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Exploration of DSM-IV criteria in primary care patients with medically unexplained symptoms.

OBJECTIVES: Investigators and clinicians almost always rely on Diagnostic and Statistical Manual of Mental Disorder, 4th edition's (DSM-IV) somatoform disorders (and its derivative diagnoses) to characterize and identify patients with medically unexplained symptoms (MUS). Our objective was to evaluate this use by determining the prevalence of DSM-IV somatoform and nonsomatoform disorders in patients with MUS proven by a gold standard chart review. METHODS: In a community-based staff model HMO, we identified subjects for a clinical trial using a systematic and reliable chart rating procedure among high-utilizing MUS patients. Only baseline data are reported here. The World Health Organization Composite International Diagnostic Interview provided full and abridged DSM-IV diagnoses. Patients with full or abridged DSM-IV somatoform diagnoses were labeled "DSM somatoform-positive," whereas those without them were labeled "DSM somatoform-negative." RESULTS: Two hundred six MUS patients averaged 13.6 visits in the year preceding study, 79.1% were females, and the average age was 47.7 years. We found that 124 patients (60.2%) had a nonsomatoform ("psychiatric") DSM-IV diagnosis of any type; 36 (17.5%) had 2 full nonsomatoform diagnoses, and 41 (19.9%) had >2; 92 (44.7%) had some full anxiety diagnosis and 94 (45.6%) had either full depression or minor depression diagnoses. However, only 9 of 206 (4.4%) had any full DSM-IV somatoform diagnosis, and only 39 (18.9%) had abridged somatization disorder. Thus, 48 (23.3%) were "DSM somatoform-positive" and 158 (76.7%) were "DSM somatoform-negative." The latter exhibited less anxiety, depression, mental dysfunction, and psychosomatic symptoms (all p <.001) and less physical dysfunction (p = .011). Correlates of this DSM somatoform-negative status were female gender (p = .007), less severe mental (p = .007), and physical dysfunction (p = .004), a decreased proportion of MUS (p <.10), and less psychiatric comorbidity (p <.10); c-statistic = 0.77. CONCLUSION: We concluded that depression and anxiety characterized MUS patients better than the somatoform disorders. Our data suggested radically revising the somatoform disorders for DSM-V by incorporating a new, very large group of now-overlooked DSM somatoform-negative patients who were typically women with less severe dysfunction.

Anxiety Disorders↗
PubMed2006

Reclassifying DIS-III-R alcohol use disorders to DSM-IV criteria in a sample of convicted impaired drivers.

OBJECTIVE: This study used data gathered from the Diagnostic Interview Schedule, Version Three, Revised (DIS-III-R), which calculated diagnoses based on the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R), criteria and rescored the data to be compatible with the criteria of the Fourth Edition of the DSM (DSM-IV) for lifetime alcohol abuse and dependence. METHOD: A psychologist reassigned questions from the DIS-III-R according to DSM-IV criteria. Another clinician evaluated the rescoring criteria and discrepancies were discussed and resolved. Using these criteria, SAS code was written to automate the rescoring of responses to DIS-III-R questions to DSM-IV diagnoses from a population of DWI offenders. RESULTS: There was a fair-to-good level of agreement between the DSM-III-R and rescored DSM-IV diagnoses (kappa = .65). Three hundred forty-eight subjects classified as alcohol dependent using DSMIII- R were reclassified as alcohol abuse in the DSM-IV rescore. Among subjects who were alcohol dependent based on DIS-III-R criteria, the distribution of DSM-IV diagnoses was similar across gender, age, and ethnic groups. There was no difference in agreement between DSMIII- R and the rescored DSM-IV diagnoses by age category. However, women and Hispanics had significantly higher weighted kappa statistics than men and non-Hispanic whites. CONCLUSIONS: Our rescoring results were consistent with earlier studies that compared DSM-III-R and DSM-IV diagnoses. Here, we offer an approach that may be useful to investigators who used the DIS-III-R in earlier studies. The DIS-III-R questions corresponding to DSM-IV criteria for alcohol abuse and alcohol dependence are on our Web site at www.bhrcs.org, along with the scoring algorithm.

