In this issue

Controversial Issues for the Future DSM-V

Graduate student Sarah Kamens' paper regarding the future revision of the DSM-V

By Sarah Kamens
Author Note

This manuscript was prepared as an assignment for a graduate course in psychopathology taught by Professor Margaret Andover at Fordham University. I would like to thank Margaret Andover and Frederick Wertz for their encouragement and help in disseminating this manuscript.

Successive revisions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) have certainly seen their fair share of critics. Despite (or because of) this rocky history, the current preparation for the fifth edition of the DSM, with a publication deadline of 2013,[1] has been particularly characterized by controversies. These controversies, though often preceded by inconclusive empirical investigations and resulting publications in scientific journals, have become popularized through recent editorials and other commentaries in online psychiatric journals (e.g., Frances, 2009a). Likened by one psychiatrist-blogger to a "bar-room brawl" and "armageddon" (Carlat, 2009a, 2009b), the past two years have seen a slew of commentaries and other opinion pieces published by psychiatrists involved with, or otherwise interested in the DSM revision process. The topics of these articles are the political and bureaucratic policies of the DSM-V task force, as well as issues relevant to clinical treatment and the social implications of changes in psychiatric classification. As might be expected from their heated tone and public accessibility, it is these articles that have received most attention in the news and other public media in what is coming to be known as the "DSM-V controversies" (Kaplan, 2009).

In this paper, I will first discuss the online editorials and commentaries that comprise the current controversy before moving on to examine the theoretical justification and empirical research addressing these issues. I will explore the notion of a "paradigm shift" in psychiatric diagnosis through a discussion of dimensional versus categorical classification and the possibility of including risk syndromes as diagnostic categories. In addition, I will outline controversies concerning both extant and anticipated categories of disorders focusing in particular on the newly proposed addictions and controversy surrounding Gender Identity Disorder. I will conclude with suggestions for future research for the DSM-V.

Background

The confidentiality agreement. One of the more common complaints about the DSM-V task force, voiced by members of lay and mental health communities alike, is the inaccessibility of information about its future contents. The reason for this seeming impenetrability is a now-infamous confidentiality agreement (of the sort unknown to the task forces of previous DSMs), which was created to preclude "premature conclusions and misconceptions" that might "damage the viability of the DSM-V" (Stotland, Scully, Kupfer, & Regier, 2008, para. 2). However, the effect of the confidentiality agreement, despite the task force's claims of openness and honesty (see Kupfer & Regier, 2009), was to create the impression of alienation in certain members of the online psychiatric community. Johnson (2009), for example, likened the process of submitting suggestions to the DSM-V task force to "writing a letter to Santa Claus at the North Pole" (para. 1). Another psychiatrist, Berkson (2009), wrote an opinion piece published in the Psychiatric Times that stated, "I was extremely offended that a group that ought to command respect would be so hypocritical as to ask my opinion about something, only to say in response that they really don't give a damn what I thought" (para. 4).

The pharmaceutical industry. It was with a similar complaint that Cosgrove and Bursztajn composed an article that appeared in the Psychiatric Times in January, 2009. Yet Cosgrove and Bursztajn (2009) were concerned with the confidentiality agreement for a different reason: the potential influence of the pharmaceutical industry upon the task force's decisions. Seventy percent of the members, according to the article, report direct industry ties (COIs, or conflicts of interest), a 14% increase over the DSM-IV'stask force. Transparency regarding COIs is essential, according to the authors, for the teaching and practice of psychiatry as well as for public trust in the profession.

Though I will not consider the issue of the pharmaceutical industry's interest in psychiatric taxonomy in depth in this paper, it is important to note that that Cosgrove and Bursztajn's (2009) grievances are part of a larger, multivocal movement for a divestment of pharmaceutical interests in mental health (Caplan & Cosgrove, 2004; Cosgrove, Krimsky, Vijayaraghavan, & Schneider, 2006; Kirk & Kutchings, 1992; Kutchins & Kirk, 1997; Lewis, 2006; Sadler, 2002; Szasz, 2007). Authors associated with this movement are concerned with the ramifications of medicating problems that may be less physical than they are environmental, sociopolitical, and/or psychological. Though these issues arguably precede the advent of psychiatry proper (Foucault, 1972), it is perhaps no surprise that they would be revived when reified definitions of mental illness face probable change, as with the current DSM revision.  

