Coding guidelines for ICD-9 section on mental disorders and reliability of chart clinical diagnoses

A major innovation of the ICD-10 draft is provision of diagnostic guidelines. This is assumed to be appropriate for use in clinical situations. In Norway a similar approach was adopted when ICD-9 was introduced as the official classification system in 1987. This was done in order to avoid national diagnostic bias and increase diagnostic reliability. A comparison with the DSM-III criteria was included in the diagnostic guidelines. The effectiveness of this approach was investigated by comparing the chart ICD-9 diagnoses of 104 psychiatric in- and outpatients from 2 teaching hospitals with the diagnoses obtained by using case record rating forms (criterion diagnosis). According to the criterion diagnoses, the base rate of chart diagnoses of schizophrenia and manic-depressive psychosis was too low, and the base rate of reactive psychosis too high. Several chart diagnoses proved to have low reliability, particularly reactive psychosis, paranoid psychosis, depressive neurosis and personality disorders. The study suggests that the provision of extensive diagnostic guidelines does not necessarily alter previous diagnostic practice. Reasons for these findings and the implications for the ICD-10 diagnostic criteria and diagnostic guidelines are discussed.     

Obsessive-compulsive disorder: admission patterns and diagnostic stability

All first-time admissions from 1970 to 1986 with obsessive-compulsive neurosis (OCD) (ICD-8 diagnosis number 300.39) or obsessive-compulsive personality disorder (OCPD) (ICD-8 diagnosis number 301.49) were analyzed based on an extract from the nationwide Psychiatric Case Register in Denmark. All patients with secondary diagnoses other than neurotic disorders or personality disorders (including “neuroses characterogenes”) were excluded from the study. A total of 284 patients were first-time admitted with a main diagnosis of OCD during the period. The sex ratio was 0.67 (males/females). A total of 126 were first-time admitted with a diagnosis of OCPD, with a sex ratio of 1.18 (males/females). Seventy-seven percent of the readmitted patients with a first-time diagnosis of OCD kept a diagnosis within the “emotional spectrum” at the last admission. About half kept OCD as a main diagnosis, whereas only 15% shifted to a severe psychiatric diagnosis such as schizophrenia or manic-depressive psychosis. Of the readmitted patients with OCPD. 13% later developed a diagnosis of manic-depressive psychosis.     

Selenium concentrations in blood and serum from patients with mental diseases

Blood and serum concentrations of selenium have been determined in a group of psychiatric patients and in 35 healthy controls. The psychiatric group consisted of 14 schizophrenics, seven paranoid disorders, six affective psychosis (manic-depressive), four reactive psychosis, 11 dementia senilis, 17 with a diagnosis of neurosis and two with delirium tremens. Normal values were found in all groups except for delirium tremens where decreased blood and serum values were found.     

Subtypes of panic attacks and ICD-9 classification

Summary No single ICD-9 category corresponds to panic disorder (DSM-III). To investigate whether patients with panic attacks can be identified by means of ICD-9, 97 patients with three panic attacks within 3 weeks were recruited from various medical centers, and were classified independently according to DSM-111 and ICD-9.The ICD-9 diagnoses were scattered over a broad range of categories, and it was impossible to identify patients with panic disorder in this manner. Anxiety state, affective psychosis, and depressive neurosis were the most frequent ICD-9 diagnoses. The boundary between affective psychosis on the one hand and anxiety state and depressive neurosis on the other hand was validated by present and previous symptomatology and by cluster analysis. The boundary between anxiety state and depressive neurosis could not be validated in this way. Correspondingly, modifications of the ICD-9 classifications are proposed.     

