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.

At the time, I was invited to participate in one of the DSM-5 Task Force committees — the Psychosis committee, which examined the scientific evidence underlying bipolar disorder and schizophrenia — and I can see that many of the changes proposed back then (2007–2008), which ultimately were either not included or only partially incorporated into DSM-5 (2013), will now appear in the new DSM. In my view, the most important change — aside from the name itself, which aspirationally replaces ‘statistical’ with ‘scientific’ without losing the acronym — is that the DSM fully embraces the concept of Precision Psychiatry (incidentally, the first mention of this concept in the scientific literature appeared in a paper I published in 2015). To achieve this paradigm, biomarkers and symptom dimensions are now being introduced in an unequivocal and official manner. The emphasis on functioning and quality of life is also highly significant.

The DSM will continue to be a product essentially originating in the United States, even though, as in previous editions, it includes a small number of external advisers, and it will remain a practical tool that is open to criticism (and frequently criticised). Nevertheless, it exerts an enormous influence on both the clinical practice of mental healthcare and research. The direction of change is the right one and, although certain sectors will continue to criticise the ‘medicalisation’ of psychological suffering (in part due to an ideological stance that denies neurobiology and applies an unscientific form of social reductionism), I believe this represents a step forward in improving the validity and reliability of psychiatric diagnosis.

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".

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.