Former task force chairs. Responding to Cosgrove and Bursztajn's (2002) concern about the new confidentiality agreement and pharmaceutical COIs, Kupfer and Regier (2009), chair and vice-chair of the DSM-V task force, respectively, wrote that their activities comprised "the most inclusive and transparent developmental process in the 60-year history of DSM" (Kupfer & Regier, 2009, para. 10). This claim caught the attention of an already disgruntled Spitzer, chair of the DSM-III task force, architect of the multiaxial classification system that has remained in use through the current DSM-IV-TR, and author of a July 2008 Psychiatric News commentary in which he lambasted the disclosure policy and its seeming ability to foreclose knowledge. In his words, such a policy "indicates a failure to understand that revising a diagnostic manual –as a scientific process- benefits from the very exchange of information that is prohibited by the confidentiality agreement" (Spitzer, 2008).

Spitzer's later response, published in the Psychiatric Times in March of 2009, was not concerned with the pharmaceutical industry or COIs. Indeed, in writing, "this remarkable claim about DSM-V inclusiveness and transparency is simply not true" (para. 1), Spitzer did not thereby vindicate Cosgrove and Bursztajn's (2009) concern about industry influence. Those issues, in fact, appear nowhere in his letter. For Spitzer, the primary problem with the DSM-V's confidentiality agreement was its threat to the open exchange of information, which, as he saw it, amounted to a threat to the scientific integrity of the DSM-V itself (Spitzer, 2009).

The complaints multiply
Frances, chair of DSM-IV's task force, soon followed suit, and in June of 2009, he published a diatribe in the Psychiatric Times outlining numerous potential negative consequences of both the confidentiality agreement and (what was to spark even greater controversy) other purported actions and suggestions on the part of the task force (Frances, 2009a). "I believe," wrote Frances, "that the work on the DSM-V has displayed the most unhappy combination of soaring ambition and weak methodology" (para. 6). Included in Frances' complaints were the "closed and secretive" as well as "puzzling" nature of the revision process (paras. 25-26), the aspiration to effect a "paradigm shift" in psychiatric diagnosis "when there is no scientific basis for one" (para. 28), the "most reckless suggestion" of creating new categories for subthreshold and prodromal syndromes (para. 22), the composition of the task force (the majority of members hail from the "atypical" setting of university psychiatry), unforeseen forensic consequences of any taxonomic changes, the risk of "inappropriately medicalizing behavior problems" by creating a new series of behavioral additions (para. 24), and the failure of the task force to create clear methodological guidelines or timelines. In a statement that might be seen as echoing Szasz (1974), Frances wrote, "Psychiatry should not be in the business of inadvertently manufacturing mental disorders" (para. 23).

A flurry of commentaries and opinion pieces followed Frances's (2009a) letter (e.g., Alarcon, 2009; Carpenter, 2009e; Berkson, 2009), including a response by the American Psychiatric Association (APA [2] (Schatzberg, 2009) reasserting that the "process for developing DSM-V has been the most open and inclusive ever" (para. 2). Frances and Spitzer, however, persisted in making their grievances known, and in July of 2009, they published a joint letter to the APA Board of Trustees objecting to the current task force's "rigid fortress mentality" (Frances & Spitzer, 2009, para. 1). "It is your responsibility," Frances and Spitzer warned the trustees "to save DSM-V from itself before it is too late" (para. 3).

Shifting paradigms

In March of 2009, Costello, a former member of the DSM-V task workgroup on Child and Adolescent Disorders, submitted a letter of resignation from the committee. Costello (2009) felt "increasingly uncomfortable with the whole underlying principle of rewriting the entire psychiatric taxonomy at one time," whereas "the gap between what we need to know in order to make revisions and what we do know has grown wider and wider" (paras. 2-3). Similarly, in their letter to the APA Board of Trustees, Frances and Spitzer (2009) complain of the "unrealistic" and "grandiose" premise of a paradigm shift (para. 14).

What is the nature of this purported "paradigm shift," and does it have a basis in the empirical literature? The phrase is derived from A research agenda for the DSM-V, a book published in 2002 by the current task forcein which they expressed the "need to explore the possibility of fundamental changes to the neo-Krapelinian diagnostic paradigm" (Kupfer, First, & Regier, 2002, p. xviii). Concerned about "researchers' slavish adoption of DSM-IV definitions" and hitherto unsuccessful attempts at uncovering the etiologies of mental disorders, the authors state, "for that [the identification of etiologies] to happen, an as yet unknown paradigm shift may need to occur" (p. xix).

