Psychiatric Diagnosis, 5th ed.

What is it about Midwesterners? Pragmatic, direct—above all, cautious. It's not for nothing that Missouri, home to Washington University, is called the “Show Me” state. For the last 40 years, psychiatric academicians in the Eli Robins constellation at Washington University have had an enormous, transforming effect on American psychiatry. Samuel Guze and Donald Goodwin have been articulate disciples of this gospel, and Psychiatric Diagnosis has been its manifesto in textbook form.

The authors strongly hold the view that a lean, descriptive, and totally objective approach is the way that psychiatry works best. This has value in terms of nosology. For the beginning student of psychiatry, it is easier to deal with only a few psychiatric illnesses (the authors prefer to call them syndromes), and, according to the authors, there is sound evidence for only 12 such syndromes. These 12 constitute the chapters in this book.

Even though the book is in its fifth edition, the preface to the first edition describes what this book is all about. It succinctly states the necessity of a diagnosis (without which, the authors state, there cannot be rational treatment or prognosis); the need to maintain the “medical model” in psychiatry; the fact that there are only limited numbers of identifiable psychiatric “diseases” (a.k.a. syndromes); and that evidence—not assumptions—should be the only firm underpinning of psychiatry.

This lean, clean psychiatry, however, is not what most clinicians experience. Too often the correct diagnosis (or diagnoses) emerge during the course of treatment. And many of these additional or corrected diagnoses are personality disorders. Except for sociopathy, however, this book dismisses “personality disorders”—by using quotation marks—stating that they are “either too vaguely defined or too poorly studied to be useful diagnostic categories” (p. 317). If one were to follow the authors' logic—that there cannot be rational treatment without a diagnosis—how could one justify treating passive dependent or borderline personality disorder? This is but one example of why the book can be a beginning text for the student but is not suited for the clinician.

That having been said, however, Psychiatric Diagnosis is useful for laying out a rational psychiatry in such a manner that the reader participates actively in the logic leading to psychiatric diagnoses, treatments, and prognoses.

The organization of the book is user-friendly for the medical student. It takes each of the dozen diagnoses in psychiatry “that have been sufficiently studied to be useful” and discusses them in the same way that a medical textbook would deal with pernicious anemia, for example. Missing, however, are the nuances, the subtleties, the implicits, and the subjectiveness that punctuate the most productive interactions between psychiatrist and patient. In fact, the authors struggle to avoid using the word “psychotherapy” in dealing with the treatment of somatization disorder: “The physician should strive to substitute discussions of the patient's life problems, personality, and concerns for a quick-triggered response of ordering additional tests and X-rays or yet another drug” (p. 122).

When they do invoke a need for psychotherapy, it is of the most elementary form: “Supportive psychotherapy is almost always indicated, yet there is no evidence that psychological management more extensive than reassurance has any better effect than reassurance alone” (p. 98). This statement, derived from a 1950 citation, is found in the chapter on anxiety neurosis.

A clear phenomenological bias exists. The authors go out of their way to discount the importance of early life experiences in adults; for example: “Details about early life experiences rarely bear on the problem of making a differential diagnosis in adults.” The “medical model” is adhered to, and physical signs are accorded importance. (When is the last time you remember seeing arcus senilis in a psychiatric text?)

In the book are found many clinical “pearls.” The difference from those casually tossed at the bedside by an attending physician to eager students and residents is that the book's pearls are based on studies and referenced. For instance: “Sociopaths tend to marry sociopaths . . . this is particularly true of women.” “Very few sociopathic women . . . fail to marry.” “Conversion symptoms are common in sociopathy.” “Rheumatoid arthritis is absent in schizophrenia.” “Somatization disorder and sociopathy cluster in the same families.”

The authors take you through the logic of their own conclusions, citing this study and that, patiently pointing out some not so subtle observations, such as, “A Swedish study . . . reported a strong correlation between cannabis use and schizophrenia . . . . Those who reported using cannabis on more than fifty occasions were six times more likely subsequently to receive a diagnosis of schizophrenia than were nonusers. The risk increased with increased consumption. The study did not demonstrate that cannabis use caused schizophrenia; cannabis consumption might, on the contrary, be caused by an emerging schizophrenia” (p. 246). This, then, becomes a type of journal club discussion that takes the student through the perils of making “first glance” assumptions.

