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Pr David Kupfer: Wrights and Wrongs about DSM-5

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MD-FM INSIGHT Tuesday 4 June 2013




Hello! You’re on MD-FM INSIGHT, the first medical web radio.

Clementine: Today we’re pleased to offer you a "Question & Answer" program devoted to the Rights and Wrongs about the DSM-5.



This new « bible book » was released during this year’s annual meeting of the American Psychiatric Association, in San Francisco.

We interviewed the chairman of the DSM-5 Task Force, Dr. David Kupfer, from the University of Pittsburg, in Pennsylvania.


1. Clementine:

So Dr. Kupfer, why is this new edition of the DSM a real breakthrough for the diagnosis of Mental Disorders?

David Kupfer:

“There are some major ways in which DSM-5 represents a considerable advance over DSM-4. Remember –it’s been 19 years since we had DSM-4. DSM-5 incorporates some of the latest advances in clinical science in all of psychiatry, and empirical data, to make the diagnoses more precise. It also includes segments that allow us to deal with levels of severity, and thresholds of dimensional measures, which we did not have previously.”

2. Clementine:

Could you give us an example?

David Kupfer

“So an example would be autism, where we have put together four disparate disorders into one autism spectrum disorder, which allows us to give a more precise diagnosis and do that diagnosis in such a way that children can be diagnosed with levels of impairment that relate to the kinds of services that they may very well need. It also means, in doing autism spectrum disorder, that the research that is going on, both in terms of genetics and other neuroscience findings, lays out much better on the new autism spectrum disorder. We’ve also looked at areas of substance use, ADHD, bipolar disorder and there are considerable improvements in these diagnostic criteria, which make it a much better tool for clinicians to use.”

3. Clementine:

You also changed the general organization of the book?

David Kupfer

“Other changes that are in the organization of the book is a much greater sensitivity to cultural diversity, a much greater sensitivity to gender expressions of disorder and, perhaps, most importantly, there is a much better sense of development across the lifespan. And so the book is organized along a chapter structure that allows us to understand that many of these very serious and chronic mental disorders really begin in childhood and adolescence. This then leads to several other changes that we’ve made: we’ve paid much more attention to the notion that we need to intervene more early in the course of these illnesses. And so there’s considerable criteria and also text that point to the way of trying to understand better pro-dromes, risk and resilent  factors and more importantly, the way we would go about dealing with early intervention. And I think that’s particularly important for some of the disorders that relate to schizophrenia, depression and the like. And I think that that will be, hopefully, used much more by clinicians in the future.”

4. Clementine:

How long will you wait before reviewing this book?

David Kupfer

“We’ve waited 19 years for a new edition. We don’t want to wait another 19 years. And so, therefore, by making this a living document, making this an electronic document, making this a document where, if you think about the version that we’ve changed from a roman numeral to an Arabic 5, think of it as 5.0. The fact is that, if we have considerable new and important findings, we can move to a 5.1, we can move to a 5.2, and not have to wait 19 years to revise the book. So all in all, we believe that it’s a very important clinical guide for all mental health clinicians. We think that it is a much better tool than we had previously for teaching, for training and, really, to align ourselves with the rest of medicine.

5. Clementine:

Don’t you think that the new classification in children, the “Disruptive Mood Dysregulation Disorder” classification, is at risk of increasing overdiagnosis in children?

David Kupfer:

“We worked very hard on this diagnosis –Disruptive Mood Dysregulation Disorder. Because what we’ve been concerned about, in the United States, is that too many children have been diagnosed either with bipolar disorders as children, or bipolar disorder not otherwise specified. When in fact, we know that many of these children, if they continue to have difficulties, grow up and develop depressive disorders and anxiety disorders. So what we felt we needed would be something potentially that might be an appropriate diagnosis for many of these children who have a great deal of irritability and a chronic level of temper tantrums and somewhat even being a bit out of control -- but it is chronic, it is not episodic. And the research data and the longitudinal follow-up data do support the fact that this diagnosis, hopefully, will fill a vacuum that currently is not available for children and adolescents. We don’t believe that this will necessarily increase the prevalence of childhood disorders but that individuals will get a more appropriate diagnosis.”

6. Clementine:

And with the suppression of “bereavement” from the exclusion criteria of major depressive disorder, isn’t there again a risk of overdiagnosis there too?

