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DSM-IV-TR CasebookReview - DSM-IV-TR Casebook
A Learning Companion to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
by Robert Spitzer et al. (Editors)
American Psychiatric Press, 2002
Review by Heike Schmidt-Felzmann
Jan 10th 2003 (Volume 7, Issue 2)

This DSM-IV-TR Casebook was published two years after the DSM-IV-TR, and eight years after the last extensive revision of the DSM, the DSM-IV. Its purpose is, as in its previous editions, to familiarize the reader with the different categories of mental disorders in the DSM. It is intended as an illustration as well as a learning companion for clinicians, and the authors see its use as “an effective and enjoyable way for clinicians and students to get experience applying the principles of differential diagnosis” (xi).

In more than 500 pages the Casebook provides, as promised, a large collection of “real life” cases that cover a broad range of psychiatric phenomena. Most cases are between two and three pages long; some cover only half a page, others up to five pages. They include a brief description of the case and a separate discussion section, in which the diagnosis is explained and follow-up information is presented, if available. As in the DSM itself, the largest part of the Casebook is dedicated to mental disorders in adults (300 pages); this is followed by a section on mental disorders in children and adolescents (80 pages). In addition, there is a short chapter on multiaxial assessment (30 pages), one on “international cases”, i.e. cases that depict disorders that seem specific to certain countries or cultures (60 pages), and one on historical cases e.g. from Kraepelin and Freud (60 pages).

For those who consider buying the most recent Casebook, they should be aware that the cases in this most recent edition are exactly the same as in the DSM-IV Casebook (they differ only slightly from those in the DSM-III-R Casebook). As most of the changes in the DSM-IV-TR concern not the diagnostic categories and criteria but those sections of the manual that report research data, the new Casebook is on the whole very similar to the previous edition. Minor changes can be found in the discussion sections; these have also become somewhat longer on average.

What really struck me at my first reading of a Casebook were the titles of a number of the cases, which I found disturbingly snappy (e.g. “Disco Di”, “Twisted Sister”, “Mr. Macho” – the case of a serial rapist and murderer!) or disrespectful (e.g. “Fatty”, “Jerk”, “Slime”). Unfortunately, these titles have remained the same, while the case presentations themselves are, as before, less spectacular than their titles: they are mostly standard psychiatric case presentations that do not necessarily convey the impression that one is witnessing a particularly entertaining freak show.

More generally, the Casebook is illustrative of the problems that beset the whole enterprise of DSM diagnostics and have been at the core of much controversy. I will just mention three issues that I found myself confronted with in reading the Casebook, namely (i) the general question of definition of mental disorder, (ii) the problems of multiaxial diagnosis as proposed in the DSM, and (iii) the questionable treatment of controversial diagnostic categories. (For those who are interested in these and additional issues, there are also other reviews of DSM related material on Metapsychology, for example a very positive review of the DSM-IV-TR as well as highly critical reviews of two volumes of the DSM-IV Sourcebook.)

(i) The authors of the DSM have so far largely tried to avoid the question of theoretical definition of mental disorder. They intend the DSM classificatory scheme to be empirically grounded without subscribing to a specific theory of mental disorders. Instead, the classification describes specific clusters of symptoms, mostly in behavioral terms. The formation of categories is supposed to be based on empirical similarities, and not on specific etiological or clinical theories. The authors point out that one of the most important advantages of the DSM is its criterial operationalization of mental disorders that promises easy use in empirical research and subsequent comparability of results concerning specific disorders. There has been much debate concerning the possibility of such an “atheoretical”, “merely descriptive” approach. Being atheoretical means, however, not to be free of assumptions concerning the nature and status of mental disorders. The authors seem to consider mental disorders as “real” in a rather strong sense; the criterial approach is clearly not meant as conventional. That is, there is a fact to the matter whether something is a case of X or just looks like it superficially and is “really” Y (as is apparent in arguments on differential diagnosis). In addition, the authors also imply that diagnosing somebody with a mental disorder has at least some negative meaning – when they do not diagnose a certain disorder due to lacking information, they sometimes give the patient “the benefit of the doubt” (e.g. 23).

