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Study Guide to the DSM-IV-TRReview - Study Guide to the DSM-IV-TR
by Michael A. Fauman
American Psychiatric Publishing, 2002
Review by Roy Sugarman, Ph.D.
Dec 12th 2003 (Volume 7, Issue 50)

Any system that tries to quantify and qualify the wide, disorderly and vague set of phenomena that make up the human experience along its continua, is a bugger to teach. When trying to understand complex equipment, we are all advised, in the words of the sages, to read the damn manual first. Trouble is, our patients simply refuse to do this, and so they fail miserably to fit into the neat nosological categories a committee of people across the seas have created.

However, across the world, inter-rater reliability is good, when we use the manuals we have created to pigeonhole human emotional and behavioural aberrations, mainly because we teach our pupils well.

But still, if Scott Lilienfeld and others are to be believed, we often create a set of response biases and availability heuristics that compound the problem, and psychiatry is one of the few professions where consumers of that service kill their helpers, and widespread assault is not unheard of.

Biopsychosocial approaches such as the Rochester model urge us, in essence, to ask somewhat different questions of the patient. Rather than trying to ascertain into what neat category, or set of categories a patient’s presentation fits, a somewhat more humane endeavour might be to attempt to penetrate the dense phenomenology of the neurobehavioral presentation, and answer the questions: why this person, why these symptoms, and why now at this stage of their lives?

Into this arena comes a rather helpful book, the study guide for the DSM-IV text revision.

Chapters two through seventeen follow the DSM organisation faithfully, and each chapter begins with one or two vignettes, a kind of simulator that sets the tone of the chapter, and these are discussed later. The pupil is thus exposed to the thinking behind the decision tree-approach of such diagnostic tomes. The ‘core concept’ of the diagnostic grouping is then discussed, with definitions, and overlapping conditions, which would provide alternatives, are then introduced. The vagaries of each condition are discussed, and further use of ‘prototypical’ vignettes is the method used to manage the controversies of each diagnosis and overlapping information which bedevils exclusionary diagnostic attempts. The step-by-step discussion that follows each is a further tree-climbing, or rather descending and deconstructive explanation for the diagnosis that is being illustrated. Over and over again, the common and compounding, confounding variables are discussed, and finally the precedence of one over the other is evaluated for each condition. Finally, with a return to the opening vignettes, the whole process is largely repeated, briefly, with FAQ kind of endings for each to explain the precedence of this diagnosis, in the face of others.

Of course, in this age of cyberspace, patients can access most if not all the possible mental illness definitions, and the drugs prescribed, and one hopes the consumer is becoming more informed. This may or may not make our job easier, and may of course make it harder.

More ominously, drug companies may begin to target their research, and have already done so, leading to some weird anomalies.

Why for instance do we never see drugs emerging that target anxiety, if it exists as a separate entity from depression? Why are the antidepressants so good at treating anxiety, but why do some of them increase the sense of arousal or dysphoria in the first few days? Most of us believe we know the answers, but that is so often illusionary.

Most students will struggle with the DSM, and most of mine joke that they went into psychiatry because it was the best way to forget general medicine and medical practice!

Systematic categorisation of human experience being what it is, this book answers many of these questions in a novel way. The use of the invariant headings for each chapter, picked out in bold, lull the student into a rocking and cradling along the lines of each category, and thus set up a preservative framework for each contact with the patient, creating a clinical mindset, which, although hardly creative, cuts out the middleman, the golem of psychiatry, namely the gut feel, the hara gai, the availability heuristic, or confirmatory bias.

This is indeed where such manuals, or rather guides to manuals, are so vital. We do after all recognise what we know, and see only what we look for so often. How do we reliably go after the answers to why this person, why these symptoms, why now? Not all psychosis is schizophrenia, it is after all a rare 1% illness, but psychosis is not, coming as it does from all sorts of heteromodal cortex dysfunction. On page 168 for instance, there is a discussion of a psychotic presentation. The sudden onset of the symptoms AND his elevated blood pressure indicate for the author an immediate caveat that there may be an organic basis for his presentation. We do not abandon medicine when such formulations are made. For many of us this seems just simple normal practice, and yet many of my students simply forget to do the medical workup and certainly often forget to make the attribution necessary.

Worse, without such workbooks, and a plodding approach to nitpicky diagnosis, fundamental attribution errors abound. We do not see bad brain, we see bad person. Each behavior has a homeostatic purpose after all, but we often see, lets say, the experience of thirst as being separate to the search for something to drink, but of course, they are one and the same thing.

I was told the other day by a consultant that my patient’s problems were behavioural and psychological, nothing to do with his brain. I responded that if such problems had nothing to do with the brain, then we should all become proctologists, since that is where the consultant’s opinion was coming from, which explains my behaviour of late, which is seeking new employment: but I do mean this. We have to embark on a systematic approach to teaching dangerously linear tomes such as the DSM by seriously enforcing the non-linear medical model, and such workbooks train such thinking as well as it can be done.

The chapter on the most vexing of diagnoses, the personality disorders, is the most fun obviously, but lacks much of what one would hope to see in this biological age. However it also stresses, without saying, a conservative approach to labelling patients as sad, bad or mad. This temperate tone dominates much of the book, and is the sign of a wise writer, who tries to teach with a balance, and mostly succeeds.

There is nothing to replace this book that I have seen, and Fauman has spent a long, long time on it, and this shows. I cannot see how any programme that teaches the DSM can function without it, and every student of psychology and psychiatry has to buy this one, and work through it day by day, group by group.

Not only students. If Scott is to be believed, and I have no reason to doubt him, we all need to do this once a year, and get CME credits for it. We simply hear what we want to hear, and the validity of our expert pronouncements is tainted.

One of my colleagues recently was asked to confirm the detention, under the mental health acts, of an elderly patient, on the basis of schizophrenia. She had decompensated after being told that she had to have a cataract operation. By the time he saw her, she had become scared that her eyes would be cut up, and now she was being poisoned (depot typical). Her concrete and overwhelmed brain was now being insulted and she was to be locked up as insane. He found her simply overwhelmed, and would not detain her or confirm the diagnosis, to the horror of his colleagues.

I worked though her case as this book suggests, and the book agrees with my colleague, this is not schizophrenia. Why have his detractors, all eminent, not read a handbook lately?

It's always going to be news to us all, and deconstructs. As Laing said, if you don’t know you don’t know, then you think you do know. On the other hand, if you don’t know that you do know, than you may think you don’t.

It’s a nice, easy to use book, and required reading for neophyte and lofty proctologist, all. Otherwise, to paraphrase Othmer, Othmer and Othmer in their family collaboration in the last Psychiatric Clinics of North America edition of 1999, we will be diagnosing fat ankle syndrome for a long time to come, and forgetting our medicine, and our brain.

 

 

2003 Roy Sugarman

 

Roy Sugarman, PhD, is post of Clinical Director of the Clinical Therapies Programme in Liverpool (Sydney) and Clinical Associate Professor at the University of New South Wales.


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