Elisabet Domínguez
Psychologist and doctor of pharmacology at the Hospital de Sant Pau in Barcelona, president of the Spanish Society for Psychedelic Medicine (SEMPsi) and coordinator of the Psychedelicare initiative in Spain
What criticisms have been levelled at the manuals published to date?
“The various editions of the DSM have been fundamental tools for clinical practice, but they have also attracted significant criticism. Historically, they have been descriptive and atheoretical manuals, focused on symptom lists and diagnostic categories, with limited integration of biological, psychological and social mechanisms. As a result, many diagnoses have become decontextualised, and numerous patients do not fit neatly into rigid categories, instead presenting with comorbidities or mixed clinical pictures. Moreover, mental disorders are not clearly delimited ‘natural’ entities, but rather complex and evolving phenomena, which makes it difficult for a purely categorical or dimensional model to capture their true clinical nature.
Added to this are practical limitations: difficulties in reflecting severity, change over time and the impact of each person’s life context. Although the DSM has prioritised diagnostic reliability — that is, ensuring that different professionals reach the same conclusion — this has sometimes been achieved at the expense of biological and contextual validity. It has also been criticised for its limited integration of biomarkers (which remain very restricted in psychiatry) and for certain cultural biases stemming from a Western tradition. The APA’s current proposals are precisely aimed at overcoming these limitations and moving towards a more dynamic, integrative DSM that is closer to people’s clinical reality".
What new features stand out in comparison with previous editions?
“The APA proposes moving towards a DSM that combines diagnostic categories with severity dimensions, contextual factors and transdiagnostic features, and that is ready to incorporate biomarkers when the evidence allows. This represents a major shift from previous DSM editions: the manual moves away from a focus on labels towards a tool designed to better capture clinical complexity, personalise treatment and reduce trial and error in mental healthcare".
A diagnostic model with four interconnected domains is proposed (contextual factors, biomarkers, diagnoses and transdiagnostic factors). How do you assess this development?
“This change is probably one of the most significant in the history of the DSM. For the first time, it is acknowledged that a psychiatric diagnosis cannot be reduced to a label, but must integrate context, biology, clinical course and lived experience. The four-domain model allows people to be described in a way that is far more faithful to reality, without forcing them into rigid categories that often fail to reflect their suffering or life trajectory. From a clinical perspective, this is a necessary and long-awaited advance.
Moreover, what is most valuable is that this is not an idealistic or difficult-to-apply model, but one designed for real-world practice. It can be completed using the standard information gathered in a clinical assessment, updated over time, and is compatible with existing healthcare systems. In my view, this approach marks a paradigm shift: we move from a psychiatry focused on classifying disorders to one centred on understanding people, opening the door to more tailored, more humane and more effective treatments".
How might the new DSM help in clinical practice?
“The new DSM has the potential to be far more useful in clinical practice because it allows clinicians to work with the real-world complexity of patients — something the current model does not always facilitate. Until now, many clinicians have been forced to simplify complex presentations in order to fit them into a diagnostic category, losing relevant information about severity, course or context. The more flexible approach of the new DSM makes it possible to record this clinical reality more accurately, without sacrificing structure or usefulness.
In my opinion, its greatest strength lies in its ability to reconcile three needs that were previously in tension: accurately describing the patient, remaining useful for research, and opening the door to new scientific advances. Dimensional measures, severity indicators and the progressive integration of biological, contextual and transdiagnostic factors enable a more dynamic and less rigid form of diagnosis. This not only improves clinical understanding, but may also reduce therapeutic trial and error and lead to more precise, more person-centred decision-making".