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.     

Diagnosis of severely ill inpatients in China. A collaborative project using the structured clinical interview for DSM-III (SCID)

The purpose of this project was to investigate any differences in diagnostic practice between Chinese psychiatry and Western psychiatry with regard to severe psychiatric illness among Chinese inpatients. Specifically, the project aimed to look at differences between the Chinese diagnostic system and DSM-III. This study stemmed partly from a desire to investigate the supposed "overdiagnosis" of schizophrenia in China relative to the West. A second objective was to use a structured interview format to obtain clinical data for DSM-III and to decide whether a translated version of such an interview offered promise for future transcultural psychiatric research. Forty-two inpatients on a psychiatric ward in China were interviewed by an American psychiatrist assisted by a Chinese faculty translator and a diagnosis was made using the Structured Clinical Interview for DSM-III. A Chinese professor of psychiatry who was blind to the structured interview results interviewed each patient independently and assigned a diagnosis within the current Chinese system. Follow-up data was obtained on 69% of the patients after 16 months to check for stability of diagnosis. Results of the study pointed to less diagnostic disagreement than previous work had predicted. On cases where there was disagreement, DSM-III diagnoses tended toward affective disorders or atypical forms of psychosis while the Chinese diagnosis tended towards schizophrenia.(ABSTRACT TRUNCATED AT 250 WORDS)     

The impact of DSM-III on diagnostic practice in a university hospital. A comparison of DSM-II and DSM-III in 10,914 patients

The DSM-III is the first criteria-based, multiaxial classification system of mental disorders. Since its introduction in 1980, it has received more attention than any previous nosology in the history of psychiatry. The present report attempts to gauge the impact of DSM-III on diagnostic practice at one of the largest university-affiliated psychiatric hospitals in the United States. It compares the diagnoses given to 10,914 hospitalized patients during the last 5 years of the DSM-II era and the first 5 years of the DSM-III era. There were two major consequences of the change from DSM-II to DSM-III: (1) a marked reduction in the diagnosis of schizophrenia and a corresponding increase in the diagnosis of affective disorders, and (2) a marked increase in the diagnosis of personality disorders.     

Psychiatric diagnosis in a state hospital: Manhattan state revisited

Studies have documented the predeliction of New York hospitals to overdiagnose schizophrenia and to underdiagnose affective disorders. To further investigate that predeliction following the introduction of DSM-III diagnostic criteria, seven clinical experts at the Manhattan Psychiatric Center reevaluated the charts of 131 randomly selected patients and conducted clinical reviews of two subgroups of the sample. Rediagnosis essentially reversed the ratio of schizophrenia to affective disorder shown in the charts, indicated a lack of documented DSM-III criteria for the chart diagnoses, and revealed significant numbers of undiagnosed disorders. The diagnostic, prognostic, and treatment implications of the findings are discussed, especially the need for more precise differential diagnosis according to DSM-III criteria.     

A comparative study on schizophrenia diagnosed by ICD-9 and DSM-III: course, family history and stability of diagnosis

Data from the Taipei Center of the International Pilot Study of Schizophrenia were reanalyzed using the ICD-9 and DSM-III diagnoses at 7-year follow-up. Patients diagnosed as schizophrenic according to DSM-III were shown to be a more homogeneous group in terms of their clinical manifestations, social functions and family psychiatric history than those defined as schizophrenic by ICD-9. The discordant cases of ICD-9 schizophrenia and DSM-III affective disorders were found to be different from the concordant schizophrenic group, but similar to the concordant group of affective disorders diagnosed by ICD-9 and DSM-III. Thirty-five per cent of mood-incongruent psychotic major depressive disorders defined by DSM-III at initial evaluation were diagnosed as schizophrenia at 7-year follow-up.     

