Steering Committee member: Even small DSM changes matter

Even minor updates to the Diagnostic and Statistical Manual of Mental Disorders can influence day-to-day clinical practice, from how clinicians document cases to how patients qualify for services. Kimberly Yonkers, MD, a psychiatrist and researcher who chairs psychiatry at UMass Chan Medical School and serves on the DSM-5 steering committee, said most changes are incremental and focus on clarifying language rather than adding new diagnoses.

“Most of what we do is not earthshattering… but that’s really how it should be,” Yonkers said. She estimated that roughly 80 to 90 percent of the committee’s work focuses on minor language adjustments and ensuring consistency within the current DSM-5-TR rather than making major changes.

What clinicians should know

These phased updates follow a deliberate process, ensuring that clarifications are carefully reviewed and implemented. Proposals can come from researchers, clinician groups, or advocacy organizations. Each proposal is reviewed by the steering committee, consulted on by external experts, and posted for public comment before final approval by the APA board.

“The process is pretty rigorous,” Yonkers said. She emphasized that proposals are reviewed carefully at multiple stages. “We advise various groups that we are looking for comment on a particular change,” she said, and public input is actively used in decision-making.

Most updates involve wording clarifications, specifier adjustments, or alignment with International Classification of Diseases (ICD) codes rather than structural overhauls. Even small edits can matter in practice. As Yonkers put it, “sometimes seemingly trivial changes can have a big impact.”

In some disorders, changes to specifier terminology, such as using “like” specifiers instead of disorder labels, exist “so that people are not automatically given two diagnoses,” Yonkers said.

Wording adjustments can also have practical consequences. For instance, criteria for substance use disorders now state that symptoms are “met” rather than “reported” or “endorsed.”

Yonkers said this reflects the fact that some indicators are observable by clinicians, not only self-reported by patients. “Some of the signs and symptoms in a substance use disorder can be seen… You can see if somebody is excessively drinking alcohol,” she said. These changes can even influence legal or mandated treatment decisions. “If it’s ‘symptoms that are met,’ then it’s easier to meet diagnostic criteria for one of these conditions,” Yonkers said.

Major additions are rare

Significant new diagnoses are uncommon. One recent example is prolonged grief disorder, which was added after extensive review and evidence evaluation. Yonkers said proposals for new diagnoses go through multiple levels of expert review and public comment before adoption.

“There are possible medical-legal consequences to some of these changes,” Yonkers said.

Even though reimbursement decisions rely on ICD codes rather than DSM criteria, clinicians often use DSM descriptions to operationalize diagnoses, which can influence coding, severity interpretation, and care planning.

“It is a very conservative approach that we take,” Yonkers said. “It’s not a whiplash where we’re changing this and changing that.” She compared the process to the Supreme Court, noting that “you don’t want them to be changing their decisions from five years ago.”

That cautious approach, she said, is rooted in patient safety, which is prioritized in every decision. “We have to really make sure that we do no harm and ultimately we want to do no harm for our patients.”

Looking ahead

Yonkers said the DSM is gradually moving toward a more continuously updated model, sometimes called a “living document,” that will allow research findings to be incorporated more quickly between editions. “The future DSM will just be better poised to make changes,” she said, noting that this approach will help the manual integrate new science and implement substantive updates when needed.

She also emphasized that clinician and community feedback will continue to play a key role in any updates. “We do value input from the behavioral health community,” Yonkers said. “I would hope that people don’t feel disenfranchised and that they would feel comfortable joining us in this whole process.”