It started with this article by Allen Frances, chair of the DSM-IV taskforce.
and this article
which had a reply from the chair of the DSM-V taskforce
The debate surrounds many areas, one of which is the idea of premorbid psychiatric illness. It goes without saying that such a situation is possible, i.e a state of being with a high probability of incurring a 'real' psychiatric diagnosis of mental illness. America's insurance-backed healthcare system means this makes even more sense because it means people can get treatment without having severe illness. There's research that backups the idea that premorbid psychosis can be treated as a preventative measure.
That's all well and good, except the reality is that academia's understanding of premorbidity will be different to clinicians. The concerns of the old guard are that there will be a repeat of the overdiagnosis of ADHD and the use of medication on huge swathes of the population who were once considered 'normal' will ensue. The operational diagnostic cluster of symptoms will also not accurately predict a premorbid state, i.e. some people will receive a diagnosis who have no chance or very little chance of full blown psychosis.
These false positives will be treated when treatment is unnecessary. Treatment usually means antipsychotics and these have profound effects on an individual. Unintended or not they can cause a lack of volition as well as a number of physical disorders. Medicine hasn't got the balance of harm of medication versus outcome correct without premorbid psychiatric illness to confuse the picture further.
Another interesting development in DSM-V is the use of the dimensional model. I'm afraid I know little about this except that it is a radical change to the diagnostic paradigm. Schizoaffective disorder can be seen on three dimensions of psychotic, mood and depression (check this) whereas schizophrenia may be on one or two. It means rather than lump different behaviours into one diagnosis the individual behaviours are separated out. This means treatment happens for each dimension and it solves the problem of comorbidity.
The old guard have suggested this is a welcomed shift and that the dimensional model of mental illness is the future, however it is not ready to be included in a major revision of the psychiatric bible. DSM bases itself on epidemiological studies and other forms of research that provide the robust scientific justifcation of the different illnesses, their course and treatments. This simply doesn't exist for the dimensional model and it is seen as a huge risk by the DSM-V taskforce.
A large part of the criticism of the DSM-V process has been its secrecy. The debate is happened behind closed doors, or it was till Frances and Spitzer made their criticisms vocal from informal conversations with taskforce members (they were not on the DSM-V taskforce). I find myself having to agree with the old guard that this has the highest potential to make DSM-V a dangerous revision.
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