Comparison of Diagnostic Methods for Asperger Syndrome

Several different diagnostic sets of criteria exist for Asperger syndrome (AS), but there is no agreement on a gold standard. The aim of this study was to compare four diagnostic sets of criteria for AS: the ICD-10, the DSM-IV, the Gillberg & Gillberg, and the Szatmari criteria. The series consists of 36 children who had been referred to two centers with a tentative diagnosis of AS. The best agreement was between the ICD-10 and the DSM-IV criteria (Kappa coefficient 0.48), and the lowest between the Gillberg & Gillberg and Szatmari criteria (Kappa coefficient -0.21). The poor agreement between these sets of diagnostic criteria compromises the comparability of studies on AS.     

Prevalence of DSM-III-R and ICD-10 psychiatric disorders in a Spanish population of 18-year-olds

The aim of this study was to estimate the current prevalence of DSM-III-R and ICD-10 psychiatric disorders in Spanish 18-year-old members of the general population. Subjects were assessed using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN). Nearly 30% of the study subjects reported at least one current disorder according to ICD-10 criteria, and almost 21% reported at least one current disorder according to DSM-III-R criteria. Women had a significantly higher probability of suffering from any psychiatric disorder than men. The most common disorders were insomnia, dysthymia, major depression and simple phobia. Nearly 40% of the diagnosed subjects had one or more comorbid disorders. Comorbidity was found to be higher among female subjects. Consistent with previous risk factor research, it was found that women had higher rates of mood, anxiety and sleep disorders than men. Good communication between parents and their offspring was found to be a protecting factor for all disorders.     

Psychogenic (reactive) and hysterical psychoses: a cross-system reliability study

The aim of this study was to investigate the concepts of reactive and hysterical psychoses and how they are classified in standardized diagnostic Systems. To this end we identified all of the patients who had been admitted to a psychiatric in-patient unit and diagnosed as suffering from psychogenic psychosis, reactive psychosis, hysterical psychosis or hysteria, using ICD-9 criteria. The case notes of these patients were then re-examined and diagnoses reached using DSM-III-R, DSM-IV and ICD-10 criteria and the Present State Examination (PSE)/catego computer program. The objective of this study was to evaluate the agreement between the diagnoses of reactive and hysterical psychosis obtained using ICD-9 criteria with those obtained using the DSM-III-R, DSM-IV, ICD-10 and PSE diagnostic Systems. A total of 67 case notes were identified in which the above diagnoses had been made: 27 cases with ICD-9 ‘hysteria’ and 26 cases with ‘other reactive and not otherwise specified psychoses’. Using the DSM-III-R criteria, 27 cases were diagnosed as psychotic disorder NOS, 12 as brief reactive psychosis and 11 as bipolar disorder. Using the DSM-IV criteria, 21 cases were diagnosed as psychotic disorder NOS, 11 as mood disorder, 7 as brief disorder without stressor, and 12 as brief disorder with stressor. Using the ICD-10 criteria, 18 cases were diagnosed as unspecified non-organic psychosis, 12 as mood disorder, 10 as acute and transient psychotic disorder without stressor and 13 as acute and transient psychotic disorder with stressor. Using the PSE/catego program, the most common diagnoses were class ‘S’ schizophrenia (17), class ‘P?’ uncertain psychosis (16) and class ‘M+’ mixed and manic affective disorder (11). Using the kappa coefficient a very low level of agreement was found between ICD-9 ‘hysteria’ and ‘other reactive and non-specified psychoses’ and the corresponding categories of DSM-III-R and the PSE/catego program. We concluded that, although DSM-III-R provides operational criteria for brief reactive psychosis, and DSM-IV and ICD-10 provide such criteria for brief or acute psychotic disorder, these bear little relationship to the original concept of the disorder. The PSE/catego program provides a very systematic approach to symptomatology, but the diagnostic classes have little clinical usefulness.     

Reliability of the ICD-10 diagnostic criteria for research in mental disorders in the Republic of Korea

The interrater reliability, confidence and ease of use of ICD-10 diagnostic criteria for research were assessed in the Republic of Korea as part of the field trials of World Health Organization collaborative study. A total of 279 patients were diagnosed according to the ICD-10 diagnostic criteria for research. Interrater reliability, calculated by kappa statistics, was found to be between 0.74 and 0.91 on 2-character categories and between 0.64 and 0.90 on 3-character categories except schizotypal disorder (F21). On the 4-character categories, the agreement in the affective states between raters was lower. The reasons are discussed based on cultural differences.     

