A massive reference book of mental health conditions known as the \u201cbible\u201d of psychiatry is going to change.<\/p>\n
The fifth and current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) lists nearly 300 distinct conditions that mental health care providers can diagnose and treat. But this dictionary of disorders has long been a lightning rod for criticism\u2014in particular, about the way it classifies mental illnesses, which experts have said is not scientifically valid<\/a>.<\/p>\n Today the DSM\u2019s publisher, the American Psychiatric Association (APA), announced plans<\/a> to address these problems by changing how the book works<\/a>. The Future DSM Strategic Committee is proposing that the DSM change its guidance for diagnosis and increase its focus on ostensibly more objective measures of disease\u2014\u201cbiomarkers\u201d that may indicate mental illness. The changes would completely reshape future iterations of the manual.<\/p>\n On supporting science journalism<\/p>\n If you’re enjoying this article, consider supporting our award-winning journalism by subscribing<\/a>. By purchasing a subscription you are helping to ensure the future of impactful stories about the discoveries and ideas shaping our world today.<\/p>\n \u201cWe have to do it right, so it might take a little bit of a time, but we\u2019ll try and do it as fast as possible because the field is ready for it,\u201d said APA psychiatrist Nitin Gogtay at a recent press conference about the changes.<\/p>\n The overhaul, outlined in five papers published today<\/a> in the American Journal of Psychiatry, reflects the APA\u2019s optimism that the DSM can be retooled to become more scientific. The committee has even suggested to change the DSM\u2019s name so that the \u201cS\u201d stands for \u201cscientific\u201d rather than \u201cstatistical.\u201d But some experts don\u2019t think the changes will do much to improve the manual.<\/p>\n \u201cI\u2019m not sure [this new model for diagnosis] will have any strong utility at this point,\u201d says psychologist Ashley Watts. \u201cI\u2019m worried that by trying to please everyone, we please no one.\u201d<\/p>\n The proposed changes would allow mental health professionals to give more nuanced diagnoses. Currently, people are diagnosed with named conditions, such as major depressive disorder or bipolar I disorder, with very specific criteria\u2014partly because health insurance needs these for accurate billing. But providers might not have enough information available to make a correct diagnosis; an emergency room doctor treating someone experiencing a psychotic episode likely doesn\u2019t have the capacity to know if their diagnosis should be schizophrenia, bipolar I or something else.<\/p>\n \u201cClinicians often see themselves as being compelled to give a specific diagnosis, even when there\u2019s very little certainty,\u201d and that is ultimately unhelpful to patients, said psychiatrist Maria Oquendo, who leads the committee, at the press conference.<\/p>\n The plan for the new DSM will allow doctors to give people diagnoses at varying levels of specificity. It will also make space to gather more information about individual patients. This includes contextual details about their life (such as their socioeconomic status, medical conditions and quality of life), other mental health symptoms (such as anxiety or lack of pleasure) and biological features (such as genetics).<\/p>\n The DSM committee has been clear that the model it is proposing will evolve based on feedback from clinicians, scientists, patients and their families before a new version of the manual is released.<\/p>\n Including biomarkers is perhaps the most controversial possible change. Scientists haven\u2019t yet found reliable biological signatures that reveal if someone has a particular mental illness. The closest we have come to that is for Alzheimer\u2019s disease; doctors can now screen people for it with blood tests<\/a>.<\/p>\n The APA\u2019s researchers plainly state in the new papers that there are no other established biomarkers for DSM diagnoses but that they want the manual to be able to incorporate them if and when they become available.<\/p>\n \u201cThe question is really no longer whether biomarkers belong in DSM but really how to introduce them in a way that is rigorous, transparent, ethical and clinically useful,\u201d said psychiatrist Jonathan Alpert, a member of the DSM subcommittee on biomarkers, in the press conference.<\/p>\n Watts, for one, is skeptical that biomarkers will ever be useful for doctors in diagnosing mental illness, assuming they can even be found. Pinpointing biomarkers would likely involve expensive and sometimes invasive tests that wouldn\u2019t necessarily offer people anything better than doctors can now using their current practice of diagnosing based on behavior, she says.<\/p>\n Steve Hyman, former director of the National Institute of Mental Health and a vocal critic of the DSM, doesn\u2019t think scientists will ever find biomarkers for the conditions listed in the manual. Part of the reason is that the DSM\u2019s disorder categories may not reflect how mental illness actually works. The manual\u2019s third edition, DSM-III, published in 1980, drew borders across the landscape of mental illness based on how people\u2019s symptoms seemed to cluster together. Going into the 1990s, psychiatrists were optimistic that these borders would also show up in brain scans and genetics research. But that didn\u2019t happen.<\/p>\n There are very few obvious \u201cclusters\u201d of illnesses around which to draw borders, leading many experts to suggest that our models of mental health conditions should be based on spectrums of traits rather than specific named disorders. Such a model would be challenging to implement in doctor\u2019s offices, however. Even Watts, who has helped develop a dimensional alternative to the DSM called the Hierarchical Taxonomy of Psychopathology (HiTOP), has \u201csome misgivings\u201d about how this would work in practice.<\/p>\n