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)