Adult↗
PubMed2004

Delirium among patients with and without dementia: does the diagnosis according to the DSM-IV differ from the previous classifications?

BACKGROUND: Different diagnostic criteria differ in their capacity to identify subjects as delirious. It is not known how DSM-IV classification, compared with the DSM-III, DSM-III-R, and ICD-10, identifies delirium among individuals with and without dementia and whether the symptom profiles differ between these two subgroups. METHODS: A cross-sectional study was performed on patients (age > or = 70 years) in seven acute geriatric wards (n = 230) and in seven nursing-homes (n = 195) in Helsinki, Finland. Delirium was diagnosed according to the operationalized criteria according to the DSM-III, DSM-III-R, DSM-IV, and clinical criteria of ICD-10. Dementia was defined according to consensus judgment among three geriatricians with concise information including: prior dementia diagnoses, Clinical Dementia Rating Scale, operationalized criteria according to the DSM-IV, nurses and/or caregivers interviews, and the results of the brain CT/MRI and prior Mini-Mental State Examination scores, when available. RESULTS: According to the DSM-III, DSM-IIIR, DSM-IV and ICD-10 criteria of delirium 22.7, 23.5, 25.9 and 14.9% of the demented, and 12.9, 13.5, 23.5 and 2.9% of the non-demented, respectively, were diagnosed as delirious. In stepwise logistic regression analysis clouding of consciousness, perceptual disturbances, and disorganized thinking were the most significant contributors to delirium diagnosis according to the DSM-IV among individuals with dementia, whereas perceptual disturbances, motor disturbances, and disorientation were the most significant contributors among those without dementia. CONCLUSIONS: DSM-IV criteria of delirium identify new, often non-demented, subjects as being delirious, while ICD-10 is overly restrictive. The symptom profile of delirium was slightly different among individuals with and without dementia.

Aged↗
PubMed2001

DSM-IV and ICD-10 generalized anxiety disorder: discrepant diagnoses and associated disability.

BACKGROUND: It is commonly assumed that diagnoses according to DSM-IV and ICD-10 are equivalent. Recent discussions on generalized anxiety disorder (GAD) have suggested that ICD-10 criteria may be identifying a milder form of the disorder than DSM-IV. This report examines prevalence and associated disability of DSM-IV and ICD-10 GAD. METHODS: The Composite International Diagnostic Interview was administered to a community sample of 10,641 people, and the diagnostic criteria that contributed to discrepancies between DSM-IV and ICD-10 GAD were identified. A multiple linear regression analysis was carried out to determine the strength of the relationship between disability, as measured by the SF-12, and discrepant diagnoses of GAD. RESULTS: The concordance between DSM-IV and ICD-10 GAD was fair (kappa = 0.39). The two sources of discrepancy when DSM-IV was positive and ICD-10 was negative resulted from the requirement in ICD-10 that the respondent endorse symptoms of autonomic arousal (ICD-10 criterion B) and the requirement that ICD-10 GAD does not co-occur with panic/agoraphobia, social phobia or obsessive-compulsive disorder (ICD-10 criterion C). The two major sources of discrepancy when ICD-10 was positive and DSM-IV was negative resulted from the requirement in DSM-IV that the worry be excessive (DSM-IV criterion A) and that it causes clinically significant distress or impairment (DSM-IV criterion E). DSM-only GAD cases had significantly higher levels of disability than ICD-only cases of GAD after controlling for demographic variables and the presence of comorbid psychiatric disorders. CONCLUSIONS: While the prevalence rates for DSM-IV and ICD-10 GAD are almost identical, these classification systems are diagnosing different groups of people.

Adult↗
PubMed1991

DSM-IV: a nosology sold before its time?

