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Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR Fourth Edition (Text Revision)

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The diagnostic sections remain largely unchanged. Only significant changes were to the text portion, hence the TR designation-- text revised. This is important if you are a student or in a research position. They produced this version in response to the fact that many graduate programs are using the DSM as a text book in their Pathology courses. In this regard, the new version is worthwhile and clearly justified. It also buys them a little more time in development of the DSM V. For clinical purposes, don't bother, it's not worth the money. If you are getting your first copy, or are looking for class, then you want this edition.

The text-revised version is virtually identical to the 1994 version of the DSM-IV and not worth buying if you have the 1994 version. Along with the DSM-IV, the DSM-IV Text Revised version is, however, an informative book that provides good introductory information, especially in the "Diagnostic Features" section, about a wide variety of mental disorders. A problem of the manual, in my opinion, is its use of a categorical classification system while ignoring the dimensional nature of psychological phenomena.

Lee J. Markowitz, Department of Psychology, University of Waterloo (Ontario, Canada)

Of course, this is the bible of mental disorder diagnoses, at least in the U.S. The diagnoses are pretty inclusive, but there are several problems with this book as it pertains to the practice of Psychiatry. First, the book offers about 900 pages on symptom diagnosis, and about half a paragraph on the types of psychiatric medications that are effective for the particular diagnosis. 95% of diagnoses have absolutely no recommendations for treatment.

This leads to the second problem: differentiation of primary vs. secondary symptoms. The primary symptoms are the cornerstone of diagnosis. The secondary symptoms take way too much space in this book, and are generally not helpful in making a diagnosis, because the vast majority of secondary symptoms overlap in most mental illnesses. The important use for secondary symptoms is for the type of therapy that should be used (psychotherapy or pharmacotherapy). For example, if two patients are depressed, the diagnosis is made from primary symptoms (tiredness, irritability, difficulty concentrating, psychomotor retardation). However, if patient "A" has no significant secondary symptoms like anxiety or insomnia, they can take a high dose of SSRI or Effexor. But if patient "B" has the secondary symptoms of prominent anxiety and insomnia, Remeron or Serzone may be more helpful, and perhaps a benzodiazepine can be added.

The DSM IV does nothing to further the practicality of psychiatry. And that's a shame, because only a few hundred extra pages of pharmacotherapy recommendations would make the book so much more helpful to psychiatrists, who currently waste a lot of time experienting with every drug for the treatment-resistant patients. Some drugs work better for some people based on secondary symptoms, which cannot be ignored in the choice of drug treatment. A good book that does match secondary symptoms to drug treatment is The Failures of American Medicine.

The DSM is very clearly written and can be understood by anyone no matter what his or her educational level. It also contains an exceptional psychiatric glossary and an exceptional psychoanalytically oriented section describing the "defense mechanisms." The public is ambivalent about psychiatry but has embraced the DSM because it provides readers with the illusion that if you read this book you can diagnosis yourself and your acquaintances. What most mental health professional know is that this book is a political document as well as a scientific one. It advances the cause of the psychobioligists (over the environmentalists) and the alliance of drug companies, insurance companies and psychopharmacologists. What the sub-committees who wrote each section of the DSM have done is to organize the vast array of life problems that we have long thought of as "neurotic" (and stemming from early family experience) and placed them side by side with clearly biological diseases like schizophrenia and manic-depression. Why? The aim is to create the impression that all of the ordinary habitual problems in love and work that pretty much everyone agrees come from the way you were brought up in your family are in fact biological - and probably inherited - illnesses. Chronic unhappiness, for example, is coded with the "mood disorders" like classic manic depressive illness. Another facet of the DSM that is pernicisous is that each problem the patient has must be coded separately. There is no way to describe the patient in holistic terms. The patient as described by the DSM (and treated by the psychiatrist guided by this document) ends up looking something like a cubist painting by Picasso. What is discouraged is trying to understand the person's various problems as interrelated parts of a comprehensible whole that has developed over a lifetime from a continual ongoing interaction between the person's life experience and their biology. Among the most pernicious effects of the DSM has been its influence on psychiatric education. Psychiatric trainees are encouraged to use the DSM as their first approach to the patient. It is very sad to see these fledglings struggle to make diagnosis rather than to understand their patient. Do they ask whether the patient has a brother or a sister or was born rich or poor. No! Conference after conference is devoted to figuring out which DSM category the patient fits into. No one dares tells the trainee the little secret of the DSM, which is that about half of patients don't fit into any category at all. Some of us, of course, do have OCD or ADD or are narcissistic or suffer from moderate autism (Asperger's Syndrome) but most of us are not so neatly described. Most people have to be squeezed into categories that we don't fit into. The overall chairman of the committee that wrote the DSM IV (Dr. Allen Frances) has, to his credit, acknowledged (in a New Yorker magazine interview) that the DSM IV categories are neither valid nor reliable and don't describe (in his words) "reality." All of this said, the DSM is a crystalline clearly written document that well summarizes contemporary descriptive psychiatry.

