throughout to stimulate users to think, ''is this code the

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throughout to stimulate users to think, ‘‘is this code the best, most congruent diagnostic fit with the clinical features of the case I’ve encountered? If I’m not fully sure, what other information would I need to achieve greater clarity?’’ Despite facetious predictions among mental health professionals as well as the public at large that with DSM-5, ‘‘everyone will be in there, except for you and me, and I’m not so sure about you,’’ care appears to have been taken in several instances to delimit, rather than expand, overutilization of diagnoses. DSM has always been controversial and will never be

perfect, but this edition moves the work in a very respectable future direction.

Frances, A. Essentials of psychiatric diagnosis: Responding to the challenge of DSM-5. New York, NY: The Guilford Press, 2013. 201 pp. $35.00, ISBN 978-14625-1049-8.

diagnosis, and the new diagnosis of binge eating disorder creates millions of new potential patients needing mental health care. He provides some sound advice, as in:

Reviewed by: Bruce A. Thyer, Florida State University, Tallahassee, FL, USA DOI: 10.1177/1049731513505000

This is both a most interesting and a most curious book. The author, Allen Frances, is a psychiatrist, one of America’s foremost experts in the field of psychiatric nosology, and the former chair of the Task Force which produced the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). He has written what I take to be a CliffsNotes version of the DSM-5. It is intended to pare down the process of diagnosis via the use of a relatively small number of screening questions for each major disorder found in the DSM-5. Each disorder is succinctly described, as are the most likely differential diagnoses (alternative diagnoses which could be a better fit for the client’s signs and symptoms). The audience is supposed to be all mental health clinicians, as well as primary care providers at all levels of experience. He also says it will be useful to patients and families to help them become more informed consumers of mental health care, but I have my doubts about this particular claim, since I think that the effective use of the present book requires a familiarity with the full DSM-5. Dr. Frances has an obvious second agenda in writing this book—to acquaint the reader with some of the deficiencies (in his opinion) found in the DSM-5, to provide some appropriate cautions against making some diagnostic errors, and frankly, to advise the reader what diagnoses should NOT be used, even though they are contained within the pages of DSM-5. Some of the problems he outlines are the inclusion of disorders that are diagnostically ‘‘fuzzy,’’ in the sense that there is no clear distinction between normal behavioral variation and psychopathology. He highlights that experiencing 2 weeks of normal grief may now qualify one for the diagnosis of major depressive disorder, that the criteria for adult attention deficit hyperactivity disorder (ADHD) has been lowered to the extent that normal distractibility may now qualify for this

References American Psychiatric Association (APA). (2000). Diagnostic and statistical manual of mental disorders, (4th ed., Text Rev.). Washington, DC, American Psychiatric Association. American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders, (5th ed.), Arlington, VA: American Psychiatric Association.

Be mindful that not all symptoms and problems in living are caused by mental disorders, and that mislabeling can be extremely harmful to those mislabeled. In judgment call situations, it is always much safer and more accurate to underdiagnose than to overdiagnose. It is easy enough to add a diagnosis when time and experience prove it to be appropriate, but once a misdiagnosis is made, it takes on a life of its own and is very hard to unmake. (Frances, 2013, p. 6)

This latter warning acquires particular salience, as we move more into the era of electronic medical records and the risks of inappropriate diagnoses sticking with someone as the record builds up over time. Frances stresses the importance of a collaborative relationship between the clinician and patient, and of having the patient feel both understood and enlightened following a diagnostic consultation. He recommends refraining from prematurely deciding upon a given diagnosis, and maintaining a balance between getting bogged down in irrelevant details versus coming to premature diagnostic closure during the diagnostic interview. He suggests listening closely to the patient’s presenting problem and using some broad screening questions to narrow down the most relevant diagnosis. He views one’s diagnosis as a hypothesis to be tested and should not function as a blinder. Always consider the possible roles of substance use, medication side effects, or medical disorders as possible etiological or contributory causal roles. This is all very sensible. This book does not follow the organizational structure found in the DSM-5. Instead, he presents disorders roughly in the order of their frequency of being encountered in clinical practice, which does, in my opinion, make the book more interesting and useful. More controversially, where Frances disagrees with the conventions found within the DSM-5, he forthrightly tells the reader to follow his advice, not the DSM-5 standards. One may interpret this as the sound clinical judgment of an expert diagnostician seeking to help practitioners avoid making serious mistakes, or as chutzpah. I am inclined toward the former view. Some examples of his contrarian advice include:

