On Dec. 1, 2012, the American Psychiatric Association (APA) announced that its Board of Trustees approved the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Some of the proposed changes in this revision — the first since 1994 — have generated heated controversy on the part of medical professionals, as well as patients and consumers. Below, David Kupfer, MD, Thomas Detre Professor of Psychiatry and professor of Neuroscience and Clinical and Translational Science at the University of Pittsburgh School of Medicine, and chair of the DSM-5 Task Force, offers insight into some of the most controversial issues.

These issues include:

  • Removal of the “bereavement exclusion” in the major depression section — patients may be called clinically depressed sooner than two months, although the criteria will include advice to clinicians about distinguishing normal grief from depression that should be treated.
  • Addition of “disruptive mood dysregulation disorder” diagnosis for children >6 years old who show frequent bursts of anger along with chronic irritability.
  • Collapse a number of autism-related conditions treated as separate disorders in DSM-IV into a single “autism spectrum disorder” category

In general, what did the committee hope to achieve with the DSM-5 revisions?
The overarching goal of the DSM-5 revision has been to take into account the scientific and clinical advances that have been made over the past 20 years since the last revision. The aim has been to, wherever possible, make appropriate changes in criteria and establish new diagnoses that would make the DSM more useful to clinicians and the patients they serve.

Please comment on the removal of the “bereavement exclusion.” What was the rationale for this, given that clinicians are going to be given specific advice about how to distinguish normal grief from depression?
As part of the ongoing study of major depression, the bereavement exclusion has been removed from DSM. This deletion from DSM-IV will be replaced by notes in the criteria and text that caution clinicians to differentiate between normal grieving associated with a significant loss and a diagnosis of a mental disorder. We reviewed the literature and had a number of advisors go over the available research to help inform this decision.We made this change because it is very important that clinicians have an opportunity to make sure that patients and their families receive the appropriate diagnosis and the correct intervention without necessarily being constrained by a period of time. In the same sense, it is important to realize that we have provided several notes in the manual to make sure that it is understood that sadness, grief, and bereavement are not things that have a time limitation to them. It is not something that goes away within two or three months. The changes encourage clinicians to assess clients on a case by case basis, without limiting them by an arbitrary period of time.