OBJECTIVE: The purpose of this study was to determine whether American psychiatrists believe that DSM-IV is being published too soon after DSM-III-R. METHOD: The authors conducted a mail survey of the attitudes of practicing psychiatrists (N = 454), residency program directors (N = 128), residents (N = 1,331), and researchers (N = 196) toward the scheduled publication of DSM-IV in the early 1990s. RESULTS: They found that the majority of all four groups believed that DSM-IV is being published prematurely. In contrast to respondents who believed that the timing of DSM-IV is appropriate, those who indicated that it is being published too soon had more recently completed their residency training and also believed that DSM-III-R was published prematurely. There was no association between the psychiatrists' responses and their theoretical orientation, Board certification status, ownership of the DSM manuals, the length of time they had used DSM-III, and the diagnostic manual (DSM-III or DSM-III-R) they were currently using. CONCLUSIONS: The belief that DSM-IV is being published too soon could contribute to underuse of DSM-IV by substantial numbers of psychiatrists. Thus, to foster compliance with it, APA must preserve in its efforts to demonstrate that the advantages of publishing it in 1993 outweigh the disadvantages of adopting yet another manual.

Adult↗
PubMed2000

Withdrawal and tolerance: prognostic significance in DSM-IV alcohol dependence.

OBJECTIVE: The clinical and research importance of tolerance and/or withdrawal in the diagnosis of substance dependence has been identified as a key area needing clarification. Earlier longitudinal studies did not identify whether diagnoses of alcohol dependence were current or lifetime. In this study, the prognostic significance of the DSM-IV physiological specifier was investigated among cases of alcohol dependence current at the baseline interview. The role of tremors, required in DSM-III and DSM-III-R, was investigated as well. METHOD: Household residents (N = 130; 57% men) meeting full criteria for current DSM-IV alcohol dependence in a baseline interview were re-interviewed a year later and DSM-IV alcohol dependence was again evaluated. Reliable structured interviews were used to make the diagnoses. The DSM-IV physiologic specifier and its components were tested as predictors of outcome of DSM-IV alcohol dependence, and included an additional definition of alcohol withdrawal that required tremors. Chi-square tests and adjusted odds ratios indicated statistical significance of group differences on outcome. RESULTS: The DSM-IV physiological specifier (tolerance or withdrawal) did not predict 1-year chronicity of DSM-IV alcohol dependence, nor did tolerance when considered separately. However, withdrawal predicted poor outcome (e.g., 1-year chronicity of DSM-IV alcohol dependence). The effect of withdrawal was strengthened when tremors were required as part of the withdrawal syndrome. CONCLUSIONS: In contrast to earlier longitudinal research, this study supports the prognostic relevance of one component of the present DSM-IV physiological specifier--withdrawal. Withdrawal appears to have stronger prognostic meaning when the DSM-III-R version, in which tremors were required, is used. Further studies of the physiological subtype may benefit from studying subjects who have been clearly identified at the baseline evaluation as having a current diagnosis of dependence.

Adolescent↗
PubMed1989

On the way to expert systems. Comparing DSM-III computer diagnoses with CATEGO (ICD) diagnoses in depressive and schizophrenic patients.

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.(ABSTRACT TRUNCATED AT 250 WORDS)

Algorithms↗
PubMed2006

Human brain evolution and the "Neuroevolutionary Time-depth Principle:" Implications for the Reclassification of fear-circuitry-related traits in DSM-V and for studying resilience to warzone-related posttraumatic stress disorder.

