Essentials of Psychiatric Diagnosis, Revised Edition: Responding to the Challenge of DSM-5
Is having Allen Frances respond to the challenge of DSM-5 like asking Richard Dawkins to review the Bible (or, perhaps, like pulling inside the walls of Troy that huge, irresistible, wooden horse from Greece)? Well, read on.
As might be expected, the book is not organized in parallel with the DSM-5 format. Frances, instead, sequences his diagnostic entities in the order of the frequency with which he believes they will be encountered by the average clinician. Somewhat irreverently, Frances simply omits those disorders he does not feel are useful. ICD-9-CM and –10-CM codes are provided for reference. Instead of a large list of diagnostic criteria for each disorder, he provides a descriptive prototype for each, as well as a differential diagnosis and diagnostic tips. An index of disorders by symptoms is also provided with brief but helpful screening questions to hone in on each diagnostic group. Frances believes that DSM-5 suffers from "unrealistically lofty ambitions and sloppy methodology," resulting in "a manual that is not safe and not scientifically sound" (p 5). Well! Scattered liberally throughout are "caution boxes" warning readers against using diagnostic labels that Frances feels are unwarranted and listing those diagnoses that are most likely to be misdiagnosed "if the lowered DSM-5 diagnostic thresholds are employed."
Most of the caution boxes serve as containers for Frances’ criticisms of DSM-5. Most of these editorial comments I endorse, but with certain reservations. They include diagnosing adult-onset attention-deficit/hyperactivity disorder and liberally prescribing stimulants for it; pathologizing grief; overdiagnosing childhood and adolescent bipolar disorders; extending the diagnosis of posttraumatic stress disorder (PTSD) to those who are friends and relatives of the actual victims but who did not necessarily witness the event (a sort of "secondhand PTSD"); combining substance abuse and substance dependence under 1 heading, substance use disorder; the use of the term mild neurocognitive disorder for those whose disorder is too mild to warrant a diagnosis of dementia yet but might later (I confess to having my own age-related concerns about how far away "yet" is); and overdiagnosing DSM-5 somatic symptom disorder (terming it "ridiculously over-inclusive" [p 175]). Frances’ positions on these topics are a few of the many I would also endorse. What I am less sanguine about relates to his apparently blithely suggesting that there are diagnoses that one may elect to just not use even were the patient to meet DSM-5 diagnostic criteria for them. Like it or not, DSM-5 is our current nosologic standard until DSM-5-R or DSM-6 comes along, hopefully with improved science. In a court of law, failure to diagnose in accord with DSM-5 is likely to be viewed as "below an acceptable standard" for a psychiatrist despite Frances’ standard of care. Frances advises, conversely, that we should continue to diagnose shared psychotic disorder when appropriate even though DSM-5 has deleted it. He also elects to keep pathological gambling in its former grouping under impulse control disorders rather than listing it under behavioral addictions.
In summary, my initial fears were unwarranted. This is a very worthwhile book that highlights concerns about DSM-5 that many will share.
Author affiliation: University of Pennsylvania School of Medicine, Philadelphia.
Potential conflicts of interest: None reported.
J Clin Psychiatry 2014;75(6):e595 (doi:10.4088/JCP.14bk09107).
© Copyright 2014 Physicians Postgraduate Press, Inc.