Operationalisierte Diagnostik der Borderline-Persönlichkeitsstörung Eine Befragung von Psychiatern und Psychologen bezüglich ihrer Syndromvorstellungen

Despite the diagnostic criteria of the ICD-10 and DSM-IV, the term borderline has been used in a non-specific way for a long time. For our investigation we constructed a questionnaire, which contained the ICD-10 diagnostic criteria for the borderline personality disorder (BPD), plus the criteria for the other personality disorders and for the schizotype disorder. The two additional criteria for the BPD used by the DSM-IV were added. 800 psychiatrists and psychologists were asked to mark all criteria, which they thought were typical for the BPD. By using the operational diagnostic approach for ICD-10 and DSM-IV a disorder was diagnosed from each of the 162 received questionnaires based on the marked criteria. 92.0% of the questionnaires contained marked criteria for the diagnosis of the BPD by ICD-10 and 96.3% by DSM-IV. In addition each questionnaire contained up to eight other diagnosis. This is a sign for the difficulty to separate the BPD from other personality disorders or the schizotype disorder by using operationalized criteria. Looking at the lack of specificity of the operational diagnostic systems for personality disorders, e.g. for the BPD which has been discussed by many authors for years, modification of the diagnostic systems should be considered.     

Reliability of clinical ICD-10 schizophrenia diagnoses

Concern has been expressed as to the reliability of clinical ICD-10 diagnosis of schizophrenia. This study was designed to assess the diagnostic reliability of the clinical ICD-10 diagnosis of schizophrenia in a random sample of Danish in- and outpatients with a history of psychosis. A sample of 100 subjects was assessed using the operational criteria OPCRIT checklist for psychotic and affective illness. The most recent principal and clinical ICD-10 diagnosis was compared with diagnoses generated by the OPCRIT instrument. Data documented very high sensitivity (93%) and positive predictive value (87%) of ICD-10 schizophrenia and an overall good agreement between clinical and OPCRIT-derived diagnoses (kappa=0.60). An even higher positive predictive value was obtained when diagnoses were amalgamated into a diagnostic entity of schizophrenia-spectrum disorders (98%). Near perfect agreement was seen between OPCRIT-derived ICD-10 and DSM-IV diagnoses (kappa=0.87). Thus, this study demonstrates high reliability of the clinical diagnosis of schizophrenia and even more so of the diagnosis of schizophrenia-spectrum disorder.     

Comparison of different clinical diagnostic criteria for depression in Alzheimer disease.

OBJECTIVE: Data in the literature show different estimates of the prevalence of depression in patients with Alzheimer disease (AD) when different classification systems are used. This study describes the prevalence and clinical features of depression in AD based on five different depression classification systems. METHODS: This was a cross-sectional, observational study of 491 patients with probable AD. Depression was diagnosed using five classification systems (International Classification of Diseases, 10th Revision [ICD-10], Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition [DSM-IV], Cambridge Examination for Mental Disorder of the Elderly [CAMDEX], Provisional Diagnostic Criteria for depression in AD [PDC-dAD], Neuropsychiatric Inventory [NPI]). RESULTS: The prevalence of depression was 4.9% (95% confidence interval [CI]: 3.2-7.1) according to ICD-10 criteria; 9.8% (95% CI: 7.3-12.6) according to CAMDEX; 13.4% (95% CI: 10.6-16.6) according to DSM-IV; 27.4% (95% CI: 23.6-31.5) according to PDC-dAD criteria; and 43.7% (95% CI: 39.4-48.2) when using the screening questions from the NPI depression subscale. The level of agreement between the classification systems was low to moderate (kappa <0.52). The characteristics associated with the most diagnostic disagreement were loss of confidence or self-esteem and irritability. CONCLUSIONS: This study shows that there is a high variability in the prevalence rates of depression in AD depending on the diagnostic criteria used and that there is a low rate of agreement among the diagnostic criteria analyzed. The results suggest that the use of generic diagnostic criteria such as the ICD-10, the CAMDEX, or DSM-IV provides low prevalence rates of depression in patients with AD compared with specific diagnostic criteria such as the PDC-dAD.     