The DSM-III, DSM-IV, DSM-IV-TR and ICD-10 have judiciously minimized discussion of etiologies to distance clinical psychiatry from Freudian psychoanalysis. With this goal mostly achieved, discussion of etiological factors should be reintroduced into the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). A research agenda for the DSM-V advocated the "development of a pathophysiologically based classification system". The author critically reviews the neuroevolutionary literature on stress-induced and fear circuitry disorders and related amygdala-driven, species-atypical fear behaviors of clinical severity in adult humans. Over 30 empirically testable/falsifiable predictions are presented. It is noted that in DSM-IV-TR and ICD-10, the classification of stress and fear circuitry disorders is neither mode-of-acquisition-based nor brain-evolution-based. For example, snake phobia (innate) and dog phobia (overconsolidational) are clustered together. Similarly, research on blood-injection-injury-type-specific phobia clusters two fears different in their innateness: 1) an arguably ontogenetic memory-trace-overconsolidation-based fear (hospital phobia) and 2) a hardwired (innate) fear of the sight of one's blood or a sharp object penetrating one's skin. Genetic architecture-charting of fear-circuitry-related traits has been challenging. Various, non-phenotype-based architectures can serve as targets for research. In this article, the author will propose one such alternative genetic architecture. This article was inspired by the following: A) Nesse's "Smoke-Detector Principle", B) the increasing suspicion that the "smooth" rather than "lumpy" distribution of complex psychiatric phenotypes (including fear-circuitry disorders) may in some cases be accounted for by oligogenic (and not necessarily polygenic) transmission, and C) insights from the initial sequence of the chimpanzee genome and comparison with the human genome by the Chimpanzee Sequencing and Analysis Consortium published in late 2005. Neuroevolutionary insights relevant to fear circuitry symptoms that primarily emerge overconsolidationally (especially Combat related Posttraumatic Stress Disorder) are presented. Also introduced is a human-evolution-based principle for clustering innate fear traits. The "Neuroevolutionary Time-depth Principle" of innate fears proposed in this article may be useful in the development of a neuroevolution-based taxonomic re-clustering of stress-triggered and fear-circuitry disorders in DSM-V. Four broad clusters of evolved fear circuits are proposed based on their time-depths: 1) Mesozoic (mammalian-wide) circuits hardwired by wild-type alleles driven to fixation by Mesozoic selective sweeps; 2) Cenozoic (simian-wide) circuits relevant to many specific phobias; 3) mid Paleolithic and upper Paleolithic (Homo sapiens-specific) circuits (arguably resulting mostly from mate-choice-driven stabilizing selection); 4) Neolithic circuits (arguably mostly related to stabilizing selection driven by gene-culture co-evolution). More importantly, the author presents evolutionary perspectives on warzone-related PTSD, Combat-Stress Reaction, Combat-related Stress, Operational-Stress, and other deployment-stress-induced symptoms. The Neuroevolutionary Time-depth Principle presented in this article may help explain the dissimilar stress-resilience levels following different types of acute threat to survival of oneself or one's progency (aka DSM-III and DSM-V PTSD Criterion-A events). PTSD rates following exposure to lethal inter-group violence (combat, warzone exposure or intentionally caused disasters such as terrorism) are usually 5-10 times higher than rates following large-scale natural disasters such as forest fires, floods, hurricanes, volcanic eruptions, and earthquakes. The author predicts that both intentionally-caused large-scale bioevent-disasters, as well as natural bioevents such as SARS and avian flu pandemics will be an exception and are likely to be followed by PTSD rates approaching those that follow warzone exposure. During bioevents, Amygdala-driven and locus-coeruleus-driven epidemic pseudosomatic symptoms may be an order of magnitude more common than infection-caused cytokine-driven symptoms. Implications for the red cross and FEMA are discussed. It is also argued that hospital phobia as well as dog phobia, bird phobia and bat phobia require re-taxonomization in DSM-V in a new "overconsolidational disorders" category anchored around PTSD. The overconsolidational spectrum category may be conceptualized as straddling the fear circuitry spectrum disorders and the affective spectrum disorders categories, and may be a category for which Pitman's secondary prevention propranolol regimen may be specifically indicated as a "morning after pill" intervention. Predictions are presented regarding obsessive-compulsive disorder (OCD) (e.g., female-pattern hoarding vs. male-pattern hoarding) and "culture-bound" acute anxiety symptoms (taijin-kyofusho, koro, shuk yang, shook yong, suo yang, rok-joo, jinjinia-bemar, karoshi, gwarosa, Voodoo death). Also discussed are insights relevant to pseudoneurological symptoms and to the forthcoming Dissociative-Conversive disorders category in DSM-V, including what the author terms fright-triggered acute pseudo-localized symptoms (i.e., pseudoparalysis, pseudocerebellar imbalance, psychogenic blindness, pseudoseizures, and epidemic sociogenic illness). Speculations based on studies of the human abnormal-spindle-like, microcephaly-associated (ASPM) gene, the microcephaly primary autosomal recessive (MCPH) gene, and the forkhead box p2 (FOXP2) gene are made and incorporated into what is termed "The pre-FOXP2 Hypothesis of Blood-Injection-Injury Phobia." Finally, the author argues for a non-reductionistic fusion of "distal (evolutionary) neurobiology" with clinical "proximal neurobiology," utilizing neurological heuristics. It is noted that the value of re-clustering fear traits based on behavioral ethology, human-phylogenomics-derived endophenotypes and on ontogenomics (gene-environment interactions) can be confirmed or disconfirmed using epidemiological or twin studies and psychiatric genomics.

