DSM-III Diagnoses Research Articles

Diagnostic importance of combined parent and teacher ratings on the Revised Behavior Problem Checklist.

The Revised Behavior Problem Checklist (RBPC) was completed by parents and teachers for 105 child psychiatry outpatient boys aged 6 to 12 years. In addition, DSM-III diagnoses were determined independent of checklist results, and the children were divided into major diagnostic groups of externalizing, internalizing, and mixed disorders. Combined parent and teacher ratings proved more effective than separate ratings in distinguishing the externalizing and mixed groups from the internalizing group on the RBPC externalizing factors. The overall classification of individual boys with discriminant function analysis increased from 72% to 83% when the ratings of both parents, rather than one parent, were combined with teacher ratings. Enhancing diagnostic accuracy of type of psychiatric disorder by using combined parent and teacher behavior checklist ratings is discussed.

Agreement of parent and teacher rating scales with comprehensive clinical assessments of attention deficit disorder with hyperactivity

Forty-one clinic-referred children were given the DSM-III diagnosis of attention deficit disorder with hyperactivity (ADD/H) based on structured diagnostic interviews of the child and mother and on two teacher and two parent rating scales. The degree of agreement between diagnostic classification of ADD/H based solely on criterion scores on each rating scale and classification based on the comprehensive clinical assessments that included use of the same rating scaleswas assessed by comparing the ratings of the 41 children with ADD/H to those of 47 clinic-referred children given other diagnoses or no diagnosis. The accuracy of classification was highly similar across scales. Increasing the cutoff score increased the acing “true positives.” Using the point of intersection of these two curves to choose the optimal cutoff scores resulted in 70–75% accurate classification and 25–30% misclassification of children given clinical diagnoses of ADD/H. This rate of misclassification suggests that rating scales alone should not be used to classify ADD/H for most clinical and research purposes, especially because the method of comparison used in this study favored finding a high degree of correspondence.

A Review of Computer Diagnosis in Psychiatry with Special Emphasis on DSM-III

Several approaches to computerized psychiatric diagnosis (Bayesian probability, linear discriminant function, and logical decision tree) have been used in the past. Recently, however, computer programs have been developed to make DSM-III diagnoses. DSM-III's explicit criteria aid development of such programs, while DSM-III's complexity allows such programs to be clinically useful. Common characteristics of these programs are feature that help to structure and shorten the user's interaction with the program. Examples of structuring aids include screening questions and incorporation of DSM-III's decision trees for differential diagnosis. These programs also include features that help users learn about DSM-III. The potential for such programs, as well as reasons why they may not be fully accepted, are discussed.

Computer Programs to Support Clinical Decision Making

To the Editor.— Dr Shortliffe's otherwise thorough discussion of computer programs that support clinical decision making 1 contains a significant omission in that it fails to discuss diagnostic programs in psychiatry. Psychiatric problems are more common than most of the disease entities discussed in the article and are routinely diagnosed and treated by most physicians. In particular, I have been using a computerized version of the Diagnostic Interview Schedule of the National Institute of Mental Health to obtain a DSM-III diagnosis. I have used this expert system for about 75 patients in my private psychiatry practice over the past two years. The Diagnostic Interview Schedule is a structured psychiatric interview developed at the National Institute of Mental Health. The computer-administered and computer-scored Diagnostic Interview Schedule was developed at the University of Wisconsin under the direction of John H. Grist, MD, and Marjory H. Klein, PhD. A recently published study 2 showed

Level of social-cognitive development, adaptive functioning, and DSM-III diagnoses in adolescent offspring of parents with affective disorders: Implications of the development of the capacity for mutuality.

This study examines the relation between the developmental social-cognitive capacity for interpersonal negotiation and both parental-risk and adolescent-outcome variables in 172 adolescents 11 to 19 years of age. The sample was divided into two groups: those at risk because of affective disorder in one or both of their parents and a comparison group whose parents have never experienced affective illness. Adolescents' interpersonal negotiation strategy (INS) levels were negatively associated with the duration of parental affective illness (and with associated lower socioeconomic status and marital discord). INS level significantly predicted adolescents' adaptive social functioning (AFR) even after controlling for age, sex, intelligence, number of adolescent diagnoses, and parental-risk factors. Two additioaal patterns were found in the risk group: adolescents with both high AFR and high INS, and adolescents who have disturbed functioning despite high INS, These findings are consistent with a risk model in which social-cognitive capacity mediates between parental disorder and adaptive child behavior, and they suggest the importance of assessing children at risk with a developmental measure of relational capacity to complement the more traditional diagnostic and behavioral outcome measures.

