Few people are better qualified to write a guide to psychiatric diagnosis than Dr Allen Frances. Now emeritus professor of psychiatry in Duke University, Dr Frances was the chair of the task force that wrote the DSM-IV, published in 1994. He has been called ‘the guy who wrote the book on mental illness’, a description that is as close to literally true about him as it is about anyone living.
Latterly, Dr Frances has acquired a level of post-retirement celebrity as a result of a highly public critique of the DSM-5, conducted through interviews and prolific writings, including an op-ed in the New York Times (‘Diagnosing the DSM’) and a book (Saving Normal). Dr Frances argues that changes in the new edition (additional diagnoses, which he sees as untested and ‘fuzzy’; a broadening of diagnostic criteria, such as the loss of the grief exclusion in major depression) are bound to lead to a narrowing of what psychiatry considers normal behaviour – another way of saying an over-pathologizing of the general population. He writes in his introductory chapter ‘How to use this book’ that the DSM-5 has ‘opened the floodgates to worsened diagnostic inflation and to excessive medication use’.
Knowing this background, and seeing that Essentials of Psychiatric Diagnosis is subtitled ‘Responding to the Challenge of DSM-5®’, one might expect to find oneself reading as much of a polemic as a clinical text, but in fact Essentials of Psychiatric Diagnosis largely leaves the well-rehearsed arguments about the DSM-5 to one side. The book is actually an eminently readable, chatty, and thoroughly practical assistant to diagnosis, based on 40 years of experience as a psychiatric interviewer.
The author certainly strives for clarity throughout (one suspects that ‘fuzzy’ is the worst form of insult he can muster). He writes about almost every diagnosis in the DSM-5, although noting ‘I have omitted a few that do not seem useful’.
Dr Frances introduces each diagnosis with a screening question such as ‘Do you ever get so depressed that you can't function?’ for major depression, or ‘Are you comfortable with your physical appearance?’ for body dysmorphic disorder. These are largely intuitive and helpful, albeit I wouldn't be comfortable with some of the screening questions: for bipolar disorder, he suggests asking ‘do you sometimes have mood swings – sometimes way up, other times way down’?
My own experience is that the overused term ‘mood swings’ can mean anything and doesn't come close to capturing the experience of manic depression. The DSM-IV's own suggestion as a screen for mania – ‘Have you ever had a period of time when you were feeling so good or hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?’ – is the question I'll continue to use.
Dr Frances then provides a prototypical description of each diagnosis ‘rather than complex and cumbersome criteria sets that are often ignored’. This is a great idea, with a caveat, and indeed chimes with some recent research in JAMA Psychiatry on prototype diagnosis in mood and anxiety disorders. The descriptions provided are clear, crisp, and coherent, if, by necessity, neater than real life.
In particular, the personality disorders section is a good read for anyone left struggling (as I admit I often am) to count up almost indistinguishable DSM diagnostic criteria. He paints mini-portraits of Axis II syndromes, such as dependent personality disorder (‘These are people who feel stupid and weak’), histrionic personality disorder – (She is a Blanche DuBois), or schizoid personality disorder – ‘These individuals basically just want to be left alone’.
Of course any prototype approach to diagnosis has to be used cautiously – or not at all, in the absence of complementary criteria. There's an obvious risk of over-diagnosis in matching people to paragraph-length prototypical descriptions, and these prototypes haven't been tested for validity or reliability.
So here we have to be clear about what Dr Frances’ book does. He has not provided a substitute to criterion-based diagnosis. He has provided a memorable description of the typical presentation of each diagnosis, a question to be asked to begin the process of making each diagnosis, and a set of important differential diagnoses.
I would recommend this book to any student or NCHD struggling to make sense of the myriad lists of symptoms that populate the ICD-10 and the DSM-IV. I'd recommend it for any psychiatrist at any level who enjoys a read of bracing clarity, personality, and authority. I will keep this book in my office, close to hand, and I will refer to it often. But I won't delete the DSM from my phone just yet.
