Especially problematic is the impact of changed criteria sets on research. All the widely used interview instruments have for decades been keyed to the existing DSM criteria items. Changed wording would disrupt the conduct of future research and the interpretation of the existing clinical and epidemiological literature. The research community will be justifiably upset by a DSM-V that liberally alters criteria sets when there is no clear reason to do so.
The forensic applications of the DSM system are extremely sensitive to even slight changes in criteria sets. I have discussed how a seemingly trivial “or” for “and” wording change in the DSM-IV paraphilia section had a very unfortunate impact on the civil commitment of rapists.1 It must be anticipated that the legal system will parse DSM-V wording changes much more precisely and idiosyncratically than will work group members. Experts in forensic psychiatry will be very concerned about any changes in DSM-V and should be recruited to vet the wording of every option with a fine-tooth comb.
Problems can result even from improvements in the wording of criteria sets. For example, the better written and more easily remembered DSM-IV criteria set for ADHD may have resulted in its overuse—especially by primary care doctors and the general public.
However perilous it is to change existing criteria sets, the risks are much greater still whenever the system adds new diagnoses that are at best lightly tested. The potential for false-positive epidemics and forensic conundrums are much harder to predict for anything novel.
New disorders are best kept in the appendix until they have achieved wide acceptance in the field. The DSM system should always follow, not lead, research and practice. It can never be paradigm-shifting on its own weight.
The final caution, if one were needed, is that it is surprisingly difficult to write foolproof criteria items. I know this from frustrating personal experience. Despite many years of effort, I never mastered this technical writing skill. Until the DSM-V options are posted, it is impossible to judge whether they will meet the necessary standards of precision, clarity, and consistency. However, the obscure writing displayed in the available papers about DSM-V does not inspire confidence.2,3 Moreover, it is troubling that no one working on DSM-V has had any exten-sive experience in writing diagnostic criteria.
Areas for innovation
DSM-V should update and greatly improve the text of DSM-IV-TR. Most in need of exhaustive revision are the sections on biological factors; epidemiology; and the developmental, cultural, and gender contributions to diagnosis. But all of the DSM-IV-TR text should be up for grabs. Its current formulaic style fails to convey any of the vividness of actual clinical practice. There could be less rote repetition of the wording of items in the criteria sets and more illustration with rich clinical examples.
The DSM-V Task Force has suggested another possible innovation: the reorganization of the grouping of disorders. Obsessive-compulsive disorder might be pulled from the anxiety disorders and placed as the lead of its own section with accompanying spectrum disorders (eg, tic disorders, body dysmorphic disorder). The section “Disorders First Diagnosed in Infancy, Childhood, or Adolescence” might be eliminated altogether (or stripped down) and its component disorders given their own sections or sorted with their closest counterparts in other sections (eg, separation anxiety disorder with the anxiety disorders).
I am neutral on these suggested reorganizations—plausible arguments can be made either way. But the point here is that such restructuring is much less risky than changing criteria sets. Similarly, the suggestion to add dimensional ratings to DSM-V has its pluses and minuses but is more likely to be neglected by clinicians than to cause any serious harm.