The incidence of schizophrenia in Nottingham.

Attempts were made to identify, and include in a two-year follow-up study, every patient living in the catchment area of the Mapperley group of psychiatric hospitals in Nottingham (population 390,000) who made their first-ever contact with the psychiatric services for a potentially schizophrenic illness during a two-year period (1 August 1978 to 31 July 1980). Screening was based upon symptoms rather than diagnosis, covering both in-patient and out-patient services; a consensus diagnosis using ICD-9 was made by the project team. The Nottingham Psychiatric Case Register was used in a retrospective Leakage Study which added nine cases to the 99 identified by the screening procedures. Incidence rates are given for both broad and narrow concepts of schizophrenia, and for DSM-III diagnosis. The Nottingham incidence rates are similar to those reported from other UK centers, and are near the middle of the range found in the other collaborating centres in the WHO study on Determinants of Outcome of Severe Mental Disorders. At entry to the study, 27 patients were out-patients, and 11 were never admitted to hospital at any time in the two-year follow-up period. Reasons for believing that the Nottingham administrative incidence may be close to the incidence in the community are discussed.

A laboratory procedure for the induction of flashbacks.

The authors administered infusions of lactate intravenously to seven patients with a DSM-III diagnosis of posttraumatic stress disorder, six of whom also met DSM-III criteria for panic disorder. The lactate infusions resulted in flashbacks in all seven patients and panic attacks in six patients. The authors conclude that with further development intravenous lactate infusion may be used to study flashbacks and other dissociative phenomena and to determine the relationship between flashbacks and panic anxiety.

Children of parents with manic-depressive illness: a follow-up study.

Thirty-seven offspring from 21 families with a manic-depressive parent were studied 3 to 7 years following initial evaluation. The study examined both pedigree information and psychosocial variables including parental, marital and overall adjustment, measures of chronicity and severity of parental illness and family assessment measures in relationship to offspring functioning. Nine of the 37 offspring (24%) received a positive DSM-III diagnosis, which is a similar percentage of positive diagnosis of children as we found previously. The diagnoses clustered in the affective illness spectrum. When the presence of affective traits was considered, there was evidence for continuity of psychopathology in most cases. Associations between offspring psychopathology and both non-specific and specific parental risk factors are discussed.

Psychometric Screening for Attention Deficit Disorder in a Clinical Setting

There is growing dissatisfaction with the DSM-III definition of Attention Deficit Disorder (ADD) and considerable debate among researchers as to whether ADD is a distinct disorder. Additionally, clinicians have relied on nonobjective behavioral observation to diagnose ADD. The present study attempted to find commonly used tests that could discriminate between an ADD sample and a control group with no DSM-III diagnosis. Subjects were 88 children, 7 to 10 years of age, who had received a battery of psychological tests. Discriminant analysis confirmed that hypothesized attention tests from the WISC-R, ITPA, Detroit, plus the GFW Auditory Selective Attention Test, significantly differentiated between the two groups and classified 74% of the cases correctly. It was concluded that use of these tests might add objective evidence to ADD screening and that the overall results lent support to ADD as a valid diagnostic classification.

DSM-III diagnoses associated with dyspepsia of unknown cause.

The frequencies of DSM-III diagnoses in 30 patients with dyspepsia of unknown origin and 20 patients with organic dyspepsia were compared. Dyspepsia of unknown origin was associated with a higher prevalence of psychiatric diagnoses (86.7% versus 25.0%), particularly anxiety disturbances (66.7%).

The establishment of a mood disorders unit.