Indeed, the Agenda's chapter on nomenclatural issues (Rounsaville et al., 2002) advised future research into a number of philosophically weighty issues. For example, Rounsaville et al. recommend reconsideration of the very definition of "mental disorder" as a sociopolitical and biomedical concept. In order to do so, they suggest research approaches such as the surveying of mental health practitioners and others about the meanings they attribute to terms like "mental illness" and "disorder," asking clinicians and others to list "contentious conditions" they themselves consider to be actual disorders, and studying the "views and assumptions" about individuals with mental disorders versus others with milder forms or intermittent symptoms (p. 7). The authors also endorsed research into validation techniques for assessing diagnoses and their criteria, the use of the DSM-V in "nonpsychiatric settings" (e.g., in laboratory or psychological testing), and investigations into the cross-cultural applicability of diagnostic categories, including cultural differences in explanatory models of mental disorders.

Integration with ICD
Rounsaville et al. (2002) emphasized the need to align the DSM with the International statistical classification of diseases and related health problems (ICD, which is approaching its eleventh edition). Due to coordination difficulties that have plagued the DSM since its inception (during ICD-6) (Blashfield, Keeley, & Burgess, 2009), concerned practitioners often find the two systems to be "very similar, but annoyingly different […] in mostly trivial and arbitrary ways" (Frances, 2009b, paras. 2; 5). The extent of coordination between the DSM-V and the ICD-11 is as yet unknown. However, Frances (2009b), in a recent editorial, suggested that integration of the two systems will be difficult and unlikely unless the DSM-V extends its publication deadline, as the ICD-11 has already done by postponing publication until at least 2014. (The APA has since extended the DSM-V publication deadline from 2012 to 2013; see the Postscript below.)

Categories versus dimensions
Perhaps most central in Rounsaville et al.'s (2002) discussion of nomenclatural issues was the question of categorical versus dimensional approaches to mental disorders. The authors listed what they saw as the potential benefits of moving to a dimensional system, including the lack of empirical evidence for boundaries between so-called categorical syndromes (Cloninger, 1999; Kendell & Jablensky, 2003), the eradication of the problem of comorbidity, and the potential increase in specificity via more accurate measurement. Though the DSM-V task force has announced that one major difference between their manual and its predecessors will be the "more prominent use" of dimensional measures (Regier, Narrow, Kuhl, & Kupfer, 2009, p. 649), one editorial in the Psychiatric Times by a current task force member suggests that dimensions, if implemented, will coexist with, not eclipse categories in the DSM-V (Carpenter, 2009e).

The future DSM-V is predicted to be a "living document with a permanent revision infrastructure" that will change over time (Regier, Narrow, Kuhl, & Kupfer, 2009, p. 650), and recent trends in empirical research seem to suggest an increasingly dimensional future for many of the DSM diagnostic classes (e.g., Helzer, Van den Brink, & Guth, 2006; Kamphuis & Noordhof, 2009; Krueger & Markon, 2006; Vancleef, Vlaeyen, & Peters, 2009; Widiger & Samuel, 2006; Widiger, Livesley, & Clark, 2009; Watson, 2005). At this point, however, the research literature remains inconclusive and polarized. While some authors (e.g., First, 2005) have echoed Frances' (2009a) concern that a dimensional approach, especially if prematurely introduced, might lead to disorganization in clinical work and research, others suggest that clinicians do find dimensional systems to be more promising than their categorical counterparts in terms of clinical utility (Widiger & Samuel, 2006). Lowe and Widiger (2005), for example, found that clinicians rated dimensional models to be higher than the DSM-IV in five of six aspects of clinical utility, including client communication, treatment planning, professional communication, comprehensiveness (of difficulties), and description of global personality. The aspect of clinical utility that clinicians did not find superior in the dimensional models was ease of application. These results, however, should be interpreted with caution due to potential response bias; Lowe and Widiger received only 182 survey packets of the 1,440 originally distributed.