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Do not make the diagnosis of ADHD in children unless clear signs have appeared by age 7 or earlier (the DSM-5 allows for the initial onset of ADHD by age 12). Be very cautious in using the diagnosis of bipolar disorder with children and teenagers even though the DSM-5 permits this. Be very cautious in applying the diagnosis of generalized anxiety disorder, as Frances views the new criteria as too loose and now inappropriately subsume the ‘‘worried well.’’ In forensic proceedings, only use the diagnosis of posttraumatic stress disorder when the patient has had direct experience with the traumatic stressor (even though the DSM-5 permits the diagnosis among people who learned about a violent, traumatic event that was experienced by a close relative or friend). Frances asserts that the diagnosis of unspecified trauma— or stressor-related disorder is not a reliable one and should not be used in forensic proceedings. Frances vigorously disagrees with the DSM-5 collapsing the previously separate categories of substance abuse and substance dependence into one omnibus condition now called substance use disorder, and goes so far as to recommend not using the DSM-5 system for these conditions, and to use the alternative International Classification of Diseases (ICD) system, which continues to distinguish the two diagnoses. ‘‘I am not convinced that Intermittent Explosive Disorder has merit as a mental disorder, and I doubt whether it should be included in the DSM-5. Certainly the diagnosis should never be made until every other explanation has been carefully considered and ruled out. It is also inherently unreliable and not suitable for use in forensic proceedings. Estimates of its prevalence in epidemiological studies are likely to be meaningless.’’ (Frances, 2013, p. 141) Conversely, he asserts: ‘‘Kleptomania has also not been included in DSM-5, but it too still has an ICD-9-CM code and is clinically useful.’’ (Frances, 2013, p. 142) ‘‘The category of Unspecified Impulse Control Disorder is being misused in forensic situations. Don’t be too free in using this category for every foolish thing that anyone does. There is a lot of impulsivity in this world, most of which is best not considered mental disorder. This is a residual and unreliable category not likely to have any meaning.’’ (Frances, 2013, p. 143, bold in original) ‘‘Binge-Eating Disorder . . . I worry that this diagnosis will be overused in everyday clinical practice, and I strongly advise against using it . . . The problem is that recurrent binge eating is a commonplace of human experience, not necessarily or usually a mental disorder . . . there has been very little research on how it should be defined and assessed.’’ (Frances, 2013, p. 148) ‘‘Unspecified Paraphilic Disorder, Nonconsent is a mostly fake and completely unreliable diagnosis created for forensic purposes’’ (Frances, 2013, p. 172)

 ‘‘Dissociative Identity Disorder (Multiple Personality Disorder) . . . I recommend avoiding this diagnosis altogether.’’ (Frances, 2013, p. 183, bold in original)  ‘‘Dissociative Amnesia . . . I have never seen an actual case of fugue and don’t think you will either . . . I wonder whether true fugues ever really happen’’. (Frances, 2013, p. 185, bold in original) I take the space to provide this lengthy list to illustrate one serious and fundamental problem with the DSM-5. A genuine leader in the field of psychiatric diagnosis is unsparing in this criticism of this newest iteration of the categorization of abnormal behaviors. He recommends ignoring or going against some of the new criteria in arriving at a diagnosis. He says clinicians should continue to use some diagnoses no longer included in the DSM-5 and to not use others now included, due to their lack of credible reliability and validity studies. Informed criticism can be a good thing, and I personally find most of Dr. Frances’ eristic recommendations to have merit. Frances alludes to another problem in the DSM-5, the very real possibility that these so-called categories have little to no correspondence with medical diseases commonly understood as biologically based illnesses. For example, he states that ‘‘The DSM mental disorders are no more than descriptive syndromes; they are not necessarily discrete diseases’’ (p. 9). Moreover, ‘‘There are no biological tests in psychiatry, and (with the exception of tests for dementia) none are in the pipeline for at least the next decade. Psychiatric diagnosis depends completely on subjective judgments that are necessarily fallible, should always be tentative, and must constantly be tested as you know the patient better and see how the course evolves . . . You shouldn’t necessarily believe past diagnoses—people change, and diagnostic errors are frequent—but you should take them into account. And whenever treatment isn’t working, always reconsider the diagnosis’’ (pp. 11–12). The existence of most of the conditions labeled by the DSM-5 are inferences made on the basis of the very behaviors these so-called mental illnesses are said to cause. The lack of independent evidence for the existence of these supposed diseases, akin to a diagnostic test or genetic marker, indicates that these diagnoses are reified constructs possessing no explanatory power at all, in terms of giving rise to dysfunctional behavior. The reasoning is circular. For example, a severe fear and avoidance of dogs may yield the DSM5 diagnosis of specific phobia. How do you know the client ‘‘has’’ a phobia? He runs away from dogs. Why does he run away from dogs? He has a phobia. Arriving as a diagnostic label provides a superficial causal explanation (‘‘Why does he act crazy? He has schizophrenia.’’), but if the only evidence for the disorder is the behavior the disorder is said to cause, then there is no genuine explanation, only the appearance of one. This conundrum of reifying disorders and then using these disorders as explanations is ubiquitous throughout the psychiatric diagnostic enterprise.