I quote Karl Menninger, on the publication of the DSM-II in 1968:
"This year [1968] the APA took a great step backward when it abandoned the principles used in the simple useful nosology [DSM-I]. In the interest of uniformity, in the interest of having some kind of international code of designation for different kinds of human troubles, in the interest of statistics and computers, the American medical scientists were asked to repudiate some of the advances they had made in conceptualization and in the designation of mental illness."
Since then, it's gotten worse, not better, with thousands of symptom checklists and numbered diagnoses, conveniently correlated to the ICD-9 standard diagnosis codes for easier billing.
But people, medical students and physicians included, will insist on treating DSM-IV as a textbook in psychiatry. It's nothing of the sort - it never touches on the essential topics of etiology, prognosis, and treatment. People memorize the checklists and think they understand psychiatry, when in fact they have entirely failed to grasp the noble and great endeavor: riddling out the first causes and mechanisms of our humanity, and how those mechanisms go awry.
Well, then, you say, what about diagnosis? Isn't this a diagnostic manual?
In my opinion, for that purpose DSM-IV is worse than useless to a lay person. Consider the previous reviewer who thought the book made a good party game, diagnosing his healthy friends with all sorts of 'disorders'. It wouldn't take much experience in a psychiatric emergency room to realize that psychiatric illness is no party game - but it would take some. Without the context provided by direct, caring relationships with the mentally ill, the jargon and symptoms discussed in this book are meaningless. This book will not teach you to be a psychiatric diagnostician! Only experience can do that. It's intended as a quick reference guide for people with that experience, and a reference concerned with very practical matters not relevant to the patient-physician relationship (such as the standardized conduct and reporting of clinical trials, or how to justify billled services).
I'd disagree strongly with the prior reviewer who felt psychiatric patients should read their DSM-IV. If you're a psychiatric patient "on the same page" as your health care practictioner, get off the page and get on top of your life! You have more pressing concerns than making yourself into an expert psychiatric diagnostician and quibbling over the learned APA's compilation of symptom checklists - you need to heal.
In short, I can't imagine recommending this tome to anyone for any purpose - people who need it don't need me to tell them so.
If you're interested, however, in psychiatry, I urge you to read the classics - Freud for the grounding of psychodynamics, Skinner on behaviorism, Menninger's superb "Man Against Himself" on suicide and depression, Erich Fromm's "Escape From Freedom" and "Man For Himself" for academic psychophilosophy, Kraepelin on dementia praecox (what we now call 'schizophrenia' - I prefer his original term), Wundt on introspective self-analysis, Kraft-Ebbing's "Psychopathia Sexualis" for a laugh and for a serious understanding of the social construction of sexual "disorder" - if you're really interested in these topics, you'll find these authors far more stimulating, I guarantee!

Hey, it is what it is. I've heard people discuss DSM-IV-TR as if it were the bible of psychiatry, the ultimate textbook of psychiatric pathology. On the other side are the people who would throw it out completely in fear that any label applied to anyone dehumanizes them, reduces them to a category, dooms them to a lifetime of struggling with their new pathological identity.

DSM is for research purposes. It is a collection of constellations of symptoms, compiled by clinicians, organized into categories by vote of committee, and it does make convenient shorthand for describing patients. If you want to do a study looking at how people respond to a certain medication versus placebo, you need some kind of criteria for deciding which people are appropriate to include in the study, some kind of rigorous way to establish the parameters so that each subject isn't a soft call, and that is what DSM is appropriate for. It's big on reliability, low on validity. Its inter-rater reliability is also what makes it a convenient shorthand for describing patients to other clinicians (or, more often and more urgently, to insurance utilization reviewers). I'm not going to review hours of process notes in a presentation, but if I say someone suffers from recurrent severe major depression with psychosis, you quickly know some relevant things about what the problems are. Even with the big garbage bin categories of schizoaffective disorder or cognitive brain disorder not otherwise specified, you can at least characterize someone within the right ballpark. But that's as far as it is useful for and that's as far as it should be used. Diagnosis is a tricky part of individual patient care and often the hunt for diagnostic precision is a distracter. It plays into to reification myths, the idea that attaching a name to something makes it a distinct, concrete entity. All of these symptoms exist on spectrums, most psychiatric symptoms in their mild to moderate forms can be a normal part of life, and the search for concrete categories can lead us down the wrong road when it drives the treatment rather than being one piece in the formulation of an individual patient. By the way, if there is any doubt that DSM categories are nothing more than descriptions of observations, let the diagnosis "intermittent explosive disorder" illustrate the case, the mostly inanely concrete and pointless reification of anger and/or impulsiveness as a distinct syndrome. It's not just impractical, it's downright embarrassing. An article appeared in the local paper about a proposed link between road rage and intermittent explosive disorder, and two separate patients brought it into session, mockingly questioning me on the authenticity of this diagnosis.

