Book Review

Diagnostic and Statistical Manual of Mental Disorders

DSM-IV Sourcebook

Study Guide to DSM-IV

DSM-IV Casebook: A Learning Companion to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition

The Clinical Interview: Using DSM-IV

N Engl J Med 1994; 331:1163-1166October 27, 1994

Article

Diagnostic and Statistical Manual of Mental Disorders
Fourth edition. 886 pp. Washington, D.C., American Psychiatric Press, 1994. $42.95. ISBN: 0-89042-062-9

DSM-IV Sourcebook
(Vol. 1.) Edited by Thomas A. Widiger, Allen J. Frances, Harold Alan Pincus, Michael B. First, Ruth Ross, and Wendy Davis. 768 pp. Washington, D.C., American Psychiatric Press, 1994. $112.50. ISBN: 0-89042-065-3

Study Guide to DSM-IV
By Michael A. Fauman. 420 pp. Washington, D.C., American Psychiatric Press, 1994. $26.95. ISBN: 0-88048-696-1

DSM-IV Casebook: A Learning Companion to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition
Edited by Robert L. Spitzer, Miriam Gibbon, Andrew E. Skodol, Janet B.W. Williams, and Michael B. First. 576 pp. Washington, D.C., American Psychiatric Press, 1994. $40.50 (cloth); $29.25 (paper). ISBN: 0-88048-674-0 (cloth); 0-88048-675-9 (paper).

The Clinical Interview: Using DSM-IV
(Vol. 1: Fundamentals.) By Ekkehard Othmer and Sieglinde C. Othmer. 513 pp. Washington, D.C., American Psychiatric Press, 1994. $40.50. ISBN: 0-88048-541-8

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) is the most comprehensive and authoritative book devoted to the classification of psychiatric illness. There have been four major revisions since 1950. The fourth edition (DSM-IV) closely follows the formats of the third edition (DSM-III; Washington, D.C.: American Psychiatric Press, 1980) and the revised third edition (DSM-III-R; Washington, D.C.: American Psychiatric Press, 1987), but is a third longer than the latter and includes more diagnostic categories.

Why do we need a new edition when the DSM-III-R was published only seven years ago? The answer is simple: scientific knowledge is not static. Previous editions relied heavily on a consensus of experts in the classification of disorders, but the DSM-IV relies more closely on research, including extensive reviews of the literature, reanalyses of data, and results of clinical trials.

With conservatism as its general philosophy, the task force that compiled this edition simplified many diagnostic categories and more precisely defined the differences between similar disorders. Its guiding principle was a reliance on a systematic review of the literature and empirical data. The members of the task force added few new categories. Moreover, they retired several categories, including idiosyncratic alcohol intoxication, identity disorder, overanxious disorder of childhood, avoidant disorder of childhood, and transsexualism.

The organization of the manual discourages an approach encompassing mind-body dualism and facilitates the differential diagnosis. The term “organic mental disorders” has been deleted. If a general medical condition or substance (drug of abuse, prescribed medication, or toxin) is responsible for psychiatric symptoms, the DSM-IV labels the disorder as “due to a general medical condition” or as a “substance-induced disorder.” Conditions that share certain symptoms are placed together. For instance, organic anxiety disorder was renamed and is now included in the section on anxiety disorders. Thus, under the new system a patient might have anxiety disorder due to hyperthyroidism.

The DSM-IV warns against misdiagnosis due to cultural misunderstandings. In addition to the appendix of “culture-bound syndromes,” many descriptions of individual disorders have sections entitled “Specific Culture, Age, and Gender Features.”

A major goal in developing the DSM-IV was to make it more compatible with the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10). The DSM-IV task force took important steps in that direction, but the definitions of several disorders differ in basic and important ways in the two systems. For instance, the ICD-10, which incorporates a broader definition of schizophrenia than the DSM-IV, does not include the concept of prodromal or residual symptoms. The ICD-10 definition of schizophrenia specifies a much shorter duration of symptoms (one month), in contrast to the duration of six months specified by the DSM-IV.