Sensitivity of ICD-10 diagnosis of psychotic disorders in the Israeli National Hospitalization Registry compared with RDC diagnoses based on SADS-L

OBJECTIVE: The Israeli National Psychiatric Hospitalization Registry is a nationwide list of all psychiatric hospitalizations in the country and has been widely used as a source of data for psychiatric research. This study assessed the sensitivity of the diagnosis of psychotic disorders ( International Statistical Classification of Diseases, 10th Revision [ ICD-10 ] F20.0-F29.9) and schizophrenia ( ICD-10 F20.0-F20.9) in the Registry. METHOD: Registry discharge diagnoses of psychotic disorders ( ICD-10 F20.0-F29.9) and schizophrenia ( ICD-10 F20.0-F20.9) were compared with research diagnoses derived from best-estimate procedures based on Research Diagnostic Criteria (RDC) using structured clinical research interviews, hospital records, and family information. RESULTS: Out of 169 patients meeting RDC for psychotic disorder, 150 also had a diagnosis of psychotic disorders in the Registry, yielding a sensitivity of 0.89. Re-running this analysis for the narrow definition of schizophrenia identified 94 patients who were diagnosed with schizophrenia using RDC; 82 of those patients also had a diagnosis of schizophrenia in the Registry, yielding a sensitivity of 0.87. CONCLUSION: In 87% to 89% of cases with psychotic disorders or with schizophrenia, Registry diagnoses agreed with RDC diagnoses, a rate of agreement comparable with those of other, similar registries. Because a large number of analyses derived from this and similar national registries will be published in the coming years, this constitutes relevant information.     

DSM-IV or ICD-10-DCR diagnoses in child and adolescent psychiatry: does it matter?

OBJECTIVE: DSM-IV is the most widely used diagnostic classification system in research, whereas ICD-10 is more widely used clinically. Knowledge of differences is essential when research findings are implemented in daily clinical practice. We examined differences between the two diagnostic systems regarding three major child psychiatric diagnostic categories. METHODS: A total of 199 consecutively referred, child psychiatric patients were interviewed with a semistructured diagnostic interview (K-SADS-PL) including questions covering specific ICD-10-DCR criteria, and diagnosed according to both diagnostic systems. RESULTS: Differences were found regarding the diagnoses major depressive disorder/depressive episode and attention deficit hyperactivity disorder/disturbance of activity and attention. In both cases, more children met DSM-IV-TR criteria than ICD-10-DCR criteria. The diagnosis, oppositional defiant disorder, proved interchangeable between the two diagnostic systems. CONCLUSION: Differences between diagnostic systems must be taken into account when research findings using one diagnostic system are implemented with children diagnosed by another diagnostic system.     

The prevalence of somatoform disorders among internal medical inpatients

OBJECTIVE: To find the prevalence of somatoform disorders (SDs) among internal medical inpatients and to study the comorbidity with other psychiatric disorders. METHODS: Of 392 eligible consecutive medical inpatients, 294 (75%) accepted to participate and, using a two-phase design, were assessed for ICD and DSM-IV somatoform diagnoses and for ICD-10 psychiatric diagnoses. RESULTS: A total of 18.1% (95% CI: 12.8-24.9%) of the patients fulfilled the diagnostic criteria for an ICD-10 disorder, and 20.2% (95% CI:14.7-27.2% ) for a DSM-IV SD. The prevalence of specified disorders revealed marked differences between the two diagnostic systems, e.g., concerning somatisation disorder (SD), which was more prevalent in the ICD-10 (5%) than in the DSM-IV (1.5%) equivalent. Quite the contrary was found in undifferentiated SD (0.7% in ICD-10 and 10% in DSM-IV). According to ICD-10 criteria, 3.5% had hypochondriasis, 2.6% a dissociative disorder, 3.2% a somatoform autonomic dysfunction, 1.5% had neurasthenia or persistent somatoform pain disorder, and 5% had an SD, unspecified. SDs were more prevalent among younger females. Thirty-six percent of the patients with SDs also had another psychiatric disorder, 11% a depression, and 25% an anxiety disorder. The physicians detected about 1/3 of the cases. CONCLUSION: Somatoform disorders were prevalent among internal medical inpatients especially among younger women.     

Diagnosis in adolescent inpatients: Diagnostic confidence and comparison of diagnoses using ICD-9 and DSM-III

In a prospective Multi-Centre research study involving four British Adolescent Psychiatry Inpatient Units, all 276 adolescent admissions were diagnosed using both ICD-9 and DSM-III. Ratings of diagnostic confidence for each diagnostic group varied considerably. Clinicians recorded high levels of confidence in the diagnosis of both Schizophrenia and Anorexia nervosa, while considerably lower scores were noted for Adjustment Disorders (ICD-9 3-digit code 309.), and for Emotional Disorders (ICD-9 3-digit code 313.).Exact concordance in diagnoses made for each case using both ICD-9 and DSM-III occurred in 72% of the entire cohort. The dissimilar concordance rates comparing ICD-9 and DSM-III diagnoses for the same patient admissions suggest differences in validity measures, such as face validity and content validity, in the reliability of diagnostic criteria between similarly named disorders across the two systems, and in the clinician's training and attitude to diagnosis. With the recent introduction of DSM-IV following upon ICD-10, further comparative studies are needed to examine both reliability and validity issues into diagnosis and classification in child and adolescent psychiatry.     

