The American Psychiatric Association is hard at work planning their next edition of psychiatry’s “Bible,” the DSM. According to one APA committee involved, the purpose of the DSM is not to provide diagnosis (or treatment) guidance for known medical problems, but to “meaningfully change the way clinicians think.” To this end, they have proposed using “candidate” biomarkers to define “mental illness”—”candidate” here meaning theoretical biological associations which have not actually been found. The committee notes that “including only validated biomarkers, as per FDA criteria, would be too limiting, since these exist only for Alzheimer’s disease and opioid use disorder at this time.” The committee also notes that even these biomarkers are controversial, as they are FDA-approved but not technically validated.
Other researchers, though, are pushing back against this, arguing for a more holistic paradigm of distress that uses diagnosis as a starting point for understanding each service user’s unique situation. A new editorial published in Psychological Medicine argues that the DSM is in need of a serious overhaul. This redesign should go well beyond currently proposed revisions that emphasize increasingly precise psychiatric categories which fail to capture the complexity of individual mental health struggles. Authors Lars Veldmeijer and Jim Van Os from Utrecht University and Laura Batstrain from the University of Groningen in the Netherlands believe that psychiatric diagnosis should be a starting point for understanding a person’s psychological distress rather than a clinical endpoint.
Their proposed overhaul of the DSM would retain broad categories as a clinical starting point and to allow for a shared vocabulary among clinicians, researchers, patients, and service users, but the central focus would be understanding mental health struggles in context and exploring how the service user attaches meaning to their distress. This would result in highly individualized and more appropriate care. The authors write:
“We argue that current revision considerations risk increasing complexity without resolving fundamental limitations in psychiatric classification. Specifically, our analysis highlights several areas that warrant further consideration … In response, we propose redesigning the DSM as a hybrid dialogical system that retains coarse-grained classificatory categories for pragmatic purposes while shifting diagnostic practice toward contextual interpretation, collaborative meaning-making, relational understanding, and individualized care formulation.”
Problems with the DSM
Past research has found that the DSM-5 lacks reliability, meaning that two clinicians often arrive at a different diagnosis when considering identical symptoms. Experts have criticized the DSM-5 as lacking validity. In other words, its diagnoses do not reflect the reality of mental health struggles. Research has also concluded that DSM-5 diagnoses are “scientifically meaningless” and arbitrary. One clinician described the DSM-5 as “more like a religion, and less and less scientific.”
Experts have said that the DSM is too reductionist, simple, unscientific, and likely undermines advances in understanding mental health struggles. Researchers have criticized the DSM-5 for its cultural insensitivity and ties to the pharmaceutical industry, with 69% of DSM-5 task force members accepting some form of industry payment. Academics, clinicians, and other experts have denounced the DSM-5 for oversimplifying human experience, having limited clinical usefulness, and pathologizing normal emotional responses such as grief. One study found that a majority of psychologists are dissatisfied with the DSM.
DSM-style diagnosis has been linked to numerous harms, including stigma, social isolation, strained relationships, bullying, discrimination, hopelessness, worse quality of life, and increased risk of medical errors. These psychiatric labels can also result in patients and service users having their testimony taken less seriously and their medical complaints dismissed as part of their psychiatric diagnosis.
DSM “Blind Spots”
The authors of the current work fear that proposed reforms of the DSM-5 focus too heavily on attempting to improve diagnostic precision without questioning whether the underlying model of classification is actually appropriate for understanding psychological distress. They believe adding more psychiatric labels and questionable biomarkers risks making the system more complicated without improving its ability to explain psychological distress or recommend appropriate care. The authors identify five “blind spots” in the DSM and proposed revisions that make it unreliable as a diagnostic system.
(1) The DSM largely ignores public mental health issues and social conditions that contribute to psychological distress. Mental health diagnoses are on the rise. According to DSM diagnostic criteria, roughly 25% of people living in high-income countries has a “mental disorder.” This rate is especially high for adolescents and young adults. While this is often interpreted as a rise in individual mental “illness,” the authors believe this rise may be the result of diagnostic inflation, overdiagnosis, and worsening collective conditions such as social inequality and housing insecurity that contribute to psychological distress. Focusing on individual pathlologies, as prescribed by the DSM, risks overlooking the social causes of suffering.