Animals↗
PubMed2006

Adolescents and substance-related disorders: research agenda to guide decisions on Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V).

AIMS: Since the publication of the Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV), many studies have addressed substance use disorders (SUD) in adolescents. Based on that adolescent literature, this paper suggests further research to help guide decisions about revising for DSM-V the SUD criteria in DSM-IV. METHODS: The author has reviewed the 'Substance Related Disorders' section of DSM-IV-TR, recalled his experience in helping to draft that section, accessed relevant articles in PubMed and reviewed his own extensive file of literature citations. RESULTS: This paper suggests six questions for adolescent research to help guide the framers of DSM-V's 'Substance Related Disorders' section: (a) DSM-IV did not provide a diagnosis of cannabis withdrawal; should DSM-V continue that position? (b) Should SUD be included or referenced among 'Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence'? (c) Can inter-rater reliability of the substance abuse (SA) criteria be improved with altered example situations, text descriptions or phrasing of the current criteria? (d) Between ages 14 and 18 years is earlier onset of SUD a severity marker that could be incorporated into DSM-V as a predictor of worse course? (e) In DSM-V could a phenotypic descriptor of pathological multi-substance involvement document severity and predict course of SUD? (f) Could clinicians and patients benefit from DSM-V-related postpublication procedures for classifying emerging new drugs into DSM-V's categories? CONCLUSIONS: Without substantive changes in SA or substance dependence diagnostic criteria, research may improve the usefulness of those criteria for adolescents.

Adolescent↗
PubMed1995

DSM-IV field trial: testing a new proposal for somatization disorder.

OBJECTIVE: The purpose of this study was to evaluate for APA a proposed strategy to diagnose somatization disorder for possible inclusion in DSM-IV. METHOD: Five sites--Washington University, University of Kansas, University of Iowa, University of Arkansas, and Mount Sinai Medical Center in New York--participated in a collaborative field trial. Female subjects (N = 353) were recruited from several different services (psychiatry, internal medicine, and family practice) and were evaluated for the presence or absence of the disorder. This assessment was performed with a new instrument constructed by combining all the criteria for somatization disorder from the proposed criteria for DSM-IV, DSM-III, DSM-III-R, Perley-Guze, and proposed criteria for ICD-10. RESULTS: A high level of concordance was found between the proposed diagnostic strategy for DSM-IV and the current criteria (DSM-III-R), as well as the earlier criteria (Perley-Guze and DSM-III). The ICD-10 criteria agreed poorly with all other criteria sets. The level of experience of the rater (expert versus novice) with the earlier (Perley-Guze, DSM-III) and current (DSM-III-R) criteria did not influence the identification of cases by use of DSM-IV criteria. No racial effect was introduced by any of the criteria sets. CONCLUSIONS: The strategy for DSM-IV is an accurate and simpler method of diagnosing somatization disorder that does not require special expertise for proper use.

Adult↗
PubMed2002

The DSM-IV Text Revision: rationale and potential impact on clinical practice.

One consequence of the longer interval between major revisions of the DSM(from seven years between DSM-III-R and DSM-IV to more than 15 years between DSM-IV and DSM-V) is that the accompanying descriptive text will become increasingly out of step with the psychiatric database. To remedy this problem, the DSM-IV Text Revision (DSM-IV-TR) was published in July 2000. The main objectives of the revision were to review the DSM-IV text and make changes to reflect information newly available since the close of the initial DSM-IV literature review process in mid-1992; to correct errors and ambiguities that have been identified in DSM-IV; and to update the diagnostic codes to reflect changes in the ICD-9-CM coding system the U.S. government uses officially for health care reporting. This paper reviews the rationale for the text revision and describes changes that may have an impact on the day-to-day use of DSM-IV.

Guidelines as Topic↗
PubMed2004

Comparisons between the South Oaks Gambling Screen and a DSM-IV-based interview in a community survey of problem gambling.