The establishment within a general hospital psychiatry ward of a mood disorders unit (MDU), a specialised facility for the assessment and treatment of patients with affective disorders, is described. The aims include provision of a clinical service, a teaching resource for affective disorders and the development of a research centre. Details are provided of the organisation of the MDU, the development of programs for management of patients and the difficulties encountered. In the first year, 164 patients were assessed, of whom 36 were judged not to have a primary mood disorder. For the remainder, the most common DSM-III diagnosis was major depressive episode (n = 68), with about half having the melancholic sub-type. It is argued that a specialised diagnosis-related facility is feasible within a general hospital psychiatry service with area health commitments.

Psychological Functioning in Children With Crohn's Disease and Ulcerative Colitis: Implications for Models of Psychobiological Interaction

Implications for psychobiological models of psychosomatic interaction relevant to the DSM-III diagnosis 316.00 (Psychological Factors Affecting Physical Condition) were drawn from a study of outpatient gastroenterology patients (ages 6 to 17) with Crohn's disease (CD) (N = 51) and ulcerative colitis (UC) (N = 37), and their siblings (N = 41 and N – 24, respectively). Reliable and valid measures were used to assess disease activity, severity, growth failure, social competence, psychological health and disorder, and psychological style. Both patient groups had statistically and clinically significant psychological dysfunction, and patients were characterized by internalizing psychological styles. The degree of illness and psychological dysfunction did not predict one another. However, internalizing psychological styles were associated with greater disease activity. CD and UC patients differed in relationships among psychological and disease factors, with UC patients more accurate in reporting physical and psychological functioning. Implications for psychobiological models of psychosomatic interaction relevant to the DSM-III diagnosis 316.00 (Psychological Factors Affecting Physical Condition) were drawn from a study of outpatient gastroenterology patients (ages 6 to 17) with Crohn's disease (CD) (N = 51) and ulcerative colitis (UC) (N = 37), and their siblings (N = 41 and N – 24, respectively). Reliable and valid measures were used to assess disease activity, severity, growth failure, social competence, psychological health and disorder, and psychological style. Both patient groups had statistically and clinically significant psychological dysfunction, and patients were characterized by internalizing psychological styles. The degree of illness and psychological dysfunction did not predict one another. However, internalizing psychological styles were associated with greater disease activity. CD and UC patients differed in relationships among psychological and disease factors, with UC patients more accurate in reporting physical and psychological functioning.

Agoraphobia and Parental Bereavement

The prevalence of parental bereavement was determined in 50 married female outpatients with a DSM-III diagnosis of agoraphobia and in a control group of married female outpatients diagnosed as having non-psychotic psychiatric disorders other than agoraphobia. The two groups were matched for age and overall severity of psychiatric symptoms. Compared with the general population, the patient control group reported a statistically significant excess of parental, but not maternal, bereavement. The agoraphobic group was significantly younger than the control group at the time of parental loss. These data, together with other reports, suggest a contribution of paternal bereavement before the age of 30 years to agoraphobia in married women and a contribution of recent parental bereavement ot psychiatric disorder in general.

A 20-month follow-up study of 628 women with eating disorders, I: Course and severity

A national sample of 628 women with eating disorders completed questionnaires in 1982 and again in 1984. According to initial simulated DSM-III diagnoses, 34 had anorexia nervosa with bulimic features, 392 had normal-weight bulimia, and 202 had a subdiagnostic eating disorder. Most respondents in the latter two groups met some criteria for alternative eating disorders. At follow-up, 29% of the anorexia nervosa group and 43% of the normal-weight bulimia group had improved enough to be classified as having a subdiagnostic disorder. Respondents who sought professional help between the initial survey and follow-up reported no more improvement than those who did not seek help.

Attention deficit, conduct, oppositional, and anxiety disorders in children: III. Laboratory differences.

Children aged 5-13 years with DSM-III diagnoses of Attention Deficit (ADDH), Anxiety, (ANX), or Conduct plus ADDH (HC) Disorder and matched normal controls were compared on a set of laboratory measures of impulsivity, arousal, motor performance, activity level, and cognition, and on behavior ratings during testing. While ANX patients did not differ from their controls, ADDH and HC patients did on Verbal IQ, most of the behavior ratings, and on about one-third of the test variables. ANX patients were about 1 year older, and more likely to be female, than ADDH and HC patients. When age, sex, and verbal IQ effects were partialed out, very few differences among the three diagnostic groups remained. The importance of precise control of such variables is emphasized and the impact of the failure to do so in past studies is discussed. The question is raised whether the deficit in verbal IQ is not so much a defect of matching as the essential feature of ADDH from which most of the other commonly reported cognitive symptoms stem.

