APA Unveils Early Plans for the Next DSM

LOS ANGELES — Exploratory plans for a new iteration of the Diagnostic and Statistical Manual of Mental Disorders (DSM) were presented publicly for the first time at American Psychiatry Association (APA) 2025 Annual Meeting. However, the APA stopped short of calling it a full sixth version of the DSM (DSM-6) at least for now.

The Chair of the Future DSM Strategic Committee Maria Oquendo, MD, PhD, head of Psychiatry at the Perelman School of Medicine, University of Pennsylvania, Philadelphia, noted that the group’s goal is transparency and to solicit public feedback.

“There are people who are DSM fans and some who kind of hate it. So we have made it a point to talk to people and ask how we can fix it because we are all ears. If there are things we can do better, we definitely want to know,” Oquendo told Medscape Medical News.

To date, four DSM subcommittees have been established, focusing on social determinants, quality of life and functioning, biomarkers, and structure. During dedicated oral sessions held throughout the meeting, each subcommittee chair presented preliminary plans, emphasizing that these are still in development and remain open to revision.

“Why now? We want to advance the efforts that were started in the DSM-5 revision process, with the idea that it’s time to move the psychiatry nosology forward. Specifically, we want to reflect evolving knowledge,” Oquendo said. She added that the goal is to make the manual a “truly living document,” with updates occurring in step with scientific advances.

Although she would not confirm whether this work is laying the groundwork for what will eventually become DSM-6, Oquendo said the target publication date for the new iteration is about 4 years from now.

Looking Back, Moving Forward

The last fully new DSM was DSM-5, which was published in 2013. The latest update, the Text Revision version (DSM-5-TR), was released in 2022.

The manual has a long history. The first DSM was published in 1952, followed by the second edition (DSM-II) in 1968, the third edition (DSM-III) in 1980, and the fourth edition (DSM-IV) in 1994.

In addition to revising classifications for several diagnoses and discontinuing the use of Roman numerals in its abbreviation, the most significant change in DSM-5 was the removal of the multiaxial system first introduced in DSM-III.

Instead, it shifted toward a greater emphasis on dimensional assessments, especially functioning and symptom severity. It also rearranged the chapter order and grouping of disorders.

The development of the DSM-5 took nearly a decade, involving years of planning, field trials, revisions, public feedback, and multiple rounds of updates.

In March 2024, the APA’s Board of Trustees approved the creation of the Future DSM Strategic Committee, with Oquendo becoming its chair. The full group was tasked with monitoring new developments that could affect the structure, definition, and criteria of DSM disorders.

“The rapidity of scientific developments in psychiatry has never been faster. The idea is: We want to integrate critical feedback on the DSM and work towards [including] classification models, measurements, and advances in neuroscience,” Oquendo said.

Additionally, she said, the APA wants to “harmonize” with the International Classification of Diseases (ICD-11) as much as possible.

Integrating Psychiatry and Neuroscience

The first DSM oral session introduced the subcommittee focused on the importance of functioning and quality of life.

Its goal, as noted in the abstract, is to evaluate how these two factors “can provide valuable insight into the patient’s perspective on how their disease impacts their ability to carry out important activities, as well as provide key indicators for treatment progress toward patient-centered recovery goals.”

The Chair Karen Drexler, MD, associate professor, Department of Psychiatry and Behavior Sciences, Emory University School of Medicine, Atlanta, told attendees that key aspects include considering the perspectives of the individual, family, community, and clinician over time. “All are valid,” Drexler said.

The Social Determinants subcommittee is tasked with assessing the impact on mental health from factors such as ethno-racial backgrounds, sex and gender, belief systems, personality, income, an individual’s living circumstances, and exposures through the years to both advantages and disadvantages.

Both subcommittees are also examining single and/or multiple instruments to determine which are most reliable in assessing these factors.

The mandate of the Biomarkers subcommittee is to “bridge the gap between psychiatry and neuroscience” and to evaluate both the benefits and potential risks of incorporating a biological approach into the diagnostic process. The group is also exploring the use of wearable devices.

