Dr. Kupfer Defends DSM-5

David J. Kupfer, MD


June 01, 2012

Editor's Note:
In a recent Medscape interview with Dr. Stephen Strakowski, DSM-IV Task Force Chair Dr. Allen J. Frances expressed serious concerns about a number of proposals being considered for inclusion in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), scheduled for release in May 2013. Below, DSM-5 Task Force Chair Dr. David Kupfer defends the proposed revision.

A DSM-5 Defense

It is the largest project in which most of us have ever been involved: review of several decades of scientific research and 10 years of international conferences and deliberation, with the involvement of more than 900 experts from this country and abroad, including clinicians and researchers in psychiatry, psychology, statistics, epidemiology, neurology, pediatrics, social work, and other disciplines and specialities.

The stakes are far reaching: the first full revision since 1994 of the DSM, a document that influences the lives of millions of people around the world.

When our work draws to a close in late 2012, this fifth edition of the manual, DSM-5, will set new standards for the organization of disorders and quality of evidence. We believe that it will not only address the diagnostic inflation and inconsistencies of its predecessors but will also move the field forward in a focused, lucid way.

The development process that has brought DSM-5 to this point has been highly visible, transparent to an unprecedented degree, and inclusive, with 3 online comment periods since early 2010 that have drawn nearly 12,000 responses to date. Medical groups, advocacy organizations, individuals who work in mental health settings, and most certainly patients and family members have all offered feedback. Yet, predictably in this blogosphere age, the process has at times provoked heated commentary and dire warnings from some critics. Unfortunately, their conclusions have often relied on incomplete, secondhand, or skewed information.

So, where exactly is DSM-5 today and where is it going?

Without question, the upcoming edition is an iterative work and will remain so until the final proofs go to the publisher. Although nearing completion, it continues to be shaped by discussions with leading experts, new research, results from our field trials, and other professional and public feedback.

Contrary to how some have preferred to characterize it, our recent recommendation to include attenuated psychosis syndrome and mixed anxiety depression only as conditions in need of further study reflects this ongoing evaluation. We anticipate several shifts in other criteria and in the placement of other proposed disorders in the coming months, with the American Psychiatric Association's Board of Trustees scheduled to make the final decisions late this year.

But some outcomes already are clear, and they presage a fundamentally different manual for the future. For the first time in the history of DSM, the total number of diagnoses will not grow. (DSM-5's final count may even fall below that of DSM-III, published more than 30 years ago.) Disorders are being placed along a developmental continuum, and cross-cultural guidelines are being added to increase the manual's global utility. Also, for the first time, the next DSM will have a cohesive organization that sequences disorder groups in terms of how conditions relate to one another. This framework will positively influence patient care and future research.


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