Announcing … DSM-6

More of the same.

These posts examine modern psychiatry from a critical point of view. Unfortunately, mainstream psychiatrists usually react badly to any sort of critical analysis of their activities, labelling critics as “anti-psychiatry,” whatever that is. Regardless, criticism is an integral part of any scientific field and psychiatry is no different. As it emerges, there is a lot to be critical about.

If you like what you read, please click the “like” button at the bottom of the text, it helps spread the posts to new readers. If you want to comment, please use the link at the end rather than email me as they get lost and nobody sees them.

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Imagine a community of people who live in merciful isolation from the madness of today’s world. Perhaps their home is a valley like the people of Erewhon in Samuel Butlers whimsical story, or in Herbert Wells’ Country of the Blind, although I prefer them to live on a palmy tropical island, dominated by a towering mountain and ringed by coral reefs enclosing limpid lagoons. While they know nothing about the rest of humanity, they know a great deal about their world. They build their houses from carved volcanic rock, rather like the elegant double gates of Bali, and have similar musical instruments to gamelin. With their solid canoes, they can catch fish in the lagoons and even dive for pearls. All their clothing comes from the coconut palms but they don’t need much. They have their own system of medicine, a system of laws and their own creation stories. Very importantly for fishermen, they can look at the sky and predict the weather for the next few days. However, as much as they are dependent on the weather, they don’t know what clouds are. Their forecasters have an elaborate system of classifying clouds and know that this cloud will bring rain but that one won’t. Of course, they have no idea how water gets up in the sky but are not much concerned because it’s so reliable. Some people say they’re scared of clouds but the forecasters shrug their shoulders and tell them not to be silly.

Every now and then, one of their young people disappears for a few days and then comes back very excited. “I’ve climbed the mountain,” he says, because most of them are young men, “and now I know what clouds are. I’ve walked around inside a cloud, I got wet from it. There’s nothing to fear, they’re actually quite nice.” The forecasters and all the old people scoff at this. “How ridiculous. Everybody can see that clouds are solid, look, you can’t see the sun through them, how much more solid do you want? You’d better lay off the kava, junior, it’s scrambling your brains.”

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About every fifteen years, the American Psychiatric Association (APA) launches yet another version of their magnum opus, the Diagnostic and Statistical Manual or DSM. These days, No. 5 is getting a bit long in the tooth so they’re gearing up for No. 6. The amount of work that goes into this thing is simply astounding, with thousands of people meeting regularly for years, huge amounts of research sifted by dozens of committees, drafts, redrafts and penultimate drafts galore for a work that steadily gets bigger and extends its reach further into normal daily life. Their job is quite difficult. They have to convince everybody that the old one, launched with such fanfare a few years ago, is no longer fit for purpose, it’s holding psychiatry back, creating stigma and so on, problems the new one will resolve. However, they have to do so without admitting there may be anything actually wrong with the old one in case anybody gets the idea there may be major flaws in the entire conceptual approach. What is its conceptual approach? Well, that’s an interesting question because according to them, it doesn’t have one.

The first DSM in 1952 was little more that the US Army system of classification for psychiatrists, dressed up with some psychoanalytic terms to make it acceptable to private psychiatrists. It was needed because health insurers wouldn’t pay unless they had a standard diagnosis, same as in the rest of medicine, so psychiatry obliged. DSM II, published in 1968, listed 182 disorders in just 134 pages and was again dominated by Freudian ideas, more a literary work than scientific. It was subjective and open to interpretation so, after a series of embarrassments, they decided to dump the whole thing and start again. DSM III, in 1980, was a radical change in that it was purely a classification based on observable facts only, while saying nothing about the mind or the nature of mental disorder itself. It was deliberately descriptive, with no attempt at explanation of what it was describing. This atheoretical approach was seen as just the first step in making sure everybody was talking about the same thing, the essential preliminary to a science of mental disorder. With various amendments and a bad case of middle-aged spread, this remains the case today.

Trouble is, it wasn’t atheoretical. It made a number of major assumptions that made sense if and only if all mental disorder is biological. They started with the idea of categories of mental disorder, that each condition was a separate category, distinct from normality and from all the others, and could be reliably identified by asking a few questions. Why did they do that? If you ask somebody in the street, they’ll tell you that obviously, mental troubles are related to each other, one woe quickly leads to another, and that there’s no cut off point between normal and loopy. The categorical approach in DSM only makes sense if we assume that all mental disorder is biological in nature, that each distinct surface syndrome will map down to a specific disorder on the genome with no cross-over. Then, the story goes, the drug companies will make a drug for each disorder and hey presto, humanity would be freed of the scourge of mental disorder.