The prognosis in early adulthood of child psychiatric patients: a case register study in Denmark

A register-based study of 485 children (0-15 years of age) admitted to a child psychiatric hospital from January 1, 1970 to December 31, 1972 who were followed up on December 31, 1986 showed higher rates of admission to psychiatric hospital in late adolescence or young adulthood (i.e. greater than or equal to 16 years of age) than found in an age-standardized general population. Patients with the childhood diagnosis neurosis (ICD-8 300 + 308.00) were found to have higher rates of admission with personality disorders (ICD-8 301.09-301.39 + 301.82-301.99) but not of other diagnoses including neurotic disorders. Patients with the childhood diagnosis of conduct disorder (ICD-8 301.09-301.99 + 308.01) had a higher risk of admission in adulthood with the diagnosis of personality disorders and drug or alcohol abuse. Girls with adjustment disorder (ICD-8 307 + 308.02-308.06) had higher risks of admission in young adulthood with diagnosis of personality disorders and psychosis. No connection was found between the age at first referral and the incidence of admission after the age of 15 years.     

INCIDENCE OF DEPRESSIVE SYNDROMES IN A DANISH COUNTY

On the basis of a material from a cumulative registration of the psychiatric morbidity in a geographically delimited population group - the County of Aarhus with approximately 175,000 inhabitants over the age of 15 years - the frequency of depressive syndromes in psychiatric and other medical services was investigated. The material fulfils the following criteria: During the calendar years 1960 to 1964, the patients 1) were residents in the County of Aarhus, 2) had attained the age of 15 years or more, 3) had contacted at least one of the services which systematically sent information to the psychiatric register; and 4) based on an evaluation of all available data, had a main diagnosis of manic-depressive psychosis, psychogenic depression or neurotic depression. An average yearly registration rate of 1.30 per 1,000 men and 3.28 per 1,000 women was found (males: manic-depressive psychosis 0.60, psychogenic depression 0.23 and neurotic depression 0.47; females: manic-depressive psychosis 1.00, psychogenic depression 0.88 and neurotic depression 1.40). The three diagnostic groups show differences in age distribution, geographical pattern and distribution by marital status.     

Brief reactive psychosis

A careful reevaluation of 24 patients diagnosed as suffering brief reactive psychosis failed to validate this diagnosis according to DSM-III criteria. Fourteen of the patients had other psychiatric disorders that could explain their symptoms, and 8 had psychosis lasting longer than 2 weeks; the precipitating events were unclear or had uncertain relationships to the psychoses. The criteria proposed for the DSM-III-R do not facilitate the diagnosis of brief reactive psychosis but perhaps make it even more confusing.     

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.     

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.     

Course of schizoaffective psychosis: a retrospective study

This study investigated the clinical course and outcome of 72 patients diagnosed as suffering from schizoaffective psychosis according to ICD-9 criteria who also satisfied RDC criteria for schizoaffective disorder. The results show a clear relationship between patients' overall functioning and premorbid personality: a better premorbid social adjustment indicates a better current state. Those who met DSM-III criteria for schizophrenic or schizophreniform disorder had an earlier age of onset and a higher frequency of relapse, followed by schizoaffective and affective patients. Patients who presented interepisodic psychotic symptoms differed from those who did not in that they showed more recurrences, an earlier age of onset and a premorbid personality with poorer social adjustment. The age of onset of the disease was significantly earlier in patients who had hyperthymic episodes. Schizoaffective disorders therefore are a heterogeneous group as regards premorbid personality, DSM-III diagnosis, and the presence or absence of interepisodic psychotic symptoms and hyperthymic episodes.     

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.     

Behavioral and psychological symptoms of dementia in developing countries

BACKGROUND: Little is known about the prevalence of, or associations with behavioral and psychological symptoms of dementia (BPSD) in developing countries. METHODS: Individuals diagnosed as having dementia according to DSM-IV criteria (mild and moderate cases as defined by the Clinical Dementia Rating scale only), together with their main caregiver, were recruited from 21 centers in 17 developing countries. People with dementia were directly assessed with the Community Screening Interview for Dementia and the Geriatric Mental State Schedule (GMS); GMS data were processed by the AGECAT computer program to yield diagnostic information on 8 psychiatric syndromes. Caregivers answered direct questions about behavioral symptoms of dementia (BSD) and completed the Zarit Burden Inventory. RESULTS: At least one BSD was reported in 70.9% of the 555 participants. At least one case-level AGECAT psychiatric syndrome (not including the organic syndrome) was exhibited by 49.5% of people with dementia. Depression syndromes (43.8%) were most common followed by anxiety neurosis (14.2%) and schizophreniform/paranoid psychosis (10.9%). Caregivers were more likely to report BSD in people with dementia who were married, younger and better educated. More advanced dementia, poorer functioning and the presence of depression or anxiety were each associated with BSD. BSD, and psychiatric syndromes (anxiety neurosis and schizophreniform/paranoid psychosis) predicted caregiver strain after controlling for cognitive impairment. BPSD are poorly understood, leading to shame and blame. CONCLUSIONS: BPSD are common among people with dementia in developing countries, though we found marked regional variations. Representative population studies are needed to clarify prevalence and impact, but our research suggests considerable unmet need, with much scope for intervention. Raising awareness of the problem should be the first step.     

