Reliability and validity of DSM-IV axis V

OBJECTIVE: The authors investigated the reliability and convergent and discriminant validity of the DSM-IV Global Assessment of Functioning Scale and two experimental DSM-IV axis V global rating scales, the Global Assessment of Relational Functioning Scale and the Social and Occupational Functioning Assessment Scale. METHOD: Forty-four patients admitted to a university-based outpatient community clinic were rated by trained clinicians on the three DSM-IV axis V scales. Patients also completed self-report measures of DSM-IV symptoms as well as measures of relational, social, and occupational functioning. RESULTS: The Global Assessment of Functioning Scale, Global Assessment of Relational Functioning Scale, and Social and Occupational Functioning Assessment Scale all exhibited very high levels of interrater reliability. Factor analysis revealed that the Global Assessment of Relational Functioning Scale and the Social and Occupational Functioning Assessment Scale are each more related to the Global Assessment of Functioning Scale individually than they are to each other. The Global Assessment of Functioning Scale was significantly related to concurrent patient responses on the SCL-90-R global severity index. The Social and Occupational Functioning Assessment Scale was significantly related to concurrent patient responses on the SCL-90-R global severity index and to a greater degree with both the Social Adjustment Scale global score and the Inventory of Interpersonal Problems total score. Although the Global Assessment of Relational Functioning Scale was not significantly related to any of the three self-report measures, it was related to the presence of clinician-rated axis II pathology. CONCLUSIONS: The three axis V scales can be scored reliably. The Global Assessment of Relational Functioning Scale and the Social and Occupational Functioning Assessment Scale evaluate different constructs. These findings support the validity of the Global Assessment of Functioning Scale as a scale of global psychopathology; the Social and Occupational Functioning Assessment Scale as a measure of problems in social, occupational, and interpersonal functioning; and the Global Assessment of Relational Functioning Scale as an index of personality pathology. The authors discuss further refinement and use of the three axis V measures in treatment research.     

Revising axis V for DSM-IV: a review of measures of social functioning.

OBJECTIVE: Axis V, which uses the Global Assessment of Functioning Scale in the multiaxial system of DSM-III-R, is under review for DSM-IV. This article examines what is known about axis V and selectively reviews the literature on measures of social functioning to identify potential alternatives to the Global Assessment of Functioning Scale. METHOD: About 25 studies on the use, reliability, and validity of axis V in DSM-III and DSM-III-R are reviewed. In addition, nearly 30 measures of social functioning are reviewed and analyzed as potential substitutes for the Global Assessment of Functioning Scale. The analysis focuses on the strengths and weaknesses of each measure for assessing functioning on axis V. RESULTS: Axis V measures are modestly reliable and valid but not widely used. The authors identify and discuss two particular limitations of the Global Assessment of Functioning Scale: 1) the combination of measures of symptoms and measures of social functioning on a single axis and 2) the exclusion of physical impairments from the rating of functioning. CONCLUSIONS: None of the measures of social functioning reviewed is clearly superior to the Global Assessment of Functioning Scale for use on axis V. A modified version of the Global Assessment of Functioning Scale, separating the measures of social and occupational functioning from the measures of symptoms and psychological functioning, is proposed for field testing, along with a new set of instructions permitting the rating of limitations due to both physical and mental impairments.     

A two-year follow-up study and prospective evaluation of the DSM-IV axis V

A six-month cohort of general adult psychiatric inpatients was followed for up to two years to evaluate outcome and contrast the validity of DSM-IV measures of adaptive functioning-the Global Assessment of Functioning (GAF), the Social and Occupational Functioning Assessment Scale (SOFAS), and the Global Assessment of Relational Functioning Scale (GARF). Detailed data, including quality-of-life ratings and DSM-IV axis I and V codes, were collected by interview and self-report questionnaires for 53 study participants. Patients' retrospective ratings of the care they received were not predictive of outcome. Adaptive functioning at discharge was predictive of both severity of illness and social functioning at follow-up. The SOFAS had the strongest concurrent and predictive validity, the latter both for length of initial inpatient stay and two-year outcome.     

