, M
elanie Joanisse, Olga Karpen-
ko, Shoko Kawaguchi, Nicole Khauli, Valery Krasnov, Huajian
Ma, Anne Marcus, Mariko Nakau, Tetsuro Ohmori, Pavel Poni-
zovsky, Alexandre Quach, Natalia Semenova, Dominique Ser-
vant, Sosuke Suga, Chisato Tanaka, Takeshi Yamasaki, Keiko
Yoshida. The WHO Department of Mental Health and Substance
Abuse received direct support that contributed to the conduct of
this work from several sources: the International Union of Psy-
chological Science, the National Institute of Mental Health
(U.S.), the World Psychiatric Association, the Columbia Univer-
sity Global Mental Health Programs, the University of Kansas,
 A Global Field Study of Anxiety Disorders in the ICD-11 501

and the Departments of Psychiatry at the Universidad Aut
onoma 18. Kogan CS, Stein DJ, Maj M, et al. The classification of anxiety and
de Madrid and the Universidad Nacional Aut
onoma de M
exico. fear-related disorders in the ICD-11. Depress Anxiety 2016;33:
Unless specifically stated, the views expressed in this paper are 1141e1154.
those of the authors and do not represent the official policies 19. Reed GM, Correia JM, Esparza P, et al. The WPA-WHO global sur-
vey of psychiatrists’ attitudes towards mental disorders classification.
or positions of WHO.
World Psychiatry 2011;10:118e131.
20. Evans SC, Reed GM, Roberts MC, et al. Psychologists’ perspectives
References on the diagnostic classification of mental disorders: results from the
WHO-IUPsyS global survey. Int J Psychol 2013;48:177e193.
1. Steel Z, Marnane C, Iranpour C, et al. The global prevalence of com-
21. Reed GM, Roberts MC, Keeley J, et al. Mental health professionals’
mon mental disorders: a systematic review and meta-analysis
natural taxonomies of mental disorders: implications for the clinical
1980e2013. Int J Epidemiol 2014;43:476e493.
utility of the ICD-11 and the DSM-5. J Clin Psychol 2013;69:
2. Kessler RC, Aguilar-Gaxiola S, Alonso J, et al. The WHO World
1191e1212.
Mental Health (WMH) Surveys. Psychiatrie 2009;6:5e9.
22. Silove D, Alonso J, Bromet E, et al. Pediatric-onset and adult-onset
3. Baxter AJ, Scott KM, Vos T, et al. Global prevalence of anxiety dis-
separation anxiety disorder across countries in the World Mental
orders: a systematic review and meta-regression. Psychol Med 2013;
Health Survey. American Journal of Psychiatry 2015;172:647e656.
43:897e910.
23. Keeley JW, Reed GM, Roberts MC, et al. Developing a science of
4. Whiteford HA, Degenhardt L, Rehm J, et al. Global burden of dis-
clinical utility in diagnostic classification systems: Field study strate-
ease attributable to mental and substance use disorders: findings
gies for ICD-11 mental and behavioral disorders. Am Psychol 2016;
from the Global Burden of Disease Study 2010. Lancet 2013;
71:3.
382:1575e1586.
24. Keeley JW, Reed GM, Roberts MC, et al. Disorders specifically asso-
5. Chisolm D, Sweeney K, Sheehan P, et al. Scaling-up treatment of
ciated with stress: A case-controlled field study for ICD-11 mental
depression and anxiety: a global return on investment analysis. Lan-
and behavioural disorders. Int J Clin Health Psychol 2016;16:
cet Psychiatry 2016;3:415e424.
109e127.
6. Hoffman DL, Dukes EM, Wittchen HU. Human and economic
25. Claudino AM, Pike KM, Hay P, et al. The classification of feeding
burden of generalized anxiety disorder. Depress Anxiety 2008;25:
and eating disorders in the ICD-11: results of a field study comparing
72e90.
proposed ICD-11 guidelines with existing ICD-10 guidelines. BMC
7. Alonso J, Liu Z, Evans-Lacko S, et al. Treatment gap for anxiety dis-
Med 2019;17:93.
orders is global: Results of the World Mental Health Surveys in 21
26. Peterson DL, Webb CA, Keeley JW, et al. The reliability and clinical
countries. Depress Anxiety 2018;35:195e208.
utility of ICD-11 schizoaffective disorder: A field trial. Schizophr
8. Collins KA, Westra HA, Dozois DJ, et al. Gaps in accessing treat-
Res 2019;208:235e241.
ment for anxiety and depression: challenges for the delivery of care.