OBJECTIVE: To directly compare 2 forms of assessment for determining gambling problems in a community survey, and to examine the characteristics of respondents who endorsed DSM-IV symptoms but who scored below the formal DSM-IV diagnostic cut-off for pathological gambling. METHOD: We interviewed 1489 Winnipeg adults by phone (response rate 70.5%) using th South Oaks Gambling Screen (SOGS), a DSM-IV-based instrument, and several gambling-related variables. RESULTS: The lifetime prevalence of "probable pathological gambling" (according to the SOGS, having a score of > or = 5) was 2.6%. The SOGS items and DSM-IV symptoms were highly correlated (r = 0.80), but a score of 5 or more symptoms for a DSM-IV diagnosis produced lower prevalence figures. Comparisons between recreational gamblers (those with no DSM-IV symptoms), subthreshold pathological gamblers (those with 1 to 4 DSM-IV symptoms), and pathological gamblers (those with > or = 5 DSM-IV symptoms) on series of gambling-related variables (for example, high use of video lottery terminals) revealed that subthreshold individuals significantly differed from recreational gamblers and more closely approximated the characteristics displayed by pathological gamblers. CONCLUSIONS: SOGS items show a high degree of association with the DSM-IV clinical symptoms of pathological gambling, but the DSM-IV cut-off of 5 symptoms is more conservative in defining gambling problems. Results support a continuum view of gambling problems in the community. DSM-IV scores of 3 or 4 represent the higher end of the group officially considered diagnostically "subthreshold" and may be important from both a clinical and public health perspective.

Adult↗
PubMed2001

The myth of DSM's invention of new categories of disorder: Houts's diagnostic discontinuity thesis disconfirmed.

Houts (2001) argues that increases in DSM diagnostic categories are due to the invention of new disorders that are discontinuous with old conceptions of disorder and would not have been previously diagnosed. He maintains that DSM category increases are not comparable in nature to ICD category increases, which are mainly refinements of recognized disorders. I survey categories of disorder introduced after DSM-II and assess whether they are discontinuous with old concepts and categories of disorder. Candidate categories are identified from: Houts and Follette (1998), Mentalism, mechanisms, and medical analogues: Reply to Wakefield. Journal of Consulting and Clinical Psychology; Kutchins and Kirk (1997) Making us crazy: DSM: The psychiatric bible and the creation of mental disorders. New York: Free Press; and my own list. The result is that virtually none of the candidate categories are invented, discontinuous categories. In almost every case, the newly labeled conditions were considered disorders at the time of DSM-II and would have been diagnosed under DSM-II categories. I also reexamine DSM-IV sleep disorder categories, which Houts claims are discontinuous with past diagnostic conceptions. The result is that all DSM-IV sleep disorders were recognized as disorders at the time of DSM-II, and most were recognized as mental disorders. I conclude that DSM category increases are comparable in nature to ICD category increases, and that the invention-of-disorder account cannot explain the vast majority of such increases.

Diagnosis-Related Groups↗
PubMed1994

DSM-IV field trials for oppositional defiant disorder and conduct disorder in children and adolescents.

OBJECTIVE: The purpose of the field trials for oppositional defiant disorder and conduct disorder was to select valid diagnostic thresholds for these disorders and to compare the psychometric properties of DSM-IV criteria for oppositional defiant disorder and conduct disorder with previous DSM diagnostic formulations. METHOD: Structured diagnostic interviews, standardized clinician's validation diagnoses, and multiple measures of impairment were obtained for 440 clinic-referred children and adolescents aged 4-17 years. RESULTS: A diagnostic threshold of four symptoms of oppositional defiant disorder optimized identification of impaired children, improved agreement somewhat with the clinician's validation diagnosis, and had somewhat better test-retest agreement than DSM-III-R. In the case of conduct disorder, the optimal time window for ascertainment of symptoms was clarified. A diagnostic threshold of three symptoms of conduct disorder maximized accurate identification of impaired children and agreement with the clinician's validation diagnosis and resulted in slightly better test-retest agreement than DSM-III-R. Compared with the DSM-III-R definition, the DSM-IV definition of oppositional defiant disorder was somewhat more prevalent, but the prevalence of conduct disorder was essentially unchanged. CONCLUSIONS: DSM-IV definitions of oppositional defiant disorder and conduct disorder are somewhat better than DSM-III-R definitions in terms of internal consistency and test-retest agreement, and the validity of the DSM-IV definition of oppositional defiant disorder is slightly better than that of DSM-III-R.

