Architect of DSM-5 rejects claims it will lead to labelling of more people as mentally ill

BMJ 2013; 346 doi: (Published 04 June 2013) Cite this as: BMJ 2013;346:f3648
  1. Ingrid Torjesen
  1. 1London

The man responsible for the long awaited fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has rebuffed criticism that the updated manual medicalises everyday life traumas by classifying them as psychiatric conditions and that it would increase the prevalence of certain disorders as a result.

David Kupfer, professor of psychiatry at the University of Pittsburgh and chairman of the DSM-5 task force, said, “The suggestions [have been] that we were medicalising grief, we were increasing the incidence of depression, and that was all for the good of American companies that use medications as their way of making money.”

He added that there was a perception that DSM-5 included more disorders and that this would mean that more people would be given diagnoses of psychiatric conditions “and therefore there are very few people left who are called ‘normal.’”1

Kupfer, who was in London to attend a two day international conference on DSM-5 and the future of psychiatric diagnosis, held at the Institute of Psychiatry at King’s College London on 4 and 5 June, told a press briefing that DSM-5 actually had fewer disorders than the 1994 fourth edition. He added, “The criteria sets have been heightened across the board,” and therefore DSM-5 would “if anything possibly decrease the prevalence of some of these disorders.”

For example, he said, the diagnosis of autism spectrum disorder put four disorders into one. Similarly, the criteria for substance abuse disorder have been tightened, so contrary to speculation that its incidence would rise by 40%, it “may go down.” And the new diagnosis of mood disorder in children had been introduced, he said, because in the United States too many such children were currently being labelled as having bipolar disorder.

Particular criticism has been levelled at the decision to remove a clause from DSM-IV that prevented bereavement for up to two months after the death of a loved one being diagnosed as a major depressive disorder.2

The reason for this change, Kupfer said, was to ensure that the loss of a loved one or a job (or the occurrence of any other traumatic event) would not preclude someone being assessed for major depression. “What we tried this time is to make it very clear—again and again in the text, in the notes, and the criteria—that sadness and grief and bereavement are normal. They are not disorders, they are not diseases, but we need to always have the option that if there is indeed a tremendous amount of suffering, suicidal behaviour, and the like, that a family and a patient should have the right to get an assessment at any point in time for clinical depression.”

Kupfer anticipated that DSM-5 would be updated in just a few years’ time, with DSM-5.1, DSM-5.2, and so on, to incorporate biomarkers into the diagnostic criteria. He said that biomarkers were already being used for some types of sleep disorder, such as narcolepsy. There were also promising indicators for Alzheimer’s disease and even autism, he said, but there was some way to go on biomarkers for schizophrenia and bipolar disorder.


Cite this as: BMJ 2013;346:f3648