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Essentials of Psychiatric DiagnosisReview - Essentials of Psychiatric Diagnosis
Responding to the Challenge of DSM-5
by Allen Frances
Guilford Press, 2013
Review by Anthony O'Brien, RN, MPhil
Jun 27th 2014 (Volume 18, Issue 26)

Essentials of Psychiatric Diagnosis is a brief and readable guide to the DSM-5 that combines a summary of diagnostic criteria, clinical advice, as well as, at times, some pointed critique of what the author, psychiatrist Allen Frances, sees as the major shortcomings of the psychiatric bible. The book contains an introductory chapter followed by 17 chapters on groups of disorders. These chapters use a standard template covering a screening question, description of a typical case, in some cases a black box warning outlining Frances's reservations about specific diagnoses. There is also a list of differential diagnoses, and a list of diagnostic tips. The book combines an overview of diagnoses with some informative, even opinionated commentary. Essentials of Psychiatric Diagnosis is an interesting addition to the DSM literature that most clinicians will find worthwhile reading, even if they don't agree with all Frances's arguments. They style is informal and Frances makes no attempt to present the views in the book as anything other than his own ideas. There is no "balanced argument" and no references. This unapologetic presentation of personal views is one of the strengths of the book.

In many respects the American Psychiatric Association's Diagnostic and Statistical Manual is an American affair. Offered as a universal guide to psychiatric diagnosis, the DSM has ballooned from around 100 diagnoses described in its first (1952) edition to well over 300 categories in the most recent edition, the DSM-5. Is there really over 300 mental illnesses? That's an improbable number, even allowing for the diversity of human experience and behavior. But under the DSM, nosology is not dependent solely on clinical observations, it is driven by a cat-and-mouse game played between US health insurers, pharmaceutical companies, and clinical practitioners. The DSM is as much a cultural artefact as a scientific codex. Insurance companies demand reliably described categories, pharmaceutical companies are only too happy to oblige, and the clinical and scientific communities often have little option but to play the game and apply categories that don't necessarily map on to the experience of patients or clinical practitioners. Researchers fare little better. It is all but impossible to conduct clinical research, let alone publish it, without adherence to the DSM's criteria. Psychiatric diagnosis is criticised from a variety of quarters, including psychologists, sociologists, legal scholars, nurses and others. One source of criticism is within psychiatry itself, in the case of Essentials of Psychiatric Diagnosis, from an experienced psychiatrist closely identified with the development of the previous edition of the DSM. Perhaps Frances now feels freed from the constraints of his role as Chair of the DSM-IV Task Force. He is certainly sharply critical about what he regards as mistakes of the architects of DSM-5.

One place where tensions are evident is in Frances's views of behavioral addictions such as gambling. Frances sees this as a potential Pandora's Box of behavioral categories from shopping to internet surfing. Frances is concerned about the potential medicalization of over-indulged pleasurable behaviors. Other criticisms are directed at the category of mild neurocognitive disorder which Frances considers is "not yet ready for prime time". In this case the problem is extending the boundaries of disorder with an accepted severity continuum rather than inventing a whole new category. Frances argues against the extension of Post Traumatic Stress Disorder to include relatives of the victims of trauma, against the removal of the bereavement exclusion from the criteria for major depression, and against what he sees as the faddish nature of diagnoses such as childhood bipolar disorder. His most vitriolic criticism is saved for dissociative disorders. Rather than outline the criteria for this disorder Frances gives the whole of this section to his black box dismissal of this category.

I recommend this book as a corrective to the DSM-5 itself, and to its uncritical supporters. Those philosophically opposed to the idea of psychiatric diagnosis will not be satisfied: they will see the potential for Frances's arguments to be applied to most, if not all of the DSM. Others might consider Essentials of Psychiatric Diagnosis to represent the thoughts of a former leading light, now dissatisfied with the status quo, like those "retired generals" regularly paraded by TV channels to critique current defence policy. However the book is well worth reading as an introduction and supplement to the DSM-5. It is not, and is not presented as, as stand-alone guide, but it has a helpful contribution to make.


© 2014 Anthony O'Brien


Anthony O'Brien, RN, MPhil is a lecturer in mental health nursing at The University of Auckland, New Zealand, and a clinical nurse specialist in liaison psychiatry at Auckland Hospital.


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