The likelihood that DSM-V will suffer from many such serious unintended consequences is enhanced by the way it is being done. “There are no constraints on the degree of change,” according to a telling quote from Dr David Kupfer, chairman of the DSM-V Task Force.26 The work groups have been instructed to think innovatively about their disorders but have received little guidance on the systematic methods of conducting literature reviews.6 It is a fundamental error of the DSM-V process that it has not put a priori methods in place to provide standards for making changes and for instructing work group members on how to do a careful risk-benefit analysis of each proposal.
Even a cursory review of some of the suggestions for DSM-V clearly illustrates the painful surprises that can inadvertently creep into a system if there are no careful doorkeepers to evaluate the risks of change. I will discuss some representative types of problems for purposes of illustration, but most of the suggested changes for DSM-V will likely have problems of one sort or another.
Undoubtedly, the most reckless suggestion for DSM-V is that it include many new categories to capture the subthreshhold (eg, minor depression, mild cognitive disorder) or premorbid (eg, prepsychotic) versions of the existing official disorders. The beneficial intended purpose is to improve early case finding and promote preventive treatments. Unfortunately, however, the DSM-V Task Force has failed to adequately consider the potentially disastrous unintended consequence that DSM-V may flood the world with tens of millions of newly labeled false-positive “patients.” The reported rates of DSM-V mental disorders would skyrocket, especially because there are many more people at the boundary than those who present with the more severe and clearly “clinical” disorders. The result would be a wholesale imperial medicalization of normality that will trivialize mental disorder and lead to a deluge of unneeded medication treatments—a bonanza for the pharmaceutical industry but at a huge cost to the new false-positive patients caught in the excessively wide DSM-V net. They will pay a high price in adverse effects, dollars, and stigma, not to mention the unpredictable impact on insurability, disability, and forensics.
In my experience, experts on any given diagnosis always worry a great deal about missed cases but rarely consider the risks of creating a large pool of false positives—especially in primary care settings. The experts’ motives are pure, but their awareness of risks is often naive. Psychiatry should not be in the business of inadvertently manufacturing mental disorders. The clinching argument against including subthreshold and prodromal “disorders” is that they are supported only by thin literatures and will not have extensive field trials to predict the extent of the false-positive risks, particularly in primary care settings. I am convinced that none of the proposed subthreshold or premorbid suggestions should be converted to official diagnoses of mental disorder in DSM-V. Each should instead be included in an appendix of suggested disorders that require more research and testing.
Another DSM-V innovation would create a whole new series of so-called behavioral addictions to shopping, sex, food, videogames, the Internet, and so on. Each of these proposals has the potential for dangerous unintended consequences by inappropriately medicalizing behavioral problems; reducing individual responsibility; and complicating disability, insurance, and forensic evaluations. None of these suggestions is remotely ready for prime time as an officially recognized mental disorder.
Getting as much outside opinion as possible is crucial to smoking out and avoiding unforeseen problems. We believed that the more eyes and minds that were engaged at all stages of DSM-IV, the fewer the errors we would make. In contrast, DSM-V has had an inexplicably closed and secretive process.27 Communication to and from the field has been highly restricted. Indeed, even the very slight recent increase in openness about DSM-V was forced on to an unwilling leadership only after a series of embarrassing articles appeared in the public press.28-30 It is completely ludicrous that the DSM-V work group members had to sign confidentiality agreements that prevent the kind of free discussion that brings to light otherwise hidden problems. DSM-V has also chosen to have relatively few and highly select advisors. It appears that it will have no Options Book to allow wide scrutiny and contributions from the field.
The secretiveness of the DSM-V process is extremely puzzling. In my entire experience working on DSM-III, DSM-III-R, and DSM-IV, nothing ever came up that even remotely had to be hidden from anyone. There is everything to gain and absolutely nothing to lose from having a totally open process. Obviously, it is much better to discover problems before publication—and this can only be done with rigorous scrutiny and the welcoming of all possible criticisms.