Diagnosis of physical illness in psychiatric patients using axis III and a standardized medical history

Psychiatrists' axis III diagnoses of physical illnesses in 357 psychiatric patients were compared with diagnoses by a physician's assistant using a standardized medical history form. The physician's assistant detected nearly three times as many physical illnesses as the psychiatrists. The psychiatrists were significantly more likely to miss diagnoses among older patients and women. Patients who met criteria for depressive disorders appeared to be at greatest risk for undetected illnesses, followed by patients with bipolar disorders and schizophrenia. Patients with a secondary diagnosis of substance abuse had significantly more undetected illness than those who did not abuse substances. The authors suggest that current axis III guidelines are inadequate and that a systematic review of physical health problems should be part of the psychiatric diagnostic assessment.

Validity of the Personality Diagnostic Questionnaire--revised: comparison with two structured interviews

The authors gave the self-report Personality Diagnostic Questionnaire--Revised (PDQ-R) to 87 applicants for inpatient treatment of severe personality psychopathology and, blind to these results, diagnosed personality disorders in the applicants by using the Personality Disorder Examination and the Structured Clinical Interview for DSM-III-R Personality Disorders. The PDQ-R was not a substitute for a structured interview assessment of axis II disorders because many of its diagnoses were false positives. Its high sensitivity and moderate specificity for most of the axis II disorders suggest, however, that it is an efficient instrument for screening patients with DSM-III-R personality disorders.

Characterizing life events as risk factors for depression: the role of fateful loss events

Empirical associations between life events and health are often weak, in part because event exposure measures may group together very different kinds of experiences within a single event category. Attempts to refine the measures (by using respondents' subjective appraisals of event stressfulness or by taking into consideration situational and personal factors that influence the contextual threat of the events) may strengthen the association, but they cloud the clarity of any causal inference by confounding the measure with extraneous variation. Instead, the use of descriptive information about what actually happened before, during, and after each event is recommended to define exposure to potent, fateful life events. In a comparison of 96 patients with major depression and 404 community residents with no apparent depression, the odds that a person would have experienced one or more events meeting criteria for fatefulness and disruptiveness was 2.5 times greater in the depressed group.

Use of DSM-III Axis IV in clinical practice: rating the severity of psychosocial stressors

This study investigates the usefulness of DSM-III Axis IV ratings of Severity of Psychosocial Stressors. Multiaxial evaluations were made on a diagnostically heterogeneous group of 362 psychiatric patients. Severity ratings on Axis IV were compared to a more extensive system for measuring life event stress, embedded in the Psychiatric Epidemiology Research Interview (PERI). The results indicate that Axis IV ratings are consistent with meaningful diagnostic and demographic group differences, and correlate significantly with PERI ratings of normative change or disruption associated with rated events. The Axis IV guideline that the stressor reflect the summed effect of all psychosocial stressors listed, however, appeared to be too complex to be incorporated into routine clinical practice, even by relatively well-trained evaluators with expert supervision.

DSM-III-R schizotypal personality traits in offspring of schizophrenic disorder, affective disorder, and normal control parents

The aggregation of disorder in families identified by a schizophrenic disorder proband (index case) has provided indirect clues to the question of diagnostic boundaries of schizophrenic spectrum categories. The Danish Adoption Studies provided quasi-experimental evidence for the range of expression of a putative schizophrenic spectrum disorder which was subsequently denoted schizotypal personality disorder (STPD) in DSM-III-R. It has been hypothesized that such schizophrenic spectrum categories bear a genetic relationship to schizophrenic disorder and thus are continuous with schizophrenia in terms of etiology and pathogenesis. For meaningful use of such spectrum categories in genetic analyses, i.e., linkage analysis, it is important that rates of spectrum traits and disorder in normal control and in psychiatric control populations are known. The rate of DSM-III-R schizotypal traits and disorder was assessed in three offspring groups (ages 18-29) defined by parental diagnoses, including schizophrenic disorder (N = 90), affective disorder (N = 79), and no parental disorder (N = 161). The assessment was conducted by trained social workers and psychologists by means of a direct interview (Personality Disorder Examination). The interviewers were blind to the parental status and to previous psychiatric assessments of these offspring. The rates of three, four and five schizotypal features were elevated in the offspring with parental psychiatric disorder in contrast to the offspring with no parental psychiatric disorder. However, the rates between the offspring of the schizophrenic disorder parental group and the offspring of the affective disorder parental group did not differ significantly, thus failing to support the assumption of diagnostic specificity.

