Radical changes could be coming to ‘psychiatry’s bible’

By Jen Christensen, CNN

(CNN) — How a person will be diagnosed with mental illness could look significantly different in the near future.

The American Psychiatric Association announced Wednesday that it is radically reconceptualizing the main manual that clinicians use to make a mental health diagnosis. The Diagnostic and Statistical Manual of Mental Disorders will get a new name, new voices shaping its content and a new approach that will add more layers to a diagnosis.

The hope is that it will turn what some call “psychiatry’s bible” into more of a guidebook to mental health disorders — one that’s more inclusive, dynamic and educational, so patients will receive more effective treatments.

How the DSM is used

A mental health disorder impacts an individual’s thoughts and behavior and can cause ongoing distress or impair their ability to function. Why someone has a particular mental health disorder can vary, stemming from a complicated mix of brain chemistry, genetics, life experience and a person’s environment.

Unlike with an infection, where doctors can use an objective blood test to pinpoint the bacteria or virus causing the problem, there are few simple tests to determine what kind of mental health disorder someone has.

So, psychiatrists created the Diagnostic and Statistical Manual of Mental Disorders, commonly known as the DSM, to categorize mental health disorders, create diagnostic criteria and provide descriptive text to help professionals make an appropriate diagnosis based on their observations of a patient’s symptoms.

More than half of all people will experience a psychiatric disorder in their lifetime, research shows.

Putting a label on a mental health disorder is essential so that clinicians know how to treat a patient. The DSM is also important for practical reasons, like billing and insurance purposes.

Used by more than just psychiatrists, the DSM is considered the very foundation of how mental health issues are understood. The DSM gives patients, researchers, insurance, lawyers and others a common language to identify particular mental health issues.

The current edition, DSM-5-TR, contains more than 300 distinct mental disorders such as schizophrenia, obsessive compulsive disorder and alcohol use disorder.

While APA updates the manual regularly to reflect the most up-to-date science, the last update was 2022. Over the years, the DSM has come under heavy criticism. Some argue it’s not scientific enough, others argue it’s not specific enough, or even practical.

So, to improve the manual, the APA turned to an unlikely source for inspiration: its critics.

“The critics are loud, so it’s very hard to ignore them,” joked Dr. Maria Oquendo, chair of APA’s Future DSM Strategic Committee.

Oquendo said the APA spoke with several to get a better sense of how the DSM could be improved.

“We don’t have ownership of all the best ideas, and if they’re out there, we want to hear them,” she said.

What’s changing in the DSM

One of the first things APA said it will change is the manual’s name. Going forward, DSM will stand for Diagnostic Science Manual of Mental Disorders.

When the APA first created the DSM in the 1950s, many people were institutionalized, Oquendo said. Public policy makers who funded mental institutions wanted to keep track of the number of people with particular disorders, but in an era of deinstitutionalization, numbers aren’t as important.

To create the DSM, the APA pulls together hundreds of experts from around the world who discuss definitions and treatments. There are also field trials and tests. One of the bigger changes going forward is that the APA will invite people with a lived experience of a particular diagnosis to sit on the APA’s committees and shape diagnostic descriptions.

Another change is to take more of a person’s life into consideration when a clinician gives a diagnosis.

The traditional focus of the DSM has been on observable characteristics and symptoms — in other words, “the way things appear, rather than on their underlying mechanisms,” said Dr. Jonathan Alpert, the vice chair of the Future DSM Strategic Committee.

“Psychiatric disorders, as we’ve come to understand them, reflect a complex interplay of really, all features of the human condition, environmental, socioeconomic, cultural, developmental as well as biological factors,” said Alpert, who also chairs the Department of Psychiatry and Behavioral Sciences at Montefiore’s Albert Einstein College of Medicine.

The new approach will not necessarily replace a particular diagnosis, like opioid use disorder. Rather, it would add another layer to the diagnosis that will take into account more contextual experience.

For instance, if someone’s been mistreated as a child, that can have a profound impact on their psychiatric illness, said Dr. Diana Clark, who is the APA’s senior director of research. Factors that impact mental disorders “don’t occur in a vacuum,” Clark said.

A person’s background and experience have always been a part of diagnosing a mental illness, but foregrounding it will “help the clinician look at the person as a whole and not just at the symptoms.”

How to make the proposed changes practical is something the APA is still trying to figure out, Clark said.

“We know we need to be brief so the clinician can use it, but in also doing anything that’s brief, we know that can also lead to some kind of oversimplification,” Clark said.

Biological factors are also something the APA wants to incorporate better into the DSM. While there is no genetic test for obsessive compulsive disorder yet, the hope is to make the DSM flexible enough to incorporate technology that may not exist yet.

“We’ve reached a stage in psychiatry where the question is really no longer whether biomarkers belong in the DSM, but really how to introduce them in a way that is something transparent, ethically and clinically useful,” Alpert said.

The APA also wants to make it so that a diagnosis has more flexibility, said Oquendo, who also chairs the Department of Psychiatry at the Perelman School of Medicine at the University of Pennsylvania.

For instance, a patient may turn up in the ER with a mental health problem, but if a doctor only has 15 minutes to assess the problem, a doctor may feel compelled to pick a diagnosis, even if it isn’t completely clear. The APA hopes to create diagnostic categories that can lead to less specific labels.

No set timeline for major changes

There is no timeline to make these major changes to the DSM. Changes often can take years, but the APA said it’s already having conversations with insurance companies about this shift.

Categorizing mental health disorders is not easy, said Dr. Daniel Morehead, a psychiatrist who is not working on the DSM project.

“The most complex physical object in the universe that we know is the human brain, and so we’re not going to put it into a few neat little categories,” said Morehead, who is a program director of the Adult Psychiatry Residency Program at Tufts Medical Center.

Morehead hopes the APA will make the DSM a much more dynamic document that takes more of the whole person into account, not just their symptoms.

“It’s very hard to do,” he said.

Oquendo said she believes the APA is up to the task.

“I think we will not only be pragmatic, but also scientifically rigorous and forward thinking,” she said. “We have to do it right so it might take a little bit of time, but we’ll try and do it as fast as possible because the field is ready for it.”

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