Reliability and validity of DSM-IV generalized anxiety disorder features

The reliability of generalized anxiety disorder (GAD) features has been shown to be moderate, based on research utilizing the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV), a semi-structured diagnostic interview. This may be a function of the criteria for the diagnosis of GAD, which have undergone much revision since its first inclusion in the Diagnostic and Statistical Manual of Mental Disorders. The reliability and validity of disorder feature ratings were examined in a diverse sample of patients who presented for assessment and treatment of excessive worry, generalized anxiety, or tension at an anxiety specialty clinic and who met criteria for a principal diagnosis of GAD (N = 129). Internal consistency of the ratings of excessiveness of worry, uncontrollability of worry, and the associated symptom cluster was moderate to low and varied by disorder feature. Inter-rater reliability for all features of GAD and severity of the disorder varied between good and poor. Additional findings showed that the GAD features, as measured using the ADIS-IV module, have modest to strong convergent validity, varying by feature, and poor discriminant validity when tested against measures of social anxiety. Potential reasons for rater disagreement are discussed. Results are also considered in terms of how they may inform the evolving criteria for GAD in DSM-V.     

Ten-year review of rating scales. V: scales assessing attention-deficit/hyperactivity disorder

OBJECTIVE: This article summarizes information on scales assessing attention-deficit/hyperactivity disorder (ADHD) in children and adolescents. METHOD: The authors sampled articles on ADHD over the past decade. Several popular older ADHD measures have recently been revised, and new ADHD scales have been developed. The authors selected primarily ADHD scales based on the DSM-IV construct of ADHD that also have multiple literature citations. They then reviewed their psychometric properties. Those with adequate psychometric functioning plus considerable literature citations, known wide usage in clinical practice, or a current niche are presented here. RESULTS: Several rating scales consistent with the DSM-IV conceptualization of ADHD are now available for use in both home and school settings. Many of the instruments demonstrate solid psychometric properties and a strong normative base. However, some popular scales have not been adequately investigated. Some measures are restricted to the comprehensive assessment of ADHD, whereas others also include symptoms of other disorders. The potential applications for these scales with youths diagnosed with ADHD are broad. CONCLUSIONS: Rating scales can reliably, validly, and efficiently measure DSM-IV-based ADHD symptoms in youths. They have great utility in research and clinical work, assist treatment planning, and help to ensure accountability in practice.     

The usefulness of DSM-III axis IV and axis V assessments

DSM-III multiaxial diagnoses were given to 257 patients. Analysis of axis I diagnoses and axis IV and axis V assessments generally revealed the expected associations between particular psychiatric disorders and levels of psychosocial stress and social and occupational functioning. However, a major difficulty affecting the usefulness of axis IV and axis V data when they are routinely gathered according to the current DSM-III instructions is the stipulation that the clinician judge the etiological significance of a stressor before it is coded.     

Reliability and stability of a semistructured DSM-IV interview designed for family studies

OBJECTIVE: To determine the interrater reliability and stability of diagnoses, and to compare the results of in-person versus telephone administration of the Missouri Assessment of Genetics Interview for Children (the MAGIC), a new, semistructured, glossary-based diagnostic interview for children and adolescents. METHOD: The interview was developed for a large-scale epidemiological family genetics study. For reliability measures, parent report on offspring, child self-report, and adolescent self-report interviews were independently scored by two different raters on a population-based sample of respondents. The stability of diagnoses was assessed by comparing repeat interviews of parents, children, and adolescents, separated on average by 13 months. Frequencies of parent and adolescent report of disorders were determined for telephone and in-person interviews. RESULTS: High interrater reliabilities were achieved for individual DSM-IV symptoms and diagnoses and for individual characteristics of diagnostic domains, including number, clustering, duration, and impairment of symptoms. The stability of diagnoses was also high for parents and adolescents. No significant differences in the prevalence of attention-deficit/hyperactivity disorder and major depressive disorder were found for interviews administered in person or by telephone. CONCLUSIONS: The MAGIC demonstrates high interrater reliability and stability for DSM-IV symptoms and diagnoses.     