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There are some exceptions to this problem, residing in those conditions found within the DSM-5 which do possess a clear biological etiology. ‘‘Dementia due to Alzheimer’s Disease’’ is one example. ‘‘Intellectual Developmental Disorder’’ related to genetically caused conditions such as Downs’ syndrome is another. When you actually examine the individual conditions found within the DSM-5 which are biologically based, a surprisingly large number can be found. All of the ‘‘SubstanceInduced Disorders,’’ ‘‘Disorders due to another Medical Condition,’’ ‘‘Substance-Related Disorders,’’ and ‘‘Neurocognitive Disorders’’ (and there are dozens of these) are etiologically based in factors outside of the behaviors used to arrive at the diagnosis. This is a good thing, in terms of the scientific credibility of the existence of these conditions as genuine entities which really exist. However, the psychiatrist is then faced with the dilemma that these conditions do not properly belong in any compendium of mental disorders. Does it make clinical or scientific sense to assert, as does the DSM-5, that ‘‘Alcohol Intoxication’’ is a mental disorder? That ‘‘Dementia due to Traumatic Brain Injury,’’ ‘‘Dementia due to HIV Infection,’’ or ‘‘Genital-Pelvic Pain/Penetration Disorder due to another Medical Condition’’ also represent ‘‘mental’’ illnesses? Of course not. These are biologically based conditions with behavioral, intellectual, and affective sequelae. It is scientific nonsense to assert that these conditions reside in the client’s mind, any more than the febrile hallucinations of the patient suffering from malaria reflects an underlying mental disorder. Over a century ago, psychiatrists commonly treated patients suffering from epilepsy or from dementia occurring in the later stages of syphilis. As the organic causes of these conditions became established, their treatment migrated to other medical specialists, such as neurologists. Faced with an analogous shifting of treatment for these biologically based disorders (and these are ‘‘real’’ medical conditions, not fictive reifications), psychiatry would experience a dramatically a shrinking patient population. At the other end of this set of implacable diagnostic conundrums, we find DSM-5 conditions which can be clearly attributable to the client’s psychosocial environment and/ or culture. Frances touches on this problem briefly in regard to the diagnosis of conduct disorder: The concept of mental disorder implies that the repetitive misbehaviors arise from problems within the individual and are not just the result of being brought up in a chaotic and hostile environment where misbehavior is a cultural norm . . . Be on the cautious side before applying the psychiatric term Conduct Disorder to kids growing up in impossible environments. The diagnosis may focus too much attention on the child’s contribution, and too little on the need to do everything possible to provide a more wholesome setting. (Frances, 2013, pp. 22–23, italics added)

Social worker Edith Abbott discussed this identical problem over 80 years ago: . . . it is . . . very wasteful to commit a child to a truant school because he is the victim of serious behavior disorders or because

home conditions are such that there seems to no hope of an improvement in his conduct and no possibility of regular school attendance, and then in a few months return him to the surroundings in which he had been demoralized and, probably, with the same conduct problems. Sure, this is the old story of the vicious circle. (Abbott, 1931, pp. 109–110)

