Mental health articles

In DSM-IV, the criteria set for schizoaffective disorder ‘‘has been changed to focus on an uninterrupted episode of illness rather than on the lifetime pattern of symptoms’’. Obviously, there are significant differences in validity and reliability of diagnosis among diagnostic categories. In recent years, some of the personality diagnoses such as narcissistic personality disorder or borderline personality disorder have been popularized by several psychoanalytically oriented clinicians and, in part due to this, have been included as distinct disorders in the official nomenclature. Although a definite diagnosis of a borderline condition has always seemed rather illogical to me, apparently it is no problem to many people. However, as some have noted, the category of borderline personality disorder has been used to include a variety of pathological behaviors. ‘‘Exhibiting almost all of the clinical attributes known to descriptive psychopathology, borderline conditions lend themselves to a simplistic, if not perverse, form of diagnostic logic, that is, patients who display a potpourri of clinical indices, especially where symptomatic relationships are unclear or seem inconsistent, must perforce be borderlines’’. The use of a multiaxial system has also led to an increase in what has been termed ‘‘comorbidity,’’ having two or more concurrent diagnoses. Axis I in DSM-IV, Clinical Disorders, contains most of the more traditional psychiatric diagnoses, whereas Axis II includes only Personality Disorders and Mental Retardation. In DSM-III, it was originally stated that ‘‘This separation ensures that consideration is given to the possible presence of disorders that are frequently overlooked when attention is directed to the usually more florid Axis I disorder’’.

However, it appears that personality disorders are diagnosed quite frequently as either a primary diagnosis or as a secondary diagnosis. In a recent critical appraisal of the use of the terms of comorbidity or comorbid in psychopathology research, Lilienfeld, Waldman, & Israel) indicated the growth in their use. After appearing only twice in 1986, ‘‘the number of journal abstracts or titles containing these terms increased to 21 in 1987, 43 in 1988, 97 in 1989, 147 in 1990, 192 in 1991, 191 in 1992, and 243 in1993’’. This trend raises some question concerning the use of traditional views of medical diagnosis in psychopathology and ‘‘implicitly assumes a categorical model of diagnosis that may be inappropriate for personality disorders …’’. In a study of more than 200 adults at risk of AIDS, multiple diagnoses of personality disorder were recorded for most individuals with any DSMIII-R Axis II diagnosis. Almost half of the subjects with a diagnosis in one personality cluster also had a concurrent diagnosis in another cluster. A study of the comorbidity of alcoholism and personality disorders in a clinical population of 366 patients also obtained comparable findings. There was extensive overlap between Axis I disorders and personality disorders, as well as among personality disorders themselves. In another study of 118 gay men conducted to investigate the stability of personality disorder, it was reported that diagnoses of personality disorders had low stability over a 2-year period. A study of seventy-eight adult outpatients with attention deficit hyperactive disorder evaluated by standard tests showed high comorbidity with current depressive disorder, antisocial personality disorder, and alcohol and drug abuse dependence. In a sample of 716 opioid abusers, psychiatric comorbidity was documented in 47% of the sample based on aDSM-III-R diagnostic assessment. Such comorbidity was especially noted for personality and mood disorders for both sexes. There have been additional studies published on this issue, but there is no need to review them here. As Robins commented, ‘‘When standardized interviews demonstrate that a single patient qualifies for an unreasonable number of diagnoses, that should motivate the field to rethink this proliferation of categories’’. Thus, the categorical delineation of psychiatric disorders presents problems for meaningful diagnosis. Dumont, for example, feels strongly that psychiatry errs in attempting to divide all abnormal behavior into discrete illness categories. He believes that labels such as ‘‘hyperactivity’’ and ‘‘learning disorders’’ for children ‘‘are a capricious and arbitrary drawing of lines through a spectrum of behavioral, intellectual, emotional, and social disabilities’’

Marmor  in discussing systems thinking in psychiatry also emphasizes ‘‘that the growing tendency to think in terms of distinct and sharply demarcated phenomenological entities, as exemplified in DSM-III, deserves some skeptical evaluation despite its usefulness pragmatically’’. Although categorization may be simpler to handle than a dimensional approach, a combination of the two suggested by Lorr and by McReynolds  may be more meaningful in the long run and provide more information as well as potentially greater predictive power. Others also suggest that the use of both psychometric and f ixed diagnostic criteria could lead to a better and more valid definition of schizophrenia. However, despite such criticisms, as well as others, the neo-Kraepelinian model has continued to be used.

Tags: diagnosis, DSM, DSM-IV