Diagnostic and Statistical Manual of Mental Disorde~ Third Edition, Revised. Washington, D.C., American Psychiatric Association, 1987, 567 pages. ISBN 0-89042-018-1, $39.95 (hardcover) ISBN 0-89042-o19-X, $29.95 (paper)
Reviewed by Thomas P. Koby/ski, M.D. ith the introduction of the Third Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980, psychiatric nosology was radically changed by the use of operational criteria for each diagnostic category and a multiaxial system of evaluation. It became apparent after a few years of experience with D~M-III that some categories were disputed among clinicians and researchers, and that a revision of the DSM-III would be required long before the anticipated publication of the DSM-IV, which would be timed to coincide with the ICD-lOin the early 19905. To expedite this process, the American Psychiatric Association (APA) established a Work Group in 1983, along with 26 Advisory Committees. After developing two successive drafts in 1985 and 1986, the final version of DSMIII-R was accepted in December 1986 by the Board of Trustees and the Assembly of District Branches of the APA. The format of the DSM-III-R is quite similar to its predecessor, including chapters on the use of the manual, a listing of the entire classification, the diagnostic categories, and the appendices and indices. There are also subtle but striking changes that have been made in the revised edition. Of particular import is that the concept of a mental disorder has been reworded to include a significantly increased risk of suffering, death, pain, disability, or an important loss of freedom. Also, a cautionary statement is specifically cited to note that the proper use of the text requires specialized clinical training. Appendix A contains three proposed diagnostic categories needing further study (late luteal phase dysphoric disorder and self-defeating and sadistic personality disor-
VOLUME 29. NUMBER I • WINTER 1988
ders), the result of a compromise over these highly debated entities. For clinical convenience, there now exists an alphabetical and numerical listing of DSM-III-R codes, as well as both a symptom and a diagnostic index. Perhaps most immediately useful to clinicians will be Appendix D, an annotated comparative listing of DSM-III and DSM-III-R. For example, the criteria of schizophrenia have been slightly modified to exclude the requirement that the illness begin before age 45, since several studies have not supported the validity of this criterion. Other major changes include a modification of delusional (paranoid) disorder, the establishment of operational criteria for schizoaffective disorder, deletion of egodystonic homosexuality, the addition of a somatoform disorder (body dysmorphic disorder), and the creation of an entire new section of sleep disorders, which included the disorders of insomnia, hypersomnia, sleep-wake schedule, dream anxiety, sleep terror, and sleepwalking. Interestingly, very few changes have been made to the personality disorders on Axis II. The severity of psychosocial stressors (Axis IV), however, now distinguishes between acute events and enduring circumstances, as has been suggested by Zimmerman et at. I Axis V has been changed to a global assessment of functioning and is now coded on a scale of 0 to 90 based on psychological, social, and occupational functioning, as has been reported in the literature to improve reliability.2 In his review of the DSM-III in 1980, Kendell stated that "everything now depends on the response of the APA membership as a whole over the next few years.") Judging from the quick acceptance of the DSM-III nationally and in many other countries,4 the DSMIII-R in its highly researched, organized, wellwritten, and now more simplified style for clinicians can be expected to generate a similar response. It will maintain the advantages of the DSM-III system: more reliable diagnostic assessments, an increased awareness of differential diagnosis, and a common language for clinicians and researchers-as well as the perceived disadvantages: the question of valid133
avoidance of sex (a modification of the DSMIII diagnostic criteria for simple phobia) as related clinical variants of sexual panic states. A substantial percentage of these patients with sexual aversion or phobias further match the DSM-III criteria for panic disorder, a prevalence far exceeding the estimated prevalence of panic disorder in the general population. Dr. Kaplan describes a comprehensive treatment approach that integrates biologic and psychoReferences dynamic perspectives of sexual anxiety I. Zimmerman M, Pfohl BAp, Stangl D, et al: The through the use of antipanic medication and validity of DSM-III Axis IV (Severity of Psychosocial Stressors). Am J Psychiatry 142:1437-1441. psychodynamically oriented sex therapy. The rationale for this treatment approach 1986 2. Fernandot T, Mellsop G, Nelson K, et al: The reli- is clearly delineated in the chapter sequencing. ability of Axis V of DSM-III. Am J Psychiatry The sexual avoidance syndromes first are de143:752-755, 1986 scribed clinically, including variations of topog3. Kendell RE: DSM-III: a British perspective (letter). raphy, intensity of phobic response, and impact Am J Psychiatry 137:1630-1631. 1980 of anticipatory anxiety and avoidance patterns 4. Malt V: Five years of experience with the DSM-III system in clinical work and research: some conclud- on sexual functioning. Criteria for that subset ing remarks. Acta Psychiatr Scand Suppi 328:76- of sexually avoidant patients whose anxiety 84, 1986 may be drug-responsive are suggested based 5. Jampala VC, Sierles FS, Taylor M: Consumers' upon clinical impression and treatment outviews of DSM-III: attitudes and practices of U.S. come. A theoretically based discussion of etiolpsychiatrists and 1984 graduating psychiatric residents. Am J Psychiatry 143:148-153. 1986 ogy then follows with presentation of respective 6. The American Psychiatric Association: Diagnostic learning, psychodynamic, and biological and Statistical Manual of Mental Disorders. 3rd conceptualizations of sexual phobic anxiety ed. revised. Washington, DC. American Psychiatric states. An integration of these perspectives is Association. 1987 offered as well as cultural and relational influDr. Kobylski is a Resident at Georgetown University. ences, and a comprehensive treatment model emerges. Leading into the discussion of treatment Sexual Aversion, Sexual Phobias, and of sexual panic states is a valuable chapter by Panic Disorder Donald F. Klein, M.D., on sexual disorders and By Helen Singer Kaplan, M.D., Ph.D., medication. Dr. Klein stresses differential diagwith a chapter by Donald F. Klein, M.D. nosis of depression and anxiety states in patients presenting with sexual disorders. He reNew York, N.Y., Brunner/Mazel, 1987, views the various anxiety syndromes and their 280 pages. ISBN 0-87630-450-1, $25.00 specific treatment implications with recomReviewed by Yula Ponticas, Ph.D. mendations concerning dosage maintenance his most recent contribution to the field of and long-term management of antianxiety and sexual disorders brings to the foreground antipanic medications. Sexual side effects of the sexual anxiety syndromes that to date have these medications are presented as they apply received little recognition as separate clinical to desire, arousal, and orgasm. Medication entities requiring specialized assessment and treatment is presented as adjunctive to psychotreatment. Based upon 10 years of clinical therapy. Discussion of treatment of sexual panic work, Dr. Kaplan has conceptualized sexual state includes the contributions and limitation aversion disorder (DSM-III-R) and phobic ity and the complexity of the multiaxial system for some clinicians. S To conclude with the words of the text, "DSM-III-R is still only another frame in the ongoing process of attempting to better understand mental disorders,"6 while at the same time being the most reliable classification system of mental disorders available to clinicians in the world.