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.     

Epidemiology and prognosis of specific disorders of language and scholastic skills

 Data from a prospective longitudinal study on the development of children born at biological and psychosocial risk were utilised to examine language and learning abilities of 320 children at ages 4.5 and 8 years. Following the research criteria of the ICD-10, specific developmental disorders of speech and language and specific developmental disorders of scholastic skills were diagnosed. Data were also provided for a clinical and general low achievement group according to less stringent criteria. Frequencies in the risk population were low for specific disorders (ICD-10) (0.6%–3.7% depending on age and type of disorder). Higher frequencies were found when a clinical definition (0.6%–13.6%) or overall low achievement score (0.6%–18.6%) was chosen. The impact of well-documented organic and psychosocial risks was analysed. Organic risk affected language abilities at 4.5 years of age but neither language nor learning abilities at 8 years of age. Psychosocial aspects of a child's environment proved to be associated with both specific language and learning abilities. Stability of language disorders, association between language and reading/spelling disorders as well as gender effects were investigated. Accepted: 17 December 1999     

Classification of functional psychoses and its implication for prognosis: comparison between ICD-10 and DSM-IV

BACKGROUND: The aim was to examine the agreement and differences between ICD-10 and DSM-IV in the classification of functional psychoses. Sampling and METHODS: In a sample of 218 first-hospitalised patients, ICD-10 diagnoses were compared with DSM-IV diagnoses. Functional psychoses of both diagnostic systems were classified into the four diagnostic groups schizophrenia, transient/episodic psychoses, delusional disorders and affective disorders. Based on information from a 15-year follow-up, it was examined which course is associated with each diagnostic group. RESULTS: Although in ICD-10 there was a higher frequency of schizophrenia and a lower one of affective disorders, a high agreement between ICD-10 and DSM-IV (kappa value of 0.82) was found. In both diagnostic systems, transient/episodic psychoses and affective disorders were mainly associated with a non-chronic course and schizophrenia was mainly associated with a chronic one. Nevertheless, several patients with transient/episodic psychoses showed a chronic course (ICD-10: 10%, DSM-IV: 15%) and more than one third of patients with schizophrenia a non-chronic one (ICD-10: 40%, DSM-IV: 33%). CONCLUSIONS: In the cross-sectional assessment, there is a high diagnostic agreement between ICD-10 and DSM-IV. With respect to the long-term course, the delimitation of transient/episodic psychoses from schizophrenia was neither completely achieved by ICD-10 nor by DSM-IV.     

Long-term course of schizophrenic illness: Bleuler's study reconsidered

OBJECTIVE: The influential 1972 study by Manfred Bleuler on the long-term course of schizophrenic illness has been reconsidered. The authors tested the diagnosis of schizophrenia in all patients and investigated how the distribution of the types of illness course and outcome would change after exclusion of patients whose diagnosis of schizophrenia could not be confirmed by modern diagnostic standards. METHOD: Clinical charts and Bleuler's research notes on the original sample were assessed, and all patients were rediagnosed with the help of DSM-IV, DSM-III-R, ICD-10, the Research Diagnostic Criteria (RDC), Schneider's criteria, and an operationalized version of the criteria of Eugen Bleuler. RESULTS: The diagnosis of schizophrenia was not confirmed in about 30% of the sample; the majority of these patients were rediagnosed with schizoaffective disorder. High diagnostic agreement was found between DSM-IV, DSM-III-R, ICD-10, and RDC; there was much less agreement with Bleuler's and Schneider's criteria. After exclusion of patients whose schizophrenia diagnosis was not confirmed, the proportion of patients with undulating course and recovery slightly decreased, and the proportion of patients with severe end state slightly increased. Nevertheless, the distribution of the types of long-term course did not significantly change, and even among patients with strictly defined schizophrenia, half had an undulating course with remissions and 12%-15% recovered. CONCLUSIONS: Schizophrenic illness remains heterogeneous with regard to illness course and outcome even when narrowly diagnosed with the help of modern operationalized diagnostic criteria. Contemporary differentiation between schizophrenic and schizoaffective disorders is prognostically valid.     

Postconcussional disorder: Are the DSM-IV criteria an improvement over the ICD-10?