Use of DSM-III axis IV in clinical practice: rating etiologically significant stressors

This study compared the etiologically significant stressors listed on DSM-III axis IV (severity of psychosocial stressors) with life events elicited by the Psychiatric Epidemiology Research Interview (PERI). Multiaxial evaluations of a diagnostically heterogeneous group of 362 patients were made, and all patients were subsequently administered the PERI by interviewers blind to the clinical assessments. The results indicated that axis IV functions well as a shorthand method for identifying the more severe psychosocial stressors. However, the DSM-III requirement that the stressor be important in the development or exacerbation of the current disorder resulted in discrepancies between the axis IV and PERI assessments.

Characterizing life events as risk factors for depression: The role of fateful loss events

Empirical associations between life events and health are often weak, in part because event exposure measures may group together very different kinds of experiences within a single event category. Attempts to refine the measures (by using respondents' subjective appraisals of event stressfulness or by taking into consideration situational and personal factors that influence the contextual threat of the events) may strengthen the association, but they cloud the clarity of any causal inference by confounding the measure with extraneous variation. Instead, the use of descriptive information about what actually happened before, during, and after each event is recommended to define exposure to potent, fateful life events. In a comparison of 96 patients with major depression and 404 community residents with no apparent depression, the odds that a person would have experienced one or more events meeting criteria for fatefulness and disruptiveness was 2.5 times greater in the depressed group.

Validating structured DSM-III-R personality disorder assessments with longitudinal data

The authors observed 20 patients over time for mal-adaptive personality traits during hospitalization and made longitudinal diagnoses to validate Structured Clinical Interview for DSM-III-R (SCID) assessments of personality disorders. The SCID assessments identified certain personality disorders better than others.

The specificity of DSM-III schizotypal personality traits

The rate of DSM-III schizotypal personality traits was evaluated in three groups of adolescent offspring (ages 15-21), defined by the psychiatric diagnosis of their parents. Parental diagnoses included schizophrenic disorder (40 adolescents), affective disorder (35 adolescents), and 'no psychiatric disorder' (normal controls) parents (82 adolescents). The presence of the eight component features of schizotypal personality disorder was assessed from video-taped semistructured psychiatric interviews, subsequently rated by trained psychiatrists, blind to the parental psychiatric status of the subjects. The effect of age, sex, and social class on the pattern of prevalence results was examined. The expected specificity of DSM-III schizotypal personality traits to schizophrenia was not supported by the prevalence pattern of the traits. Rates of 2 or more, 3 or more, and 4 or more schizotypal personality features were highest in the parental psychiatric groups. The rates of schizotypal personality traits in adolescent offspring of affective disorder parents were as high as those previously reported for relatives of schizophrenic disorder probands.

The revision of axis V in DSM-III-R: should symptoms have been included?

The authors studied the relationship of psychological symptoms to clinicians' ratings on DSM-III's axis V. A total of 355 patients received multiaxial assessments and were reinterviewed under blind conditions with the Psychiatric Epidemiology Research Interview, which contains scales to measure aspects of social and occupational functioning and various symptom dimensions. The majority of symptom scales were correlated significantly with axis V ratings. Axis I diagnosis explained 19.0% of the variance in axis V; demographics, 6.5%; and symptoms, 7%. Symptoms had a larger effect, in terms of explained variance, than adaptive functioning variables and tended to detract from the latter's significance. These results have implications for axis V in DSM-III-R and for planning DSM-IV.

