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

Classification algorithm for the International Classification of Diseases-11 chronic pain classification: development and results from a preliminary pilot evaluation

ABSTRACT

The International Classification of Diseases-11 (ICD-11) chronic pain classification includes about 100 chronic pain diagnoses on different diagnostic levels. Each of these diagnoses requires specific operationalized diagnostic criteria to be present. The classification comprises more than 200 diagnostic criteria. The aim of the Classification Algorithm for Chronic Pain in ICD-11 (CAL-CP) is to facilitate the use of the classification by guiding users through these diagnostic criteria. The diagnostic criteria were ordered hierarchically and visualized in accordance with the standards defined by the Society for Medical Decision Making Committee on Standardization of Clinical Algorithms. The resulting linear decision tree underwent several rounds of iterative checks and feedback by its developers, as well as other pain experts. A preliminary pilot evaluation was conducted in the context of an ecological implementation field study of the classification itself. The resulting algorithm consists of a linear decision tree, an introduction form, and an appendix. The initial decision trunk can be used as a standalone algorithm in primary care. Each diagnostic criterion is represented in a decision box. The user needs to decide for each criterion whether it is present or not, and then follow the respective yes or no arrows to arrive at the corresponding ICD-11 diagnosis. The results of the pilot evaluation showed good clinical utility of the algorithm. The CAL-CP can contribute to reliable diagnoses by structuring a way through the classification and by increasing adherence to the criteria. Future studies need to evaluate its utility further and analyze its impact on the accuracy of the assigned diagnoses.

Do the DSM decision trees improve diagnostic ability?

Experiment 1 examined whether the use of the DSM-III-R decision trees increased the accuracy of DSM-III-R diagnoses. Results indicated that the use of the decision trees interacted with the level of DSM-III-R experience to affect diagnostic accuracy. The use of the decision trees resulted in a modest increase in diagnostic accuracy for participants with less DSM-III-R experience; for participants with more DSM-III-R experience, the use of the decision trees had no significant effect on diagnostic accuracy. Experiment 2 examined whether the use of the DSM-III-R decision trees increased the accuracy and confidence and decreased the time of DSM-IlI-R diagnosis across participants with varying levels of DSM-III-R experience. The primary analyses consisted of a 3 x 2 x 2-multivariate analysis of variance (MANOVA) to determine whether the use of the decision trees increased diagnostic accuracy and diagnostic confidence and decreased diagnostic time. Results indicated (1) the experienced participants made more accurate diagnoses than the less-experienced and no-experience participants: (2) the decision trees, combined with practice, increased class diagnostic accuracy and decreased diagnostic time; and (3) participants were more confident in their diagnosis when they used the decision trees than when they did not use the decision trees. Supplementary analyses consisted of two one-way analysis of variance (ANOVA) procedures and indicated that participants' preference for and knowledge of how to use the decision trees did not significantly affect their diagnostic accuracy.

Shared characteristics in the clinical expression and pharmacological responses of mental disorders and their possible collective significance

This paper points out the existence of, and enumerates, common characteristics spanning the clinical expression and pharmacological responses of most mental disorders. Central to the developed argument, the paper also points out an important overall property of brain function which normally insures a coordinated smoothness and synchronism across the expression of all the higher mental functions. Evidence from positron emission tomography studies supports the existence of a common initial structural abnormality which renders the brain vulnerable to a periodic loss of synchronism. This loss then expresses itself in a kind of 'psychic Parkinsonism', as shown in the characteristic, antithetical, oscillating format of the familiar cluster of symptoms of most mental disorders. The arguments are based on clinical observations and supported by a survey of the clinical and experimental literature.

The ECLW Collaborative Study: III. Training and reliability of ICD-10 psychiatric diagnoses in the general hospital setting--an investigation of 220 consultants from 14 European countries. European Consultation Liaison Workgroup

A comprehensive training program for reliable use of the ICD/10 in Consultation-Liaison (C-L) psychiatry was conducted with 220 psychiatrists and psychologists from 14 European countries. The training included rating of written test cases and development of a coding manual to avoid diagnostic pitfalls not addressed in the ICD-10 manual. Following this training, all consultants rated 13 written case histories. One hundred sixty-seven consultants (76%) had a kappa (kappa) of at least 0.70. Only 13 (6%) had a kappa 0.40. The percentage of high reliability raters was evenly distributed among the different countries. Consultants had some problems in the differentiation between adjustment disorders and depressive disorders, and in the classification of disorders where ICD-10 differs from the DSM-III-R system. National biases in diagnostic practice were found with regard to the "case" concept and the role of alcohol in confusional states. Finnish consultants coded "no psychiatric disorder" significantly more often, whereas German and Italian consultants attributed delirious state more often to alcohol than consultants from other European countries. The study demonstrates that it is possible to achieve acceptable interrater reliability in applying the ICD-10 guidelines, through training programs designed for C-L psychiatrists and psychologists. Nevertheless, this first cross-national study shows the importance of addressing differences in national diagnostic practice.

