There are several controversies associated with the current review of the Diagnostic and Statistical Manual-Fifth Edition, currently in preparation for publication in 2012. Arguments proposing revisions to various diagnostic clusters have been made in several forums. Some, such as the proposal to classify the dementias according to well-validated and established criteria from the neurological literature, are relatively uncontroversial (Reisberg, Reference Reisberg2006), while others are generating more debate.
Several proposed revisions regarding the diagnostic classifications for the anxiety disorders are addressed in Current Perspectives on the Anxiety Disorders: Implications for DSM-V and Beyond. Overall, some good arguments are made but the chapters are variable in quality, and some chapters are extremely weak. Potential readers should also be aware that this book focuses on etiological theories and classification accuracy for research purposes. It offers very little discussion of clinical diagnostic utility, and no discussion of specific clinical techniques for either diagnosis or treatment. As such, this book has little to offer someone seeking concrete clinical suggestions.
The book is divided into 19 chapters. It is loosely organized into chapters examining the current neo-Kraepelinian classification structure, potential theoretical groupings that would cluster the anxiety disorders based on common genetic or neuropathological bases, and classification of specific anxiety experiences such as worry or obsessions and compulsions. Many of the chapters make the argument for regrouping the mood and anxiety disorders into “distress” and “fear” disorders, and introducing a third category of obsessive-compulsive spectrum disorders. The “distress” disorders would include generalized anxiety disorder (GAD), major depressive disorder (MDD), dysthymia, and posttraumatic stress disorder (PTSD). The “fear” disorders would include panic disorder, agoraphobia, social anxiety, and the phobias, although various authors note the unique role of disgust rather than anxiety in many of the simple phobias. This potential classification scheme has a lot to offer when viewed through the lens of treatment strategies. Across several chapters, the authors note that a shift to this model is supported by the high levels of comorbidity seen within the “fear” and “distress” categories, and across the current anxiety and mood disorders. While Chapter 6 presents the current literature on the behavioral genetics of anxiety, it is acknowledged that at the current time, there are no clear genetic markers to make a diagnosis.
The argument that obsessive-compulsive disorder (OCD) is not a “true” anxiety disorder is raised repeatedly. Many authors suggest that OCD and other disorders with a strong compulsive component, such as tic disorders, trichotillomania, body dysmorphic disorder, hypochondriasis, and perhaps other impulse control disorders, should be grouped together in an obsessive-compulsive spectrum disorders (OCSD) category. However, Chapter 13 argues convincingly against the proposal that all of these varied disorders should be reconsidered for potential OCSD. In clinical samples, the vast majority of patients with OCD experience both obsessions and compulsions. In OCD, compulsive behavior produces only a reduction in the anxiety triggered by the obsessional thought rather than any intrinsic experience, unlike impulse control disorders, where the impulsive behavior is intrinsically rewarding. The authors argue that the difference between the excellent treatment response to exposure with response prevention for OCD, but the more limited treatment response for trichotillomania, binge eating, or substance abuse, supports considering OCD separately from many other proposed OCSD diagnoses. They further note the limited comorbidity between OCSD and OCD diagnoses, with the exception of body dysmorphic disorder and hypochondriasis.
Besides these interesting arguments about distress, fear, and compulsions, the book has some major weaknesses. The discussion of PTSD is limited by the decision to avoid any discussion of the potential role external incentives may play in many clinical and forensic settings. In Chapter 4, when discussing the PTSD criterion A, the authors note that “DSM-IV broadened the definition of trauma to include events that are in the range of all human experience,” (p. 93) and that this may lead to “significant consequences.” However, they fail to discuss the implications of these consequences on patterns of patient presentation and symptom maintenance across clinical settings. Nor do they discuss the history of the diagnosis of PTSD or the continued advocacy surrounding this diagnosis, or how this advocacy may impact the diagnosis, prevalence, course, and outcome of this disorder. Chapter 15 provides a more thorough review of the history of the diagnosis of PTSD noting both that the decision to withdraw the diagnosis of gross stress reaction from the DSM-II during the Vietnam war was probably politically rather than scientifically driven, and that political advocacy led to the eventual reintroduction of this diagnosis as PTSD.
Chapter 17 reviews hypochondriasis and the somatoform disorders noting the complex history of these disorders and the challenges with them under the current diagnostic structure. Again, a weakness of the chapter is a lack of discussion about how external incentives may impact the presentation, prevalence, and course of these disorders. The chapter presents the argument that hypochondriasis reflects an anxiety disorder rather than a somatoform disorder, and that hypochondriasis should be renamed health anxiety disorder and reclassified as an anxiety disorder. They also argue that pain disorder should be deleted from the DSM-V and recommend reclassifying pain disorders on Axis III, despite the large body of research finding that health anxiety is a factor in the maintenance of chronic pain for a large number of patients.
Chapter 8, by Tryon, offers a particularly unconvincing argument and distracts from the premise of the book generally. The author enthusiastically advocates for the use of actigraphy, the mobile computerized monitoring of physical activity. While actigraphy has an established role in the study of sleep disorders, the use of actigraphy in the diagnosis of anxiety disorders is currently experimental. Tryon advances the argument that psychiatrists are deficient when compared with other medical specialties because psychiatry does not use “instrumented tests” for diagnosis. He offers actigraphy as a way to remediate this perceived lack by making the post hoc ergo propter hoc argument that anxiety disrupts sleep and therefore sleep disturbance, measured by actigraphy, can act as a proxy for anxiety. Neuropsychologists may be surprised by his assertion, when discussing psychological testing, that “except for intelligence tests, none of these numerous tests is used to guide clinical assessment or inform clinical diagnosis” (p. 193).
In contrast to these weaker chapters, two chapters stand out as particularly useful and engaging. Chapter 5 presents an excellent review of the role of the amygdala in the anxiety response. This chapter would be an asset for anyone teaching a graduate class on either neuroanatomy or the anxiety disorders. Chapter 10 provides an excellent review of the usefulness of cultural anthropology in anxiety disorder research using the Cambodian traditional model of health and wellness as an example and illustrating how these traditional views can lead to culturally specific presentations of panic disorder, GAD, and PTSD.
In conclusion, the editors note the concerns associated with making diagnostic classification systems based on expert consensus rather than clear data, and the difficulties associated with developing these systems by committee. Interestingly, the editors note the likelihood that external influences, including sociopolitical factors, financial factors, and lobbying by such groups as insurers, research funding sources, and pharmaceutical companies will influence DSM workgroup behavior to at least some degree. Unfortunately, the issues related specifically to the role of external factors in the development and maintenance of PTSD, the somatoform disorders, and hypochondriasis remain unaddressed.
The editors recommend re-grouping the mood and anxiety disorders into fear, distress, and obsessive-compulsive disorders, a reclassification that is likely to offer benefits for both research and clinical practice. At this point, the editors believe that it is premature to move to either a mechanism-based or a laboratory test-based diagnostic system. They note the conflicting needs of researchers and clinicians in diagnostic systems. Their book supports the conclusion that diagnostic revision should be slow and gradual.
While this book may be of interest to neuropsychologists who are heavily involved in anxiety disorder research or neuropsychologists who are intrigued by the arguments surrounding the upcoming DSM-V, those readers seeking a clinically relevant current perspective on the anxiety disorders would do best to look elsewhere.