Clinical assessment of psychiatric consultations in a medical long-term care facility: Interrater reliability for DSM-III diagnostic groups

The reliability of the DSM-III diagnostic system was assessed in a medical long-term care facility population that was recently seen in psychiatric consultation. Six standard rating scales were used to determine interrater agreement for perceiving psychopathology prior to selecting diagnoses. The findings were that six major diagnostic groups could be accurately distinguished from one another: no disorder; organic mental disorders; affective disorders; paranoid disorders; schizophrenia and psychotic disorders not elsewhere classified; and a mixed group of other diagnoses that occurred in low frequency in this study population. The interrater reliability (kappa = 0.64–0.70) was comparable to that found in the general psychiatric population.     

A survey of sexual problems amongst psychiatric inpatients

This paper reports the findings of a survey of 39 men and 17 women who had been admitted to the acute psychiatric wards of an inner London psychiatric unit. The patients were seen within 7 days of their admission and were interviewed about existing sexual and relationship problems. The admissions consisted largely of single men with schizophrenia and married or cohabiting women with affective disorders. Of the men, 62% of those with a diagnosis of schizophrenia, between 63 and 75% of those with affective disorders and 17% of those with other diagnoses reported current sexual or relationship problems. Of the women, 25% of those with a diagnosis of schizophrenia, 50–100% of those with affective disorders and 25% with other diagnoses reported a sexual or relationship problem. The high prevalence of such problems amongst inpatients indicates that such matters should be enquired after and therapeutic interventions considered at the time of admission. We examined the limitations of this work and proposed areas of potential research.     

Diagnosis and clinical course of erotomanic and other delusional patients

Twenty-eight patients with erotomanic delusions were compared with 80 patients with other delusions to clarify questions about diagnosis and course of illness in erotomania. The erotomanic patients were a heterogeneous group with respect to both diagnosis and course. They had significantly more manic symptoms than the comparison group and more affective diagnoses than would be expected from the literature; 25% (N = 7) had schizoaffective disorder and 7% (N = 2) had bipolar disorder. A subgroup of monodelusional erotomanic patients was identified who met the DSM-III-R criteria for delusional disorder, thus supporting the decision to include erotomanic delusions in this diagnostic category in the revision of DSM-III.     

DSM-III disorders in a large sample of psychiatric patients: frequency and specificity of diagnoses

This study examined certain nosological features of DSM-III axis I diagnostic categories and subcategories as applied to 11,292 general psychiatric patients presenting for care, using a semistructured assessment procedure. The most frequently used major categories were affective, substance use, childhood-onset, and adjustment disorders. Secondary diagnoses were given to 26% of the patients. Male patients predominated in the categories of impulse-control, psychosexual, and substance use disorders, and female patients predominated in the categories of anxiety, affective, and somatoform disorders. Of the 329 five-digit subcategories available in DSM-III, 296 (90%) were actually used. Sixteen percent of the patients were given unspecific primary diagnoses.     

Catatonia in a University Inpatient Service (1985-1990)

Catatonia is defined only as a subtype of schizophrenia in the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition (DSM-III) and DSM-III-revised (DSM-III-R), but catatonic symptoms are prominent in patients with psychoses, affective disorders, systemic illnesses, and neurotoxic states. We reviewed the case records of a 30-bed University Hospital adult inpatient psychiatric unit between 1985 and 1990, and identified 43 cases with admission or discharge diagnoses of schizophrenia, catatonic type (295.2). Of these, the records were adequate for detailed review in 19 cases. On discharge, seven were classified as schizophrenia, seven as affective disorder, and five as organic affective disorder. Eleven patients underwent electroconvulsive therapy (ECT), with excellent results in eight; 34 psychotropic medication trials were administered, with successful results in only two patients. Catatonia should be defined as a separate class in DSM-IV, thus encouraging the proper diagnosis and management of a treatable condition.     