Risk syndromes
Frances' (2009a) letter in the Psychiatric Times reserved some of its harshest language for criticizing the DSM-V's potential inclusion of subthreshold or prodromal versions of extant syndromes. In his own words:

The DSM-V task force has failed to adequately consider the potentially disastrous unintended consequence that DSM-V may flood the world with ends of millions of newly labeled false-positive 'patients.' […] The result would be a wholesale imperial medicalization of normality that will trivialize mental disorder and lead to a deluge of unneeded medication treatments (para. 22)

The consequences may affect professionals and patients alike. Frances and Spitzer (2009), in their letter to the APA Board of Trustees, also described potential ramifications for the APA, which "might well be accused of a conflict of interest in fashioning DSM-V to create new patients for psychiatrists and new customers for the pharmaceutical companies" (para. 11).

What are the subthreshold categories under consideration, and why might they be included in the DSM-V? Compton (2008) reported on an "industry-sponsored symposium" at the 2008 meeting of the American Psychiatric Association in which current interests in the area were described as being stimulated by a 1994 Institute of Medicine (IOM) report entitled, Reducing risks for mental disorders: Frontiers for preventative intervention research (Mrazek & Haggerty, 1994). Citing research in risk factors from epidemiology, neuroscience, genetics, and developmental psychopathology, the authors of the IOM report listed specific (e.g., eye tracking anomalies in schizophrenia and family history of mood disorders in depression) and nonspecific (e.g., gender and low birth weight) risk factors highlighted by past research. Their illustrative examples focused on research concerning five DSM-IV categories: depressive disorders, alcoholism, Alzheimer's, conduct disorder, and schizophrenia. The authors' conclusion, emphasized in italics, was, "For some mental disorders, the knowledge base is now at a stage comparable to that available for many physical disorders before successful large-scale prevention trials for those disorders were mounted" (p. 10).

Though the number of workgroups (corresponding to classes of disorders) currently considering risk-syndrome categories for DSM-V is currently unknown (Mrazek & Haggerty, 1994), the debate about subthreshold inclusions has come to a head in the area of symptomatic precursors of schizophrenia, also known as the prodromal phase of psychosis (e.g., Auther, Gillet, & Cornblatt, 2008). The likelihood of such an inclusion seems high: Carpenter, head of the DSM-V Workgroup on Psychotic Disorders, recently published an editorial seemingly in favor of creating a "Risk Syndrome for Psychosis," a label he has deemed less stigmatizing than "prodrome" (Carpenter, 2009a). In addition, the official April 2009 report of the Work Group mentioned the possibility of adding a risk syndrome in its list of issues currently under consideration (Carpenter, 2009b).

The proposed criteria for the "Risk Syndrome for First Psychosis" (Carpenter et al., 2009a) is one (perhaps the only) proposed criteria set currently available to the public, published (not on the official APA or DSM-V websites but rather) on the Schizophrenia Research Forum's online "Live discussion: Is the Risk Syndrome for Psychosis risky business?" (Carpenter et al, 2009b). The proposed criteria include the presence of at least one of the Criterion A Schizophrenia symptoms (delusions, hallucinations, or disorganized speech) present "in attenuated form (attenuated positive symptoms)" at least once per week in the past month, where the criteria for "any DSM-V frank psychotic disorder" have not been met (Carpenter et al., 2009a, p. 1). Some examples (appearing in the criteria's description) of attenuated delusions are feeling perplexed, confused or strange, and thinking (but often being unable to describe how) the self, world, and time have changed. Examples of attenuated hallucinations include alterations in sensory perceptions that are "often unformed" and "experienced as unusual, seldom as worrisome" (p. 4). Though the authors claimed that "the prevalence of the risk syndrome for psychosis in general population has not been well-studied," they also predicted that 20% to 50% of patients will progress to "frank psychosis" within one month to two years of receiving the risk syndrome diagnosis (pp. 6-7).

Recent research has investigated the diagnostic validity of a risk syndrome for psychosis. For example, Woods et al. (2009) conducted a comparison study of 377 prodromal individuals with normal and clinical control groups and concluded that the prodrome is a valid class, of which 10% of individuals will convert to affective psychosis. However, Woods et al.'s argument that comorbidity rates provide validity evidence by distinguishing prodromal from normal individuals (69% of the prodrome individuals in their study had comorbid diagnoses) is difficult to verify; the prodromal syndrome may have comprised secondary or residual symptoms of primary diagnoses, rather than the other way around. Indeed, previous research has seen comorbidity as signaling the absence, not the presence of diagnostic validity (e.g., Bogenschutz & Nurnberg, 2000).