(2) The push for including questionable biomarkers for mental health diagnoses and the focus on group-level associations ignores that findings about groups do not necessarily explain what is happening at the individual level. The authors note that people sharing the same diagnosis can have significantly different experiences and outcomes. Psychiatric labels have limited value in predicting how mental “illness” will develop over time and how service users will respond to treatment. With the exception of Alzheimer’s disease and opioid use disorder, there are currently no other DSM diagnoses for which reliable biomarkers have been identified. Based on these limitations, the authors caution that accumulating more scientific data will likely not produce more accurate diagnoses.
(3) The DSM neglects the importance of lived experience in treatment and recovery. Mental health struggles are more than a collection of symptoms. They involve subjective experiences, relationships, personal meaning, and social contexts. Diagnostic systems like the DSM tend to place more significance on professional opinions than the actual lived experiences of people with mental health struggles. Recovery often depends on experienced factors such as relational safety, social support, and agency. The authors caution that more specific diagnostic labels will likely not lead to improved recovery or treatment.
(4) The DSM diagnostic system does not meaningfully involve people with lived experience of mental health diagnoses. While current reform efforts have acknowledged the importance of involving people with lived experience in revising the DSM, these roles are relegated to token consultations rather than active participation. This means the DSM diagnostic framework is mostly maintained and designed by clinicians and academics while people with lived experience are only invited to comment on expert proposals.
(5) DSM diagnosis does not consistently predict outcomes or guide appropriate care, but often has negative consequences. Two people with the same diagnosis can vary tremendously in terms of life circumstances, available resources, needs, strengths, and vulnerabilities. This means a DSM diagnosis cannot provide a suitably individualized care plan. Additionally, while some service users and patients find psychiatric labels helpful in understanding their struggles, finding community, and obtaining accommodations, others report that diagnosis negatively affects their sense of self, limits agency, and makes temporary struggles feel more permanent.
An Alternative “Dialogical” DSM
The authors propose a hybrid diagnostic model that combines more broad categories with a collaborative approach to understanding mental health struggles. They propose retaining categories such as depression, anxiety, psychosis, and autism for practical reasons like having a shared vocabulary around these struggles and access to support. However, these categories would be the starting point for a dialogue between the service user and clinician. Clinicians should try to understand the experiences of service users, and the meanings they assign to those experiences, through conversation. In addition to biological variables, clinicians should consider the social, cultural, and relational context as well as circumstances that may be contributing to service users’ distress. Treatment would be highly individualized and dependent on the individual patient or service user’s specific difficulties, strengths, needs, and circumstances rather than a one-size-fits-all solution based on shaky psychiatric labels.
The authors conclude:
“The challenges facing psychiatric diagnosis require more than incremental refinement. We therefore argue for a dialogical redesign of the DSM that better reflects the context-dependent, experiential, and relational nature of mental health conditions, positioning diagnosis as a starting point for collaborative inquiry.”
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Veldmeijer, L., Batstra, L., & Van Os, J. (2026). The DSM needs more than revision: Five blind spots and a case for dialogical redesign. Psychological Medicine, 56. (Link)
i would create an Integral / Holistic ‘Categorization’ –
Individualised whole person – mind / body / soul / spirit & environment –
Fully integrating all areas of Biology, Psychology, Sociology & Spirituality.
i would keep the main Diagnostic Nosology of the DSM / ICD as it has been proven to be valid.
i don’t think that switching to a Primary Sociological Bias & Social Model of Disability from a Primary Biomedical model will solve anything & it will also bring it’s own problems – it needs to be Integral / Holistic.
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Your latest post raises certain fundamental issues.
“Spirituality” is such a broad, diffuse concept. Exactly what kind do you propose for complementing the prevailing reductionist biomedical paradigm—Scientology, Sufism, Rosicrucianism, Swedenborgian doctrine, Huna, Tibetan Buddhism, Jung’s esoteric beliefs?
What if a person suffering from emotional distress is a confirmed atheist and stubbornly rejects your notion of spirituality? Would you consider him or her “treatment-resistant?”