The chapter on affective disorders is the most engaging. The authors take up questions that clinicians are reluctant to ask. Why, for instance, are there so many subcategories of depression in DSM-IV? Why not consider depression in terms of dichotomies found clinically—reactive versus endogenous, psychotic versus neurotic, agitated versus retarded, primary versus secondary? For the clinician, these descriptive categories have more utility. The authors take to task the subcategories of DSM-IV that are unsupported by clinical studies. For example, mood congruence as a diagnostic feature of affective disorder is discounted because it is based on clinical impression rather than systematic study. Despite the wealth of material found in the chapter on affective disorders, there is spotty mention of the newer selective serotonin reuptake inhibitors and mood stabilizers and not much on affective disorders that are secondary to newer medications.

In the chapter on schizophrenia, it is unclear how much of the authors' statements are based on references cited or on more recent studies. For instance, they imply that good-prognosis cases of schizophrenia could be atypical forms of affective illness. This is not an unusual assertion and has been widely acknowledged over the past two decades, but the reference used is from 1970.

Pragmatism (and subjectivity!) sometimes win out over objectivity, as when the authors assert that diagnosing dementia is best done by a clinician estimating what the patient should know rather than using a test or scale.

The book fascinates when it states the derivations of medical terms and historic roots of an illness. For example, somatization disorder (Briquet's syndrome) has captured the interest of ancient Egyptians, Greeks, Medieval sorcerers, Mesmer, Charcot, Freud, Briquet, and, of course, the Washington University group. References from mythology and the classics also illuminate the text.

Throughout the book an older nomenclature is used. Although the use of “chronic brain syndrome” is undoubtedly comforting to the older psychiatrist (myself included), it must be a bit confusing to the younger psychiatrist weaned on DSM-IV.

The book does not “flow” gracefully from one paragraph to another. There are few “lead-ins,” but this is due to the authors' use of only factual information backed by published research. This, coupled with typographical errors, misspellings, and mistakes in references makes the going a bit rough, but there is a directness in style that keeps one moving along.

The authors do not shy away from (perhaps they even relish) “politically incorrect” issues: “Schizophrenic men are less likely to marry, presumably because male initiative is more important than female initiative in getting married” (p. 58).

A major failing in the book is poor proofing and editing. There is no excuse for more than 30 typographical errors/misspellings in the first 200 pages. In addition, most of the references are dated, and a few are simply wrong in their exact citations. The authors presumably delegated too much to the publishing house and trusted their assistants to look at the proofs. What saves the book is lucid style, brevity, and pragmatism—all welcome in a field too much encumbered by ponderous writing and untested theories. For instance, how is this for succinctness in describing a sociopath? “A charming manner, lack of guilt or remorse, absence of anxiety, and a failure to learn by experience are said to be characteristics of sociopathy. The easy going, open, and winning style, when present, presumably accounts for the sociopath's success as a confidence man” (p. 262).

In sum, this is a useful book that draws attention to the importance of clear thinking in psychiatry. Because our field deals with not only objective but also inherently subjective events, it is important for distinctions to be established between the two. There is no question that the Washington University group was the moving force for the objectivity that now dominates psychiatry. The publication in 1975 of Psychiatric Diagnosis as the manifesto of this opinion was an important milestone in American psychiatry. The reassertion of a Kraepelinian/agnostic/organic approach to psychiatry was needed for balance in the 1970s, and this book's first edition satisfied a thirst for scientific credibility in psychiatry.

However, we have now turned the corner, and there is a thirst for an integrated psychiatry, inclusive of psychodynamic understandings, informed by—yes—clinical research. So, in updating the next edition, the authors, while not backing off from their philosophy, need to clean up and update the references, fire the editor, and allow the “biomedical” to flirt with—if they are daring, even to marry—the “psychosocial.”