It is what it is. Worth studying and being very familiar with since it serves as an oft referenced interface between research, Big Pharm, the clinical world, and the business world. Worth studying as, just as the acronym suggests, a statistical manual of carved out syndromes negotiated by mostly dull men sitting through dull meetings. I've never been involved, but I picture constipated men, with coffee and stale non-dairy creamer breath intermingled with a musty smell from their clothes. And these men are passionately arguing and negotiating, with their prides on the line. But that's not really the point, sorry. The point is, if DSM categories are anything other than a minor factor in guiding how you care for your patients, that is your sloppiness. Let's not blame an inert stack of papers for not living up to the sacredness that's been fallaciously imposed on it.

The study of mental disorders is an ever evolving process. It is good to see a revision of the old DSM IV which has been in use for the past five years. The book is printed in a easy to read print size and the layout has been updated. There will be other revisions so this is the first of many, until DSM V.

We live in increasingly complex societies where knowledge is endlessly expanding. Unless it is ordered, of course, information itself does us no good. The medical profession was among the first to recognize the need for ordered, cataloged information.

I became involved with DSM by accident: one of my projects required me to include a few pages copied from the DSM, well within the limits of Fair Use. Normally I would have hopped over to the library, copied the pages and been on my way. One of the local libraries, however, had a circulating copy so I spent more time with the volume than I would have otherwise.

Consider that there is no small amount of controversy surrounding the DSM (which, by the wsy, stands for "Diagnostic and Statistical Manual of Mental Disorders"). Many point wagging fingers at it for becoming involved with political issues, such as its well publicized dropping some years back of homosexuality as a "mental disorder". Others claim it is a make-word project for psychiatrists, psychologists, counselors, social workers and others who are presented with an ever expanding array of mental disorders which are, in turn, covered by insurance and become cash flow producers for practitioners.

For the practitioner, however, it is easy to see that it provides a framework within which to compare their observations of a specific client against the collective knowledge of the American Psychiatric Association and its DSM publication committee.

Leafing through it is a solid reminder of how fortunate many of us are: we don't have any of the major disorders described here. On the other hand, it is interesting to see how inventive the mental health professionals have been in turning so many seemingly commonplace conditions into "mental disorders" for which they can be paid to treat. (Like many, I have a somewhat jaundiced view of psychotherapy. I have know two women who spent more than 25 years each in therapy - before deciding to become therapists.)

The introductory description of how the DSM came to be, how it is compiled and how it should be applied is fascinating in itself. The 1840 U.S. Census recorded only one variety of mental illness: "idiocy/insanity". By 1870, seven categories were listed. There are now, counting sub-divisions, hundreds of categories.

It is indeed fascinating to read the descriptions of the disorders and the diagnostic criteria. It is possible - with a little stretching - to see that the future of such medicine may rest in automated diagnostics. The computer program Eliza and other experiments gave a foretaste of that.

All in all, from a layman's perspective, a fascinating look at the human penchant for collecting, organizing, preserving and disseminating knowledge in action.

Jerry

Buyer Beware-- This book is found to contain many diagnostic coding errors. I recently took an abnormal psychology class at the master's level and found that the book that I purchased through Amazon was incorrectly published with coding errors for some of the disorders. When I contacted Amazon customer service they said that it had been past my 30 day return and they could not help me, I am in the process of contacting the publisher as I write this review; because I paid over $70 for a book that is incorrect and will not help me professionally when I need it later in my courses. So be very careful to screen the books as soon as you get them, I did not know until I had already gone through the course that the book was incorrect and now am out the money I spent and will have to spend another $70 for a new edition in order to complete my class work.

Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR Fourth Edition (Text Revision)

I should've known that the price was misleading...this text was the "Indian" version...what is that all about? I haven't compared it yet, but it claims to be the same.