The DSM-IV-TR recognized this old story and included the following cautionary language: Concerns have been raised that the Conduct Disorder diagnosis may at times be misapplied to individuals in settings where patterns of undesirable behavior are sometimes viewed as protective (e.g., threatening, impoverished, high-crime) . . . . the Conduct Disorder diagnosis should be applied only when the behavior in question is symptomatic of an underlying dysfunction within the individual and not simply a reaction to the immediate social context. Moreover, immigrant youth from war-ravaged countries who have a history of aggressive behaviors that may have been necessary for their survival in that context would not necessarily warrant a diagnosis of conduct disorder. It may be helpful for the clinician to consider the social and economic contexts in which the undesirable behaviors have occurred. (American Psychiatric Association, 2000, pp. 96–97, emphasis added)

This is a remarkable concession—Behaviors which are adaptive to one’s environment and psychosocial contexts, what the behaviorist would call learned behaviors, should not be viewed as mental illnesses! Compare this with the more flexible standard found in the DSM-5: Conduct Disorder may at times be potentially misapplied to individuals in settings where patterns of disruptive behavior are viewed as near-normative (e.g., in very threatening, high-crime areas or war zones). Therefore, the context in which the undesirable behaviors have occurred should be considered. (American Psychiatric Association, 2013, p. 474)

Although the DSM-5 cautionary language seems weaker than that found in the DSM-IV-TR, it remains evident that an environmental context obviously causally responsible for a youth’s misbehavior continues to preclude applying a diagnosis of conduct disorder. This is good practice since clearly a mental illness is not present. Experimental studies using clinical vignettes found that diagnosis does indeed vary as more or less environment information was provided to clinicians and that this ‘‘ . . . shatters the illusion that diagnostic judgment can simply be a matter of matching presenting symptoms with DSM criteria, without the need to account for the social context.’’ (Kirk & Hsieh, 2004, p. 51; see also Hsieh & Kirk, 2003) Similarly, take the instance of an adult currently meeting the DSM-5 criteria for a specific phobia of dogs, due to having been badly bitten by a dog as a child. The etiology of this problem is clearly environmental, not mental. The child traumatized by a dog bite does not have a mental illness

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whose etiology resides in the individual, any more that the woman who, within a 6-month period, suffers a serious illness, loses her job, experiences the death of a beloved spouse, and comes to experience depression as a result of these trauma. Are her reactions real? Of course, but they are not reflective of some underlying disease process called a mental illness, they are the sequelae of a series of serious aversive experiences and a lack of reinforcing ones. Philosophically and scientifically, the diagnosis of a mental illness should be excluded whenever plausible environmental or cultural factors can account for behavioral, affective, or intellectual problems, just as when biological factors (e.g., drugs, disease, genetics, toxins) should similarly preclude asserting that someone is mentally ill. This places psychiatry in a Procrustean bed of service provision. They are not the medical specialists best trained to treat clients with behavioral problems secondary to medical diseases, toxic substances, or genetic disorders. Nor are they usually well trained in psychosocial interventions. Psychotherapy is vanishing from the practice of most psychiatrists, in favor of pharmacotherapy, and relatively few can deliver the research supported behaviorally based therapies useful in ameliorating learned behaviors or in improving client’s environments. Some psychiatrists have warned their discipline about this problem. ‘‘If psychiatry stays on its current course, it will be left treating only those disorders caused by demonstrable brain defects, while the pains and sufferings of everyday life will be left to other clinicians’’ (Nesse & Williams, 1993, p. 21). Thus, psychiatry as a discipline is forced to assert, beyond the limits of credible data, that mental illnesses are brain diseases and best treated pharmacologically or via other ‘‘medical’’ therapies which they provide, such as other somatic treatments or hospitalization. A profession built upon a framework of etiological lies and exaggerations cannot long endure. In the long run, truth will win out. Thus, we witnessed the passing of lobotomies, bromide therapies, hydrotherapy, excessive seclusion and restraint, and the widespread use of electroconvulsive therapy. Newer more comprehensive studies disclose the serious and lasting side effects of many pharmacological treatments, the lack of superiority of newer psychiatric drugs versus older, less expensive ones, and in some cases the failure of commonly prescribed psychotropics to exert beneficial effects above those obtained via placebo therapy (Whitaker, 2011). The publication of the DSM-5 has refocused attention on the shoddy science undergirding the psychiatric nosological system. Many diagnostic criteria were created based on consensus or expert opinion, not solid empirical research. Even something as fundamental as determining acceptable interrater and test–retest reliability when using the DSM-5 standards under clinically representative conditions is sadly lacking for many of the disorders. When senior expert diagnosticians such as Allen Frances openly critique the new psychiatric nomenclature, and the National Institutes of Mental Health announces a move away from using the DSM system to fund research into mental illnesses and their treatments (Insel,

