Reacción a "The roadmap for the new DSM, the ‘bible’ of psychiatry, unveiled"

The American Psychiatric Association (APA) is currently preparing a new DSM. To date, there have been five editions, each with their respective text revisions (TR). The main criticism levelled at all of them has consistently referred to their categorical diagnostic model (you either have a mental disorder or you do not). However, in real-world clinical practice we find that most psychological problems operate in a dimensional and continuous manner. A person may present with moderate symptoms but, if they do not meet 5 out of 7 criteria, they may not receive the care they deserve; similarly, we may encounter another person with several simultaneous diagnoses, not because they truly have them, but because diagnostic criteria often overlap and certain disorders share underlying mechanisms, leading to similar behavioural expressions.

The new DSM, in addition to changing its name (with the ‘S’ shifting from statistical to scientific, implying a move from a statistical description of symptoms to a system based on mechanisms, processes and contexts that can help to design better interventions), proposes a full paradigm shift towards a more integrative and multidimensional model. Mental disorders are defined not only by their symptoms (in a descriptive sense), but also by their causes, psychological mechanisms or neurobiological bases (in an explanatory sense), which in turn help mental health professionals to better understand why a person is suffering and which processes maintain their distress. Specifically, four domains are proposed: contextual factors (with functioning and quality of life as key variables), biomarkers, traditional clinical diagnoses, and transdiagnostic factors (understood as sets of symptoms underlying multiple diagnostic entities). This represents a move away from a mere diagnostic label towards an assessment of underlying processes and, in particular, the interaction between the individual and their context.

In terms of practical usefulness, a DSM based on this approach could be far more valuable than the current one. It would allow for the creation of personalised clinical profiles, tailoring interventions to the specific mechanisms that maintain each person’s difficulties. It also places greater emphasis on interdisciplinary work (psychology, psychiatry, nursing, social work, occupational therapy) and on the role of prevention by addressing potential risk factors before a disorder emerges. Nevertheless, it is important to remain mindful of the potential risk of placing too much emphasis on biomarkers, as this could lead to a new form of medicalisation of distress if a clear balance with contextual and social factors is not maintained.