The British Journal of Psychiatry
Diagnostic and Statistical Manual of Mental Disorders (4th edn, text revision) (DSM-IV-TR)
John Cooper

The arrival of a book for review usually gives rise to pleasant anticipation, and whatever criticisms have to be made, it is that almost always possible to find some pleasant things to say. But finding praise for this tome is a problem — it is a volume too far. It is to be hoped that the authors of DSM-IV-TR agree that the assembly of psychiatric classifications has much in common with the compilation of dictionaries. They will then be in good company, since that most distinguished of lexicographers, Dr Samuel Johnson, warned that “lexico-graphers should never expect praise; they can hope only to escape undue criticism”.

The good news is that ‘TR’ refers to revision confined to the text of the descriptions and explanations that are a preamble to the lists of criteria by which the disorders are identified; with one exception discussed later, there are no changes to the criteria themselves. Presumably this means that DSM-V is some years in the future. The textual revisions that have been made are few and far between, which makes it difficult to understand why it has been thought necessary to reproduce the many hundreds of pages that are unchanged. The diligent reader will find the gist of these textual changes listed in the 14 pages of Appendix D, towards the end of the volume. This is not actually hidden, but it would have been helpful if its presence had been announced loudly and clearly in a more obvious place. Having read Appendix D, it is impossible to avoid asking “Why not just publish these changes in a small pamphlet that could be kept alongside the existing version?”

The justification for the only change in the criteria is worth quoting: “ The criteria set for Tic Disorders has been corrected by eliminating the requirement for ‘clinically significant distress or impairment’ that was added to the majority of disorders in DSM-IV (Tic Disorders among them). This criterion has been problematic in Tic Disorders for a number of reasons, including the fact that it is at variance with clinical experience (i.e. most children with Tourette's Disorder do not experience marked distress or impairment) and that it hinders epidemiological research and epidemiological studies”. The change is actually greater than that quoted in Appendix D, since the previous Criterion C, now omitted, did not just mention impairment, but went on to say “... impairment in social, occupational, or other important areas of functioning”. It seems natural to ask why this correction cannot be made for all the other disorders? One of the weaknesses of the DSM system has always been the frequently available option of including the social effects of disorders in the criteria by which the same disorders are identified.

The authors claim that most of the textual changes are justified by the findings of new research. This may well be true, but since the references are not given it is necessary to look elsewhere to assess this new evidence. This raises another problem about the purposes of so much explanatory and descriptive text accompanying the criteria. It is made clear in the first sentence of the Introduction that this volume, like its predecessors, has educational aims. Presumably this is why it reaches textbook size. The absence of literature references means that it is in no way a substitute for a good textbook, but the amount of information it contains (and the usual high standard of writing and presentation) means that many readers will be tempted not to bother looking any further. This degree of convenience can be the enemy of the critical and curious approach so necessary in psychiatry. There is a danger that the omission of references will suggest to young American clinicians that all they need to know is contained in the DSM-IV volume.

There are other signs that these otherwise distinguished authors are sometimes reluctant to acknowledge that there is another world out there. They have again missed the opportunity to note that although terms such as neurosis, hysteria and neurasthenia are not disorders in the DSM system, they are widely used throughout the rest of the world; none of these three terms is given an entry in the general index to the volume. This is a particularly unfortunate omission with regard to neurasthenia, since it means that the claim about taking notice of recent research cannot be taken very seriously. A comment should have been included on the recent large-scale international collaborative study on psychiatric disorders in general health care, coordinated by the World Health Organization. This found that the ICD-10 criteria for neurasthenia were fulfilled in an important proportion of consecutive series of patients (a mean frequency of 5.4% in centres in 14 different countries; Ustun & Sartorius, 1995). Whatever it means, more research is needed into this puzzling concept, and all educated psychiatrists should know about it.

Another example concerns ‘bouffée delirante’, designated here as “a French term”, but no hint is given of its importance in the history of French psychiatry in particular, and in the development of European and international concepts of acute psychoses in general.

Many experts are listed as contributors to the discussions and consultations that were required for the production of this revision. Librarians will probably feel obliged to purchase a copy, since it is clear that the DSM mountain has laboured. But the mouse-sized new content is unlikely to attract money from the personal pockets of private individuals.

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