Little is known about the characteristics and outcomes of patients diagnosed with postconcussional disorder (PCD) under the provisionally proposed criteria in the DSM-IV and how they differ from patients diagnosed with postconcussional syndrome (PCS) under the International Classification of Diseases, 10th edition clinical (ICD-10) criteria. This study investigated differences in outcome based on a diagnosis of PCD (DSM-IV) versus PCS (ICD-10 clinical criteria) as to which criteria set might be preferred for clinical practice. A consecutive series of adult patients with mild (N = 319) to moderate (N = 21) traumatic brain injury was assessed at 3 months postinjury with a brief neuropsychological battery and measures of specific outcome domains. In two separate series of analyses, patients with PCD were compared with those without PCD, and those with PCS were compared with those without PCS. Although the two criteria sets resulted in markedly different incidence rates, there was no substantial pattern of differences between the DSM-IV and ICD-10 in the outcome domains of psychiatric symptoms and disorders, social and community integration, health-related quality of life, or global outcome as measured by the Glasgow Outcome Scale-Extended. In spite of significant differences between the two diagnostic criteria sets and different incidence rates for PCD/PCS, outcome in all measured domains was very similar at 3 months postinjury. There is no compelling evidence, based on these outcome domains, to suggest which of the two diagnostic criteria sets should be clinically preferred.     

Classification of obsessive-compulsive disorder in childhood and adolescence

OBJECTIVE: In child and adolescent psychiatry the validation of the diagnosis must be seen in the context of development. Comparing different diagnostic formulations DSM-IV and ICD-10-DCR in a clinical sample of children and adolescents suffering from obsessive-compulsive disorder (OCD) and their validation on external criteria represent such a heuristic approach. METHOD: We investigated 61 children seen consecutively in a specialized out-patient clinic for OCD. All of them were assessed by the International Diagnostic Checklists (IDCL). Diagnosis and diagnostic certainty were validated regarding age, age of onset and duration of illness. RESULTS: The agreement between the two diagnostic systems was low. The diagnostic stability of ICD-10-DCR was highly dependent on age, whereas that of the criteria DSM-IV did not depend on age and almost all subjects could be diagnosed definitely. CONCLUSION: This study suggests that the DSM-IV criteria are superior to that of ICD-10-DCR for diagnosing OCD in children and younger adolescents.     

Diagnosing dementia -- ICD-10 not so bad after all: a comparison between dementia criteria according to DSM-IV and ICD-10

BACKGROUND: The discrepancy between results of diagnosing dementia with ICD-10 and DSM-IV has been shown by several studies. Our aim was to show that the two diagnostic systems are more or less alike if ICD-10 is interpreted in the way we believe is in the intention of the ICD-10 authors. METHODS: Two hundred and seven patients consecutively referred patients and their caregivers were interviewed and the patients were clinically examined. Algorithms using criteria for the World health Organization's International classification of Diseases, 10(th) revision (ICD-10) and the American Psychiatric Association's, the fourth edition (DSM-IV) were followed to diagnose dementia. RESULTS: A diagnosis of dementia was made for 198 patients and there was 100% agreement (kappa = 1,0) between ICD-10 and DSM-IV diagnosis. CONCLUSION: In the ICD-10 criteria 'decline in other cognitive abilities such as abstraction, judgement, problem solving' has been interpreted in a way that all the above executive functions must be impaired for diagnosing dementia. According to our interpretation these are meant to be examples of functions which may be compromised in demented patients.The results of our study demonstrate that this interpretation of ICD-10 has shown that the authors of ICD-10 and DSM-IV have succeeded in harmonising the two systems. However, the ICD-10 criteria are phrased in a way that leaves much to individual interpretation. WHO has to define the ICD criteria in such a way that there is uniformity in its interpretation.     

An American view of the ICD-10 personality disorders

The 1986 version of the ICD-10 diagnostic criteria for the personality disorders was analyzed. In one part of the study, clinicians in the United States were asked to assign the ICD-10 criteria to the ICD-10 categories. In a second part, the ICD-10 criteria were assigned to DSM-III-R categories. In the first part, the face validities of the ICD-10 criteria were highly variable. Thirty percent of the criteria were assigned to the correct parent category by over 80% of the clinicians. In contrast, 34% of the criteria failed to be correctly assigned by at least half of the clinicians. Concerning the correspondence between ICD-10 and DSM-III-R categories, only anankastic (ICD) and obsessive-compulsive (DSM) showed a high level of correspondence. The correspondences of anxious (ICD) with avoidant (DSM), impulsive (ICD) with borderline (DSM), and histronic (ICD) with histrionic (DSM) were poor.