On the other hand, if we start with the idea that mental disorder is wholly psychological in nature, that it starts with life experiences and what we believe and perceive, then the whole categorical thing breaks down. Clearly, there’s no line separating normal and abnormal, and a person can be feeling fine today and terrible tomorrow just because of what happens. His biology doesn’t change at all, only his experiences. In this approach, mental life becomes a hugely complex mess with no certainty that what we think is happening is actually true, and opens the door to all sorts of quacks and crooks. That was what the DSM committees wanted to avoid. If psychiatry is to be part of mainstream medicine, it has to be based in observations only, with no fanciful theories like ids or egos or penis envy, and no room for guesswork. Also, the biological approach had the very real benefit of not needing a theory of mind as its starting point. All the mental stuff could be dismissed with a wave of the hand, as in: “Don’t you worry about that, science will give us the answers. Meantime, just keep taking these.”

Trouble is, half a century after the DSM-III project started, we’re no closer to that goal. Psychiatrists are still arguing over basics, like whether fidgety children are normal or not, or how long grief should last and so on. However, help is on the way in the form of a bunch of committees to start the long job of writing DSM-6. In a series of introductory articles a few weeks ago, they marked out their “road map” to the future. The first paper, Initial Strategy for the Future of DSM, starts on an optimistic note:

In the 45 years since the publication of DSM-III, knowledge about psychiatric disorders, the psychosocial and cultural impact on them, their treatment, and their biology has evolved tremendously [1].

Focussing on biology, they point out a real risk for psychiatry, as in: be careful what you wish for. If we find biological causes for mental disorders, then “… once biological underpinnings become known … it might lead to an erosion, if not erasure, of (psychiatry) as neuroscience advances.” Oh dear, psychiatry might end up with the shrinking disease. Their response is four subcommittees, each of which set out its agenda in the remaining articles. The first one is the “Structure and Dimensions” Subcommittee [2], who proposed a new model for DSM-6, although they admitted it was all very early and vague and would need to be hammered into shape over time. What model? That’s where their horse stumbles at the starting gate: there is no “model.” After talking vaguely of how to incorporate biology with psychosocial material such as early life events, unemployment or other traumatic events, they concluded:

… it is unlikely that there will be empirically validated biomarkers or biological factors for the overwhelming majority of patients with psychiatric disorders in the next several years …

Or ever? After decades of effort and untold billions spent, by their own admission, biology has delivered precisely nothing, with no prospect that this will change for as far as we can see ahead. However, there is another committee to look at this, reporting on “The Future of DSM: Role of Candidate Biomarkers and Biological Factors” [3]. Their goal is “… developing a long-term strategic plan to realize a vision for biomarker-informed … evidence-based practice and precision psychiatry.” Or something. They consider a range of blood tests, genetic studies, scans of various types, all of which appear to be going nowhere, until they finally pull up something called neurocircuitry.

This may sound impressive but it’s not. Pinned down, it means only that the brain has circuits connecting one part to another, just as Ramon y Cajal told us nearly 150 years ago, but it tells us nothing about the information they’re actually carrying. It’s the same as looking at a plain envelope: you know where it came from but you can’t tell what’s written inside it. They conclude: “As scientific research delivers vigorous validation of candidate biomarkers, transformative approaches to defining and treating psychiatric illnesses will become available” Their program, in other words, is just promissory materialism, the idea that ordinary physical science will one day answer every question we can ask. Logically, this is as weak as it gets, just an unproven belief system, little more than a ploy for not answering sticky questions. However, they think they deserve lots of money to investigate it (and would prefer people to stop bothering them for results).

Now we move to the interesting bit, “A Strategic Vision for Incorporating Socioeconomic, Cultural, and Environmental Determinants and Intersectionality” [4]. Unfortunately, it simply gives them the chance to talk in vague generalisations about how “… demographic, economic, neighborhood and built environment, environmental events, and social/cultural context … affecting the prevalence and severity of health and mental health disorders and outcomes across the life course.” No mention of individual psychology, like what was my early family life like? What do I believe about myself and how do I fit in the world I inhabit? None of that, and there’s a reason we’ll come to. It ends with a few motherhood statements, like: “Unique vulnerabilities across overlapping identities bring about compounded barriers to stable housing, quality education, and culturally competent care that would not be apparent if we considered each identity (e.g., gender, race and ethnicity, or socioeconomic status) in isolation.” And so we come to the last subcommittee, which asks: “Are Functioning and Quality of Life Essential Elements of a Complete Psychiatric Diagnosis?” This shortens to the FunQoL subcommittee and lets them have lots of pretty diagrams about the “Interplay between the dimensional domains of psychiatric symptoms, distress, functioning, and quality of life and their role in psychiatric illness burden,” diagrams that leave us none the wiser.

