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 For several years, the discussions about the  deliberations of the various task forces involved in constructing the  latest revision of the Diagnostic and Statistical Manual of the American  Psychiatric Association, the DSM-V, have been  shrouded in secrecy. The lack of transparency of the discussions generated highly  publicized criticisms from such luminaries as Robert Spitzer, the major developer of the  revolutionary DSM-III, and Allen  Frances, chair of the DSM-IV task force. This  situation radically changed in February with the release of the  revisions of the changes proposed by the 13 work groups charged with  revising the DSM. Most of the  public response to the proposed changes has centered on several  alterations to particular diagnostic categories. The suggestions include  using a new diagnosis of “temper dysregulation with dysphoria” for  children instead of bipolar disorder, incorporating Asperger’s disorder,  autistic disorder, and several other conditions into a single “autism  spectrum disorders” category, and recognizing some new types of eating  disorders. The focus on these specific changes, most of which are  sensible, has deflected attention away from other suggestions that have  much greater potential import. Three changes,  in particular, could lead to an enormous pathologization of  non-disordered conditions. The first is the suggested revision  of the criteria for Major Depressive Episode to remove the bereavement  exclusion from this diagnosis. At present, the criteria for  major depression require five or more out of nine symptoms including  sadness or lack of interest or pleasure that least for  at least two weeks. However, the criteria exclude people who  experience these symptoms in response to bereavement: “The symptoms are  not better accounted for by Bereavement” That is, people who develop  enough symptoms to meet the criteria after the death of an intimate are  nevertheless not defined as disordered but instead as suffering from a  natural, nondisordered response to loss. The reason for the bereavement exclusion is  obvious. Voluminous evidence indicates that bereavement after the loss  of an intimate is a natural reaction. The earliest literary portrayals  of human experience such as Gilgamesh and The Iliad indicate that  grief is a basic human emotion. Likewise, while different cultures have  vastly different expressions of grief, sadness and accompanying  psychological and somatic symptoms after the loss of a loved one is a  universal experience. Even many primates show demonstrable signs of  depression-like symptoms after the death of a close relation.  In the  vast majority of cases, the universal symptoms of grief dissipate with  the passage of time and only a minority of the bereaved remains highly  symptomatic after several months pass.  If the suggested revision is implemented  anyone who is sad, fails to derive pleasure from usual activities, finds  it difficult to concentrate, and has sleep and appetite difficulties for  a mere two weeks could be diagnosed with Major Depressive Disorder.  Because virtually the entire population will be bereaved at some point  in their lives and because such a high proportion of the bereaved would  meet diagnostic criteria that require two week duration, this proposal  could pathologize an enormous number of people. A second proposal that has the promise of massively medicalizing  natural emotions is to adapt dimensional assessments for the existing  categorical diagnoses. On the surface, this proposal sounds sensible and  desirable. Major Depression, for example, requires the presence of five  symptoms but there is no natural cut-off point between four and five  symptoms, or at any other particular point for this  diagnosis. Depression, as well as the other major conditions in the DSM, seems to  naturally be a continuous rather than a categorical condition. The problem in dimensionalizing common  conditions such as depression and anxiety is that a small number of  “subthreshold” symptoms typically indicate a non-disordered condition,  not a milder form of disorder. The only way to accurately use a  dimensional system is to initially use criteria for  disorder that separates natural from disordered conditions, regardless  of how many symptoms are present. If adequate conceptions of disorder  first distinguish contextually appropriate symptoms that are commonly  transitory responses to stressors from mental disorders, then  dimensional measurement could represent a distinct improvement in the DSM. As the  discussion of bereavement indicates, however, the separation of  disorders from non-disorders in the DSM-V seems to be  getting worse rather than better. The current proposal to dimensionalize  measures of frequently occurring disorders threatens to  pathologize even mildly distressing conditions. While potentially  valuable, it needs reconsideration and reformulation. A final worrisome proposal lies in the  creation of “at-risk” categories for mental disorder. At present, this  possible category is limited to psychotic conditions; people who have  just one symptom from among delusions, hallucinations, and disorganized  speech who have never met the criteria for a psychotic disorder could  receive the “at-risk” diagnosis. The diagnosis is well-intentioned and  aimed at identifying people who might be at an early  stage of a psychotic condition but who don’t yet meet the full criteria.  Such people might benefit from early identification and treatment. The problem with the “at-risk” category is  it’s potential as a Trojan horse that would diagnose nearly  a-symptomatic people as being in the early stages of a  disorder. Yet, at present, there is no way of knowing which people with a  single or a small number of symptoms will go on to meet the full  diagnostic criteria and which will not. The latter group will typically  outnumber the former group so that the potential for false positive  diagnoses is enormous.  The current  suggested revision only applies to psychotic conditions where it might  not create too much damage. If it were applied to widely occurring  conditions such as depression and anxiety, however, the result  could be a massive amount of new pathology. For example, one of the best  known studies of depression, the Dunedin Study, ties the presence of the small  allele of the 5-HT gene to this condition.  Yet, nearly 20% of  people have two copies of the small allele and over half have one copy, so over  two-thirds of the population could be viewed as “at-risk” for developing  depression . Once a gene is identified as a risk factor for depression,  anyone who has the gene may be a candidate for intervention,  even if they don’t actually have a depressive condition. Genetic tests  could identify “at risk” individuals, who could then be placed on  long-term regimes of drug therapies. In the case of the 5-HT  gene, a majority of people would be at risk for depression. While  the DSM-V working groups have not (yet) proposed an at-risk category  for depression or any other commonly occurring condition, this  danger might be lurking in the future. Overall, it appears that the original  promise of the DSM-III in 1980 – the  creation of a clear, precise, and reliable diagnostic system that would  eventually lead to more accurate knowledge about the causes, prognoses,  and treatments of mental disorders has not been fulfilled. Indeed, it is  difficult to think of a single breakthrough that has resulted from  psychiatry’s classificatory system. The major proposals in the DSM-V do not seem as  if they will change this situation and could wind up making psychiatry’s central  problem of distinguishing pathology from normality even more difficult  to resolve.Allan Horwitzimage©Vincent W. Hevern