Determinants of decision-making in the screening procedure of a community psychiatric service

This study is a predictor analysis of the screening procedure followed by a psychiatric service for a period of 1 year preceding and a period of 1 year following the introduction of community psychiatry. Throughout this period, the psychiatric service consisted of a local service within the catchment area and a central service at a psychiatric hospital outside the area. At the time of the reorganization, the responsibility for the psychiatric service was transferred from the public health authorities to the social services. Before the reorganization, screenings were conducted on the basis of referral papers or simply as a result of telephone communication. After the reorganization, the screening procedure was intensified by means of a pre-examination. One aim of the reorganization was to ensure that the severely mentally ill take priority over patients characterized predominantly by social strain. Patients with manic-depressive psychosis and other psychoses showed a significantly increased probability of being accepted for treatment, whereas those with schizophrenia showed no significant increase, irrespective of the service reorganization. Similarly, manic-depressive psychosis and other psychoses (not schizophrenia) were significant predictors of hospitalization at the mental hospital outside the catchment area as well as hospitalization in the local facilities, irrespective of the service reorganization. Indicators of social strain were not given higher priority following the service reorganization.     

Admission pattern and diagnostic stability among unipolar and bipolar manic-depressive patients

The instability of the diagnoses in a psychiatric register causes practical problems when groups of probands with specific diagnoses are selected for further studies. A cohort of 3,062 first admissions with at least one manic-depressive admission was followed for 5-7 years. 623 had at least one admission for mania and were considered bipolar. The percentage of patients who changed their diagnoses was highest at first readmission; at each later readmission about 10% of the bipolars and 25% of the unipolars changed from manic-depressive psychosis and a similar number changed from other diagnoses to manic-depressive psychosis. Compared with the diagnostic distribution of all register cases, reactive psychoses were more frequent than expected as former diagnoses and schizophrenia as later diagnosis. Neuroses and character deviations were frequent alternative diagnoses among unipolars, not among bipolars. The consequences of different selection criteria for the composition of proband groups are discussed.     

Decreased risk of acute appendicitis in patients with schizophrenia or manic-depressive psychosis

The present study tests the hypothesis of a negative association between patients with schizophrenia, manic-depressive psychosis and acute appendicitis.Using the nation-wide Danish case registers the occurrence of acute appendicitis among up to 20,402 inpatients with schizophrenia and up to 10,281 inpatients with manic-depressive psychosis and ten individually matched control persons for each psychiatric patient was investigated. A case-control and follow-up design was applied.Persons who developed schizophrenia had a significantly decreased relative risk of acute appendicitis of 0.49 before and of 0.59 after first psychiatric admission. Similarly the occurrence of manic-depressive psychosis was associated with a decreased relative risk of acute appendicitis of 0.50 before and of 0.70 after first psychiatric admission.One or more unknown factors inversely affect the risk for the subsequent development of psychoses and acute appendicitis. Further studies of this relationship may help to clarify etiological or pathophysiological aspects of schizophrenia and manic-depressive psychosis.     

