The boundary between mental disorder and normality is inherently unclear. Wherever the artificial line is drawn, some people who need treatment will be missed and some who should avoid treatment will be diagnosed.
I have a fundamental disagreement with the DSM5 drafts on where the boundaries should be set. My view is that the diagnostic system is already overinclusive and captures too many people who might be better off with no diagnosis and no treatment. A recent study found that by age 32, 50 percent of the general population had already qualified for a diagnosis of anxiety disorder and about 40 percent each for a depressive or an addictive disorder. This suggests to me that it is already too easy to get a DSM diagnosis.
In contrast, those working on DSM5 have proposed including six new disorders that would make it much easier to get a diagnosis. These currently "subthreshold" conditions are Mixed Anxiety Depression, Binge Eating, Psychosis Risk, Hypersexuality, and Minor Neurocognitive. Elsewhere, I have discussed specific problems each of these would cause (see "Opening Pandora's Box" at www.psychiatrictimes.com). Here I will take up the general issues raised whenever any subthreshold condition is made an official diagnostic category.
Impact On Prevalence Rates Of Psychiatric Disorders: The severe disorders in psychiatry tend to be fairly uncommon in the general population. In contrast, because they are at the populous boundary with normality, the new milder disorders would be extremely common. Several would likely have a prevalence of five percent or more. "Mixed anxiety depression" or "binge eating disorder" would probably each include at least ten million people in the US alone.
Because there are frequent fads in psychiatric diagnosis, it is difficult to predict in advance just how popular any disorder will eventually become once it is official. Prevalence rates are pushed upward by drug company marketing, advocacy groups, and the media. It is always possible that the rates of the subthreshold diagnoses may turn out to be even higher than anticipated.
Impact On Diagnostic Reliability: Because the subthreshold diagnoses occupy the unclear boundary with normality, different clinicians will often disagree in any given case whether diagnosis and treatment is necessary. This will be confusing to patients and damaging to the credibility of psychiatry.
Impact on stigma: There are unpredictable costs attached to having an inappropriate diagnosis. It can affect how you see yourself and how others see you; result in reduced ambitions and sense of personal control and responsibility, and difficulty getting insurance.
Impact On Treatment: None of the suggested subthreshold disorders has a proven effective treatment. In fact, there is good reason to doubt whether currently available treatments will have any specific positive effect. Milder conditions have such high placebo response rates that medication routinely fails to show any added advantage. Also unfortunate, placebo responders tend to mistakenly attribute their gains to medication and will therefore continue to use it even when no purpose is served. Most people with milder diagnoses will get better with time, experience, or nonspecific interventions. Or they will continue to have symptoms at a tolerable level as part of the aches and pains of everyday life. Calculations of risk versus benefit for subthreshold conditions should account for the fact that the specific benefits of medication treatment are unproven, but the cost, side effects, and complications are considerable. This would favor psychotherapy over medication.
Impact On Society: The medicalization of everyday problems and symptoms has many detrimental implications. Scarce medical resources would be diverted from those who really need them to those for whom treatment may do more harm than good. Diagnosing and treating ever increasingly large segments of the population implies a lack of tolerance for variability and for the inherent imperfectability of human existence. There is also an implied lack of faith in the resilience of our species if every problem has to have a medical label and be offered a medical treatment. Medicalization also reduces personal responsibility and sense of control. It seems patently absurd to create a diagnostic system which makes normality an endangered species.