Coding guidelines for ICD-9 section on mental disorders and reliability of chart clinical diagnoses

A major innovation of the ICD-10 draft is provision of diagnostic guidelines. This is assumed to be appropriate for use in clinical situations. In Norway a similar approach was adopted when ICD-9 was introduced as the official classification system in 1987. This was done in order to avoid national diagnostic bias and increase diagnostic reliability. A comparison with the DSM-III criteria was included in the diagnostic guidelines. The effectiveness of this approach was investigated by comparing the chart ICD-9 diagnoses of 104 psychiatric in- and outpatients from 2 teaching hospitals with the diagnoses obtained by using case record rating forms (criterion diagnosis). According to the criterion diagnoses, the base rate of chart diagnoses of schizophrenia and manic-depressive psychosis was too low, and the base rate of reactive psychosis too high. Several chart diagnoses proved to have low reliability, particularly reactive psychosis, paranoid psychosis, depressive neurosis and personality disorders. The study suggests that the provision of extensive diagnostic guidelines does not necessarily alter previous diagnostic practice. Reasons for these findings and the implications for the ICD-10 diagnostic criteria and diagnostic guidelines are discussed.

Five years of experience with the DSM-III system in clinical work and research: some concluding remarks

The reliability of the DSM-III is superior to other classification systems available in psychiatry. However, reliability depends on proper knowledge of the system. Some pitfalls reducing reliability of axis 1 diagnosis which commonly are overlooked are discussed. Secondly, some problems of validity of axis 1 and 2 are considered. This is done by discussing the differential diagnosis of organic mental disorders and other psychiatric disorders with concomittant physical dysfunction, and the diagnoses of post-traumatic stress disorders and adjustment disorders among others. The emphasis on health care seeking behaviour as a diagnostic criteria in the DSM-III system, may cause a social, racial and sexual bias in DSM-III diagnoses. The present discussion of the DSM-III system from a clinical point of view indicates the need for validation studies based on clinical experience with the DSM-III. These studies should include more out-patients and patients with psychopathology who do not seek psychiatric treatment. Such studies must also apply alternative diagnostic standards like the ICD-9 and not only rely on structured psychiatric interviews constructed for DSM-III diagnoses. The discussion of axis 4 points to the problem of wanting to combine reliable rating with clinically meaningful information. It is concluded that the most important issue to be settled regarding axis 4 in the future revisions is the aim of including this axis. The discussion of axis 5 concludes that axis 5 is biased toward poor functioning and thus may be less usefull when applied on patients seen outside hospitals. Despite these problems of the DSM-III, our experiences indicate that the use of the DSM-III is fruitful both for the patient, the clinician and the researcher. Thus, the cost of time and effort needed to learn to use the DSM-III properly are small compared to the benefits achieved by using the system.

DSM-III and Norway. History, attitudes and future

The first Norwegian evaluation of the DSM-III system of classification occurred in 1980. A Norwegian translation of the diagnostic criteria was published as part of a textbook in psychiatry in 1984. The Mini DSM-III (Quick reference) was published in 1985. The DSM-III system has been generally well accepted in Norway and is currently used in most research projects besides the ICD system. Several training courses have been arranged for senior psychiatrists and psychologists. Introduction to the DSM-III system is also part of the obligatory training course for psychiatric residents in Norway. From 1987 Norway will use a clinical modification of the ICD-9 system of classification. This modification applies 5 digit coding and includes diagnostic categories found in the DSM-III system but not in the 4 digit ICD-9 version. The DSM-III system of classification represents a major step forward in psychiatric classification. However, revisions are necessary to increase clinical validity. Although Norwegian psychiatry has been inspired by the DSM-III system, Norway remains committed to the ICD systems. The goal must be to make further revisions of the DSM-III and ICD systems, and in the end unite the strengths of these two systems of psychiatric classification.