2013), it suggests that some unraveling of the present status quo is occurring. Despite the above critique, I must stress that the DSM-5 will soon become the common language used in clinical practice by all of the mental health professions, including social work. I can see using this book as a useful secondary text in teaching master of social work (MSW) students about using the DSM—the analogy to CliffsNotes mentioned earlier in this review is apt. It would not make a good primary text—I certainly recommend using the DSM-5 itself for that purpose, but supplementing this with Frances’ Essentials of Psychiatric Diagnosis will greatly help in developing a clinical social worker’s diagnostic skills. MSW students in clinical specializations must learn to use this new system as accurately and efficiently as possible, even given its deficiencies, since that our discipline is the largest provider of mental health care in the United States. A thorough grounding in the new DSM-5 is an essential part of responsible professional education, necessary so that clinical social workers can stand on an equal footing with other mental health professions in diagnosing and treating clients who seek our services. Many of our state licensing laws include clinical social workers as qualified mental health diagnosticians, and despite our misgivings over the DSM-5’s limitations, we must learn to use it as effectively as possible. Yes, the DSM-5 is a flawed system, as was the periodic table of the elements 100 years ago. This foundation of modern science has undergone many changes over the years, and each generation of new chemists learns the latest version and adopts the newer ones as it evolves. Generations of astronomers were taught that there were nine planets, with Pluto being the outermost one. Recently, by a consensus vote of qualified astronomers, Pluto was voted ‘‘off the island’’ and today it is no longer considered a real planet. Similarly, homosexuality was voted to NOT be a mental disorder by psychiatrists in 1973. Pluto is unmoved by its new status, and astronomy is not crushed by this change. The sensible removal of homosexuality as a mental illness from the DSM did not change the origins of human sexual orientations. ‘‘Psychopathological phenomena certainly exist and can be observed and experienced as such. However, psychiatric diagnoses are arbitrarily defined and do not exist in the same sense as psychopathological phenomena do’’ (Katschnig, 2010, p. 22). Behavior does not equal disease. The erroneous syllogistic reasoning of psychiatry is obvious: Major Premise: Some diseases cause dysfunctional behavior. Minor Premise: A given client displays dysfunctional behavior. Conclusion: This client suffers from a disease which causes dysfunctional behavior.

Efforts to accurately classify dysfunctional behavior and affect, as reflected in the DSM-5, continue to evolve and remain sadly imperfect. However, the field of human behavior (like Pluto), the good, the bad, and the ugly, remains as it existed prior to the DSM-5. We need to learn the DSM-5 and learn to

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use it well. Allen Frances’ Essentials of Psychiatric Diagnosis can be a very useful tool to help us achieve this goal of professional social work education. References Abbott, E. (1931). Social welfare and professional education. Chicago, IL: The University of Chicago Press. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders-IV-TR. Washington, DC: Author. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders-5. Washington, DC: Author. Frances, A. (2013). Essentials of psychiatric diagnosis: Responding to the challenge of DSM-5 New York, NY: The Guilford Press. Hsieh, D. K., & Kirk, S. A. (2003). The effect of social context on psychiatrists’ judgments of adolescent antisocial behavior. Journal of Child Psychology and Psychiatry, 44, 877–887.

Insel, T. (2013, April 29). Director’s blog: Transforming diagnosis. National Institute of Mental Health. Retrieved from http://www.nimh. nih.gov/about/director/2013/transforming-diagnosis.shtml Katschnig, H. (2010). Are psychiatrists an endangered species? Observations on internal and external challenges to the profession. World Psychiatry, 9, 21–28. Kirk, S. A., & Hsieh, D. K. (2004). Diagnostic consistency in assessing conduct disorder: An experiment on the effect of social context. American Journal of Orthopsychiatry, 74, 43–55. Nesse, R., & Williams, G. (1993). Are mental disorders diseases? In S. Baron-Cohen (Ed.), The maladapted mind: Classic readings in evolutionary psychopathology (pp. 1–22). East Sussex, England: Psychology Press. Whitaker, R. (2011). Anatomy of an epidemic: Magic bullets, psychiatric drugs, and the astonishing rise of mental illness in America. New York, NY: Broadway Paperbacks.

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