Proponents of primary prevention and early detection of psychosis argue that early interventions can shorten treatment durations, lead to more favorable outcomes, and even reduce societal prevalence or severity of psychotic disorders (e.g., Auther, Gillet, & Cornblatt, 2008; Larsen, 2009; Mrazek & Haggerty, 1994; Salokangas & McGlashan, 2008). Carpenter et al. (2009a), who were careful to distinguish risk factors (stable demographic characteristics, such as family risk) from risk syndrome (mild psychotic symptoms), suggested that the risk of psychosis is lower if the risk syndrome is identified in screenings of the general population rather than treatment-seeking populations. However, the theoretical complications of such identification and treatment of risk syndromes are illustrated in the empirically unfalsifiable concept of the "false false positive," in which the treatment patients receive during the prodrome phase serves to delay, or even prevent the development of diagnosable psychosis (Compton, 2008).

The false false positive is difficult to differentiate from the subclinical psychotic experiences experienced by approximately 20% of the general population (Compton, 2008). Indeed, some researchers have proposed that psychosis exists along a continuum rather than as a discrete entity (e.g., Myin-Germeys, Krabbendam, & van Os, 2003). One study of 7,076 individuals in the Netherlands found that only eight percent of those who reported a psychotic experience at baseline showed a persistence of those symptoms at the time of a second interview (Hanssen, Bak, Bijl, Vollebergh, & van Os, 2005). The authors concluded that the incidence of positive psychotic experiences in the general population is approximately 100 times greater than traditional estimates of the incidence of schizophrenia.

Therefore, the urgent question for the DSM-V seems to be whether preventative interventions for psychosis are possible without creating a "huge cost to the new false-positive patients caught in the excessively wide DSM-V net" in stigma and side effects (Frances, 2009a, para. 22). Some have suggested a middle-ground solution in which interventions for high-risk individuals be psychological rather than pharmaceutical in nature (Johns & van Os, 2001), though this proposal does not address the potential complications in insurability and other financial aspects of disability that come with diagnostic labels (e.g., Frances, 2009a). Whereas the creation of a false epidemic is not a new criticism of the DSMs or their individual categories (e.g., Cosgrove & Caplan, 2004, Lilienfeld & Lynn, 2002, Szasz, 1974), the nomenclatural and theoretical goals of DSM-V, including dimensional modeling and a greater focus on etiology (Kupfer, First, & Regier, 2002), seem to foreshadow broader attempts to identify and treat at-risk individuals. The effects of such an attempt on both individuals and societies, however, remain unknown.  

Changing and adding diagnostic categories

In the following section, I will describe proposed changes to extant diagnoses and the potential new diagnostic categories that have been proposed for the DSM-V. These propositions have piqued the interest of both professional and non-professional communities; controversies existing outside of the professional realm will be designated where relevant. These categories include new classes of behavioral addictions, changes to sexual and gender-related disorders, additional diagnoses for apathy and parental alienation syndrome, a new category of relational disorders, and a diagnosis for complicated grief.

The new addictions
Of the six areas of progress listed in the April, 2009 report of the DSM-V Substance-Related Disorders Work Group (O'Brien, 2009), three are generating considerable controversy. One of these issues is nomenclatural; the workgroup reportedly formed a subcommittee to address dispute over the use of the terms "abuse," "dependence," and "addiction."  A brief history of disagreement among experts, starting with the publication of DSM-III, has resulted in a seeming deadlock between "addiction," seen by some as a pejorative term, and "dependence," connotatively closer to physical reliance (O'Brien, Volkow, & Li, 2006).

Cannabis. Another controversial proposition of the Substance-Related Disorders Work Group is the addition of a separate set of criteria for cannabis withdrawal. Though some studies have suggested that symptoms of withdrawal from cannabis are common amongst treatment-seeking adolescents with depression (Cornelius, Chung, Martin, Wood, & Clark, 2008), the existence of a specific cluster of symptoms for the syndrome, including restlessness, irritability, changes in appetite, and insomnia, remains controversial (Kouri, 2002). Further, research on the syndrome thus far has been plagued by comorbid abuse of additional substances and other methodological hurdles (Dawes, Richard, Mathias, & Dougherty, 2008). One study of 30 chronic, current marijuana users and 30 controls found that only 60% of the chronic users (who had used marijuana regularly for an average of 22 years) reported severe withdrawal symptoms. In addition, all symptoms except irritability and physical tension returned to pre-withdrawal levels after 28 days. The authors concluded that physical dependence on marijuana is probably not as strong as seen in other drugs of abuse. Though promising, Kouri's (2002) study relied on self-report; future research might combine self-report with objective physiological measures.

