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.

Categories: Philosophical, MentalHealth