What You Can Expect in the DSM-6 |
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Subcommittees have been formed to combine categorical and dimensional considerations for DSM-6 diagnoses.
Research on sociocultural, economic, and other features will be considered.
Functional and quality of life aspects, as well as objective, biological biomarkers are being evaluated.
The DSM, Diagnostic and Statistical Manual, is familiar worldwide as a method for mental health practitioners to communicate about mental illness. Published by the American Psychiatric Association, the DSM was originally established almost 75 years ago to describe psychiatric syndromes more clearly and to develop statistical evaluations of mental illnesses and hospital treatment patterns.
The sixth iteration of the manual, DSM-6, is predicted to be finalized around the year 2030. Experts from various professional treatment disciplines, advocacy groups, and patients from around the world are being included to update our understanding of mental illnesses.
Considerations under review by expert subcommittees include broadening the factors used to determine diagnosis; integrating dimensional elements, such as severity, into categorical descriptions; expanding the potential for future discoveries of biological determinants; aligning the DSM with the World Health Organization’s International Classification of Diseases (ICD); and reducing stigma. Since the gathering of statistics is no longer a primary goal, a name adjustment for DSM has also been contemplated—Diagnostic and Scientific Manual.
The Evolution of the DSM
DSM-I (1952) and DSM-II (1968) were developed through a lens that separated brain disease from maladaptive behavior related to unconscious conflicts. Most authorities from that time came from a culture of psychodynamic theory. DSM-III (1980) emerged as a radical departure.
The dominating theorists developing DSM-III emphasized biomedical models, attempting to bring psychiatry closer to the rest of medicine. Psychiatric syndromes were determined by observable symptomatology, rather than by psychological theory. DSM-IV in 1994 and DSM-5 in 2013 and ensuing text revisions have generally maintained this assessment of mental illnesses. (And finally, recognition that Roman numerals, as with The Super Bowl, might eventually become inscrutable!) The number of recognized illnesses has increased over the years, and there are currently almost three hundred defined mental disorders.
DSM-6: Back to the Future
The APA’s “Future of DSM Strategic Committee” is exploring broader approaches for formulating DSM-6. These include consideration of the level of functionality, socioeconomic and cultural influences in refining clinical diagnoses. These were touched in DSM-III’s multiaxial system omitted in DSM-5. DSM-6 will attempt to assess these areas more systematically. To achieve these goals, four subcommittees have been established.
The structure and dimensions subcommittee is tasked with reorganizing DSM. Categorical diagnoses are defined by a specific number of criteria, with the supposition that an individual does or does not suffer from the disorder, depending on the number of symptoms expressed. The subcommittee examines mental illness on a spectrum of severity. They evaluate how a different presentation of symptoms may define the same illness. The reality that several symptoms, such as anxiety, apathy, and cognitive impairment, may cross over into different diagnoses is also considered.
The functionality and quality of life subcommittee is reviewing how these two related areas affect diagnosis, prognosis, and treatment. DSM-I included a basic scale, from 0 to 100 percent, evaluated by the clinician, which attempted to measure levels of patient impairment. Whereas functionality may include more objective assessments (such as work performance), quality of life is more subjective, emphasizing the patient’s satisfaction with his life and abilities, including spiritual comfort. The subcommittee explores more refined measures that include assessments from the patients and those around them, with consideration for how the illness affects such interpretations.
The socioeconomic, cultural, and environmental determinants of mental health subcommittee examines how areas such as race, class, gender, physical ability, education, and social support may affect diagnosis. These considerations will also modify optimal treatment approaches.
The biomarkers subcommittee is a group focused more on the future. Currently, the only accepted psychiatric biomarker is for dementia, which is primarily more of a psychoneurological disease. The subcommittee follows current research, such as the NIMH’s Research Domain Criteria, evaluating future biological correlates with psychiatric illness. Biomarkers include blood or other fluid-based markers, genetic tests, electrical circuitry, MRI, PET, or other scanning. The goal is to identify more biological signs of psychiatric disorders by the time DSM-6 is available.
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A major goal for the next decade is to establish better diagnostic understanding and treatment for mental disorders, which continue to rise in numbers. The primary proposal for the DSM-6 is to make it a more global and comprehensive tool for professionals and their patients—to produce a “living document.”
Oquendo, M.A., Abi-Dargham, A. et al. (2016). Initial Strategy for the Future of DSM. American Journal of Psychiatrty https://doi.org/10.1176/appi.ajp.20250878