As an educational tool, the DSM-IV is splendid. It lists diagnostic criteria in easy-to-read boxes and provides trustworthy information in the accompanying text. No longer is this book a simple rehashing of the diagnostic criteria. The prevalence, age of onset, and clinical course of various disorders are given in much greater detail than in previous versions.

Primary care practitioners, medical specialists, and mental health clinicians will find the DSM-IV useful and beneficial. It has substantially expanded sections on differential diagnosis and provides laboratory data and other relevant information. For example, the section on schizophrenia mentions structural abnormalities of the brain, imaging techniques that may be useful, and neurophysiologic findings.

An appendix entitled “Criteria Sets and Axes Provided for Further Study” was expanded from three categories in the DSM-III-R to more than two dozen. Examples include post-concussional disorder, premenstrual dysphoric disorder, factitious disorder by proxy, and medication-induced movement disorders. This appendix offers a glimpse into the next edition of the book. Factor analysis, a research tool, suggests that the use of dimensional descriptors might be a clinically appropriate way of subtyping certain disorders. For example, the appendix lists three such descriptions for schizophrenia: a psychotic dimension, including hallucinations and delusions; a disorganized dimension; and a negative dimension. Clinical studies show that the severity of the symptoms in each of these dimensions tends to be similar. For example, as hallucinations become more severe, delusions also tend to be more severe. In contrast, the severity of negative symptoms (i.e., flat affect and impoverished thinking) is less closely related to the severity of delusions or hallucinations.

Investigators of psychopathology will be able to see the effect of their research on the DSM-IV. The book has not ended the controversies and questions about psychiatric nosology, but it does supply a reliable and specific diagnostic system that should encourage clinical research. It also foreshadows future changes by including a brief and somewhat out-of-place discussion of dimensional models for personality disorders, a reference to prototypes, and a proposed axis for defense mechanisms and coping styles.

Clinicians in all specialties can use the DSM-IV as a reference. It is a “must” for every serious mental health and medical library and all mental health clinicians. Primary care physicians, who treat one fourth to one half of people with psychiatric illness, should read the introduction to the manual and the instructions concerning its use.

The DSM-III, published in 1980, provided the first clinically sound and reliable multiaxial set of criteria for identifying mental disorders. A major criticism of the DSM-III and the DSM-III-R was that they created new diagnostic categories, often with little justification. It was thought that adding disorders would promote empirical studies of new and diverse areas that might otherwise be neglected. However, the validity of several of the new categories was not supported by systematic study. The following is a good example of how the task force required substantiation of a diagnostic category. The entry on passive-aggressive personality disorder appeared in the earlier versions of the DSM. Many clinicians will be surprised to learn that there are virtually no empirical studies of this disorder. The DSM-IV demotes it to an appendix.

Volume 1 of the DSM-IV Sourcebook is the first installment of a projected five-volume set that will bring together the research behind the DSM-IV. It consists of 45 chapters covering substance-related disorders; delirium, dementia, and amnestic and other cognitive disorders; schizophrenia and other psychotic disorders; medication-induced movement disorders; and sleep disorders. Each chapter reviews the literature on a topic. The four additional proposed volumes will provide the remainder of the literature searches, summaries of over 40 reanalyses of data, and results of field trials.

In one chapter the Sourcebook reviews the classic subtypes of schizophrenia to determine their validity. This chapter clearly shows how literature searches were instrumental in determining the final form of the manual. The classic subtypes were retained because there is evidence that they have prognostic value; the paranoid type has the best prognosis, and the disorganized type the worst outcome.

A weakness of the Sourcebook is its limited bibliography. It often lists less than half the references mentioned in the review. Some chapters include a count of the number of journal articles on the proposed diagnostic category; others merely mention the sources of the unnamed articles. The DSM-IV Sourcebook was meant to be an archival reference for the decisions of the task force. A more thorough bibliography would have served this purpose better.

