Big Changes to Psychiatric Diagnoses Are Coming, Maybe

Key points

• The Diagnostic and Statistical Manual (DSM) is an official list and definition of psychiatric disorders.

• A new version of the DSM is now being planned with the potential for substantial changes.

• Questions remain about whether the DSM can better reflect current science and remain practical for clinicians.

Every decade or so, the official definitions of mental health diagnoses like bipolar disorder, schizophrenia, and ADHD, change, and that time is coming around once again.

The mechanism through which these modifications happen is through a book, published by the American Psychiatric Association, called the Diagnostic and Statistical Manual of Mental Disorders, otherwise known as the DSM. This book is often described erroneously as psychiatry’s “bible,” although “dictionary” would be a much more accurate comparison.

The DSM provides the official list of psychiatric conditions and the specific criteria that must be met for someone to qualify for each diagnosis. We are now in the 5th edition of the DSM, which came out in 2013 and was gently revised a few years ago.

What the DSM says has real consequences. Medical students, psychiatric trainees, and students of other mental health professionals are taught and tested on these disorders. Insurance companies also use it, and another system known as The International Classification of Diseases, in deciding what they will pay for. Pharmaceutical companies need to match their medications to specific DSM diagnoses.

At the same time, the DSM has many limitations (many of which are acknowledged in the book) and has been a punching bag for the many critics of psychiatry who make fun of the ever-expanding number of diagnoses, the reliance on subjective history rather than more concrete evidence like lab tests or brain scans in making diagnoses, and some of its past mistakes that in today’s world look rather foolish like when being gay was considered a mental illness.

Even daily consumers of the DSM harbor a lot of skepticism about it. As a psychiatrist in training, I was expected to learn it but also to take its content with the proverbial “grain of salt.” The more experience we gain, the more we understand how frequently the people who come to us for assessment and treatment don’t fit into these tidy boxes that the DSM creates.

The diagnostic definitions are created by committees of experts. These experts rely on research and field trials as much as possible, but no one denies the degree to which politics, interpersonal dynamics, and tradition figure into the equation as well.

Recently, a series of articles were published in the American Journal of Psychiatry, announcing some more substantive changes that will be considered as folks deliberate on the next DSM edition.

These include the following:

• Changing the name from Diagnostic Statistical Manual to Diagnostic Scientific Manual.

• Having the DSM be more of a “living document” that exists primarily online and can be more easily modified.

• Getting input from a broader group of individuals, including those with lived experience.

• Including more about potential causes or evidence-based biomarkers in diagnostic formulations.

• Allowing for less-precise diagnoses in situations in which a more specific diagnosis is difficult (like in an emergency department).

• Having diagnoses be more context-dependent with regard to life experience, socioeconomic status, and a person’s individual view of their challenges.

• Giving greater weight to an individual’s quality of life and level of functioning when determining whether they meet criteria for a specific disorder.

In some ways, some of this feels like the classic “going backward to go forward” scenario. Earlier editions of the DSM did provide more definition with regard to assessment of functioning and really old DSM editions included more about causes. However, other areas do seem to represent a true advance.

It will be interesting to see how far the new DSM takes its hope to include more objective information, like lab tests, genetic markers, or neuroimaging data, into its framework. While the idea makes perfect sense theoretically and many of us have longed for this, we need to be careful about rolling this out prematurely. There are already products on the market that claim to help guide medication response by looking at specific genes. There’s also a well-known clinic chain that claims to be able to make more accurate diagnoses and treatment recommendations based on getting a specific brain scan. The evidence for some of these claims are pretty sketchy and often overhyped. I’m confident we’ll get there someday, but whether this is ready for primetime now is debatable.

Relatedly, another thorny issue that keeps coming up has to do with the way that the DSM attempts to make diagnoses binary like, you either have it or you don’t when ever accumulating evidence shows that this is just not how most things work. With perhaps a few exceptions, most conditions, from ADHD to anxiety to autism, exist very much along a spectrum with no clear boundary between disorder and non-disorder. I often tell my patients that diagnosing someone with ADHD is like declaring that someone is “tall.” This dimensionality is likely one of the reasons it has been so difficult to find clear lab tests or brain scan benchmarks for psychiatric illness.

Previous DSM editions got into big arguments about this issue, with many experts acknowledging the dimensionality of our conditions but being concerned about how to deal with this practically. Personally, I don’t think it is that impossible just look at some of the most common physical illness diagnoses, from hypertension to high cholesterol to diabetes, which are also highly dimensional in nature.

Overall, there is wide agreement from both within and outside the psychiatric community that significant changes are needed in our diagnostic system and approach. I look forward to some substantive improvements with the next edition but won’t be holding my breath that DSM-6 (or whatever it will be called) will either fix all these problems or quiet its many critics.

Note: This article originally appeared on Psychology Today.