DSM-III Diagnoses Research Articles

Mental health service utilization among Puerto Rican children ages 4 through 16

This paper examines those children receiving mental health services in Puerto Rico, their demographic and psychosocial characteristics, and describes service providers and nature of facilities. The survey was done on a probability sample of children ages 4 through 16 across the island of Puerto Rico (N=777). Need for services was clinically defined as presence of a DSM-III diagnosis and functional impairment. The overall rate of service utilization for Puerto Rican children was 6% (26.2% of “definite cases” and 5.1% of “probable cases”). In most cases services were provided by psychologists and/or social workers, and they were mainly provided in schools and general medical facilities. In over 60% of the children assessed as cases, who did not receive services, the reason, given by the parent was that they considered the problem not serious. Factors associated with service utilization were measures of psychopathology, teacher's perceived need, and parental rates of criticism and hostility. These findings suggest that there is a need for more research on the motivating factors for service use (impairment and parental criticism). Teachers could benefit from receiving special training to help them readily recognize behavioral problems in children, communicate them to parents and set up services alternatives.

Predictors of response to lithium in patients with psychoses

This study sought to characterize a subset of patients with DSM-III schizophrenia or schizophreniform disorder who respond to lithium. Sixty-six psychotic patients were given a systematic therapeutic trial of lithium alone. Differences in demographic characteristics, symptoms, and family history of psychotic disorders between the responders and nonresponders to lithium were explored. Responders and nonresponders did not differ significantly in age, duration of illness, length of current episode, distribution of RDC and DSM-III diagnoses, or number of positive symptoms. However, the responders to lithium (N = 10) exhibited a paucity of negative symptoms and an absence of familial schizophrenic spectrum disorders. These preliminary results suggest the possibility of pretreatment identification of psychotic patients for whom neuroleptic medication could be avoided by therapeutic intervention with lithium alone.

Physical and sexual abuse and associated mental disorders among alcoholic inpatients

The purpose of this study was to investigate the adult psychiatric correlates of childhood abuse among alcoholic inpatients. The 802 patients, who included 321 women, were admitted to one of five New York State alcohol treatment inpatient centers. Each patient was interviewed, and sexual and physical abuse history, DSM-III diagnosis, and other characteristics were recorded. The overall prevalence of reported childhood abuse was 59% for women and 30% for men. Family history of alcoholism was associated with higher levels of physical and sexual abuse. Gender differences in types of childhood abuse (i.e., sexual abuse only, physical abuse only, dual abuse) were evident; 49% of the women and 12% of the men reported sexual abuse (with or without physical abuse), 33% of the women and 24% of the men reported physical abuse (with or without sexual abuse), and 23% of the women and 5% of the men reported dual abuse. Abuse status, and especially dual abuse, was associated with higher rates of antisocial personality disorder and suicide attempts among women and men, with generalized anxiety disorder among women, and with major depression among men. The findings highlight the long-term associations between sexual and physical abuse and adult coexisting mental disorders among alcoholic inpatients. Addressing unresolved intrapsychic trauma associated with childhood abuse may increase the efficacy of treatment outcomes and reduce relapse rates among alcoholics.

The social network of patients with schizoaffective disorder as compared to patients with diabetes and to healthy individuals

The social network was evaluated by means of the self-rating scale ‘Interview Schedule for Social Interaction’ (ISSI) and semi-structured interviews in married patients with a DSM-III diagnosis of schizoaffective disorder ( N = 17, partners, N = 16), married patients with diabetes ( N = 10, partners, N = 10) and in married healthy individuals ( N = 8, partners, N = 8). The two latter groups were comparison control groups matched for sex and age to the patients with a schizoaffective disorder. The scores on the ISSI and its subscales for the groups were compatible to those found in other Swedish studies. Patients with a schizoaffective disorder both experienced that they had less access to (AVAT) and were less satisfied with their deep emotional relations (ADAT). The same patients had a higher level of neuroticism as compared to the rest. The patients with a schizoaffective disorder had less often than the patients with diabetes been informed about their disease. Moreover, the partners to the patients with a schizoaffective disorder had not been informed about the disease and experienced that they had fewer social contacts (AVSI). A challenge for the professional network in psychiatry is to improve the information and education to families in which one member is struck by a schizoaffective disorder.

