Whither DSM-6?

Scientific American reports that the American Psychiatric Association is optimistic that “DSM [Diagnostic and Statistical Manual] can be retooled to become more scientific” (see article). Maybe because of the current DSM-5,  people may assume that APA mean ‘scientific’ in the sense of natural scientific, implying that a biological cause of primary mental illness will be found. But the press release comes across as, at least potentially, more open-minded. And ‘scientific’ can be defined more in terms of the application of rigour to analysing data (see eg. previous post) than implying a positivistic understanding of mental illness. Science doesn’t have to be reduced to physics and chemistry or mere empiricism. It can make sense to say that psychiatry should be more scientific (eg. another previous post). There is, in fact, a need to move away from so much of the pseudoscience of biomedical psychiatry (see eg. yet another previous post). A key paper influencing the Future DSM Strategic Committee is by Steven Hyman (2021), a former National Institute of Mental Health (NIMH) director and DSM-5 Task Force member, which makes the case that psychiatric disorders are not natural kinds (see eg. previous post).

DSM-5 failed because of its misdirected aspirations (see eg. previous post). The current DSM review committee has to accommodate a range of different views. But there are some hopeful signs in its paper on the ‘Initial strategy for the Future of DSM’. One of its four subcommittees is the Socioeconomic, Cultural, and Environmental Determinants of Mental Health Subcommittee, which the paper admits 

fills a gap in DSM given that despite the influence of socioeconomic, cultural, and environmental determinants of mental health on the development, progression, and treatment of mental disorders, they are not adequately addressed in DSM or in other psychiatric nosologies.

The overall committee also wants to avoid the problem of reification of psychiatric disorders (see eg, previous post). The idea of embracing “biology and environment and their interactions as key determinants of mental disorders” is said to be under consideration. The committee wants to find a pragmatic solution to psychiatric diagnosis “without abandoning the whole effort or eschewing improving current nosology”. Let’s see how this process develops.

I may be being overoptimistic about the initial publication of the Future DSM Strategic Committee. DSM may never properly incorporate the uncertainty of psychiatry. It may find it difficult to accommodate the inevitable unreliability of psychiatric diagnosis, considering the historical motivation of DSM-III to increase reliability (see eg. previous post). Psychiatric assessment has always been about differential diagnosis and aetiology, rather than a single diagnosis, often seen as having implied biological causes. I’ve never been one for wanting to completely abandon psychiatric diagnosis but modern psychiatry does overvalue it, particularly when it takes a biomedical approach (see eg. previous post and my 2002 article).