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

Since the publication of the first edition of the DSM in 1952 through to the most recent DSM-5 in 2013, all its versions have been subject to criticism. Many voices have been raised against a diagnostic manual that some have gone so far as to label ‘the bible of psychiatry’, yet which, despite its universal aspirations, has been accused of being subjective or of lacking sufficient validity to clearly distinguish between what is normal and what is pathological. However, it can be said that it is the most recent version, DSM-5, that has attracted the harshest criticism since its release. From within the American Psychiatric Association itself, figures as authoritative as Allen Frances, chair of the DSM-IV task force, and Thomas Insel, then Director of the US National Institute of Mental Health, highlighted the weaknesses of DSM-5, particularly its high rate of false positives and comorbid cases. The latter reflects the questionable validity of its diagnostic criteria, which undoubtedly serves the interests of the pharmaceutical lobby.

Against this backdrop of controversy, the work now coordinated by Dr María Oquendo, Director of the Strategic Committee for the Future DSM, has emerged, seeking to give due recognition to the significant advances achieved over the 45 years since the publication of DSM-III in our understanding of mental disorders, the impact of psychosocial and cultural factors upon them, their treatment and their biology.

The recent publication in The American Journal of Psychiatry of the proposals put forward by the various subcommittees (Structure and Dimensions; Functioning and Quality of Life; Biomarkers and Biological Factors; Socioeconomic, Cultural and Environmental Determinants) demonstrates a genuine effort to overcome the aforementioned shortcomings of the previous version. Beyond the proposed change of name for the manual — which would become the Diagnostic and Scientific Manual — there is a clear intention to develop a tool that delves more deeply into the dimensional nature of nosological entities, moving away from its atheoretical stance to embrace, without reservation, the acknowledged influence of environmental and cultural factors, as well as biological ones and their mutual interaction.

The proposal sets out a holistic model in which contextual factors (socioeconomic, cultural and environmental variables, comorbid conditions, functioning and quality of life), diagnoses (where not only a primary syndromic diagnosis is identified but also, where applicable, more specific diagnoses, their severity and their equivalent in the International Classification of Diseases [ICD]), biomarkers (including all factors related to brain and body biology measured through any modality, such as neuroimaging, genetics, metabolomics, cognition, digital phenotypes, etc.) and transdiagnostic characteristics (including those that may not have been captured within the diagnostic dimension, such as anxiety, cognitive deficits or apathy) interact.

In short, this is a proposal that remains at the discussion stage, but which points towards a substantial shift that goes far beyond a mere change of name or the inclusion of new diagnoses. Instead, it aspires to offer a more dynamic manual that does not exclude perspectives, but rather acknowledges their interconnection and interaction, gives a voice to the patient, strengthens the role of context and, at the same time, facilitates precision psychiatry.