Violence and psychiatric disorder in the community: evidence from the Epidemiologic Catchment Area surveys

Data from the Epidemiologic Catchment Area survey were used to examine the relationship between violence and psychiatric disorders among adults living in the community. Psychiatric assessment of survey respondents was based on the Diagnostic Interview Schedule, which also provided self-report information about violent behavior. Those who reported violent behavior within the preceding year tended to be young, male, and of low socioeconomic status, and more than half met DSM-III criteria for one or more psychiatric disorders. Subjects with alcohol or drug use disorders were more than twice as likely as those with schizophrenia to report violent behavior. In a multivariate model of the predictors of violence, a significant interaction effect was found between major mental illness and substance abuse. The risk of violent behavior increased with the number of psychiatric diagnoses for which respondents met DSM-III criteria.     

On the way to expert systems

Summary Operationalized diagnostics deal with the standardized assessment of psychiatric symptoms as well as diagnostic criteria. As a diagnostic system based on criteria, the DSM-III was chosen to identify operationalized diagnoses based on the Present State Examination (PSE-9) and some additional DSM-III specific items. By relating PSE symptoms to the diagnostic criteria of DSM-III, an easily applicable expert system leading to DSM-III diagnoses was developed. In two samples of 30 schizophrenic and 51 depressive patients the DSM-III computer diagnoses are contrasted with the ICD-8 diagnoses of the PSE/CATEGO system. In defining a case, only minimal differences between the two computer programs were found. In the sample of schizophrenics, CATEGO led to 114 (81%) diagnoses and the DSM-III program to 112 (79%) diagnoses; for the depressive patients 43% cases were identified by CATEGO and 45% by the DSM-III algorithm. Comparing the diagnosis of acute schizophrenic disorders, both programs arrived at similar percentages. (CATEGO: 51%; DSM-III: 57%). However, CATEGO is limited to two different subtypes (295.2 and 295.3), whereas the DSM-III program covers the total range of possible schizophrenic subtypes. Furthermore, the DSM-III program identified residual subtypes of schizophrenia in 23% of the diagnostic decisions. In the short-term course of the schizophrenic patients, CATEGO identified 27%–43% with affective diagnoses with high stability per cross-section. Using the DSM-III algorithm affective diagnoses were rather rare (maximum of 17%), marking unstable changes from acute to residual states of the psychosis. In the cohort of affective patients the correspondence between both programs was quite good, especially for the patients with a diagnosis of depression, but in total the DSM-III program requires stricter criteria for affective — especially manic — disorders, whereas CATEGO needs a somewhat higher symptom level for anxiety syndromes to reach the diagnostic threshold.Modified version of a paper presented by K. Maurer at the 2nd Psychiatric Autumn Symposium of the ZISG at St. Martin, Palatinate, 15–17 September 1988Funded by the ZISG (Zentralinstitut für Seelische Gesundheit) and the BMFT (Bundesministerium für Forschung und Technologie) under the coordination of the GSF (Gesellschaft für Strahlenforschung)     

Mental health training of primary care physicians: an outcome study

It is well documented that primary care physicians encounter many patients in their practices who suffer psychiatric morbidity, especially affective, anxiety and substance abuse disorders. These physicians have been unable to effectively address the needs of these patients, over half of whom receive care exclusively in the primary care sector. Five years after implementing a curriculum to train family practice physicians to assume a comprehensive psychiatric role with patients in their practices, the authors undertook an outcome evaluation. The focus was on psychiatric disorder recognition, diagnosis, documentation, and management, including referral. It was hoped that biopsychosocial and community mental health orientations emphasized during training would be incorporated into the subsequent primary care practices of physicians in the study. In the research design, physician-generated diagnoses were compared with DIS/DSM-III diagnoses; physician interviews and chart audits enabled processes of care delivery to be evaluated. Unexpectedly, physicians were not found to assume an appropriately active or comprehensive mental health role in their practices following the training intervention. Of ninety-four DIS-generated diagnoses in the study population of fifty-one patients, 79 percent were unrecognized. Patients were assumed to function well emotionally, and psychiatric dimensions of patient complaints were not examined in the majority of cases. The physicians did diagnose and treat a number of patients with mental symptoms who were not identified by the DIS. These patients had high, but sub-diagnostic, DIS symptom counts. Most received a diagnosis of adjustment disorder in response to medical illness. Though this finding underscores shortcomings of present psychiatric nosology when applied in the general medical setting, the foremost consideration was the large number of DIS-identified patients with serious psychopathology, needing active assessment and intervention, who were unrecognized, undiagnosed or untreated. Implications of these findings for the psychiatric training of primary care physicians are examined.     

