COMMENTARY

Dr. Kupfer Defends DSM-5

David J. Kupfer, MD

Disclosures

June 01, 2012

Will DSM-5 Inflate Prevalence?

Charges that DSM-5 will lower diagnostic thresholds and lead to a higher prevalence of mental disorders are patently wrong. Results from our field trials, secondary data analyses, and other studies indicate that there will be essentially no change in the overall rates of disorders once DSM-5 is in use. For most disorders, including the addictive disorders that recently drew headlines, thresholds will remain the same or will increase. With other disorders, diagnostic criteria are being refined to hone specificity. The challenge is to balance specificity and sensitivity, to make sure that the language characterizes a disorder as accurately as possible.

That balance lies at the heart of our proposed autism spectrum disorder, one of several areas related to childhood disorders where we have taken key steps to improve upon previous editions of the manual. Advocates for those who suffer from Asperger syndrome and autism disorders want to ensure that children with DSM-IV-defined conditions are not denied services under DSM-5. Our field trial data do not show that people with treatment needs will be negatively affected, and all will be helped because clinicians will be guided by more explicit definitions and descriptions of symptoms and behaviors.

We learned crucial information from the field trials, which involved more than 3000 patients who were assessed by a variety of clinicians in large medical centers, community clinics, and individual practitioners' offices nationwide. Of interest, 2 diagnoses that are not changing appreciably from DSM-IV, major depressive disorder and generalized anxiety disorder, had relatively poor performance in terms of reliability. These findings raise important issues concerning the diagnostic dilemmas inherent in reliably assessing disorders that are frequently comorbid with other conditions. They provide obvious direction for further adjustments to the manual -- refinements that can be introduced efficiently in the future Web-based releases envisioned for DSM-5.

Indeed, the Internet provides the opportunity to revise the DSM as convincing new data become available, and it enables us to position the DSM as a living document, one that is as up-to-date as possible, rather than scrambling to catch up. That's the issue at the heart of the current manual's deficiencies, which have become apparent over time.

As Dr. Allen Frances concedes in his recent Medscape interview, DSM-IV never dealt adequately with childhood and adolescent disorders for numerous reasons. In addition, it offered a fuzzy delineation of disorders that led to the inflated number of comorbidities we see today and clouded matters more with its "not otherwise specified" diagnostic designation.

Some have argued that the publication of DSM-5 should be delayed. But the current manual's shortcomings, particularly in the area of childhood disorders, compel us to move forward now, with changes supported by the most credible research available and the practical experiences provided by our field trials. We then need to maintain vigilance, understanding that improvement will be an ongoing process. Science will advance and we will learn more about the intersection of brain, genes, environment, and behavior. DSM must reflect that knowledge. Our patients will be better off for it.

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