Family psychiatric screening instrument for epidemiologic studies: pilot testing and validation

Family history, a risk factor for psychiatric disorders, is infrequently assessed in epidemiologic studies due to time and cost constraints. We designed a brief computer-scorable instrument, the Family History Screen for Epidemiologic Studies (FHE), which collects a pedigree and screens for 15 DSM-III diagnoses in an informant and in his family members. The FHE was administered to one informant in 77 families in which we had collected pedigrees, interviewed 77 informants and 239 relatives using the Lifetime Anxiety version of the Schedule for Affective Disorders and Schizophrenia or the Epidemiologic version of the Schedule for Affective Disorders and Schizophrenia for School-Aged Children, and performed best-estimate diagnoses. We evaluated the accuracy with which the FHE predicted bestestimate diagnoses. For adults reporting on themselves, the FHE demonstrated high levels of sensitivity and specificity for depression (67.4, 75.0) and panic (92.5, 89.2), and low sensitivity and high specificity for substance abuse (33.3, 93.6). For informants reporting on adult relatives, sensitivity was low and specificity was high for depression (35.2, 84.9), panic (20.0, 91.7), and substance abuse (42.1, 93.4). For informants reporting on children, perhaps due to lower prevalence, sensitivity and specificity were poor. The FHE is a good screen for psychiatric disorders in adult informants, but it is not useful for family history. It may be useful in primary care medical settings as a screen for psychiatric history.

Tardive dyskinesia in schizophrenia. Relationship to minor physical anomalies, frontal lobe dysfunction and cerebral structure on magnetic resonance imaging.

It was hypothesised that schizophrenic patients with tardive dyskinesia show an excess of neurodevelopmental disturbance, particularly minor physical anomalies, in association with cognitive dysfunction and abnormalities of cerebral structure. Forty-seven out-patients with a DSM-III diagnosis of schizophrenia were examined for tardive dyskinesia using the Abnormal Involuntary Movement Scale; they were examined also for minor physical anomalies and neuropsychological test performance. Cortical atrophy, signal hyperintensities and lateral ventricular volume were determined on magnetic resonance imaging. Patients with and without tardive dyskinesia could not be distinguished by age, gender distribution or a number of clinical measures; however, patients with tardive dyskinesia sorted fewer categories on the Wisconsin Card Sorting Test (P = 0.04). Cerebral structure in patients with and without tardive dyskinesia could not be distinguished on magnetic resonance imaging but those with dyskinesia, all of whom showed involvement of the orofacial region, showed more evident minor physical anomalies of the head relative to those of the periphery (P = 0.02). Tardive orofacial dyskinesia in schizophrenia appears to be associated particularly with poorer frontal lobe function, while predominance of craniofacial dysmorphogenesis may constitute a vulnerability factor that is related to the early origins of the disease process.

A double-blind placebo-controlled study of Org 3770 in depressed outpatients

90 patients between 18 and 65 years, with a DSM-III diagnosis of moderate or severe major depressive episode, were randomized to 6 weeks of treatment with Org 3770 or placebo in a double-blind trial. On main efficacy parameters, the 17-item HAMD, MADRS and CGI, Org 3770 was significantly superior to placebo ( P ≤ 0.05) in weeks 1–4 and at endpoint and recommended as continuation treatment to significantly more patients. The tolerability of Org 3770 was good: the only significant differences as compared with placebo were in the incidences of somnolence and increased appetite. The results show that Org 3770 is an effective and well-tolerated drug for the treatment of major depressive disorder.

Mirtazapine is more effective than trazodone

Two hundred hospitalized patients with DSM-III diagnosis of moderate to severe major depressive episode were randomized to receive mirtazapine or trazodone for 6 weeks in a double-blind trial. The dosages were 24-72 mg/day for mirtazapine and 150-450 mg/day for trazodone. The improvement on all depression rating scales used was generally greater for mirtazapine, with statistically significant differences over trazodone in the Hamilton Psychiatric Rating Scale for Depression total score and two subscores (the Bech melancholia factor and retardation factor), the Brief Psychiatric Rating Scale total score, the General Psychiatric Impression Global Assessment Scale, the Beck score and responder rates. Mirtazapine was well tolerated, while the trazodone-treated patients experienced somnolence more frequently, particularly during the first 2 weeks of treatment. Furthermore, postural symptoms were a clinical problem in 6% of the trazodone-treated patients. In this trial, mirtazapine showed significant clinical advantages over trazodone in terms of overall efficacy and tolerability.

Life events and panic disorder/ agoraphobia

A patient-rated checklist adapted from the Psychiatric Epidemiology Research Interview was used to assess frequency and desirability of life events in the 12 months preceding an index evaluation of a large sample of patients with a DSM-III diagnosis of panic disorder or agoraphobia with panic, on average 12 years after onset of illness. A total of 1,360 events were reported; 25% were considered most undesirable, whereas 22% were estimated to be most desirable. Negative life events were predominantly health-related issues and interpersonal conflicts. Making new friends, having significant success at work, and taking up a new activity were examples of positive events. Correlations of life events with clinical and demographic variables and with symptom rating scales were also analyzed. Negative life events were associated with greater psychopathology and neuroticism scores. Positive life events were associated with greater extraversion scores, more years of education, better employment status, and less functional impairment due to symptoms. This exploratory study does not allow interpretation from an etiologic perspective. It begins to shed light on the possible role of life events in the course of the disorder.