27. Medina-Mora ME, Robles R, Rebello TJ, et al. ICD-11 guidelines for
Clin Psychol Rev 2004;24:583e616.
psychotic, mood, anxiety and stress-related disorders in Mexico:
9. Patel V, Chisholm D, Parikh R, et al. Addressing the burden of
Clinical utility and reliability. Int J Clin Health Psychol 2019;19:
mental, neurological, and substance use disorders: key messages
1e11.
from Disease Control Priorities, 3rd edition. Lancet 2016;387:
28. Gaebel W, Stricker J, Riesbeck M, et al. Accuracy of diagnostic clas-
1672e1685.
sification and clinical utility assessment of ICD-11 compared to ICD-
10. Kessler RC, Olfson M, Berglund PA. Patterns and predictors of treat-
10 in 10 mental disorders: findings from a web-based field study. Eur
ment contact after first onset of psychiatric disorders. Am J Psychi-
Arch Psychiatry Clin Neurosci, 2019;. https://doi.org/10.1007/
atry 1998;155:62e69.
s00406-019-01076-z. (Epub ahead of print).
11. First MB, Rebello TJ, Keeley JW, Bhargava R, Dai Y, Kulygina M,
29. Reed GM, Sharan P, Rebello TJ, et al. The ICD-11 developmental
Matsumoto C, Robles R, Stona A, Reed GM. Do mental health pro-
field study of reliability of diagnoses of high-burden mental disor-
fessionals use diagnostic classifications the way we think they do? A
ders: results among adult patients in mental health settings of 13
global survey. World Psychiatry 2018;17:187e195.
countries. World Psychiatry 2018;17:174e186.
12. International Advisory Group for the Revision of ICD-10 Mental and
30. Reed GM, Sharan P, Rebello TJ, et al. Clinical utility of ICD-11 diag-
Behavioural Disorders. A conceptual framework for the revision of
nostic guidelines for high-burden mental disorders: results from
the ICD-10 classification of mental and behavioural disorders. World
mental health settings in 13 countries. World Psychiatry 2018;17:
Psychiatry 2011;10:86e92.
306e315.
13. Reed GM, First MB, Kogan CS, et al. Innovations and changes in the
31. Evans SC, Roberts MC, Keeley JW, et al. Vignette methodologies for
ICD-11 classification of mental, behavioural and neurodevelopmen-
studying clinicians’ decision-making: validity, utility, and application
tal disorders. World Psychiatry 2019;18:3e19.
in ICD-11 field studies. Int J Clin Health Psychol 2015;15:160e170.
14. First MB, Reed GM, Hyman SE, et al. The development of the ICD-
32. World Health Organization. The ICD-10 classification of mental and
11 clinical descriptions and diagnostic guidelines for mental and be-
behavioural disorders: clinical descriptions and diagnostic guide-
havioural disorders. World Psychiatry 2015;14:82e90.
lines. Geneva: World Health Organization; 1992.
15. Rebello TJ, Reed GM, Saxena S. Core considerations in the develop-
33. Reed GM, Rebello TJ, Pike KM, et al. WHO’s Global Clinical Prac-
ment of the World Health Organizations’s International Classification
tice Network for mental health. Lancet Psychiatry 2015;2:379e380.
of Diseases, 11th Revision. Indian J Soc Psychiatry 2018;34(Suppl
34. Deacon BJ, Abramowitz JS. Cognitive and behavioral treatments for
S1):5e10.
anxiety disorders: A review of meta-analytic findings. J Clin Psychol
16. Reed GM. Toward ICD-11: improving the clinical utility of WHO’s
2004;60:429e441.
international classification of mental disorders. Prof Psychol Res Pr
35. Lee K, Noda Y, Nakano Y, et al. Interoceptive hypersensitivity and
2010;41:457e464.
interoceptive exposure in patients with panic disorder: specificity
17. Maj M, Reed GM. The ICD-11 classification of mood and
and effectiveness. BMC Psychiatry 2006;6:32. https://doi.org/
anxiety disorders: background and options. World Psychiatry 2012;
10.1186/1471-244X-6-32.
11(Suppl. 1).