Adolescent↗
PubMed2000

Preschoolers classified as having attention-deficit hyperactivity disorder (ADHD): DSM-IV symptom endorsement pattern.

In the present study, 50 preschoolers were formally and independently classified using both the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) and third edition-revised (DSM-III-R) criteria for attention-deficit hyperactivity disorder (ADHD). The sample consisted of 25 preschoolers classified as having ADHD and 25 typically developing preschoolers for comparison; the sample was matched on gender, age, and socioeconomic status. All 50 preschoolers were without neurologic or neurodevelopmental disorders, oppositional defiant disorder, or language delay. There were four key findings: first, of the 25 preschoolers with ADHD, DSM-IV classification was as follows: hyperactive-impulsivity type (68%), combined type (28%), and inattentive type (4%). Second, the DSM-IV profiles showed that several symptoms were either infrequently endorsed by parents, reflecting limited applicability to preschoolers with ADHD, or frequently endorsed by parents of typically developing preschoolers, thus reducing their diagnostic value. Third, of the 25 preschoolers classified as having ADHD using DSM-IV criteria, 16% would not have been classified as having ADHD using the DSM-III-R criteria. The DSM-IV criteria therefore appear to be more lenient than the DSM-III-R criteria for this age group. Fourth, two symptoms that were not included in the DSM-IV, but were part of the DSM-III-R, were found to have clinical value for differentiating preschoolers with ADHD from their typically developing peers.

Attention↗
PubMed1995

Patterns of DSM-IV alcohol abuse and dependence symptoms in adolescent drinkers.

OBJECTIVE: Diagnostic criteria for alcohol use disorders have largely been developed from research and clinical experience with adults. This research was designed to describe patterns of DSM-IV alcohol use disorder symptoms, and other problem domains, in adolescents with alcohol problems. METHOD: A modified version of the Structured Clinical Interview for the DSM (SCID) was used to assess DSM-IV alcohol abuse and alcohol dependence symptoms in 91 male and 90 female adolescent drinkers with various levels of alcohol consumption and alcohol-related problems. The SCID was expanded to assess other alcohol problem domains thought to be relevant for adolescents. RESULTS: DSM-IV dependence symptoms showed moderate to high covariation, supporting the utility of the alcohol dependence construct in adolescence. Compared to previous reports from adult samples, some symptoms were relatively infrequent (e.g., withdrawal, medical problems). Tolerance had low specificity for the diagnosis of alcohol dependence. There was significant heterogeneity in the symptomatology of subjects with DSM-IV alcohol abuse. Although they are not in the DSM-IV criteria, alcohol-related blackouts, craving and risky sexual behavior were common in adolescents with DSM-IV alcohol dependence and abuse diagnoses. CONCLUSIONS: The data generally support the utility of DSM-IV criteria for alcohol dependence among adolescents. However, tolerance, withdrawal and medical problems appear to present differently in adolescents than has been reported in adults. Those with DSM-IV alcohol abuse diagnoses had very heterogeneous patterns of symptomatology, suggesting limitations of the criteria for DSM-IV alcohol abuse in adolescence. Alcohol-related blackouts, craving and risky sexual behavior are common among adolescents with alcohol use disorders and are an important focus for assessment and treatment efforts.

Adolescent↗
PubMed1988

[Experimental and clinical studies on degradable starch microspheres (DSM) in the treatment of hepatic neoplasms].

To evaluate the effect of hepatic arterial chemotherapy combined with DSM, experimental and clinical studies were performed. Experimental study: Hemodynamic and histological changes induced by intra-arterial administration of DSM were investigated in the kidneys of rabbits. The degree of blockade of arterial blood flow was correlated with the dosage of DSM, and estimated by the angiographic change. Histological changes also depended on the dosage of DSM. Although administration of less than 6 mg DSM induced little or no histological changes, more than 15 mg of DSM induced extensive necrosis of renal tubules. Clinical study: The hepatic arterial chemotherapy combined with DSM was performed in 63 patients (hepatomas in 45 and metastatic tumors in 18). Fourteen patients (30%) showed partial or complete response. Patients with a higher degree of blockade of arterial blood flow tended to have a better response. Analysis of CT images suggested that DSM not only enhance the chemotherapeutic agents but also the ischemic effect. In conclusion, degree of blockade of arterial blood flow is controlled by the change in DSM dosage, and DSM administration combined with chemotherapeutic agents may have the potential to improve the therapeutic effect.