Some reviews are sophomoric, and the commentaries less than satisfying. The general outline of the chapters, which includes a statement of the issues and their importance, methods, results, discussion, and recommendations, was not followed consistently. Much information is now dated. In short, the Sourcebook will interest serious nosologists but will have little appeal for the average clinician.

How, then, can clinicians learn to use the new official nomenclature without reading the DSM-IV straight through? The DSM-IV, destined to be a best-selling psychiatric work, has spawned three additional books. Released simultaneously by the same publisher, these facilitate an understanding of the concepts and terminology in the DSM-IV.

The Study Guide to DSM-IV will chiefly benefit medical students, psychiatrists in training, and other clinicians seeking introductory information. It serves best as an organized introduction to the criteria for individual DSM-IV categories. Since it specifies diagnostic criteria for each mental disorder, the DSM-IV is a criteria-based, categorical system of diagnosis. The rules defining each disorder specify the type, intensity, duration, and effect of various types of behavior and the symptoms required for each diagnosis.

The categorical classification outlined in the DSM-IV is contrasted with the use of prototypes. Prototypes, a recent innovation in research on psychiatric nosology, are typical cases with many features associated with a category. The Study Guide highlights individual disorders with the use of prototypical vignettes. Many researchers believe that prototypes illustrate the diagnosis more vividly than a list of criteria. These clinical vignettes enhance the learning of criteria.

A key issue for primary care practitioners is how best to handle patients who do not fully meet the criteria for specific diagnostic categories. The author of the Study Guide highlights common diagnostic problems. He furnishes examples of patients who fulfill most of the diagnostic criteria, of patients who satisfy the diagnostic criteria for more than one disorder, and of psychiatric conditions associated with other psychiatric disorders or general medical conditions. This information helps clarify cases in which patients have conditions that do not meet the threshold for diagnosis or have symptoms that seem to place them in two different categories.

The DSM-IV, like its predecessors, follows a hierarchical structure. For example, if a general medical condition can account for the patient's signs and symptoms, the medical disease is given priority over all mental disorders. To minimize the number of diagnoses a person might have, the manual excludes certain diagnoses if the patient meets the criteria for other mental disorders. The Study Guide to DSM-IV provides tables of diagnoses that must be excluded before a specific diagnosis can be made. For example, a neurologic or general medical condition has precedence over somatization disorder, and somatization disorder has precedence over conversion disorder.

The author would have done well to provide a chapter on severity, specifiers of the clinical course, and subtypes. The most recognizable change in the mood-disorders section of the DSM-IV is the explosion of specifiers to denote subtypes. For example, in the section on major depressive episodes these subtypes are included: “With Melancholic Features,” “With Atypical Features,” and “With Catatonic Features.” In addition, longitudinal course modifiers allow the clinician to specify the degree of recovery between episodes. The Study Guide addresses these confusing points, although superficially.

The Study Guide to DSM-IV is helpful. Used as a companion to the DSM-IV, as it was intended, it becomes a serviceable resource for medical students and psychiatric residents. Other physicians will find it useful as an occasional quick reference and helpful in reviewing for examinations.

The DSM-IV Casebook, another companion to the DSM-IV, is educational and fun to read and highlights many changes in the DSM-IV. The clinical vignettes focus on information relevant to the differential diagnosis. Each case is followed by a discussion of diagnostic reasoning, according to the DSM-IV. When diagnostic uncertainty resulting from inadequate information or ambiguity rears its head, the editors steer the reader around obstacles.

The DSM-IV is not a cookbook. The assigned diagnosis must make sense. The DSM-IV Casebook helps the reader understand how to use clinical decision-making skills to make the best use of the manual.

The DSM-IV abbreviates and streamlines sets of criteria for several categories of disorders. The criteria for somatization disorder, generalized anxiety disorder, antisocial personality disorder, and schizophrenia are simplified in ways that do not materially affect the number of cases diagnosed. The first two chapters of the DSM-IV Casebook deal with mental disorders in adults and children. Chapter 3 takes up the multiaxial system that the DSM-IV retains. Axis I consists of clinical disorders and other conditions that may be a focus of clinical attention, axis II consists of personality disorders and mental retardation, axis III consists of general medical conditions, axis IV consists of psychosocial and environmental problems, and axis V is a global assessment of functioning. The cases demonstrating multiaxial assessments are excellent. The discussion following each case considers each axis and summarizes the different types of information.

