DSM-IV-TR Case Studies

Abstract

DSM-IV-TR Case Studies is an ambitious attempt to provide a clinically relevant guide to differential diagnosis of psychiatric illness. The book is organized into 16 chapters coinciding with major diagnostic categories of DSM-IV-TR and a very useful, final “Test Yourself” chapter. The authors of the text faced a tough challenge: collecting and creating clinical vignettes that would reflect the diagnostic criteria in a comprehensive and accurate way, yet represent what clinicians may encounter in the “real world.” Illustrations needed to be complex enough to showcase the diversity of presentation of psychopathology, yet not mislead or obfuscate. Patient histories, at their best, are infused with lifelike details—evocative, poignant, and reflective of rich clinical experience. The discussion of differential diagnosis is thorough, thoughtful, and, at times, sensitive to cultural, gender, medical, and psychodynamic influences. Helpful diagnostic algorithms are often suggested. The use of the therapeutic relationship as a diagnostic tool is hinted at on several occasions. DSM-IV-TR Case Studies, as well as the diagnostic manual it is based on, may be viewed as a culmination of an effort to codify the great diversity of human emotional, cognitive, and behavioral problems and classify them into clear-cut phenomenological categories. In spite of its “pre-Darwinian” character (conditions are grouped by their common appearance, not necessarily similar genetics or biological underpinning), it would be unfair to criticize this text for being too true to its template. Nevertheless, one can view these case histories as often being “Brady-centric”: as reflective of everyday clinical experience as the family in the Brady Bunch television show is of a typical family. All of the patients are examined in a psychiatric setting. Complex comorbidities, including medical illness, drug interactions, or side effects, are rarely present. Cultural, ethnic, and religious diversity in manifesting symptoms of psychiatric illness is seldom reflected in the selection of case histories. A patient with the same psychiatric condition is likely to have different presentations in the office of a psychiatrist versus that of a family physician, pediatrician, gynecologist, internist, or neurologist. Although the diagnostic manual is designed to be useful in all of these settings, differences in manifestation of psychopathology are not accounted for. Some of the diagnostic modifiers of depressive disorders and posttraumatic stress disorder, specifying the chronicity, may be more reflective of the treatment outcome rather than the nature of the condition. I do not believe it is fair to assign the responsibility for these relative shortcomings to the authors of the text, because, for the most part, they are the limitations of the DSM writ large. In spite of some reservations, I would recommend this text to psychiatrists-in-training, primary care physicians, and other specialists who may see patients with psychiatric ailments. Medical students and other nonmedical mental health professionals may also benefit from this reference. Recommendations for diagnostic workup and treatment planning are straightforward and practical. Readers with more scholarly aspirations can find some interesting discussions, such as diagnosing schizophrenic versus schizoaffective versus bipolar disorder and making distinctions between obsessive-compulsive disorder and obsessive-compulsive personality disorder. The chapter on medication-induced movement disorders is very timely and necessary. Clinical pearls are scattered throughout this text. I believe that DSM-IV-TR Case Studies will intrigue and educate novices to the field and provide experienced clinicians with a helpful refresher text and, possibly, a bit of nostalgia.