Behavioral addictions. Also known as "non-substance addictions" or "appetitive disorders" (O'Brien, 2009), a new class of behavioral addictions has proved to be one of the most controversial proposals for the DSM-V. Though the report of the Substance-Related Disorders Work Group does not name any of the specific disorders under consideration, publications in scientific and psychiatric journals suggest the possible inclusion of addictions to shopping, the internet, videogames, sex, and food (e.g., Block, 2008; Frances, 2009a; Hollander, Berlin, & Stein, 2008). One possible impetus for including these categories is that they provide "cleaner" models of addiction that parallel substance abuse disorders without the added physiological and behavioral complications created by the ingestion of substances (Hollander & Allen, 2006). It is of note that some researchers see the behavioral addictions as falling on an Obsessive-Compulsive Disorders (OCD) spectrum along with autism, tic disorders, eating disorders, and impulse control disorders (Hollander, Kim, Braun, Simeon, & Zohar, 2009)

Arguments in favor of a new class of behavioral addictions view the potentials for alleviation of suffering and impairment as outweighing the risks of misdiagnosis (Hollander & Allen, 2006). Hollander (2009), for example, compared Internet Addiction to compulsive gambling and drug abuse. Block (2009) estimated the comorbidity of Internet Addiction with other DSM-IV diagnoses at 86% and further subdivided the newly proposed diagnosis into excessive gaming, sexual preoccupations, and email/text messaging. Likewise, obesity has been compared to other eating disorders and is seen as the result, at least in part, of "the pathologically intense drive for food consumption" (Volkow & O'Brien, 2007, para. 6). Cognitive-behavioral therapy has been suggested for the treatment of compulsive buying disorder (Black, 2007). Goodman (2001) argues that methods currently used to treat addictive disorders may be ideal for addressing sexual compulsivity, which is therefore better termed "sexual addiction."

Opponents of behavioral addictions as diagnoses cite both empirical and ideological reasons for doubting the validity of the behavioral addictions. These arguments tend to see the disorders as empirically inchoate incentives to medicate societal problems (Hollander & Allen, 2006). Frances (2009a), for example, wrote of the newly proposed diagnoses, "none of these suggestions is remotely ready for prime time as an officially recognized mental disorder (para. 24). Further, the ethical and legal issue of personal responsibility is complicated by the inclusion of such behaviors in the DSM (Frances, 2009a; Hollander & Allen, 2006).

The methodologies that have been used to investigate the individual behavioral addictions have also been held suspect. For example, Grohol (2009) cited research concluding that the Young Diagnostic Questionnaire, used for the purpose of assessing internet addiction, may not be sensitive enough to discriminate individuals who are internet dependent from those who are not (Dowling & Quirk, 2009). Notably, even proponents of behavioral addiction diagnoses recognize the disorders as under-researched and thereby not yet fully understood (Albrecht, Kirschner, & Grüsser, 2007)

Gender and sexual disorders

Gender identity disorder. Like the diagnoses for Homosexuality and Ego-Dystonic Homosexuality in earlier versions of the DSM, the DSM-IV diagnosis of Gender Identity Disorder (GID) has been the subject of considerable debate. Lesbian, gay, bisexual, transgender (jointly LGBT), and other community groups have called for the complete removal of GID from the DSM with the argument that it pathologizes a normal variant of human sexuality (Long, 2008). Proponents of GID as a diagnostic category argue that there are cases in which gender variant behavior causes distress and impairment, and should thus be recognized as pathological (e.g., Spitzer, 2005).

One concern of the LGBT community was the appointment of two DSM-V task force members: Zucker, a known advocate of reparative therapy for change in sexual orientation (Zucker, 2003), was appointed as the head of the DSM-V Sexual and Gender Identity Disorders Work Group.  In addition, Blanchard, whose past research has addressed transvestitism and other sexual behaviors as pathological (e.g., Blanchard & Collins, 1993), was appointed as the chair of the Paraphilias subcommittee. Blanchard is recently rumored to have proposed "Pedohebehpilic Disorder" and "Transvestic Disorder" as new categories for the DSM-V (Winters, 2009).