While the authors acknowledge that there is still much work to be done in adjusting categories, their general approach to classifying disorders is not in question. However, the notion of mental disorders that results from this approach is an extraordinarily heterogeneous one. In addition to “paradigmatic” mental disorders, like schizophrenia, depression or anxiety, other categories include, for example, cases with known organic etiology (e.g. substance intoxication and withdrawal), or neurological disorders (including sleep disorders like narcolepsy), developmental disorders (like autism) or mental retardation. The reader has to wonder what makes a disorder “mental”. Known or suspected organic etiology is clearly no reason for exclusion from the class of mental disorders. However, what are the reasons for inclusion? The obvious assumption that seems to follow from the range of disorders that are included, namely that the most important reason for inclusion is the existence of significant psychological symptoms, does not seem to hold either. There are other neurological disorders that have important psychological symptoms and are not mentioned in the DSM. And conversely, it is not clear whether the symptoms of e.g. all sleep disorders should really be counted as predominantly psychological. What justifies the inclusion of some, and the exclusions of other disorders? Some more substantial general theoretical reflection on what constitutes a mental disorder is definitely called for.

(ii) In the DSM, multiaxial diagnosis is proposed as a method of integrating a broad range of information into one diagnosis. It is, however, not quite clear in what sense “axis” is used her. Each axis seems to refer to some different kind of information, but it is unclear how these relate to each other. The authors themselves mention that there are cases in which the distinction between axis I and II becomes unclear (e.g. in the case of generalized social phobia (126, 182); another case in point would be generalized anxiety). In addition, at least in the Casebook (and this reflects psychiatric practice), not every axis is represented equally in the diagnoses. Their importance seems to decrease steadily from I to V. Axis V is only mentioned at all in the brief section that explicitly deals with multiaxial diagnosis, and even there one gets the impression that it is not of particular use: what is coded seems to be rather an intuitive assessment of either moderate or severe disturbance. Of the ten cases that are coded on axis V in the DSM, 6 are rated between 30 and 35, and four between 50 and 55. (The reasons for fine distinctions, e.g. between 30 and 32, remain unclear, to say the least.)

(iii) Given the well-publicized controversies concerning certain contested proposals for mental disorders in the past decade, I was surprised to encounter most of the contested categories again in the Casebook, even though officially they have been either abandoned or moved to the DSM Appendix pending further research. Accordingly, one finds in the Casebook two cases of menstrual disturbances, one as an extreme case of PMDD (“Paranoid and Dangerous” (sic!), 409), the other distinguished from “real” PMDD (“Menstrual Madness” (sic!), 456). The case representative of “Factitious disorder by proxy” has been rediagnosed in this edition, but the diagnosis is still mentioned (52). “Masochistic or self-defeating personality disorder” is mentioned twice (111, and 223 as “Goody Two Shoes”). Sadistic Personality disorder is also mentioned twice, with one paradigmatic case (161, 308). And even the infamous “Paraphilic coercive disorder” (obsession with rape) has made it into the cases (“Perfect Relationship” (sic!), 173). This inclusion is at the very least problematic. Despite heated controversy, the authors have chosen to mention these categories without reference to any of the criticisms that preceded their abandonment or move to the Appendix. They diagnose these cases now explicitly not as the contested specific disorder, but instead mostly as belonging to the general category as NOS (“not otherwise specified”). Even though this is strictly speaking legitimate, this inclusion conveys the impression that what has actually happened is that an originally useful clinical category has been discarded, in favor of a much less precise NOS diagnosis. At no point in the discussion of these cases is the kind of criticism mentioned that led to the exclusion of the putative disorder. The disturbing choice of titles for many of these cases only reflects this complete lack of receptivity to the (mostly feminist) concerns that were at the basis of the controversy.

However, the Casebook clearly fulfills the task that it was designed for: it gives an easily accessible introduction to the use of the DSM and probably a better illustration of the practical relevance of the individual categories than the DSM is able to convey by itself. Given that there is no way around using the DSM in the mental health system today, the Casebook is probably a valuable tool for acquiring necessary competence – as long as one remains aware that the DSM is no “psychiatric bible”, but a popular and still highly contested proposal for classifying mental disorders.

 

© 2003 Heike Schmidt-Felzmann. First serial rights

 

Heike Schmidt-Felzmann holds graduate degrees in philosophy and psychology from the University of Hamburg, Germany. She is currently a doctoral candidate in philosophy and works on ethics in psychotherapy.


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