Lastly, who has definitively “proven” the validity of the DSM and the ICD, neither of which was compiled by means of rigorous testing and experimentation? The NIH does NOT recognize the DSM as a credible guide for medical practice; what authority can you cite for its standing?
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Joel – i would potentially include everything in spirituality – Ancient & Modern understandings, East & Western Philosophy – All World Religions – Atheism & Humanism – World Mythology – interlife & consciousness research – 12+ Density / 24+ Dimensional Models – The Shamanic / Mystic & Magick – The Esoteric & Occult etc.
The basis of mental health / illness in regards to the main psychiatric Nosology has always been observed & treated throughout the whole of human history – all that changes is the model & approach to understanding & treatment, across biological, psychogenic, environmental, spiritual & integral Paradigms.
i am not aware of any other point in history however of a fringe movement that has attempted to deny the existence of madness / mental illnesses?
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Concepts of what you call “madness” may have always existed, but there has never been universal consensus on its nature.
Two random examples:
Soviet psychiatry considered devout religious faith and political dissidence to be forms of psychopathology. Not only Christian clergy but also shamans were actively persecuted and murdered in the USSR during Stalin’s rule.
Psychiatrists in Nazi Germany advocated sterilization of those deemed incurably mentally ill as well as the vague category of “asocials” (sex workers, alcoholics, sexual “deviants,” vagrants, etc.) and supported the regime’s T-4 euthanasia of the disabled and extermination of Jews, Roma, and other “undesirables.’
I fail to comprehend how all those diverse and sometimes conflicting spiritual traditions (including atheism? 12+ density? 24+ Dimensional Models?) that you enumerated can be integrated into a coherent effective paradigm for the diagnosis and treatment of individuals you would classify as severely disturbed. Monotheistic Abrahamic religions such as Christianity, Islam, and Judaism could never be meaningfully combined with shamanic practices and the occult, which they condemn as satanic.
Freud and Thomas Szasz were atheists; do you think they would have accepted your proposed paradigm?
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Joel – in many ways all the structures & systems of an integral / holistic model & approach already exist – it is a question of integration.
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What about Hubbard’s work?
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Rethink the DSM? Adopt new “coarsely grained” diagnostic categories for the “pragmatic” goals and convenience of mental health specialists? Just who is to determine the precise “coarseness” of its criteria–the same APA panels whose membership often has profitable ties with pharmaceutical companies?
This document deserves to be consigned to the dustbin of history, just like the “Hammer of Witches” that centuries ago described in lurid detail the physical characteristics (e.g. birthmarks) and behaviors of women suspected of engaging in satanic practices.
The compilers of the DSM exhibit a similar obsessive medieval mindset, but cloak their sophistries with pretentious jargon such as “dysphoria,” “dysthymia,” and “anosognosia” in order to create an aura of scientific credibility.
What useful purpose is served by preserving this pseudo-scientific hodgepodge?
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Psychiatry has much bigger problems than the DSM!
I appreciate that Richard is tasked with reporting on what’s going on in Psychiatry. But what about reporting on what’s going on in the field of mental health?
Psychiatry has been preying on people with relatively mundane concerns for decades now. Most of these people should be nowhere near the “modern mental health” system. They’re just having a rough time or something. They need a friendly person to talk to, not a “mental health professional.”
Those in most need of a mental health system that actually does something to fix broken people and protect society from dangerous people are psychiatrists. Meanwhile, society limps along, thinking that it includes an accepted professional group that knows something about the mind and how to fix it when it goes off the rails. Society has NO SUCH ACCEPTED PROFESSIONAL GROUP.
So, we are going to fix our diagnostic system so that it works better? So that if I’m acting neurotic, everyone can agree that’s how I’m acting? That if I’m acting psychopathic, everyone can agree that’s how I’m acting? That’s nice, but are any more broken people actually going to get fixed up?
I have seen only two workable therapies in operation. They DO NOT start with a diagnosis! They start with a conversation. And if that conversation continues, and goes well, and is in well-trained hands, hopefully, by the end, when the “service user” finally is fixed up, he and the therapist discover what was causing the problem. So, the “diagnosis” doesn’t come at the beginning; it comes at the end. And until Psychiatry realizes that, it is useless, and beyond that, often very dangerous.
