Essentials of Psychiatric Diagnosis: Responding to the Challenge of DSM-5

Psychiatric TimesVol 31 No 6
Volume 31
Issue 6

This easy-to-read manual represents the author's concise views on how to achieve “more accurate” diagnoses with DSM-5, as well as when to avoid DSM-5 altogether.

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by Allen Frances, MD;
New York: The Guilford Press; 2013218 pages
$80 (hardcover)

[A note from the publisher: The revised edition features ICD-10-CM codes where feasible throughout the chapters, plus a Crosswalk to ICD-10-CM codes in the Appendix.]

Although I am fond of saying that DSM-5 is still a “good enough guide for clinical work,” Essentials of Psychiatric Diagnosis is a sort of guide to that guide. Perhaps the book is in the same vein as the APA DSM-IV Guidebook-which Dr Frances co-authored in 1995 in his role as DSM-IV chairperson. This time, however, Dr Frances writes as a DSM-5 critic rather than an insider. This easy-to-read manual represents his concise views on how to achieve “more accurate” diagnoses with DSM-5, as well as when to avoid DSM-5 altogether.

The book is made up of 18 chapters covering major categories of psychiatric disorders, with a screening question (eg, “Do you ever get so depressed that you can’t function?”). This is followed by a clinical description of a patient, as an adjunct to DSM-5 diagnostic criteria (which are not included). Brief sections on differential diagnoses and diagnostic tips follow.

Although written in a casual style, much of the information represents the kind of valuable clinical wisdom that one accumulates after years of diagnostic experience. These clinical pearls focus on the fuzzy boundaries and gray areas between threshold diagnoses and non-diagnostic problems of living, as well as Dr Frances’ concerns about diagnostic inflation in psychiatry. For example, he cautions that ADHD is sometimes overdiagnosed in children who are born at the end of the calendar year because they are less mature than their grade-matched peers.

Dr Frances also offers black box cautions for diagnoses he believes represent the greatest risk of being overdiagnosed. For example, he favors using the bereavement exclusion for major depression that was removed from DSM-5 and warns against conflating normal childhood behavior with bipolar disorder and ADHD. He also recommends using ICD criteria for substance abuse and dependence rather than the unified definition of addiction in DSM-5. He advises abandoning the use of disorders that he believes should not have been included in DSM-5 (eg, mild neurocognitive disorder, dissociative identity disorder). These black box warnings represent areas of controversy that are clearly stated as Dr Frances’ personal recommendations; it is up to the clinician to decide whether it is practical or useful to boycott entire sections of DSM-5.

Using a decidedly Kraepelinian perspective, Dr Frances emphasizes the clear difference between psychiatric disorders and the suffering of normal life. He realizes that diagnostic boundaries are fuzzy but falls short of acknowledging a mental illness–mental health continuum and recognizes the potential value of diagnosing minor disorders and subthreshold states.

Much of this volume offers sound clinical wisdom that will be particularly insightful to those with limited clinical experience, as well as those of us suffering from “clinician’s bias,” whereby all mental health consumers are assumed to be mentally ill (or are assigned a diagnostic code in any case to justify insurance reimbursement). Reading this book may very well help temper overzealous diagnosis and intervention.

This article was originally posted online on 8/13/2014 and has since been updated.


Dr Pierre is Associate Director of Residency Education at UCLA Semel Institute for Neuroscience; Health Sciences Clinical Professor in the department of psychiatry and biobehavioral sciences at David Geffen School of Medicine at UCLA; and Co-Chief of the Schizophrenia Treatment Unit at West Los Angeles VA Medical Center.

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