DSM-IV axis II comorbidity with borderline personality disorder in monolingual Hispanic psychiatric outpatients

The authors examined the comorbidity of DSM-IV borderline personality disorder (BPD) with other personality disorders (PD) in a series of adult monolingual (Spanish only) Hispanic psychiatric outpatients with substance use disorders. One hundred outpatients (69 men and 31 women) were assessed with the Spanish version of the Diagnostic Interview for DSM-IV Personality Disorders. PD co-occurrence in the group of patients with BPD (N = 34) was statistically compared with that in the group without BPD (N = 66). Bonferroni-corrected chi-square analysis showed significant diagnostic comorbidity with BPD for antisocial, avoidant, and depressive PD. However, analyses conducted separately by gender showed no significant comorbidity of any PD with BPD in women and significant comorbidity with antisocial, avoidant, and depressive PD in men. These results suggest that in monolingual Hispanic psychiatric outpatients with substance use disorders, gender may play a role in the nature of BPD comorbidity. The BPD diagnosis may represent a broader range of psychopathology in Hispanic men than women.     

The reliability of axis V of DSM-III

The authors studied the reliability of axis V of DSM-III by analyzing ratings of 97 psychiatric inpatients made by a multidisciplinary team of clinicians. The intraclass correlation coefficient for ratings of the overall sample was .49, lower than the figure found during the DSM-III field trials. The psychiatric diagnosis, age, ethnicity, marital status, and sex of the patient did not significantly influence reliability. The authors recommend more explicit instructions in the administration of the scale, the use of a standardized interview, and more training for raters as ways of increasing reliability.     

Under the axis II radar: clinically relevant personality constellations that escape DSM-IV diagnosis

Research suggests that personality pathology lies on a continuum from relatively severe to less severe and that subthreshold variants may not be adequately captured by axis II of DSM-IV. In this study, we used a measure of personality and psychopathology designed for experienced clinical observers (the SWAP-200) to derive subthreshold personality constellations in a sample of 159 psychotherapy patients who were high functioning but nevertheless suffered from maladaptive personality patterns. Using Q-factor analysis (an empirical clustering procedure), we identified 4 diagnostic groupings or SPC, which resembled the clinical concept of "neurotic styles": depressive, hostile-competitive, obsessive, and hysterical. The results of this study should stimulate further research on subthreshold personality configurations.     

Personality diagnoses in adolescence: DSM-IV axis II diagnoses and an empirically derived alternative

OBJECTIVE: The study of personality pathology in adolescence is in its infancy. This article examined the applicability and limits of DSM-IV axis II personality disorder diagnoses in adolescents, assessed the validity of a method for assessing adolescent personality pathology, and began to develop an empirically grounded classification. METHOD: A total of 296 randomly selected clinicians described a patient age 14-18 in treatment for maladaptive personality patterns using axis II ratings scales and the Shedler-Westen Assessment Procedure-200 for Adolescents (SWAP-200-A), a Q-sort instrument for assessing adolescent personality pathology. After examining the nature and frequency of axis II disorders in the sample, the authors used Q-factor analysis to identify naturally occurring groupings of patients on the basis of shared personality features. RESULTS: Axis II diagnoses in adolescents resembled those in adults, although application of DSM-IV criteria appeared to overdiagnose antisocial and avoidant personality disorder in adolescents. Q analysis with the SWAP-200-A isolated five personality disorders (antisocial-psychopathic, emotionally dysregulated, avoidant-constricted, narcissistic, and histrionic) and one personality style. Patients' dimensional scores on each diagnostic prototype showed predictable associations with ratings of current axis II disorders, measures of adaptive functioning, and symptoms assessed with the Child Behavior Checklist. CONCLUSIONS: With some exceptions, personality pathology in adolescence resembles that in adults and is diagnosable in adolescents ages 14-18. Categories and criteria developed for adults may not be the optimal way of diagnosing adolescents. Data from samples of adolescents may prove useful in developing an empirically and clinically grounded classification of personality pathology in adolescents.     

Classification of amok in DSM-IV.

Culture-bound syndromes have been described worldwide in many individuals and, for certain syndromes, in epidemic proportion, yet these disorders have been classified as rare and exotic conditions warranting minimal attention. Development of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders and the tenth edition of the International Classification of Diseases offers an opportunity for providing a more sophisticated classification of these phenomena. The authors examine amok, a syndrome first described in Malaysia that consists of homicidal frenzy preceded by a state of brooding and ending with somnolence and amnesia. They discuss the concept of and criteria for a culture-specific disorder and propose that amok be classified as a culture-specific explosive behavioral disorder in DSM-IV.