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I certainly favor intelligent, empathetic conversation with people seeking emotional support, but it’s high time to stop analyzing, labeling, diagnosing, treating, and generally patholgizing their distress. Such an approach is not only illogical and stigmatizng, but often leads to serious physical harm in the form of sexual dysfunctions, akathisia, cognitive impairment, and other iatrogenic conditions that exacerbate the original problems.
Haven’t the many accounts by psychiatric survivors on this website over the years demonstrated this elementary truth? How much additional evidence is needed to expose and refute the fallacious pseudo-science of psychiatry?
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The DSM has no medical validity at all. As I understand it, its primary purpose is to communicate with others, in the industry – and to serve up billing codes, for insurance companies. As for that communication? Attach a DSM label to someone’s EHR and guaranteed, there are those in legitimate medical fields who will disbelieve anything that person says (not everyone, but enough to represent neglect).
Science has moved on, since I was harmed by these fake experts. I would like to point out that these fake experts need to start their investigation, with the known effects, of the drugs they are prescribing. The following link is to the FDA insert for the drug Klonopin (scroll down to warnings):
https://www.drugs.com/pro/klonopin.html
“Antiepileptic drugs (AEDs), including Klonopin, increase the risk of suicidal thoughts or behavior in patients taking these drugs for any indication. Patients treated with any AED for any indication should be monitored for the emergence or worsening of depression, suicidal thoughts or behavior, and/or any unusual changes in mood or behavior.”
“The risk of suicidal thoughts or behavior was generally consistent among drugs in the data analyzed. The finding of increased risk with AEDs of varying mechanisms of action and across a range of indications suggests that the risk applies to all AEDs used for any indication. The risk did not vary substantially by age (5–100 years) in the clinical trials analyzed.”
“Anyone considering prescribing Klonopin or any other AED must balance the risk of suicidal thoughts or behavior with the risk of untreated illness. Epilepsy and many other illnesses for which AEDs are prescribed are themselves associated with morbidity and mortality and with an increased risk of suicidal thoughts and behavior. Should suicidal thoughts and behavior emerge during treatment, the prescriber needs to consider whether the emergence of these symptoms in any given patient may be related to the illness being treated.”
“Patients, their caregivers, and families should be informed that AEDs increase the risk of suicidal thoughts and behavior and should be advised of the need to be alert for the emergence or worsening of the signs and symptoms of depression, any unusual changes in mood or behavior, or the emergence of suicidal thoughts, behavior, or thoughts about self-harm. Behaviors of concern should be reported immediately to healthcare providers.”
I did present to the ER with those deadly thoughts – actually for years. For my trouble I was locked up and subjected to unwanted poly pharmacy against my better judgment. “They” apparently didn’t know. It was me that quit the drug (and the so called experts) and gained my life back. I had nothing to loose. To continue on, I believe would have resulted in my death.
Note that in that warning – AED. Anti Epileptic Drugs. Which in the early years of this century were rebranded as “mood stabilizers”. How many reading here are taking these drugs? Do they help? Are those bad thoughts in your head due to some DSM label, or the drugs the experts are prescribing you? Has anyone bothered to find out?
Klonopin was not the only drug that did that to me. Gabapentin also did that, but cause and effect were more closely related (3 weeks) and I quit the drug and got labeled non compliant.
These drugs were prescribed for the prevention of a hormonal migraine in perimenopause – no expert with any knowledge of a woman’s hormones anywhere in the loop! Resolution of the hormonal migraine occurred naturally with menopause. I had never experienced these bad thoughts before their drugs or since (9 years and counting).
The DSM label lives on forever in EHR’s. I asked that it be removed – it is obviously an error, and I was told that it couldn’t be removed, and that it might even be illegal to remove the fictitious diagnostic label. The institution is being protected over my health. Which says everything.
There DSM has no medical validity at all.
I apologize for all my copying and pasting – but people need to know “it’s the cure, that might kill you”. My trust of the experts was squandered on a headache that resolved naturally, in time.
Unfortunately, the mental health industry is not the only grifters in this golden age of fraud.
Buyer beware.
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