These two taskforce appointees served to intensify an already fiery debate. Internet blogs protested bias and the life-altering consequences of reparative therapy (e.g., Kailey, 2008), and online support groups and petitions were formed (e.g., Gender_ID_Coalition, 2009; Petition, 2009). The rising controversy caused the APA to issue a statement in May, 2008 that the Board of Trustees had voted to appoint a new task force to review the scientific and clinical literature on GID (APA, 2008). Though the current status of GID is unknown, a November, 2008 report of the Sexual and Gender Identity Disorders Work Group (Zucker, 2008) stated a sub-work group on GID is conducting a conceptual literature review "evaluating the rationale for GID as a psychiatric diagnosis" as well as reviewing the diagnostic literature "on 1 diagnosis (partitioned by childhood, adolescence, and adulthood)" (para. 2). The title of the workgroup itself suggests that the eradication of GID may be a far fetch from current deliberations.

Premenstrual dysphoric disorder. Formerly Late Luteal Phase Dysphoric Disorder, the DSM-IV-TR lists Premenstrual Dysphoric Disorder (PMDD), characterized by "marked depressed mood, marked anxiety, marked affective liability, and decreased interest in activities" in its Appendix B: Criteria Sets and Axes Provided for Further Study (p.771). The diagnosis has a long history of controversy, with some researchers (e.g., Cosgrove & Kaplan, 2004) suggesting that the disorder effectively objectifies and stigmatizes normal bodily states in women. Gehlert, Song, Chang, and Hartlage (2009) conducted a study of 1,246 rural and urban women and found a 1.3% prevalence of PMDD, which is lower than estimated in the DSM-IV. Though the fate of the diagnosis is not yet clear, its inclusion in the new manual may be imminent; Yonkers, chair of the DSM-V advisory work group on PMDD, stated in a 2008 New York Times interview that the disorder's prevalence is somewhere between 3% to 15% of women (Chen, 2008).

Other nascent diagnoses
Other proposed diagnostic categories have been the subject of relatively less scrutiny. They may, however, have the potential to spark controversy as the publication date of DSM-V nears. These diagnosesinclude Apathy Disorder, Parental Alienation Syndrome, Prolonged Grief Disorder, and Relational Disorder.  

Though there is little or no suggestion from the DSM-V task force that Apathy Disorder and Parental Alienation Syndrome are likely candidates for the future manual, they are worth briefly noting. Apathy as a potential diagnostic entity was a focal topic at the 16th Annual Meeting of the American Neuropsychiatric Association (Stephenson, 2005). However, a recent PsycINFO search for "apathy disorder" returned only two articles, both of which concerned the proposal of "Political Apathy Disorder" (characterized by the failure to develop a social conscience) as a new diagnostic entity for the DSM (Greening, 2004; White, 2004). "Parental Alienation Syndrome" (Gardner, 2003) on the other hand, is a relatively well-known syndrome involving the alienation of one parent by a child's belittling or ostracizing behavior (Baker & Darnall, 2007; Faller, 1998). Support for the syndrome by researchers (e.g., Ellis, 2008) and advocacy groups (Veskrna, 2009) has met with conflict in the legal realm, especially within the private litigation of child custody battles (Richmond County Bar Association, 2005).  

Perhaps more likely to appear in the DSM-V are Prolonged Grief Disorder (a.k.a. Complicated Grief) and Relational Disorder. Prolonged Grief Disorder, a period of intense mourning over loss that extends beyond a six-months duration, has already been subjected to psychometric validation (Prigerson et al., 2009) and taxometric analysis (Holland, Neimeyer, Boelen, & Prigerson, 2009), which supported a dimensional conceptualization. The demarcation of temporal boundaries for the bereavement process does not seem to be igniting controversy amongst DSM-V detractors as of yet.