Toward construct validity for DSM-III Axis V

This study investigates the construct validity of DSM-III Axis V ratings, made in diverse clinical settings, by means of independent assessments of adaptive functioning. Three hundred and sixty-two patients received supervised multiaxial assessments and were then blindly reinterviewed with the Psychiatric Epidemiology Research Interview, which contains scales measuring various aspects of social and occupational functioning. A subsample of 154 patients received a second independent interview that assessed characteristics of the individuals' social networks. The results indicate that Axis V ratings (1) demonstrate predictable diagnostic and demographic group differences, and (2) are determined by both social and occupational variables, but occupational factors predominate. The significance of the results for defining the adaptive functioning construct, for methods of assessment, and for the revisions of Axis V in DSM-III-R, is discussed.

DSM-III in residency training: results of a national survey

The authors surveyed directors of residency training to determine the extent to which DSM-III has been integrated into American psychiatric residency training programs, how this has been accomplished, and the directors' assessments of certain effects of DSM-III on residency training. Ninety-seven percent (N = 208) responded to the questionnaire. Results indicated that DSM-III has had a major impact on residency training in the United States. Although the effects of DSM-III were judged to be largely positive--for example, offering a common language for diagnostic discussions--certain negative effects, such as promoting a mechanistic "cookbook" approach to assessing patients, were reported.

Scaled ratings of DSM-III personality disorders

The authors describe the use of a 4-point rating scale for DSM-III axis II categories in a hospital-based outpatient clinic. Fifty-one percent of the sample met the criteria for one or more DSM-III personality disorders. This increased to 88% when the sample also included patients rated as having "some traits" or "almost meets DSM-III criteria." Frequency distributions were obtained for each of the 11 personality disorders, and a factor analysis was derived that was similar to the groupings described in DSM-III.

Identifying common errors in the use of DSM-III through diagnostic supervision

The authors describe the use of diagnostic supervision to identify common errors made by trainees in the application of DSM-III to multiaxial evaluations in an outpatient clinic. Errors on all five axes were due primarily to misapplications of diagnostic criteria and conventions. Errors on axes I, IV, and V were most frequent. Axis I errors were commonly due to confusion about the relationship of dysthymic disorder to major depression, neglect of substance use disorder diagnoses, and misuse of the adjustment disorder and V-code categories. On axis IV, the severity of psychosocial stressors was frequently overrated, based on several misconceptions. Axis V ratings were often erroneously overestimated because they were individualized rather than made on a uniform scale. No differences were found in the error rates of psychiatric residents compared with psychology interns except on axis I, where interns made more errors. The authors discuss the implications of these errors for training residents and psychology interns in the use of DSM-III.

Is there a characteristic pattern to the treatment history of clinic outpatients with borderline personality?

The prior psychiatric histories, dispositions, and treatment plans for a group of patients with borderline personality, evaluated in an outpatient clinic, were compared to those of evaluated patients diagnosed as having neurotic and/or other personality disorders or schizophrenia. Variables that were found to discriminate patients diagnosed as borderline from the other two groups included a history of past hospitalizations and their duration, frequency of prior outpatient treatment, previous use of psychotropic medications, rates of dropout and referral-out of the clinic, and number of treatment sessions received during a 2-year follow-up period. Patients with borderline personality who had the most previous treatment and the most severe symptoms received the least treatment. The histories of extensive previous treatment are consistent with the frequently brief and unsatisfactory nature of the index clinic contacts.

Supervising intake diagnosis. A psychiatric 'Rashomon'

Psychiatric diagnoses based on data collected during routine clinical intake evaluations done by trainees are often later used in research studies and in program evaluation. It is commonly assumed that the supervisory process can effectively overcome errors that trainees make in diagnosis. We designed a study to assess the adequacy of patient-in-absentia supervision for ensuring accurate psychiatric diagnoses. In 30% of the cases there were major diagnostic disagreements between the supervised diagnoses and consensus diagnoses based on information provided by both the trainee and an experienced clinician who sat in on the trainee's initial interview. These findings have implications for clinical care, training, and research.