Is gender dysphoria dysphoric? Elevated depression and anxiety in gender dysphoric and nondysphoric homosexual and bisexual men in an HIV sample

Few if any studies before the AIDS epidemic suggested that male homosexuals may on average have higher levels of depression than male heterosexuals. However, several samples of homosexual and bisexual men in HIV studies suggest that depression and anxiety are high in these populations, and that this psychiatric morbidity began before the AIDS epidemic. We tested the hypothesis that high childhood gender nonconformity (CGN) is associated with depression and anxiety, and so might account for differences in these variables among samples of homosexuals. A total of 254 homosexual or bisexual male subjects were assessed for depression, anxiety, and associated symptoms using various self-report and interview measures, as well as for CGN (using the Freund Feminine Gender Identity scale, FGI). For comparison purposes only, we also evaluated the subjects for the DSM-III diagnosis of Ego-Dystonic Homosexuality. Highly gender nonconforming men (high FGI scores) were more likely to have current symptoms of anxiety and depression by self-report, and to have had a lifetime history of depression by clinical interview. This association was more often due to FGI items dealing with childhood than adulthood. When the FGI was broken into subscales by a prior factor analysis, stepwise regression suggested that the subscale measuring core gender identity nonconformity (so-called "gender dysphoria") was more reliably associated with depression and anxiety than were the factors measuring nonconformity in the areas of masculine and feminine gender roles, or genitoerotic (sexual) roles. This subscale was also the only FGI measure correlating with Ego-Dystonic Homosexuality. AIDS (CDC stage and HIV serostatus) and age did not account for these findings. We conclude that the often-reported higher levels of depression, anxiety, and associated symptoms among homosexual and bisexual men in AIDS studies are more common in the subgroup of such men who are gender dysphoric. Theoretical and clinical implications of these data are discussed.

Distinguishing homelessness from poverty: a comparative study.

To separate the characteristics of the homeless from those of the housed poor, 144 adults were randomly sampled from several sites, yielding 3 groups: the currently homeless (n = 59), the previously (but not currently) homeless (n = 31), and the never-homeless poor (n = 54). The homeless were significantly less likely to be receiving public benefits, were more likely to have a DSM-III (Diagnostic and Statistical Manual of Mental Disorders [3rd ed.; American Psychiatric Association, 1980]) diagnosis of substance abuse, showed higher levels of self-rated psychological distress and were more likely to be victims of recent domestic violence and to have been physically abused as children. The homeless did not differ from the comparison groups on DSM-III diagnosis of severe mental illness (schizophrenia or major affective disorder). physical health symptoms, and social support and social networks.

Antidepressants, depression and suicide: an analysis of the San Diego study

Depression has been consistently reported in 40–50% of suicides. Previous toxicologic studies of suicides have not included diagnostic information, however. This report includes 247 (87%) of 283 suicides in whom it was possible to perform toxicological analyses for tricyclic antidepressants. We wanted to see if any relationships existed among the presence of antidepressants at autopsy, diagnosis of Depression, recent contact with physicians and prescription of antidepressant medication. Toxicology was positive in 19 (8%) subjects. Only 12% of the subjects with a DSM-III diagnosis of Major of Atypical Depression were positive. Lethal blood levels of antidepressants were found in only 4% of all subjects and most of those involved multiple drugs. Also, most of those subjects had co-morbid Depression and Substance Abuse. More than half of the Depressed subjects had been a physician within 90 days from suicide but less than half of these were prescribed antidepressants and only one-third of the latter were positive for antidepressants in toxicology. These data suggest that more suicides might be averted by decisively treating Depressed patients with ADs, including strict monitoring of dosage and compliance, than by not treating them to avoid AD overdoses. Diagnostic caution should be observed to identify co-morbid Substance Abuse when treating patients with Depression and suicidal ideation.

Electrodermal activity and clinical status in chronic schizophrenia.

The present study investigated the association between electrodermal nonresponsiveness and clinical state in schizophrenia. Sixty-three patients with a DSM-III diagnosis of chronic schizophrenia served as subjects. Clinical status was assessed using multiple measures, including age of onset, symptom severity, illness duration, hospitalization history, global functioning, and occupational functioning. Electrodermal hypoactivity was found to be associated with poorer functioning and a more severe form of illness. In addition, hyporesponsive patients displayed more conceptual disorganization and alogia.

