Allen Frances

Psychiatric Diagnosis: Lessons from the DSM-IV Past and Cautions for the DSM-5 Future

The American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders provides the authoritative list of what are considered to be mental disorders. This list has a tremendous impact on research, funding, and treatment, as well as a variety of civil and forensic decisions. The development of this diagnostic manual is an enormous responsibility. Provided herein are lessons learned during the course of the development of the fourth edition. Noted in particular is the importance of obtaining and publishing critical reviews, restraining the unbridled creativity of experts, conducting field trials that address key issues and concerns, and conducting forthright risk-benefit analyses. It is suggested that future editions of the diagnostic manual be developed under the auspices of the Institute of Medicine. The goal would be broad representation, an evidence-based approach, disinterested recommendations, and a careful attention to the risks and benefits of each suggestion for change to the individual patient, to public policy, and to forensic applications.

Interviews and inventories for the measurement of personality disorders

Abstract The clinical diagnosis of personality disorders has not demonstrated the level of interrater reliability obtained by the Axis I conditions, due in part to the absence of adequate self-report inventories and semistructured interviews. This paper reviews nine semistructured interviews and eight self-report inventories that improve the assessment of personality disorders. Choices for inclusion in this review were based on current clinical interest, empirical support, and the illustration of methodological issues. The reviews of the interviews are followed by a discussion of issues particularly relevant to this method of measurement, including the reliance on patients versus clinicians for the attribution of personality traits and the use of supplementary, non-interview data. The reviews of the self-report inventories are followed by a discussion of bandwidth versus fidelity, item content, and item number. The paper concludes with a discussion of issues shared by both methods (e.g., structure versus clinical judgment) and a review of the relative advantages and disadvantages of the various methods of measurement

Categorical and dimensional systems of personality diagnosis: A comparison

Abstract It is inherently difficult to classify personality disorders within a categorical system of diagnosis because there are no natural boundaries which clearly separate them from normality and from one another. This is one factor accounting for the relatively low reliability achieved by the DSM III personality disorder section. The author compares the advantages and disadvantages of two alternative, but potentially complementary, methods of personality diagnosis—the categorical and the dimensional. He discusses the most appropriate clinical and research applications of each of these methods, both now and for the future. The specific features of three different dimensional systems of personality description (those of Cattell, Eysenck, and Leary) are briefly outlined.

Prevalence and comorbidity of dysthymic disorder among psychiatric outpatients

We investigated prevalence and comorbidity of DSM-III dysthymic disorder in a psychiatric outpatient clinic. Seventy-five consecutive outpatients received structured interviews. Prevalence of dysthymic disorder was 36% in the consecutive sample. Thirty-four dysthymic and 56 non-dysthymic patients were compared for comorbidity. Dysthymic subjects were more likely to meet criteria for major depression, social phobia, and avoidant, self-defeating, dependent, and borderline personality disorders. Dysthymic disorder was usually of early onset, predating comorbid disorders, and had often not received adequate antidepressant treatment. These results help define dysthymic disorder as prevalent, usually predating axis I comorbidity, and associated with particular axis II diagnoses.

Eye tracking dysfunction in schizophrenia: characterization of component eye movement abnormalities, diagnostic specificity, and the role of attention.

To characterize oculomotor components and diagnostic specificity of eye tracking abnormalities in schizophrenia, we examined a large consecutively admitted series of psychotic patients and matched controls. The most common abnormality in schizophrenic patients was low gain (slow) pursuit eye movements (47% of cases). Pursuit and saccadic eye movement abnormalities were no more severe in schizophrenic Ss than in those with affective psychoses, except that high rates of catch-up saccades were unique to schizophrenic Ss (17% of cases). These findings indicate that impaired pursuit eye movements are a major cause of eye tracking impairments in schizophrenia, that tracking dysfunctions commonly occur in affective psychoses, and that markedly high rates of catch-up saccades during eye tracking may be specific to schizophrenia.

Suicide Associated with Akathisia and Depot Fluphenazine Treatment

AKATHISIA is a common and distressing side effect of neuroleptic medication that can he difficult to recognize and treat,1 Several previous reports mention maladaptive behavioral consequences, such as poor compliance with prescribed medication2 and aggressive or self-destructive outbursts2–3 We are

Medicalising unhappiness: new classification of depression risks more patients being put on drug treatment from which they will not benefit

#### Summary box Many patients report sadness or distress during consultations with primary care doctors. Such emotions may be related to grief and other life stresses, including the stress of physical illness. Sometimes sadness appears out of the blue, without obvious relation to external causes. Over recent decades there has been an increasing tendency, especially in primary care, to diagnose …

Psychological responses to serological testing for HIV.

To determine the emotional impact of serological testing for HIV, 218 physically asymptomatic adults were evaluated in a confidential clinical setting 2 weeks before HIV test notification, immediately before and after notification, and 2 and 10 weeks later. All received extensive pre- and post-test counseling. The 179 seronegatives reported one or more HIV risk behaviors: homosexual intercourse (n = 111), heterosexual intercourse with possibly infected partners (n = 62), intravenous drug use (n = 20). Immediately after notification, seronegatives had significant decreases in visual analogue scale (VAS) measures of anxiety, depression, fear of getting AIDS, and fear of having infected others. Reductions were sustained at both follow-up assessments and were complemented by significant reductions on standardized self-reported measures of anxiety (Spielberger State Anxiety Inventory, SAI), depression (Beck Depression Inventory, BDI), and psychiatric symptoms (Brief Symptom Inventory, BSI) as well as by clinical ratings of depression (Hamilton Depression Rating Scale, HDRS). Of 39 seropositives, 35 had homosexual risk behaviors, seven had been intravenous drug users (IVDUs; four of whom were homosexual men), and one was a female partner of an IVDU. Immediately after notification, VAS measures of their anxiety were not significantly increased, and at 10 weeks after notification, their VAS measures of distress and mean scores on BDI, SAI and BSI were significantly lower than at entry. Their HDRS ratings were not significantly increased.

Increased tardive dyskinesia in alcohol-abusing schizophrenic patients

Many schizophrenics have a diagnosis of substance abuse or dependence. We evaluated whether drug or alcohol abuse is an independent risk factor for tardive dyskinesia (TD) in schizophrenia. In a consecutive admission, clinical study of 75 hospitalized schizophrenics, drug or alcohol abusers had significantly higher TD scores than nonabusers. The association of alcohol abuse or dependence with TD seemed independent from other risk factors for TD.

The new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally ill

This new condition suggested in the bible of mental health diagnoses lacks specificity, says Allen Frances