Animals↗
PubMed1999

Short versions of the geriatric depression scale: a study of their validity for the diagnosis of a major depressive episode according to ICD-10 and DSM-IV.

OBJECTIVE: To determine the validity of short Geriatric Depression Scale (GDS) versions for the detection of a major depressive episode according to ICD-10 criteria for research and DSM-IV. DESIGN: Cross-sectional evaluation of depressive symptoms in a sample of elderly subjects with short GDS versions. Different GDS cutoff points were used to estimate the sensitivity, specificity, positive predictive value and negative predictive value for the diagnosis of major depressive episode. Internal consistency of the scales was estimated with the Cronbach's alpha coefficient. SETTING: Mental Health Unit for the Elderly of 'Santa Casa' Medical School in São Paulo, Brazil. PARTICIPANTS: Sixty-four consecutive outpatients aged 60 or over who met criteria for depressive disorder (current or in remission). Subjects with severe sensory impairment, aphasia or Mini-Mental State score lower than 10 were excluded from the study. MEASUREMENTS: ICD-10 Checklist of Symptoms, GDS with 15, 10, 4 and 1 items, Montgomery-Asberg Depression Rating Scale (MADRS), ICD-10 diagnostic criteria for research and DSM-IV diagnostic criteria. RESULTS: The use of the cutoff point 4/5 for the GDS-15 produced sensitivity and specificity rates of 92.7% and 65.2% respectively, and positive and negative predictive values of 82.6% and 83.3% respectively when ICD-10 diagnostic criteria for major depressive episode were used as the 'gold standard'. Similarly, rates of 97.0%, 54.8%, 69.6% and 94.4% were found when DSM-IV was the comparing diagnostic criteria. Sensitivity, specificity and positive and negative predictive values for the cutoff point 6/7 were 80.5%, 78. 3%, 86.8% and 69.2% according to ICD-10, and 84.8%, 67.7%, 73.7% and 80.8% respectively according to DSM-IV. Intermediate values were found for the cutoff point 5/6. The best fit for GDS-10 was the cutoff point 4/5, which produced a sensitivity rate of 80.5%, specificity of 78.3%, positive predictive value of 86.8% and negative predictive value of 60.2% according to ICD-10 diagnosis of a major depressive episode. Similarly, rates of 84.8%, 67.7%, 73.7% and 80.8% were found when DSM-IV criteria for major depression were used. GDS-4 cutoff point of 2/3 was associated with a sensitivity rate of 80.5%, specificity of 78.3%, positive predictive value of 86. 8% and negative predictive value of 69.2% when compared to ICD-10. Again, rates of 84.8%, 67.7%, 73.7% and 80.8% respectively were found when the criteria used were based on DSM-IV. GDS-1 had low sensitivity (61.0% and 63.6% for ICD-10 and DSM-IV respectively) and negative predictive value (56.7% and 67.6% for ICD-10 and DSM-IV respectively), suggesting that this question is of limited clinical utility in screening for depression. GDS-15 (rho=0.82), GDS-10 (rho=0.82) and GDS-4 (rho=0.81) scores were highly correlated with subjects' scores on the MADRS. Reliability coefficients were 0.81 for GDS-15, 0.75 for GDS-10 and 0.41 for GDS-4. CONCLUSION: GDS-15, GDS-10 and GDS-4 are good screening instruments for major depression as defined by both the ICD-10 and DSM-IV. The shorter four- and one-item versions are of limited clinical value due to low reliability and failure to monitor the severity of the depressive episode. General practitioners may benefit from the systematic use of short GDS versions to increase detection rates of depression among the elderly. (c) 1999 John Wiley & Sons, Ltd.

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