Preface to the Casebook
Preface to the Treatment Companion
How to Use This Book
Preface to the Casebook
This collection of cases grew out of our experience in teaching DSM-III and DSM-III-R
and participating in the development of DSM-IV. Reading these accounts of real patients,
edited to focus on information relevant to differential diagnosis, has proven to
be an effective and enjoyable way for clinicians and students to get experience
applying the principles of differential diagnosis to a wide range of patients.
We have chosen focused, edited descriptions of patients, since in standard case
summaries discussions of diagnosis often get bogged down in a swamp of details not
relevant to the purpose of establishing a diagnosis. (Nondiagnostic information,
such as details of childhood and family relationships, however, is often necessary
in actual clinical records.) In addition, routine case summaries often inadvertently
omit crucial diagnostic information, whereas the cases in this book have been prepared
to ensure that all available information necessary for making a diagnosis has been
included.
These cases have been drawn from our own experience and from the practices of a
large number of clinicians, among them many well-known experts in particular areas
of diagnosis and treatment. The identities of the patients have been disguised by
altering such details as age and occupation and, occasionally, locale. Often we
needed to go back to the contributors of the cases to obtain diagnostically crucial
information; we have avoided the temptation to manufacture the missing details.
Sometimes, as in the real world, this has led to diagnoses that had to be made provisionally
or noted as part of the differential diagnosis.
Following Freud's example, we have provided names for the cases in order to make
them easier to refer to. We have included a number of historical cases from the
writings of such great nosologists as Emil Kraepelin, Eugen Bleuler, and Sigmund
Freud himself. We have made no effort to disguise the identities of these historical
patients; we have, however, taken the liberty of providing appropriate names for
those who lacked them.
Each case is followed by a discussion of our differential diagnosis, made according
to the diagnostic criteria in the text revision of the fourth edition of the American
Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV-TR). (To aid the reader we have provided links to the diagnostic criteria
in DSM-IV-TR.) These discussions include important diagnostic considerations, such
as the rationale for making each particular diagnosis, other disorders to be considered
in formulating each diagnosis, and, in some cases, recognition of diagnostic uncertainty
because of inadequate information, ambiguity in the clinical features, or problems
in the classification itself.
These discussions are focused on differential diagnosis, not on the treatment implications
of the diagnosis. However, for some of the cases we have been able to obtain follow-up
information, which usually includes response to treatment. Often the follow-up information
confirms the original diagnosis; occasionally, it raises doubts or leads to a change
in diagnosis. (Treatment Companion to the DSM-IV-TR Casebook, published
in 2004 and included here, marks an additional step in
expanding the original cases to include treatment discussions.)
Some degree of ambiguity in diagnosis is still inevitable, despite the increase
in reliability made possible by the use of diagnostic criteria. The reader, who
may not always agree with our assessment, should understand that we sometimes disagreed
with each other about the correct diagnosis. We trust that he or she will seriously
consider our formulations, but not regard them as infallible.
These cases can be used for a variety of purposes. They should be of value to experienced
clinicians, facilitating their understanding of the concepts and terminology in
DSM-IV-TR. All clinicians, regardless of their level of experience and training,
may benefit from reading descriptions of cases that are examples of diagnostic categories
rarely seen in their treatment settings. Teachers and students of abnormal psychology
in the disciplines of psychology, psychiatry, social work, and psychiatric nursing
will find these cases useful as illustrations of various types of psychopathology.
Similarly, other professionals, such as primary care physicians, internists, and
attorneys, may find them instructive.
These cases should prove helpful to professionals studying for specialty examinations,
such as the psychiatry boards; they can serve as a means of testing one's knowledge
of diagnosis. Research investigators can use them to assess the level of diagnostic
expertise and the reliability with which members of their staff can make diagnostic
assessments. Finally, these cases provide a historical point of reference as illustrations
of diagnostic concepts in the United States at the beginning of this century and,
by means of the historical cases, a comparison with diagnostic concepts of the past.
There are five chapters dealing, respectively, with adults, children and adolescents,
multiaxial assessment, international cases, and historical cases. The international
cases are grouped by geographic region, and the historical cases by their authors.
The original DSM-III Case Book was published in 1981, a year after the
publication of DSM-III, and revised in 1988, a year after the publication of DSM-III-R.
As with the DSM-III-R revision, in the DSM-IV Casebook we eliminated some
of the earlier cases and added a large number of new cases (these are the first
cases in Chapters 1 and 2). The new cases enabled us to expand the coverage of disorders
so that we now have at least one example of virtually every diagnostic category
in DSM-IV.
Preface to the Treatment Companion
Next to the DSM manual itself, the most popular books published by the American
Psychiatric Association and American Psychiatric Publishing have been the DSM Casebooks,
beginning with the DSM-III Casebook in 1981. There are several reasons
for this. First of all, the cases, based on actual patients, bring the DSM diagnostic
criteria to life. In addition, the inclusion of cases covering virtually all of
the diagnostic categories has enabled readers to become familiar with types of patients
that they may not encounter in their work or studies. Finally, the discussions of
each case are useful for teaching the principles of differential diagnosis.
One of the main purposes of the psychiatric diagnosis is to guide treatment selection.
Although some of the cases in the DSM-IV-TR Casebook mentioned treatment
that the patient received, the discussions were focused exclusively on diagnostic
issues. In the Treatment Companion, we have taken the next step: For 34
cases (all but three from the DSM-IV-TR Casebook), we have invited experts–many
world renowned–to discuss their approach to the treatment of a case in their
specialized area. They were asked to discuss both how they would manage the specic
case and the general principles of treatment for that disorder. We encouraged them
to present their personal experience with such patients and their own approach to
treatment with the understanding that other experts might have a very different
approach. For three cases, we invited two experts, who we knew had very different
approaches, to discuss the treatment. The 34 treatment discussions are included
in the cases on this website.
We thank the contributors for providing informative and lively discussions that
we enjoyed reading–as we trust the reader will as well.
The reader who chooses to begin with Chapter 1 and read straight through the book
will find cases in no particular diagnostic order. Those who are interested in examples
of particular diagnoses (e.g., mood disorders) should consult Appendix D, Index
of Cases by DSM-IV-TR Diagnosis. Readers who are interested in cases from any of
the following categories should consult Appendix B, Cases by Special Interest: forensic,
difficult or unusual differential diagnosis, physical disorder, or medical setting.
Appendix A, Index of Case Names, will be useful to the reader who remembers cases
by their names. Appendix C, DSM-IV-TR Classification, can be used to see how a particular
diagnosis fits into the rest of the classification.
Our own residents in the Department of Psychiatry at Columbia University, College of Physicians and Surgeons, who reviewed the cases in the previous casebook, tell us that they found the cases not only very educational but also fun to read. We hope you will as well. Thanks are due to Betty Appelbaum, copy editor for DSM-III, DSM-III-R, and the original Case Book, for her meticulous copy editing of this book.