A Psychiatric Hospital 100 Years Ago: I. A Comparative Study of Treatment Outcomes Then and Now

The authors' goal was to compare distribution of diagnoses, length of stay, and readmission rates for every 16th patient admitted to the St. Louis County Insane Asylum (now St. Louis State Hospital) between 1886 and 1904 with those for every 16th patient admitted to the hospital between 1978 and 1980. A sample of 369 cases was drawn from the archival admission records, and 380 cases were selected from recent admissions. Descriptive data from the archival records were used to make DSM-III diagnoses. Data on length of stay and number of readmissions were collected from case records. The historical sample had fewer cases of major mental illness, longer mean lengths of stay, and fewer mean readmissions than the modern sample. Differences in the clinical characteristics of the two samples may be explained by differences between the two periods in treatment philosophies, admitting policies, and presence of alternative resources for accommodating long-term chronic patients.

Cannabis and acute psychosis

The Present State Examination was used to assess the psychopathology of 23 psychotic patients who were cannabis positive on urinary screening, and 46 matched drug-free controls. Cases and controls were indistinguishable in terms of psychopathology, DSMIII diagnoses, onset of recent illness, the proportion of first admissions, ethnicity, and socio-economic class, differing only in their histories of substance use. These data suggest that psychosis which develops or recurs in the context of cannabis use does not have a characteristic psychopathology or mode of onset, and is not restricted to a particular ethnic or socio-demographic group. There is thus little evidence to support the validity of ‘cannabis psychosis’ as a diagnostic entity.

Emergence of bulimia nervosa as a separate diagnostic entity: Review of the literature from 1960 to 1979

With Russell's description of bulimia nervosa in 1979, followed by the DSM-III diagnosis of bulimia, a "new" eating syndrome found its official acceptance in the scientific world. In the two preceding decades clinicians and researchers gradually payed more attention to special forms of overeating. In the 1970s the nosographic conceptualizations of binge eating, bulimia, compulsive eating, or hyperorexia clearly shifted from a symptom level--closely connected to anorexia nervosa and/or obesity--to a syndrome level. Around the same time and independently from one another, clinicians from different countries proposed various descriptive labels for this new diagnostic entity, which, finally, became accepted as bulimia nervosa.

Comorbidity of Empirically Based Syndromes in Matched General Population and Clinical Samples

Comorbidity of deviance on eight empirically based syndromes was compared in matched general population and clinical samples of 2,705 children aged 4-18, using a bidirectional formula to avoid confounding effects of differential base rates. Syndromes were assessed via parent ratings on the CBCL, teacher ratings on the TRF, and self ratings on the YSR. Significantly higher comorbidity rates were obtained for clinical than general population samples for all 28 pairings of CBCL syndromes, 15 pairings of TRF syndromes, and 22 pairings of YSR syndromes. Bidirectional comorbidity rates for empirically based syndromes were compared to pairings of comparable DSM-III diagnoses.

Suicidal ideation and suicide attempts: comorbidity with depression, anxiety disorders, and substance abuse disorder.

The effect of comorbidity on rates of suicidal ideation and suicide attempts from an adult general population of former West Germany is investigated. The assessment instrument is a modified German version of the Diagnostic Interview Schedule (DIS), a fully standardized interview for the assessment of selected DSM-III lifetime diagnoses as well as suicidal ideation and suicide attempts. Of the general population 4.1% (2.2% male and 4.1% female) made suicide attempts during their lifetime. Only 2 of 18 people who attempted suicide did not meet criteria for a DSM-III-R diagnosis. Cases with pure major depression did not have an odds ratio for suicide attempts significantly higher than subjects with no DSM-III diagnosis. However, cases with both a major depression and a lifetime-anxiety-disorder diagnosis showed significantly elevated odds ratios. Therefore, it is suggested that comorbidity of anxiety and depression, and not depression itself, seems to be a risk factor for suicide attempts.

Correlates of Hysterical Symptoms in Schizophrenic Patients

The correlations of symptoms of hysteria with 87 symptoms relevant for diagnosing schizophrenia were examined in a sample of 112 patients (70 women and 42 men whose mean age was 38.1 yr., SD = 9.8) with DSM-III diagnosis of schizophrenia. Hysterical symptoms were recorded in 37.5% of the schizophrenics. No significant relationships (phi coefficients) were found to key symptoms of schizophrenia.

Correction and Amplification

In reexamining the data on comorbidity from the Puerto Rico Child Psychiatry Epidemiologic Study that appeared in the December 1988 issue of theArchives, we have discovered an error in Table 5 (page 1124) of that article 1 in the number of children reported as having anxiety disorders. Because of a computer programming error, only those with separation anxiety disorder and phobias (n=18) were originally included as having anxiety disorders on this table. Fifteen children with other anxiety disorders had been left out (correct total, n=96). A revised Table appears here. For the same reason, the overall comorbidity rates appearing in the text on page 1124 of the article were also misstated. Of the 265 children who were classified as having one or more DSM-III diagnoses, 221 (rather than 215) fell into one or more of the supraordinate domains of psychopathology. Of those, 48.9% (53.2%