University Times

David J. Kupfer

There is nothing more influential in the world of psychiatry than the “Diagnostic and Statistical Manual of Mental Disorders” (DSM).

“I was amazed myself that the darned thing was published in 24 languages last time,” as DSM-IV in 1994, says says David J. Kupfer, Thomas P. Detre Professor of Psychiatry at the School of Medicine. Kupfer has just completed a stint as chair of the task force that spent more than a decade revising this guide to mental-disorder diagnosis and classification for clinicians and researchers, to be published in May 2013.

But, he adds, the new DSM-5 — replacing the Roman numerals at his suggestion to allow more frequent electronic updates as DSM-5.1, DSM-5.2, etc., rather than the nearly 20-year gap between previous volumes — “may be the last print version. So you can think of DSM as a living document, not something set in stone. That’s a major, pragmatic change.”

The revision process was both careful and contentious at times, Kupfer notes. It began in 1999 and included 11 research conferences on different aspects of mental disorders from 2003 to 2008. After Kupfer was chosen in 2007 as chair of the DSM-5 task force by the American Psychiatric Association (APA), which approves all revisions and publishes the book, 13 working groups focused on different aspects of the field of psychiatry, with members from pediatrics, neurology, academic clinical psychology and other areas reviewing and recommending changes, including new diagnoses.

The task force for the American manual also coordinated with the World Health Organization’s “International Classification of Diseases,” whose previous edition coincided with DSM-IV. “It’s very nice if we have one classification of disorders around the world, rather than two or three or four,” Kupfer says. “So we tried to harmonize our efforts.”

The task force’s work, he says, was a “very intense process” involving biweekly teleconferences, semiannual meetings and “thousands of emails.

“Not all of them are necessarily going to agree,” he says of the 1,500 participants in the revision process. Indeed, several working-group members quit following a dispute about reclassifying certain disorders. “To be honest with you, I’m surprised more people didn’t drop out,” Kupfer says.

In fact, he says, for him there were no surprises over the last five years, “except the usual: The unexpected happens more often than chance. And everything takes longer.”

For the first time, the task force posted proposed changes on a DSM web site (www.dsm5.org), and invited public comment. “We got something like 13,000 responses,” he says. “This was very helpful, hearing from clinicians around the world, patients, families … We don’t do that in the rest of medicine, but we felt it was important to get that kind of input.”

Of most concern and significance to the public have been changes in diagnoses that will place previously separate disorders in the same category, create newly distinct disorders, eliminate previous disorders or allow a disorder to be diagnosed officially for the first time. For instance, DSM-5 recognizes an autism spectrum for the first time, whereas such a designation has been popularly accepted for years. The task force’s debate, which included discussion of possible changes to the Asperger’s syndrome diagnosis, reportedly drew strong objections from those currently with the diagnosis.

DSM-5 also will discard a previously sanctioned “bereavement exclusion” that had not allowed physicians to diagnose someone with a new depression until more than 60 days after the death of a loved one. “Depression is different than grief,” Kupfer cautions. However, he adds, “we need to be able to make that differentiation at any point.” Those who fear that elimination of the bereavement exclusion will cause clinicians to prescribe medication too early, or too readily, are assuming that medication is the only way to treat depression, he adds. But he acknowledges that some will continue to question the ability of clinicians to diagnose an individual’s depression during his or her period of grieving. “I know a lot of people have screamed about it and will continue to scream about it. They don’t understand it.”

Another change that drew some controversy was the addition of Disruptive Mood Dysregulation Disorder (DMDD), a new diagnosis for children who previously had been lumped into the bipolar category. Now they will be eligible for treatments that more specifically target their particular symptoms — children with “persistent irritability and frequent episodes of behavior outbursts three or more times a week for more than a year,” according to the APA.

The intention was to try to fill the gap for physicians who see patients whom they suspect may be bipolar but don’t quite fit the classification, Kupfer says. “The whole point is to give physicians a choice. And we don’t know if that will work.” He hopes that, in three-five years, there will be enough research and clinical experience to judge the efficacy of the new diagnosis, allowing any necessary shifts to the DMDD designation in DSM-5.1, or DSM-5.2.

The criteria for adding a new diagnosis were stringent, Kupfer says, including a body of clinical and research data that warranted the new conclusion. For instance, hoarding, a phenomenon that has been around for a very long time, finally has accumulated enough research to separate it from other obsessions. On the other hand, with another diagnosis contender, hypersexuality, “most people at the end of the day felt there was not enough empirical evidence to recommend that it be in DSM-5 at this point. That doesn’t mean it shouldn’t be worked on.”

For clinicians, other changes to DSM-5 may be more significant. “Since so many disorders begin in childhood and adolescence, we wanted to organize the book differently,” Kupfer says. Thus, this edition is organized parallel to the chronology of human life, with early chapters covering neurodevelopmental disorders, middle chapters concerning mental disorders of adulthood and later chapters dealing with mental problems of old age. Even chapters on specific topics, such as depression, are organized in the same manner.

The new volume also gives greater emphasis to gender and cross-cultural issues in the United States, he says, and to how mental-health and medical disorders appear simultaneously in patients. The latter change will make it easier for clinicians to notice and understand the specific depression often associated with cardiovascular disease, for instance, or how half of bipolar patients also develop metabolic syndrome.

Kupfer says that the APA may publish a smaller DSM edition just for primary-care physicians, who deal daily with only 30-35 of the 200 disorders delineated in DSM-5.

Overall, he describes DSM-5 as “an aggressive, conservative document”: aggressive in its pursuit of revision; conservative in its decisions in the end. Ideally, he adds, the book’s revisions will be recognized “as change that makes it easier for people to use. I can’t stand the idea that it sits on the shelf and [clinicians] only use it for coding” of illnesses on insurance-company and other office paperwork.

He is certain it will improve teaching, especially if health-care professionals take advantages of DSM-5’s e-version, with its e-guidebooks and apps. “It will make it so much easier to carry around my iPhone and pull this out in an emergency room or wherever I am,” he says.

Kupfer objects to critiques of the DSM revision process that say “we’re medicalizing every disorder. There was concern that all we were doing was leading the way for the pharmaceutical industry to have a bigger field day than they’ve had.”

He says the effect of DSM on insurance companies’ bottom lines never was a consideration. Instead, Kupfer says: “We paid attention to: Could we come up with better diagnostic criteria that will help physicians treat patients better than we can now?” as well as ways to help bring about earlier interventions. “In many ways, we were hoping there would be a greater encouragement of behavioral, cognitive interventions … especially for children and adolescents.”

-—Marty Levine