Who seeks mental health care in China? Diagnoses of Chinese outpatients according to DSM-III criteria and the Chinese classification system

The authors gave DSM-III diagnoses to 116 Chinese psychiatric outpatients in Shanghai and compared them with the diagnoses of the same patients made by a Chinese psychiatrist according to Chinese criteria. Affective disorders were the most common DSM-III diagnoses, accounting for 26.7% of the sample. A full range of psychopathology, including schizophrenia, organic mental disorders, adjustment disorders, anxiety disorders, and paranoid disorders, was seen. Some consistent differences in diagnosis by Chinese and Western standards, especially in the area of major depression, were found. The authors discuss the implications for interpreting psychiatric studies from China and for future cross-cultural research comparing U.S. and Chinese diagnoses.     

Defining the schizophrenia spectrum: issues for genetic linkage studies

Genetic linkage studies of schizophrenia depend on accurate psychiatric diagnosis of relatives within multiply affected families. Each investigator makes a series of explicit or implicit decisions to define which relatives will be assumed to share a schizophrenia-related genotype, that is, who is an "affected relative." In this article we delineate issues that we believe should be considered in such studies and review the relevant literature. Issues include criteria for selecting probands; whether broader criteria should be used to select affected relatives; approaches to including or excluding diagnoses for which family study data suggest a relationship to schizophrenia or to affective disorders or other psychiatric disorders; clarification of diagnostic hierarchy; and issues related to substance abuse and neurological disorders. Also discussed are whether relatives without spectrum diagnoses should be considered unaffected or undiagnosed in linkage analyses, how bilateral familial affectedness should be defined, and provision for independent review of study diagnoses. As an illustration, the clinical model for the authors' schizophrenia linkage study is described.     

The setting of psychiatric care for medicare recipients in general hospitals with specialty units

This study examined the patient and hospital characteristics associated with whether patients with psychiatric disorders were treated on the psychiatric unit or on medical wards after admission to general hospitals with psychiatric units. Medicare data for 169,798 beneficiaries who had psychiatric disorders and were admitted to general hospitals with psychiatric units were used to estimate logistic regressions of the probability of treatment on the unit. Results showed that beneficiaries who had more than one psychiatric diagnosis (except for substance use disorders), state buy-in coverage such as Medicaid, or previous psychiatric hospitalizations or who had ever been eligible for Medicare through disability were more likely to be treated on the unit. Those who were older, admitted through the emergency department, or had greater medical morbidity or primary diagnoses other than schizophrenia or bipolar or major affective disorders were less likely to be treated on the unit.     

Does racial bias influence psychiatric diagnoses assigned at first hospitalization?

BACKGROUND: Research on racial bias in psychiatric diagnosis has largely been limited to studies of admission diagnoses assigned to chronically ill patients. This study tests whether racial bias influences diagnoses assigned to patients at discharge from their first psychiatric hospitalization. METHODS: In a county-wide sample of patients with psychosis, hospital diagnoses were compared with research diagnoses formulated using structured interviews and strict adherence to DSM-III-R. Symptom patterns were also examined. RESULTS: Racial differences were observed in the distribution of both hospital and research diagnoses. Using research diagnoses as the gold standard, the sensitivities and specificities of hospital diagnoses were similar by race (for blacks the sensitivity and specificity of schizophrenia was 0.33 and 0.91, and for whites, 0.43 and 0.89). The only suggestion of possible bias was that more blacks were discharged without a definitive diagnosis (38.7% of blacks vs. 26.3% of whites, chi(2) = 5.80, df = 1, p = 0.02). CONCLUSIONS: We did not observe the expected racial bias in the assignment of diagnoses of schizophrenia and affective disorders. While there was evidence that hospital clinicians had more difficulty diagnosing black patients, the low concordance between hospital and research diagnoses for both black and white patients demonstrates the need to better understand the clinical diagnostic process for all patients with psychotic disorders at their first hospitalization.     