David Kupfer

“There is no one who is advocating, that I know, at least from the DSM (and it’s not in the DSM) that sadness, grief and bereavement are disorders –they are not. What we sought to do was to clarify the fact that they are not disorders. The bereavement exclusion, in the earlier versions, sort of meant that, for the first two months of grief, I could not be clinically depressed. I could be suicidal but I should not be given a diagnosis of clinical depression. It also implied, incorrectly, that sadness only lasts 2 months. So, we sought to correct this and the way we’ve corrected it is by not having this exclusion, by having the possibility that, if it is appropriate, during periods of sadness and grief, there may be clinical depression. The clinical depression may not be in the first two months, it may be month 6, it may be month 12. We’ve also sought to try to make it clear that sadness and grief does not have a delimited period of 2 months but can go on for a year and it can even go on longer than a year. I hope that when people actually read the DSM, they will see what we have done rather than the speculation of what we did not do.”

7. Clementine:

Many European psychiatrists are wondering why you deleted subtypes in schizophrenia

David Kupfer

“The subtypes in schizophrenia were dropped after a considerable review in the literature on the fact that they had not been used very frequently and they were not being used to either monitor clinical care or to differentiate various types of schizophrenia and, so, even though there had been discussions early, in previous DSMs, it was decided that, historically, they were there –it was time to remove them.”

8. Clementine:

What about measuring the intensity of symptoms in the DSM5?

David Kupfer

“Yes --One of the things that we have done is that we have a section 3. And section 3 is really what we call “a merging measures” and also “alternative models” for thinking about diagnosis. It is part of what we’re enthusiastic about, which is the electronic version, and it does allow a range of measures that can be used both by patients, by clinicians and by family members and parents, to provide information to the clinician on a range of cross-cutting measures and symptoms that systematically we’ve not been able to do up to date. Certainly, again, these measures could be very easily translated into other languages (we expect that will be the case), they will be found in the electronic version and the electronic version will also have additional measures that can be used. We feel that it is very important to begin to move towards a more dimensional way of thinking about psychiatric conditions, which is really the way if we think about what we are doing in biology and neuroscience –we don’t always think about it in a categorical way.”

9. Clementine:

What would you tell those who comment that the DSM is frequently used as a basis for the classification of diseases and for reimbursement?

David Kupfer

“The first think we need to remember is: What does DSM stand for? And it’s really a diagnostic statistical manual. So it is necessary for reporting procedures, it is necessary, certainly in the United States, for coding issues that relate to reimbursement. The coding, by the way, is the coding of the international classification of disorders, which was one of the major reasons that we wanted to align and harmonize, as much as possible, the chapter structure of DSM with ICD. We believe that the closer we become to one language of psychiatric disorders the less likely that there will continue to be stigmatized conditions, with different types of classifications. And so this is part of the reason that we feel this is necessary. DSM is used around the world, it is translated into many languages but we do feel that it would be very important to have one system that is really used and one language that is used for diagnostic classification.”

10. Clementine:

Will the DSM-5 have an international impact?

David Kupfer

“The international impact of DSM-5 was recognized by us very early in the planning and there were two things that we did. One is: we held a number of conferences, more than 10 conferences around the world, dealing with all kinds of topics, not necessarily disorders, in which we had 400 participants, of which half were people from outside of North America. We held conferences in Beijing, in Mexico City, in London, in Geneva. And these were important conferences in providing both ideas, research information and recommendations of where to go with DSM-5. Fully, 20 percent of the workgroup members and the task force members come from outside North America, they come from a variety of disciplines and, certainly, when we think about the 400 advisors in addition to the 160 workgroup and task force members, many of them are from various parts from around the world.”

11. Clementine

What do you think of the specific statement made by the NIMH about NOT using the DSM-5 for research purposes?

David Kupfer

“Those of us who are both researchers, clinicians (I would even say I’ve been an administrator and, certainly now really: head of the task force for the DSM-5) we move in different worlds. And I am an NIMH grantee, I am somebody who has strongly been involved in trying to push the science so we can push the clinical criteria like other sections of medicine. I have never advocated and I have said, even 15 – 20 years ago, that it was a mistake to think of the DSM as the “research framework” for us to pursue research. Unfortunately many people have used it that way. We have never suggested that the DSM-5 represents the only research framework that should be used. The DSM should incorporate the latest research when it’s available for clinical use.”

12. Clementine:

So what is your general conclusion?

David Kupfer:

“At this point in time, given all the work of all the science review groups and the many clinicians, we have the best guidelines and guidebook, for clinicians, for diagnosis of serious and not-so-serious mental disorders. And we believe that this is where we are in terms of 2013 with respect to the diagnosis of mental disorders.”


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