The DSM-IV changed axis IV from a scale to a list of psychosocial and environmental problems. Examples of these problems included in the DSM-IV Casebook are unemployment, financial problems, living in a dangerous neighborhood, knowledge of being positive for the human immunodeficiency virus, problems with a spouse, having a dying sibling, and work-related difficulties. Unfortunately, the editors limited the cases covering multiaxial assessment to 10. The point of having multiple axes is to encourage the clinician to look for certain types of information. The editors should have diagnosed every case in the DSM-IV Casebook by the multiaxial system.

The Casebook helps elucidate features of categories new to the DSM-IV. Bipolar disorder has been split into two categories -- bipolar I and bipolar II. Two cases of bipolar II disorder illustrate the hypomania and major depressive episode required for this diagnosis. A case of systemic lupus erythematosus shows how the diagnosis of catatonic disorder due to a general medical condition is made. The DSM-IV has added acute stress disorder to describe acute reactions to extreme stress that last no more than one month. The Casebook gives attention to variants of autistic disorder, a pervasive developmental disorder, and to childhood disintegrative disorder. However, Rett's disorder, which occurs in girls with deceleration of head growth and difficulty with hand movements, is omitted.

Two personality disorders, sadistic and self-defeating, were included in an appendix of the DSM-III-R, but eliminated in the DSM-IV. In the discussion of a case in the DSM-IV Casebook, there is a parenthetical comment that the editors believe sadistic personality disorder was mistakenly eliminated from the DSM-IV. The editors, including Robert L. Spitzer, who spearheaded the task force on the DSM-III and DSM-III-R, are a superb group of experts in psychiatric classification. They have clearly made a conscientious effort to help others learn to use the DSM-IV.

The Clinical Interview: Using DSM-IV is recommended reading along with the DSM-IV Casebook for physicians preparing for oral examinations in psychiatry. The authors start with an overview of interviewing techniques and lay out a model for establishing rapport, collecting information, and making a diagnosis. They have whittled down the steps of the diagnostic interview to five phases, paying special attention to beginning with open-ended strategies and narrowing the focus as data are collected.

First, the clinician fosters rapport and assesses the problem. By following up on preliminary impressions, the clinician assembles a historical data base. Next, the diagnosis is made and feedback is given to the patient. In the last phase, the clinician gives a prognosis, selects a treatment plan, and negotiates a treatment contract.

The authors' method of tackling the large number of DSM-IV categories requires the interviewer to make three lists: diagnoses consistent with the history, categories excluded by the available data, and unexplored disorders. As the diagnostic process unfolds, the long list of unexplored categories dwindles and the list of excluded disorders grows until a diagnosis is made.

Unfortunately, the authors seem incompletely familiar with the DSM-IV. For example, they use a discarded term, multiple personality disorder, interchangeably with the new term, dissociative identity disorder. Similarly, a discussion of stress disorders omitted acute stress disorder from the differential diagnosis. Otherwise, the authors teach interview strategies with skill and insight.

These five books should improve the quality of psychiatric assessment and help readers eliminate idiosyncrasies in their diagnostic habits. Even so, the DSM-IV is not a bible of psychiatric classification. If psychiatric classification is in its toddlerhood, the DSM-IV exemplifies the expanding world of the toddler. In the future, categories will be scrutinized to determine whether they should be deleted. Guided by published and reproducible standards, scientific investigation into the classification of psychiatric disorders can proceed without the emotional and political hysteria that has dominated past discussions.

With strict guidelines based on clear empirical support, future revisions should shrink the expanding world of psychiatric classification into a reliable, valid system. In the next century, psychiatric classification can regroup in its adolescence, reach a solid basis, and be on a par with the rest of medicine.

A. Kenneth Fuller, M.D.
Southwestern State Hospital, Thomasville, GA 31799