DSM-III and Norway. History, attitudes and future

Research on personality disorders in Norway *

Norway was the first European country to be introduced to the American diagnostic system DSM III. In this paper the author presents some of the main results of the Norwegian studies of the DSM III personality disorders with particular emphasis on validity, comorbidity and treatment.

An integration of the DSM-III and ICD-8 by global severity assessments for measuring multidimensional outcomes in general hospital psychiatry

A multiaxial classification system has been developed in which three ICD-8 derived axes of psychiatric syndromes, personality disorders and somatic syndromes, and two DSM-III axes of psychosocial stressors and social functioning have been included. Global assessment scales were annexed the three ICD-8 axes. This DSM-III/ICD-8 system was used for registration of 880 consequetively admitted psychiatric patients in a general hospital setting. The results showed that six psychiatric syndromes (substance use disorders, schizophrenia, manic-depressive psychosis, reactive psychosis, neurosis, and adjustment reactions) were responsible for 80% of the diagnostic variance. Of these syndromes, manic-depressive psychosis had the highest improvement rate both concerning symptoms and social functioning. Manic-depressive psychosis had also the lowest coefficient of variation in the stay in hospital indicating a high degree of homogeneity in accordance to the diagnose-related group system. However, patients within the categories of reactive psychosis and neurosis who received antidepressants also had a low coefficient of variation, although the neurotics were significantly more depressed than the manic-depressives at discharge from hospital.

Teaching DSM-III to clinicians. Some problems of the DSM-III system reducing reliability, using the diagnosis and classification of depressive disorders as an example

Experiences from teaching DSM-III to more than three hundred Norwegian psychiatrists and clinical psychologists suggest that reliable DSM-III diagnoses can be achieved within a few hours training with reference to the decision trees and the diagnostic criteria only. The diagnoses provided are more reliable than the corresponding ICD diagnoses which the participants were more familiar with. The three main sources of reduced reliability of the DSM-III diagnoses are related to: poor knowledge of the criteria which often is connected with failure of obtaining diagnostic key information during the clinical interview; unfamiliar concepts and vague or ambiguous criteria. The two first issues are related to the quality of the teaching of DSM-III. The third source of reduced reliability reflects unsolved validity issues. By using the classification of five affective case stories as examples, these sources of diagnostic pitfalls, reducing reliability and ways to overcome these problems when teaching the DSM-III system, are discussed. It is concluded that the DSM-III system of classification is easy to teach and that the system is superior to other classification systems available from a reliability point of view. The current version of the DSM-III system, however, partly owes a high degree of reliability to broad and heterogeneous diagnostic categories like the concept major depression, which may have questionable validity. Thus, the future revisions of the DSM-III system should, above all, address the issue of validity.