This commentary will suggest how the research community can be instrumental in improving DSM-V and helping it avoid unintended consequences. According to several converging, anonymous (but I think quite reliable) sources to which I have had access, the draft options for DSM-V will finally be posted between mid-January and mid-February 2010. There will then be just one additional month until mid-March for collecting comments. The good news is that the products of a previously closed process will finally be available for wide review and correction. The bad news is that there will be only a very brief period allotted for this absolutely crucial input from the field.
The research community has a central role and a great responsibility in taking advantage of this precious opportunity to carefully review and identify the problems in the DSM-V drafts and to suggest solutions.
Problems with the DSM-V process
The dangers of the “everything is on the table,”1 ambitious, innovative bias of DSM-V have been amplified by its secrecy and weak methods. There has been a remarkable lack of the free flow of ideas that is necessary to prevent any DSM process from becoming idiosyncratic and arbitrary. Many of the work groups have functioned mostly on their own without sufficient monitoring from the DSM-V Task Force, a large group of diverse advisors, or the field as a whole.
The original DSM-V timeline had the fatal flaws of scheduling field trials before the proposed changes could be vetted by the field and an impossible publication deadline of May 2012. Fortunately, my sources suggest that this plan has been shelved, and that a new timeline has field trials following the posting of options and a new DSM-V publication date of May 2013.
Unfortunately, there are still numerous process problems. There is a continued bewildering secrecy concerning timelines and methods. My sources indicate that a grant request for external funding for the DSM-V field trials has been rejected, and there is no indication that there is sufficient money, time, or expertise to conduct meaningful field trials that would measure the impact of changes on the rates of disorder. The few papers published to date by the DSM-V leadership1-3 (and the wordings of the few work group criteria sets that have surfaced at meetings or informally) display a lack of the one skill that is absolutely essential in crafting an acceptable diagnostic manual—the ability to write clearly and consistently.
It will be no surprise if the draft criteria sets that appear early next year are written poorly and include many worrisome suggestions. This should not be at all blamed on the DSM-V work group members. It is my experience (repeated 3 times with DSM-III, DSM-IV-TR, and DSM-IV) that early work group drafts are always, and probably inherently, riddled with serious problems.
Work group members are selected because of their special contribution to research in their own narrow area of expertise. They tend to overvalue their own section and make decisions based on highly selected research and clinical experiences. Thus, work groups routinely have an overconcern about false negatives; an underconcern about false positives; and insufficient concern about how suggestions will eventually play out in the general psychiatric and primary care settings, where most people receive their diagnosis. Add to this that work group members lack experience in the difficult art of criteria writing, and it is guaranteed that their first products will usually need many months of extensive internal and external review and detailed editing before being ready for field testing.
The iterative polishing and disciplining of work group product must come from an integrated effort that includes contributions from the DSM-V leadership and editorial staff; the task force as a whole; a large and diverse group of advisors; the oversight committee; and, finally and most important, the field at large. The value of the first DSM-V drafts will be only that they serve as a starting point for public comment and the painstaking revision process.
1. Kupfer D, Regier D, Kuhl E. On the road to DSM-V and ICD-11. Eur Arch Psychiatry Clin Neuroscience. 2008;258(suppl 5):2-6.
2. Kupfer D, Kuhn E, Regier D. Research for improving diagnostic systems: consideration of factors related to later life development. Am J Geriatric Psychiatry. 2009;17:355-358.
3. Regier D, Narrow W, Kuhl E, Kupfer D. The conceptual development of DSM-V. Am J Psychiatry. 2009;166:645-650.
4. First M, Halon R. Use of DSM paraphilia diagnoses in sexually violent predator commitment cases. J Am Acad Psychiatry Law. 2008;36:443-454.
5. First M, Frances A. Issues for DSM-V; Unintended consequences of small changes: the case of paraphilias Am J Psychiatry. 2008;165:1240-1241.
6. Frances A, Sreenivasan S, Weinberger LE. Defining mental disorder when it really counts— DSM-IV-TR and SVP/SDP Statutes. J Am Acad Psychiatry Law. 2008;36:375-384.
7. Robins L, Helzer J, Weissman M, et al. Lifetime prevalence of specific psychiatric disorders in three sites. Arch Gen Psychiatry. 1984;41:949-958.
8. Kessler R, McGonagle K, Zhoa S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Arch Gen Psychiatry. 1994;51:8-19.
9. Conway K, Compton W, Stinson F, Grant B. Lifetime comorbidity of DSM-IV mood and anxiety disorders and specific drug use disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry. 2006;67:247-257.
10. Kessler R, Chiu W, Demler O, et al. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:617-627.
11. Frances A. A warning sign on the road to DSM-V: beware of its unintended consequences. Psychiatric Times. August 2009;26(8):1-9.
12. Woods S, Addington J, Cadenhead K, et al. Validity of the prodromal risk syndrome for first psychosis: findings from the North American Prodrome Longitudinal Study. Schizophr Bull. 2009;35:894-908.
13. Carpenter W. Anticipating DSM-V: should psychosis risk become a diagnostic class? Schizophr Bull. 2009;35:841-843.
14. Moffitt T, Caspi A, Taylor A, et al. How common are common mental disorders? Evidence that lifetime prevalence rates are doubled by prospective versus retrospective ascertainment. Psychol Med. 2009(September).
15. Andrews G, Goldberg D, Krueger R, et al. Exploring the feasibility of a meta-structure for DSM-V and ICD-11: could it improve utility and validity? Psychol Med. In press.