These subcommittees, about 80 people in all, have already spent a huge amount of time on this, the very earliest stage of this vast project, but what have they achieved? Nothing. They’re like the people on the mythical island who could describe and name clouds but who didn’t know what clouds actually are. Same with the descriptive and supposedly atheoretical DSM: psychiatrists set out the criteria for saying “This is depression and that is a phobia,” but they don’t actually know what that means, they can’t explain it. Description is not explanation. Sure, they will mumble something about chemical imbalances or even neurocircuitry, but what does this actually mean? When pinned down, these impressive terms have no explanatory power, they do not extend our knowledge beyond the observable facts that need to be explained. They are shibboleths, terms that signal the person using them is a bit special and should therefore be treated with respect and not questioned. The last thing psychiatrists want is anybody questioning them.

The whole project for DSM-6 will go nowhere. Yes, there will be a bigger, heavier manual with dozens more diagnoses and hundreds more qualifications; yes, they will encroach on normality like the ocean eating away at the Gold Coast (in that case, not fast enough, that’s for sure); yes, the drug companies will find hugely expensive new drugs for the new diagnoses; yes, there will be specialist clinics which, for a very large fee, will confirm your self-diagnosis of lycanthropy and grant you a pension; and no, nothing will get better for the people whose mental lives are a mess. Plus ça change, plus c’est la même chose. The reason it will fail is very simple: there is no mention of humans as beings with minds. They’ve left it out. No mention of personality or how it interacts with life events, no account of hopes and beliefs or why these count, nothing that says we are dealing with humans as sentient creatures.

If biological psychiatrists want to be taken seriously, they need to set out a path that explains how mind can be reduced to brain and, crucially, why psychological explanations must fail. As it is, the DSM would work just as well for vets dealing with miserable horses or annoying bull calves that want to play. Still, we shouldn’t knock it too much. It will keep thousands of psychiatrists and their tame psychologists and social workers busy for years to come, feeling important as they’re actually doing something for all those mental people. Probably if they left them alone, most of them would be better off. So back to the quote from the lead article:

In the 45 years since the publication of DSM-III, knowledge about psychiatric disorders, the psychosocial and cultural impact on them, their treatment, and their biology has evolved tremendously [1].

What utter rubbish. Nothing has changed but if you tell that truth, you’ll never get a position on the DSM committees.

References:

1. Oquendo MA et al (2026). Initial Strategy for the Future of DSM. Am J Psychiatry; XX:1–9; doi: 10.1176/appi.ajp.20250878.

2. Ongur D et al (2026). The Future of DSM: A Report From the Structure and Dimensions Subcommittee. Am J Psychiatry; XX:1–9; doi: 10.1176/appi.ajp.20250876.

3. Cuthbert B et al (2-026). The Future of DSM: Role of Candidate Biomarkers and Biological Factors. Am J Psychiatry; XX:1–8; doi: 10.1176/appi.ajp.20250877.

4. Wainberg ML (2026). The Future of DSM: A Strategic Vision for Incorporating Socioeconomic, Cultural, and Environmental Determinants and Intersectionality. Am J Psychiatry; XX:1–8; doi: 10.1176/appi.ajp.20250875.

5. Drexler K et al (2026). The Future of DSM: Are Functioning and Quality of Life Essential Elements of a Complete Psychiatric Diagnosis? Am J Psychiatry; XX:1–7; doi: 10.1176/appi.ajp.20250874

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My critical works are best approached in this order:

The case against mainstream psychiatry:

McLaren N (2024). Theories in Psychiatry: building a post-positivist psychiatry. Ann Arbor, MI: Future Psychiatry Press. Amazon (this also covers a range of modern philosophers, showing that their work cannot be extended to account for mental disorder).

Development and justification of the biocognitive model:

McLaren N (2021): Natural Dualism and Mental Disorder: The biocognitive model for psychiatry. London, Routledge. At Amazon.

Clinical application of the biocognitive model:

McLaren N (2018). Anxiety: The Inside Story. Ann Arbor, MI: Future Psychiatry Press. At Amazon.

Testing the biocognitive model in an unrelated field:

McLaren N (2023): Narcisso-Fascism: The psychopathology of right wing extremism. Ann Arbor, MI: Future Psychiatry Press. At Amazon.

The whole of this work is copyright but may be copied or retransmitted provided the author is acknowledged.