DSM-III: rationale, basic concepts, and some differences from ICD-9

This paper reviews the major innovations in approach to psychiatric diagnosis incorporated into DSM-III. These include the classification of mental disorders according to shared descriptive clinical features, the use of specified diagnostic criteria for making psychiatric diagnoses, and the multiaxial system of patient evaluation. It describes the principal revisions of diagnostic concepts in DSM-III from several areas of classification, such as Schizophrenia and Affective Disorders, that account for some of the differences between DSM-III and ICD-9. The rationale for the changes in approach and in basic diagnostic concepts at the time of DSM-III's publication is presented. More recent evidence concerning the validity of newly-conceptualized categories is also included.

Teaching and learning DSM-III

This article presents recommendations for training programs in DSM-III to help counter feelings of apprehension expressed by many mental health professionals over the transition to the new nomenclature and its multiaxial evaluation system. The authors suggest educational objectives, didactic curricula, and methods for training in the clinical application of DSM-III and discuss supervising the use of DSM-III in patient intake and evaluation. Thorough mastery of DSM-III should not be expected after a limited program; learning its strengths and limitations will be a continuing process.

VIth axis for DSM-III: psychodynamic evaluation

DSM-III has raised questions among mental health professionals about the relationship of diagnosis to treatment. Practicing psychotherapists have been reluctant to endorse the revised classification, arguing that diagnostic discriminations needed to plan psychotherapy treatment are absent from DSM-III's multiaxial system. The clinical usefulness of a diagnostic classification is a major measure of its validity. The authors illustrate with three patients from psychotherapy practice, all with long-standing problems of depressed mood, the limits of DSM-III in planning psychotherapy treatment, and they make suggestions for the development of a treatment-oriented "axis" to complement the current multiaxial evaluation system.

Expectations of hospital treatment. Conflicting views of patients and staff

A 40-item therapeutic community questionnaire, developed from a survey of experts, was used to assess the treatment needs and expectations of a group of 30 hospitalized psychiatric patients. The patients' attitudes regarding an ideal ward atmosphere were compared to those, as measured previously by the identical instrument, of the treating staff. The results indicated that psychiatric inpatients found the therapeutic community modality consistent with their needs and expectations. However, staff and patients were divided in attitude toward the therapeutic community concept. The staff's definition of therapeutic community was broad and exceeded the principles of the therapeutic community experts. The patients desired a more conservative approach which combined respect and responsibility with a ward structure that was unambiguous and less democratic. Studies of ward atmosphere as well as premature termination in psychotherapy indicate that such conflicts in viewpoint between patients and staff might have detrimental effects on hospital outcome. A negotiated approach to inpatient treatment is suggested as a means to establish greater autonomy, growth in self-esteem, sense of responsibility, and increased trust on the part of hospitalized patients.

DSM-III: the major achievements and an overview

DSM-III will be published early this year. In the first part of this article the authors describe some of the major achievements of DSM-III: the process of its development, reaching consensus on many controversial diagnostic categories and a definition of mental disorder, the provision of diagnostic criteria and a multiaxial evaluation system, and the demonstration of improved diagnostic reliability. In the second part of the article the authors present an overview of DSM-III in which they describe its departures from DSM-II and the reasons for these changes. They conclude that in the next few years there should be systematic study of DSM-III in use, so that information about its strengths and limitations can be made available to those responsible for developing DSM-IV.

Emergency psychiatry and the assaultive patient

The authors studied 62 emergency room patients with violent ideation or action to assess the feasibility of predicting assaultive behavior. Although the likelihood of future violent acts could not be predicted accurately, they discovered that a significant majority of violent patients were potentially treatable within the setting of emergency psychiatry practice.