Clinical course and outcome of delusional psychosis

The purpose of the study was to examine first-admitted patients with delusional psychosis meaning functional psychosis with paranoid symptoms with respect to clinical course and outcome. The index population comprised 88 patients. At discharge from first admission the patients were classified according to ICD-8 and DSM-III. According to both diagnostic classifications the majority of the patients did not belong to either of the two major psychotic groups, schizophrenia or affective psychosis. During the 2-year observation period half of the patients took psychotropic drugs continuously, and almost half of the patients experienced one or more relapses. One third of the patients were readmitted, and in average the patients stayed in the hospital for 4 months during the observation period including the time of index admission. At follow-up half of the patients revealed positive psychotic symptoms, while two thirds were moderately or severely impaired because of psychotic illness or personality dysfunction. It is concluded that the present aftercare treatment is insufficient to prevent relapse and psychotic symptoms. In consequence of this the existence of delusions at first admission to hospital because of functional psychosis seems for many to predict an unfavourable course and outcome. Further study will search for clinical and social predictors of course and outcome in patients with delusional psychosis.     

Manic-depressive psychosis in children younger than 15 years: a register-based investigation of 39 cases in Denmark.

Using a nationwide psychiatric case register covering a background population of 5.1 million inhabitants, 39 children (23 boys, 16 girls) were identified who got the diagnosis of manic-depressive psychosis between 1970 and 1986 before the age of 15. The frequency of manic-depressive psychosis in this child psychiatric population was 1.2%. The mean age for first-time admission with this diagnosis was 12.7 years. There was no sex difference. Twenty-six of the children got the diagnosis of manic-depressive psychosis during their first admission. Survival analysis was used to describe the prognosis and the diagnostic development of the group. As a whole, the group had a poor prognosis with many readmissions. The most common differential diagnoses were other types of psychosis in boys and oppositional and emotional disorders in girls.     

A comparison of two diagnostic methods. Clinical ICD diagnoses vs DSM-III and Research Diagnostic Criteria using the Diagnostic Interview Schedule (version 2)

In the context of a seven-year follow-up study, 171 former psychiatric inpatients and 158 subjects from the general population were interviewed twice, first with the German version of the Diagnostic Interview Schedule (DIS) (version 2), and second with a clinical interview using the Arbeitsgemeinschaft für Methodik und Dokumentation in der Psychiatrie (AMDP) checklist to assign a clinical International Classification of Diseases (eighth revision) (ICD-8) diagnosis, independent of the DIS. With the clinicians' ICD-8 diagnosis as a measure of the quality of the DIS, the results indicate a sufficiently high overall specificity and sensitivity of the DIS as a case-finding instrument in a general population survey, and a surprisingly high concordance of most DIS diagnostic classes with comparable ICD diagnoses. Only for panic disorders (possibly due to different symptom and time criteria) and schizophrenia (possibly due to the strict probe system, the dependence on self-reports, and time criteria) was low sensitivity found. Because there is no DIS diagnostic category comparable with ICD-8 unipolar affective psychosis, a meaningful comparison of this ICD category with Research Diagnostic Criteria and DSM-III was not possible.     

A follow-up investigation of offspring of parents with bipolar disorder

Seven male children who each had a manic-depressive parent (five alos had a parent with unipolar depression) and 12 control children were studied. The proband children had shown a range of adjustment problems as infants and toddlers. Four years later, they continued to have substantial behavior problems, including ones that could be classified as DSM-III psychiatric diagnoses. On the basis of psychiatric interviews and psychological assessments, the proband children received more DSM-III diagnoses than the control children. Proband children reported internalizing symptoms; this pattern was corroborated by their mothers, who also characterized these children as showing antisocial behavior patterns.     

精神病妇女妊娠期、产后病情及治疗

通过对２１４例女精神病人妊娠期，产后病情及治疗的研究，发现精神分裂症妊娠期未服药者，复发率１５．３８％，服药者未见复发，存有症状者１７．６５％病情加重。躁郁症，癔病妊娠期未见复发者。产后３个月内，精神分裂症、躁郁证、癔病总波动率（复发＋加重），三者间无明显差异（Ｐ＞０．０５）。对妊娠期、产后的治疗及对母亲、胎儿、婴儿健康的影响进行了讨论，提出合理妊娠，用药的建议。