Relational Disorder is conceptualized as persistent patterns of behaviors or emotions that occur between two or more people, such that the relationship, not the individuals that comprise it, is viewed as being disordered. In their Research agenda for the DSM-V(Kupfer, First, & Regier, 2002), members of the DSM-V task force discussed the importance of considering relational disorders, which would necessitate, in their words, "a conceptual shift in the DSM's exclusive focus on the diagnosis of individual patients" (p. 157). While relational disorders have been notably absent from previous iterations of the DSM, there is emerging consensus that their inclusion in future manuals is important for the understanding of conflictual patterns within interpersonal configurations (Beach, Wambolt, Kaslow, Heyman, & Reiss, 2006; Denton, 2007; First, 2006). However, much remains to be learned about the implications extending diagnostic practice beyond the realm of the individual, as well as the conceptual interaction of relational versus individual diagnoses.

Conclusion

In a letter to the editor published in Psychiatric News in 2005, Chodoff proposed a new diagnostic entity for DSM-V that he titled "The Human Condition." The diagnostic criteria included, among other symptoms, "dissatisfaction with one's looks and sexual performance" and "getting upset when things go wrong" (Chodoff, 2005). The diagnosis, he wrote, would facilitate insurance reimbursement, eradicate the problem of comorbidity, and "encourage the quest for a drug to cure the disorder of being human."

Though clearly in jest, Chodoff's proposition reflects the perceived enormity of the new DSM's potential consequences. The current controversy views the stakes as never-been-higher; up for grabs are the very definition of mental disorder (Kupfer, First, & Regier, 2002), false epidemics in which millions are medicated for illnesses they don't have (Frances, 2009a), and public trust in psychiatry as a healing profession (Frances, 2009a; Frances & Spitzer, 2009). With risks like these, it is little wonder that impassioned debates have flared up in recent blogs and online psychiatry journals.

Though the publication deadline nears, future research may help to quell some of the controversy. In order to examine the ecological validity of proposed DSM-V categories, future research should pay close mind to Rounsaville et al.'s suggestions for culling definitions of mental disorders, as well as views and assumptions about them, from both clinicians and the public. In addition, in the transition to a dimensional model, surveys of behaviors and emotional states along continua of impairment levels and subjective distress might help to identify thresholds within proposed spectra models. Further, any potential paradigm shift should be approached from multiple methodological perspectives. Whereas some have argued that current knowledge of mental disorders is sufficient for large-scale preventative efforts (e.g., Mrazek & Haggerty, 1994), the potential for false positives and social stigmatization may be greater than in the primary prevention of physical diseases. Therefore, future researchers should ask questions not only about the scientific bases of proposed changes to the categories and nomenclature, but also about the sociopolitical ramifications of current and future diagnostic systems.

Postscript: January 11, 2010

The following events have occurred since the composition of this manuscript:

December 3, 2009: Frances (2009c) publishes a commentary in the Psychiatric Times urging the research community to prepare to comment on draft options for DSM-V. According to anonymous sources collected by Frances, input from the field will be solicited during the "very brief period" of one month following the posting of draft options, purportedly slated for mid-January or mid-February. (The APA has since announced a posting date of January 20 and a two- to three-month period for collecting input; see below.) Though still critical of the process, Frances suggests there might be "optimism that DSM-V can be saved from itself" (para. 15). He presents a list of the task force's recent improvements, stating they were made "reluctantly" and as a result of "external pressure" (para. 15). The list includes appointment of an oversight committee by the APA Board of Trustees, the postponement of field trials until after the posting of draft options, and "reduction of hype about a 'paradigm shift'" (para. 16).

December 10, 2009: The APA officially delays the publication of DSM-V. The purpose, according to APA President Schatzberg, is to "allow more time for public review, field trials and revisions" and to develop a manual "based on the best science available and useful to clinicians and researchers" (APA, 2009, para. 2). The delay has the further goal to better link DSM with ICD-10-CM Medicare/Medicaid claims reporting.

January 1, 2010: Schatzberg publishes an editorial in Psychiatric News titled, "Why is DSM-V being delayed?" The editorial makes no mention of the controversies. Instead, Schatzberg attributes the change in deadline to "the vetting of task force participants; it took considerably longer than expected," to the goal of better linking with the ICD, and to "the specifics of the proposed classification system," such as the assessment of symptom dimensions and the testing of these dimensions in field trials (Schatzberg, 2010, para. 2). After announcing January 20 as the posting date for the DSM-V draft guidelines, Schatzberg provides his personal email address for brief emails that would help "move the profession up a notch to an even more evidence-based specialty" (para. 7).

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