<scp>DSM</scp>‐5.1

The controversy on DSM-5 has not abated yet but, unless one wants to wait for 20 more years, changes and improvements should be ongoing. Yes, it is time to think about DSM-5.1. Complaints from antipsychiatric movements will not fade away, and criticisms from the new apostles of the Research Domain Criteria (RDoC) will continue until somebody realizes that neuroscience alone cannot solve the classification of mental disorders. Meanwhile, there is more work to be done in correcting mistakes, fine-tuning definitions, and improving the current classification system, so the forthcoming ICD-11 can look out of date by the first day of release. The first volumes of the manual that were put on sale had plenty of actual mistakes. This was caused by the extreme hurry to get the book published on time for the American Psychiatric Association Meeting in 2013. The brief version had even more, and the Spanish version of it had a horrible translation. Luckily, further versions corrected the obvious problems and the Spanish translation was undertaken by the Center of Biomedical Network Research on Mental Health (CIBERSAM) which did a great job in detecting mistakes and upgrading the previous version into a readable document. However, what needs to be addressed now is the unsolved conceptual problems that emerged during the process of making DSM-5. As early as 2005, when the research agenda for DSM-5 was under discussion, some of us had the opportunity to make conceptual proposals addressing critical issues such as the introduction of dimensions into the categorical system. We proposed a modular system which would address both categorical and dimensional issues 1. Module I would include the classification of mental disorders by categories, using data-driven, up-to-date clinical criteria. Personality disorders would be included there under a different name, but at the same level as other conditions, because personality disorders are not disorders of the personality, but disorders that affect behaviours considered part of our personality. Module II would address dimensions, meaning psychopathological constructs that cut across many diagnostic entities, such as impulsivity or suicidality, among many more. Those dimensions are often more informative than the criteria that define a given diagnosis. For example, it can be very relevant to know whether somebody who has schizophrenia has a very high suicidality, even if that item is not part of the diagnosis. Module 3 would identify laboratory data (biomarkers), family history, and treatment response, issues that can be very helpful to complete the clinical picture but are totally neglected by the current version of the manual. Module IV would address somatic comorbidity, and module V would describe psychological traits. Psychological traits are present in all human beings and can influence quite radically the way that clinical symptoms are expressed. Cognitive reserve could go there too 2. Module VI was supposed to cover environmental factors and social issues (stress, social support, and cultural factors). This was some sort of improved version of the abandoned axial structure of previous DSM editions, starting from DSM-III. Unfortunately (and I admit some bias in this statement), that proposal was not considered. It is extremely unlikely that DSM-5.1 will incorporate this radical change, so we might need to wait until DSM-6 dares to include biomarkers and other clinical and non-clinical sources of information into the system. What I hope, though, is that somebody is working on the fiasco of the personality disorders chapter of DSM-5. After the failed 'clinical vignettes' proposal, things remained the same as in DSM-IV and it is time now to do things right and make a better proposal. There are several other things to correct and update. The DSM-5 field trials 3 have shown that some new entities were reliable and made sense, such as hoarding disorder, while other proved unreliable and confusing, such as disruptive mood dysregulation disorder. The definition of mixed states, including not only bipolar, but also unipolar mixed states, has caused some perplexity. In this issue of Acta Psychiatrica Scandinavica, Kim et al. show that bipolar mixed depression can be better defined by either requiring fewer non-overlapping mood elevation symptoms 4 or by permitting overlapping and non-overlapping mood elevation symptoms 5. The question of when the presence of hypomanic symptoms in the context of depression turns it into a bipolar syndrome remains unsolved, and further data are needed to decide whether allowing unipolar mixed states was a good or a bad idea. Furthermore, there is an issue that is already well stablished in the field of bipolar disorder, which is the relevance of predominant polarity as a course specifier 6. DSM-5.1 should include predominance as a critical feature for better characterization of diagnosis and course, given its impact on treatment selection. Despite the recent progress in identifying neurocognitive deficits as a core cross-sectional feature of most psychiatric conditions, DSM-5 failed to address this issue. There is little diagnostic specificity in neuropsychological performance, but it plays a crucial role in functional outcome and this is why it should be addressed in the system 7. Similarly, staging models 8 are showing plenty of possibilities when applied to mental disorders and neuroprogression 9. DSM-5 did the right thing when pathological gambling was reclassified in the addiction section. DSM-5.1 should go even further and consider the inclusion of other behavioural addictions in that chapter. In some cases, such as Internet addiction, sex, or food addiction, more data are clearly needed before they get into the system as a stand-alone condition. Research on these behavioural syndromes would be much enhanced with the use of big data in psychiatry 10, if we are able to overcome the ethical and confidentiality challenges that such approach may imply. Despite all the criticisms and debates, the DSM-5 is still the best classification system that we ever had in psychiatry. It links tradition with new data and provides a reliable method to guide clinical decisions in psychiatry. The neurodevelopmental perspective that guided the 5th edition, in particular, was a landmark move. There is, indeed, room for improvement in making it more valid and objective. It does need input from neuroscience, but also from scientific psychopathology and clinical psychology. I cannot wait to see what DSM-5.1 may bring up.