Cross-cultural aspects of the somatization trait

Studies using a variety of diagnostic rating scales have identified much higher levels of somatic symptoms in Hispanic psychiatric patients, particularly those with a diagnosis of schizophrenia or depression, than in their Anglo counterparts. However, this cultural difference cannot be generally demonstrated by using DSM-III somatoform disorders criteria. Many patients with "unfounded" somatic symptoms have another DSM-III primary diagnosis that is often assumed to cause or explain the somatic symptoms. In addition, the true prevalence of unfounded somatic symptoms is hidden because of the strict criteria required for a DSM-III primary diagnosis of somatization disorder. The author believes a more inclusive notion of somatization should be developed that would substantiate the presence of this trait among different populations and, if operationalized, would facilitate research on this important phenomenon. This is relevant not only because of the cross-cultural variability of somatization traits but also because they may become a salient feature of the primary syndrome and determine the use of clinical services. He proposes a new operational definition of somatization that encompasses the trait concept.     

Satisfaction with care reported by psychiatric inpatients Relationship to diagnosis and medical treatment

In this survey, 274 patients were sent a questionnaire concerning satisfaction with psychiatric treatment and the ward 1 month after their discharge from hospital. Fifty-two percent of the patients responded. Answers to the 56 items of patient satisfaction were analyzed in relation to patient diagnoses and treatment given. Patients who were diagnosed as suffering from affective disorders or from reactive psychoses were more satisfied than patients with schizophrenia or paranoia or with transitory adjustment reactions. Patients who had no personality disorder diagnosis and patients with character neurosis were more satisfied than patients with antisocial or borderline personality disorders. Patients on antidepressant medication were much more satisfied than other patients. The results of the study are discussed with regard to the need of further research in this area and to quality assurance.     

Replicated psychometric correlates of schizophrenia

OBJECTIVE: The authors' goals are to use scales from the MMPI hypothesized in their previous research to be correlates of liability to schizophrenia to differentiate DSM-III schizophrenia from bipolar and unipolar affective illness and to cross-validate these correlates in an independently ascertained sample of patients with Research Diagnostic Criteria (RDC) schizophrenia or affective disorder. METHOD: The criterion sample consisted of 83 patients consecutively admitted to a state-operated community mental health center. Diagnosis of schizophrenia; bipolar disorder, manic; and major depression were assigned by using DSM-III. The replication sample consisted of 60 adults with RDC diagnoses of schizophrenia, schizoaffective disorder, bipolar disorder, and unipolar disorder who were parents of children in two samples collected for a study of offspring at high risk for schizophrenia and other psychopathology. After the patients in the criterion sample were classified by logistic regression analysis, the results were used to classify patients in the replication sample. RESULTS: The MMPI indicators had adequate sensitivity, specificity, and predictive power for classifying schizophrenia, and there was a moderately high rate of diagnostic agreement between the MMPI and DSM-III. Cross-validation in the replication sample was successful. Overall, the MMPI index was an adequate inclusion and exclusion criterion not only for DSM-III-defined but also for RDC-defined schizophrenia. CONCLUSIONS: A psychometric index composed of the paranoid schizophrenia, psychoticism, and manifest hostility scales from the MMPI would be a cost-effective measure to increase diagnostic efficacy in future schizophrenia research and clinical practice.