Reliability of DSM-III diagnoses for major depression and generalized anxiety disorder using the structured clinical interview for DSM-III.

This study examined the interrater reliability of generalized anxiety disorder (GAD) and major depressive disorder (MDD) diagnoses derived from the Structured Clinical Interview for DSM-III (SCID). Using videotaped interviews, paired raters made independent diagnoses of 75 psychiatric outpatients. The percent agreement of the raters was 82% for MDD and 86% for GAD; the respective kappa values were .72 and .79. The results indicated that the SCID can be employed reliably to differentiate MDD from GAD. The SCID is recommended for further research with these disorders.

An empirical comparison of three different borderline concepts.

Forty-six inpatients were independently diagnosed according to the DSM-III concept of borderline personality disorder, the diagnostic interview for borderlines (DIB) and the concept of borderline personality organization, which is linked to Kernbergs structural interview. The interviews were videotaped. Satisfactory inter-rater reliability was demonstrated for the DIB, which furthermore showed high sensitivity and specificity in identifying patients with a clinical DSM-III diagnosis of borderline personality disorder from patients with a other personality disorders or schizophrenic disorders. Discriminant features, demographic profile and earlier treatment history for the patients with a borderline personality disorder are described and discussed. The structural interviews were scored according to a specified format. Inter-rater reliability was satisfactory but not too impressive. Borderline personality organization turned out to be a very broad concept and only half of the patients within this concept received a syndrome diagnosis of borderline personality disorder. A general conclusion was that borderline personality organization should not be considered as a diagnostic entity but rather as a different diagnostic dimension representing an intermediate level of personality structure.

Urban environment, marital status and mental disorders. An investigation of psychiatric new referrals to outpatient clinics from a geographically defined sector.

This study examines the distribution of sex, marital status and mental disorders among new referrals to outpatient clinics from two different urban environments. Differences in the distribution of marital status among patients and inhabitants in the two urban environments were tested with the "chi-square" method for each sex separately. In proportion to the population, significantly more married, separated and divorced women were referred from satellite communities than from traditional urban areas. When DSM-III diagnoses were taken into account, there were significantly more married women with "affective and anxiety disorders" in satellite communities. Similar differences were not observed among men in satellite and traditional urban communities. Social environment seems to be a major contributor to mental disorders in women. In addition, sex role plays an important part in the development of "affective and anxiety disorders" in married women. Sex role alone does not explain the findings of this study.

Twin concordance for DSM-III schizophrenia. Scrutinizing the validity of the definition.

DSM-III diagnoses were applied to 26 monozygotic (MZ) and 34 dizygotic (DZ) probands and their co-twins from the Maudsley Hospital (1948 to 1965) schizophrenic series of Gottesman and Shields. DSM-III criteria for schizophrenia were found to be highly reliable and valid, and to have a broad heritability of 0.85, which is comparable with the Research Diagnostic Criteria and Feighner criteria from which they were derived. When the full range of DSM-III diagnoses were considered, both affective disorder and schizophrenia were found in genetically identical individuals. The effect of DSM-III nosology on the twin series was also explored by adding other diagnoses to that of schizophrenia and observing the effect on the MZ/DZ concordance ratio. The addition of affective disorder with mood-incongruent delusions to the schizophrenia spectrum produced the largest increase in the ratio and, by implication, a "more genetic" combination than schizophrenia alone. The maximum MZ/DZ concordance ratio (7.68) was produced by schizophrenia, plus affective disorder with mood-incongruent delusions, plus schizotypal personality disorder, plus atypical psychosis. The effect of adding paranoid disorder (paranoia) and all other affective categories was a reduction in the ratio.

Depression, depressive symptoms, and depressed mood among a community sample of adolescents.

Using a structured interview, the authors found that the prevalence of major depression and dysthymic disorder was 4.7% and 3.3%, respectively, in a community sample of 150 adolescents. All of the adolescents who met the criteria for major depression and dysthymic disorder had other psychiatric disorders as well; anxiety was the most frequent accompanying DSM-III diagnosis.