Impact of DSM-III on clinical practice

Classification for clinical practice: how to make ICD and DSM better able to serve clinicians

With DSM-V and ICD-11 on the horizon, now is an excellent time to consider options for improving their utility in clinical practice. A prerequisite for determining what can be done to improve their clinical utility is to establish a baseline from which to work. Surprisingly, there is virtually no information available that illuminates how clinicians actually use the DSM-IV and ICD-10 in clinical practice settings. Our first recommendation is for studies to be conducted that examine how the DSM-IV and ICD-10 is being used in the field and then to identify areas in need of improvement. We then propose two new diagnostic approaches to be considered that might significantly improve the system's clinical utility: (1) the addition of clinically useful dimensions (i.e., dimensions for indicating disorder severity, dimensions that cut across various disorders that would quantify symptoms of particular treatment-relevance such as psychosis, and dimensions to measure functioning) and (2) the augmentation of the DSM and ICD operationalized diagnostic criteria with the addition of a prototype-matching system that is likely to more closely conform to the way clinicians think about psychiatric diagnoses.

Clinical utility: a prerequisite for the adoption of a dimensional approach in DSM

A potential obstacle to implementing dimensional representations in the Diagnostic and Statistical Manual of Mental Disorders (DSM) is lack of data about clinical utility and user acceptability. Adopting a dimensional approach would likely complicate medical record keeping, create administrative and clinical barriers between mental disorders and medical conditions, require a massive retreating effort, disrupt research efforts (e.g., meta-analyses), and complicate clinicians' efforts to integrate prior clinical research using DSM categories into clinical practice. Efforts to empirically demonstrate the clinical utility of dimensional alternatives should be a prerequisite for their future implementation in order to establish that their advantages outweigh the disadvantages. Approaches to promote user acceptability and the development of an empirical database include dimensionalizing existing DSM categories and including research dimensions in the DSM appendix.

Spinning on its axes: DSM and the social construction of psychiatric diagnosis

Through a critical examination of the psychiatric profession's heavy reliance on the Diagnostic and Statistical Manual of Mental Disorders, the authors explore the central role of diagnosis in the theory and practice of psychiatry. The set of beliefs that have guided the psychiatric profession since the creation of DSM-III are viewed as being tied to the new extension of the biopsychiatric medical model. From a sociological perspective, the authors address the issue of psychiatric nosology with reference to practice styles and professional dominance, and consider the impact of DSM's intrinsic social biases both within and outside psychiatry's traditionally drawn boundaries. They conclude that working soley within the confines of a medical framework of diagnosis, with little attention to the wider social and cultural contexts that should surround diagnostic practice, psychiatry will be unable to understand and explain the changing needs of its clientele.

Paranoid schizophrenia: prognosis under DSM-II and DSM-III-R

DSM-III-R subtype-specific criteria and Tsuang-Winokur demographic criteria for paranoid schizophrenia were applied to records of discharged schizophrenic inpatients diagnosed according to DSM-II. Those meeting DSM-III-R subtype-specific criteria for paranoid schizophrenia and those who did not, ie, they received more hopeful diagnoses, had equally good prognoses. Good outcome was associated with the presence of prior affective symptomatology, absence of formal thought disorder, or other negative-type symptoms as well as Tsuang-Winokur demographic criteria of onset after age 25, married or employed status, and/or absence of family history. Patients with particularly poor outcome were identified by the coexistence of unsystematized or poorly developed persecutory ideation, symptoms of thought disorder, and/or disorganized behavior. The clinical and demographic descriptors discussed in this report may be particularly useful in creating homogeneous patient groupings for both clinical and rate-setting payment classifications.

The influence of racial factors on psychiatric diagnosis: a review and suggestions for research

Research on race and diagnosis initially focused on black-white differences in depression and schizophrenia. Statistics showing a higher treated prevalence of schizophrenia and a lower prevalence of depression for blacks seemed to support the claim that blacks did not suffer from depression. Others argued, however, that clinicians were misdiagnosing depression in blacks. This article reviews empirical studies of racial differences in individual symptoms and summarizes the evidence on misdiagnosis. It argues that more attention must be paid to resolving two contradictory assumptions made by researchers working in the area of race and diagnostic inference: (1) blacks and whites exhibit symptomatology similarly but diagnosticians mistakenly assume that they are different; (2) blacks and whites display psychopathology in different ways but diagnosticians are unaware of or insensitive to such cultural differences. The article concludes with suggested research directions and a discussion of critical research issues.

Late onset schizophrenia-like illness

A chart review of 658 psychiatric inpatients aged 65 years or older with a clinical diagnosis of schizophrenia revealed 32 patients (4.8%) with onset of symptoms after aged 45 who met DSM-III criteria for schizophrenia (except age of onset). Clinical course and response to treatment revealed only 25% to follow an unequivocally schizophrenic pattern. Almost 20% demonstrated substantial affective symptomatology, whereas 15.6% had a brief psychotic episode with full remission, and 40.6% showed signs of organic deterioration. These results suggest that diverse underlying pathologic processes may present initially as late onset schizophreniform illness. The presence of depressive symptoms and assaultive behavior on admission predicted good treatment response while sensory deficits and development of signs of organicity were associated with poor treatment response.

Autistic children grow up: an eight to twenty-four year follow-up study

Eighty questionnaires were sent to parents and/or caregivers of autistic persons diagnosed between 1960-73 at CPRI, a regional assessment and treatment centre. The objective was to determine their present place of residence, functioning ability, language development, program involvement, and seizure activity. The results of this study support evidence that more than 50 percent require long-term institutional care; almost one-third suffer epileptic seizures; there is a persistence of symptoms and difficulty in gaining useful speech; few live independently or are capable of employment.

Clinical correlates of readmission in a schizophrenic cohort

A study of a cohort of 223 schizophrenic patients from a single catchment area followed up for two years after discharge from inpatient status revealed a significant association between the presence of two of 38 clinical problem categories (social withdrawal and drug abuse) and subsequent readmission. In addition, patients without social withdrawal who were readmitted showed a significantly greater use of aftercare services than those not readmitted, while, among those with social withdrawal, male patients were significantly more likely to be readmitted than female patients. Neither prior hospitalization nor the presence of affective symptoms were significantly associated with readmission. Clinical and research implications of these findings are discussed.

The reliability of psychiatric diagnosis in Israel's Psychiatric Case Register

To determine the reliability of psychiatric diagnoses in the Israel Psychiatric Case Register, DSM-III criteria were applied to case record abstracts of first admissions to a large psychiatric hospital in Jerusalem. The DSM-III diagnoses were compared with ICD-8 records diagnoses. Between 40 and 50% of those originally diagnosed as schizophrenia were re-diagnosed into less severe categories. The proportion diagnosed as affective disorder doubled from 21% for ICD-8 diagnoses to 40% for DSM-III diagnoses. The unreliability concerned the diagnoses of schizophrenia and affective disorder. Findings suggest that the introduction of standardized diagnostic criteria in Israel will lead to a substantial increase in the number of cases diagnosed as affective disorder, although difficulties involved in differentiating schizophrenia from the major affective disorders remain. The DSM-III findings suggest a high prevalence of affective disorders among Jews.