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DSM-5 Clinical Cases

edited by John W. Barnhill, M.D. Washington, DC, American Psychiatric Publishing, 2014, 402 pp., $89.00.

Reviewed by Rachel A. Davis, M.D.
Am J Psychiatry 2014;171:586-587. doi:10.1176/appi.ajp.2014.14020214
View Author and Article Information

The author reports no financial relationships with commercial interests.

Dr. Davis is affiliated with the Department of Psychiatry, University of Colorado Health Sciences Center, Denver.

Accepted February , 2014.

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DSM-5 Clinical Cases makes the rather overwhelming DSM-5 much more accessible to mental health clinicians by using clinical examples—the way many clinicians learn best—to illustrate the changes in diagnostic criteria from DSM-IV-TR to DSM-5. More than 100 authors contributed to the 103 case vignettes and discussions in this book. Each case is concise but not oversimplified. The cases range from straightforward and typical to complicated and unusual, providing a nice repertoire of clinical material. The cases are realistic in that many portray scenarios that are complicated by confounding factors or in which not all information needed to make a diagnosis is available. The authors are candid in their discussions of difficulties arriving at the correct diagnoses, and they acknowledge the limitations of DSM-5 when appropriate.

The book is conveniently organized in a manner similar to DSM-5. The 19 chapters in DSM-5 Clinical Cases correspond to the first 19 chapters in section 2 of DSM-5. As in DSM-5, DSM-5 Clinical Cases begins with diagnoses that tend to manifest earlier in life and advances to diagnoses that usually occur later in life. Each chapter begins with a discussion of changes from DSM-IV. These changes are further explored in the cases that follow.

Some of the key changes illustrated in this book are:

  • Autism spectrum disorder is used to describe symptoms previously broken into separate categories.

  • The age limit prior to which attention deficit hyperactivity disorder symptoms must be present has been changed from 7 to 12 years, and adults must only meet five criteria from each dimension rather than six.

  • Schizophrenia subtypes have been eliminated.

  • “Other specified” is used for those patients who have symptoms in a particular diagnostic category but do not meet full criteria (e.g., other specified bipolar and related disorder).

  • “Unspecified” is used for those patients who have significant symptoms consistent with a particular diagnostic category but in whom adequate history cannot be obtained (e.g., unspecified schizophrenia spectrum and other psychotic disorder).

  • Disruptive mood dysregulation disorder is a new diagnosis for children in the depressive disorders diagnostic category.

  • Bereavement is no longer an exclusion to the diagnosis of major depressive disorder.

  • Obsessive-compulsive disorder (OCD) and posttraumatic stress disorder are now considered in their own sections rather than grouped with anxiety disorders.

  • Hoarding disorder is new.

  • Hypochondriasis has been eliminated and replaced by two separate disorders, somatic symptom disorder and illness anxiety disorder.

  • Avoidant/restrictive food intake disorder is a new diagnosis to describe people with symptoms of restricting or avoiding food in a manner that leads to impairment but do not meet criteria for anorexia nervosa.

  • Gender identity disorder has been eliminated and replaced with gender dysphoria.

  • Substance use disorders are no longer split into abuse and dependence but rather are specified by course and severity.

Each case vignette is titled with the presenting problem. The cases are formatted similarly throughout and include history of present illness, collateral information, past psychiatric history, social history, examination, any laboratory findings, any neurocognitive testing, and family history. This is followed by the diagnosis or diagnoses and the case discussion. In the discussions, the authors highlight the key symptoms relevant to DSM-5 criteria. They explore the differential diagnosis and explain their rational for arriving at their selected diagnoses versus others they considered as well. In addition, they discuss complicating factors that make the diagnoses less clear and often mention what additional information they would like to have. Each case is followed by a list of suggested readings.

As an example, case 6.1 is titled Depression. This case describes a 52-year-old man, “Mr. King,” presenting with the chief complaint of depressive symptoms for years, with minimal response to medication trials. The case goes on to describe that Mr. King had many anxieties with related compulsions. For example, he worried about contracting diseases such as HIV and would wash his hands repeatedly with bleach. He was able to function at work as a janitor by using gloves but otherwise lived a mostly isolative life. Examination was positive for a strong odor of bleach, an anxious, constricted affect, and insight that his fears and behaviors were “kinda crazy.” No laboratory findings or neurocognitive testing is mentioned.

The diagnoses given for this case are “OCD, with good or fair insight,” and “major depressive disorder.” The discussants acknowledge that evaluation for OCD can be difficult because most patients are not so forthcoming with their symptoms. DSM-5 definitions of obsessions and compulsions are reviewed, and the changes to the description of obsessions are highlighted: the term urge is used instead of impulse so as to minimize confusion with impulse-control disorders; the term unwanted instead of inappropriate is used; and obsessions are noted to generally (rather than always) cause marked anxiety or distress to reflect the research that not all obsessions result in marked anxiety or distress. The authors review the remaining DSM-5 criteria, that OCD symptoms must cause distress or impairment and must not be attributable to a substance use disorder, a medical condition, or another mental disorder. They discuss the two specifiers: degree of insight and current or past history of a tic disorder. They briefly explore the differential diagnosis, noting the importance of considering anxiety disorders and distinguishing the obsessions of OCD from the ruminations of major depressive disorder. They also point out the importance of looking for comorbid diagnoses, for example, body dysmorphic disorder and hoarding disorder.

This brief case, presented and discussed in less than three pages, leaves the reader with an overall understanding of the diagnostic criteria for OCD, as well as a good sense of the changes in DSM-5.

DSM-5 Clinical Cases is easy to read, interesting, and clinically relevant. It will improve the reader’s ability to apply the DSM-5 diagnostic classification system to real-life practice and highlights many nuances to DSM-5 that one might otherwise miss. This book will serve as a valuable supplementary manual for clinicians across many different stages and settings of practice. It may well be a more practical and efficient way to learn the DSM changes than the DSM-5 itself.

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