Mental health articles

The DSM-III-R defining features (impaired social interaction, communication, and stereotyped patterns of behavior) are retained in DSM-IV, but the individual items and the overall diagnostic algorithm have been modified to (1) improve clinical utility by reducing the number of items from 16 to 12 and by increasing the clarity of individual items; (2) increase compatibility with the ICD-10 Diagnostic Criteria for Research; and (3) narrow the definition of caseness so that it conforms more closely with clinical judgment, DSM-III, and ICD-10. In addition an ‘‘age of onset’’ requirement (before age 3 years in DSM-IV), which had been dropped in DSM-IIIR, has been reinstated to conform to clinical usage and to increase the homogeneity of this category. (American Psychiatric Association, 1994, p. 774) Another problem in clinical diagnosis is illustrated in a study of the differential diagnosis of attention deficit disorder (ADD) and conduct disorder using conditional probabilities (Milich, Widiger, & Landau, 1987). Although these two disorders are considered separate disorders, there has been a substantial overlap in symptoms. Using a standardized interview designed to represent the diagnostic criteria contained in DSM-III, seventysix boys referred to a psychiatric outpatient clinic were evaluated and the conditional probabilities and base rates of the symptoms for both disorders were ascertained. The results indicated that the symptom with the highest covariation with the specific disorder was not always the most useful in diagnosis. Furthermore, some symptoms are most useful as inclusion criteria, whereas some are most useful as exclusion criteria. The authors also point out that the interview used was based on DSM-III and that the application of different diagnostic criteria could change the pattern of results obtained. This, of course, is always a problem when diagnostic criteria are revised and new systems instituted. A final important point made by these investigators is that the symptom criteria offered for ADD in DSM-III-R are weighted equally ‘‘whereas the results of the present study suggest that some symptoms are more effective inclusion criteria than others. In addition, the DSM-III-R offers only inclusion criteria and makes no attempt to use symptoms as exclusion criteria’’. Because of space limitations, only a few other studies can be mentioned. The introduction of many new diagnoses obviously created many new potential problems, among them, estimating the incidence of specific disorders. For example, ‘‘In the years since 1980, bulimia has gone from being virtually unknown to being described by some medical investigators as a ‘major public health problem’ and being designated by one prominent nonmedical leader of contemporary female opinion as a disorder of ‘epidemic proportions’’’. This author also states that ‘‘The use of DSM-III-R seems likely to lead to a dramatic decline in the diagnosis and prevalence of bulimia’’. Somewhat comparable comparisons have been reported by others. In one study of the definitions of schizophrenia for 532 inpatients treated and reevaluated 15 years later, the use of DSM-III-R reduced the number of patients diagnosed with schizophrenia by 10%. However, the DSM-III diagnosed patients included and excluded by DSMIII-R did not differ in terms of demographic, premorbid, or long-term outcome characteristics. The authors of this report emphasized that in the absence of improved validity, frequent changes in diagnostic systems were likely to impede research progress. Zimmerman also expressed his doubts that new changes in such a short time would actually improve the practice of psychiatry. A number of clinical researchers have published various critiques of some of the diagnostic categories listed in the new classification systems. Aronson stated that the definition of panic attack in DSM-III lacks precision and that the overlap with other disorders raises questions about what is a distinct psychiatric disorder. Leavitt and Tsuang reviewed the literature on schizoaffective disorder and concluded that ‘‘Until there is greater agreement on the criteria for and the meaning of schizoaffective disorder, reports on treatment results will not be generalizable’’.

Tags: definition, DSM, dsm-iii-r