A More Organic, Functional Approach 

In addition to identifying the best structure for the new manual, a fourth subcommittee was tasked with determining “strategies to integrate a dimensional approach into the DSM’s foundation using a more organic and functional approach.” 

The Subcommittee Chair Dost Öngür, MD, PhD, of McLean Hospital and Harvard Medical School, told attendees that the current manual has faced criticism for being both overly specific and too vague — particularly in cases involving unspecified diagnoses.

“Only a minority of patients present with a classic disorder, as described in the [current] DSM. Most present with a mixture of problems to varying degrees along dimensions of mood, anxiety, psychosis, and addiction,” Öngür said.

Ideally, a new edition would incorporate multiple components beyond the diagnosis, allow for varying levels of specificity in diagnostic formulation, document severity as a separate factor, and “crosswalk” to ICD codes for billing purposes, he noted.

Öngür also introduced a preliminary and evolving concept involving four “boxes” that clinicians would fill out, that would potentially include contextual factors, biological factors, diagnoses, and transdiagnostic features.

He emphasized that the current content is only illustrative and not a formal proposal, intended to show how the group is thinking about a workable framework. The next step is to gather data and feedback from the field on what this structure should include. Step two would then focus on proposing specific content.

When asked after the presentations whether there has been detailed consideration of how future updates to the new manual might be handled, including their frequency and the use of tech-driven platforms, Session Chair Nitin Gogtay, MD, chief of research and deputy medical director at the APA, said no decisions have been made yet.

“There is such a thing as too many updates. But at the same time, as the science advances, we don’t want to wait to address that. So we need to find that sweet spot in the balance,” Gogtay said.

Suicidal Conditions as Stand-Alone Diagnoses

Another session explored the possible inclusion of four suicide-related conditions as distinct diagnoses in the next edition of the DSM — all of which have been proposed previously.

These include suicidal behavior disorder (suicidal behavior within the past 24 months), nonsuicidal self-injury disorder (which may precede suicidal behavior), suicide crisis syndrome (a mental state of entrapment “and ruminative flooding with or without suicidal ideation”), and acute suicidal affective disturbance (a conscious suicidal intent that escalates rapidly).

In the DSM-5-TR, suicidality is included only as a symptom of other conditions, such as depression and borderline personality disorder.

“Nevertheless, a recent report estimated that 19.6% of individuals who attempted suicide did so despite not meeting criteria for any existing psychiatric disorder,” the presenters noted in their abstract. They added that new suicide-specific diagnoses would help “identify at-risk individuals who would otherwise be deemed healthy by current suicide risk screenings.” 

Regardless of whether any of these conditions will be included in the next DSM, “establishing suicide risk assessment and intervention competency across disciplines will be essential over the next several years,” Edward A. Selby, PhD, professor of psychology at Rutgers, said in his presentation.

Michael Myers, MD, chair of the meeting’s Scientific Program Committee and noted expert on suicide prevention, said that he is all for the inclusion of suicide-related conditions.

“This has been in the works for at least 10 years: That there is something outside of our conceptualization in DSM and ICD that warrants it as a stand-alone,” Myers told Medscape Medical News.

Oquendo agreed but noted that the DSM is also used for its codes. So as much as a group may want a new diagnosis to be included, it’s important to understand the potential downstream effects inclusion could cause. It’s also why starting a brand new DSM manual from scratch isn’t realistic, she noted.

“We need to be pragmatic. We can’t just start over because that has implications for people who are getting treatment today and whether their insurance is going to cover it. These types of practical considerations are essential,” Oquendo said.

Öngür reported receiving honorarium from Boehringer-Ingelheim. Oquendo reported receiving royalties from the Research Foundation for Mental Hygiene and served as an advisor to Mind Medicine (pro bono), St. George’s University, and Fundacion Jimenez Diaz. She also reviewed grants for Alkermes and her family formerly owned stock in Bristol Myers Squibb. The other presenters reported no relevant financial relationships.