Re-evaluating DSM-I.

The DSM-I is currently viewed as a psychoanalytic classification, and therefore unimportant. There are four reasons to challenge the belief that DSM-I was a psychoanalytic system. First, psychoanalysts were a minority on the committee that created DSM-I. Second, psychoanalysts of the time did not use DSM-I. Third, DSM-I was as infused with Kraepelinian concepts as it was with psychoanalytic concepts. Fourth, contemporary writers who commented on DSM-I did not perceive it as psychoanalytic. The first edition of the DSM arose from a blending of concepts from the Statistical Manual for the Use of Hospitals of Mental Diseases, the military psychiatric classifications developed during World War II, and the International Classification of Diseases (6th edition). As a consensual, clinically oriented classification, DSM-I was popular, leading to 20 printings and international recognition. From the perspective inherent in this paper, the continuities between classifications from the first half of the 20th century and the systems developed in the second half (e.g. DSM-III to DSM-5) become more visible.

A comparative view of the new journal: Assessment.

The reference sections from all articles in the 1997 volumes of Assessment, Journal of Personality Assessment, and Psychological Assessment were entered into a database and analyzed. An article published in Assessment averaged almost 31 references. An article published in Journal of Personality Assessment contained an average of 33 references. Psychological Assessment averaged 38 references per article. The median age of the references in the three journals was 8 years with an interquartile range of 4 to 14 years. The Journal of Personality Assessment had the largest number of citations in this database of 5,316 references. Each of these received a relatively large number of their citations from articles published in the same journal (self-citations). Randomly selected articles from the 1997 volume of Assessment received fewer citations in the Social Science Citation Index than a similar set of articles from the other two journals. However, the data on Assessment, when compared with data available on other new scientific publications, suggests that Assessment is doing as well as other fledgling journals.

Growth of the literature on the topic of personality disorders.

OBJECTIVE: The authors assessed the growth of the literature on the topic of personality disorders before and after publication of DSM-III. METHOD: A MEDLINE search was conducted for journal articles concerning the personality disorders that were published from 1966 to 1995. RESULTS: Contrary to the authors' prediction, the growth of this literature was slower after the publication of DSM-III in 1980 than it was before that date. Other areas of psychopathology, such as Alzheimer's disease and posttraumatic stress disorder, have literatures whose growth rates since 1980 have exceeded their growth rates before publication of DSM-III. CONCLUSIONS: Over one-half of the individual personality disorders (e.g., histrionic and passive-aggressive) have either very small literatures or literatures with negative growth rates. Only three personality disorders (i.e., antisocial, borderline, and schizotypal) have modestly growing literatures.

A prototypic nonprototype of a personality disorder.

The prototype model has been suggested as an alternative to the traditional categorical model of classification. A series of studies have been performed by Blashfield and his colleagues to identify cases that are prototypic of the DSM-III-R personality disorders. A case that led to diagnostic disagreement was based on the 1985 German movie Zuckerbaby ("Sugarbaby"). In earlier research, the most popular diagnosis for the case was dependent personality disorder, although schizoid, schizotypal, and borderline were almost as frequent. In the current study, the case was presented in cumulative steps to 93 randomly selected clinicians. After each step was presented, clinicians were asked to diagnose the case. With the stepwise presentation format, borderline personality disorder was the most common diagnosis. Chi-square analysis showed that, if clinicians had chosen borderline as a diagnosis by step three, they were likely to keep this decision for the rest of the case. A social-cognitive model was used to explain these results.

Predicting the DSM-V.

Using regression estimates based upon data about past editions of the DSM, we predict various features of the DSM-V. Included in these predictions are the date of publication, number of pages, total number of categories, number of categories defined using diagnostic criteria, total number of diagnostic criteria, color of the manual, who will be in charge of the task force that creates the DSM-V, and revenues generated by the DSM-V. This article ends with comments on the changes in the editions of the DSMs and an analogy to the Sorcerer's Apprentice.

Clinician diagnoses of personality disorders: evidence of a hierarchical structure.

This study examined whether clinicians employ a hierarchical model in the diagnosis of personality disorders. Using a methodology developed by Morey and Ochoa (1989), the study compared how clinicians diagnose patients (clinical diagnoses) to the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.; American Psychiatric Association, 1987) criteria they endorsed for each patient (criterion diagnoses). A national sample of 320 clinicians served as subjects. When cases were examined in which the patients met diagnostic criteria for two or more personality disorders, clinicians used the diagnosis of borderline personality disorder more frequently. They failed to use other diagnoses whose criteria these patients met. Narcissistic personality disorder also appeared to have diagnostic dominance, although somewhat less striking than for borderline. These results suggest that clinicians do view the personality disorders as hierarchical, with borderline clearly identified as the dominant disorder.

An analogue study of the factors influencing competency decisions.

Forensic psychiatrists who were members of the American Academy of Psychiatry and the Law analyzed case histories to make a competency or incompetency decision. The case histories were created to alter background information, diagnostic information, information about the defendants' understanding of the adversarial process, courtroom behavior, and the nature of the crime. The information that had the most influence on the decisions of the forensic psychiatrists included the cognitive status of the defendant, psychotic features, courtroom behavior, and understanding of the adversarial process. Relationship with the lawyer, alcohol/drug use history, psychiatric history, and criminal history had less influence. The forensic psychiatrists tended to "error" toward a decision for competency unless compelling evidence was presented to the contrary.

Weighting criteria in the diagnosis of a personality disorder: a demonstration.

This study focused on how clinicians combine symptom information about narcissistic personality disorder (NPD) to make a diagnosis. A sample of 59 psychiatrists and clinical psychologists were asked to read and diagnose 20 case histories of which 6 cases had criteria for NPD embedded as sentences. The number of criteria and the face validity of the criteria were varied across case histories. Three models of how criteria might be combined to form a diagnosis were compared: the polythetic model, the additive model, and the weighting model. The results were most consistent with the weighting model.

Sadistic and self-defeating personality disorder criteria in a rural clinic sample.

A sample of 176 outpatients at a mental health clinic in rural southern Georgia were rated for the presence or absence of the DMS-III-R sadistic and self-defeating personality disorder criteria. On the basis of these ratings, 48 patients met the criteria for sadistic (n = 14) and self-defeating (n = 41). Surprisingly, half of the patients who met the sadistic criteria also fulfilled the self-defeating criteria. A factor analysis failed to divide the criteria cleanly into sadistic and self-defeating subsets.

Metaphorical analysis of psychiatric classification as a psychological test.

In this taxonomic article we explore the metaphor of comparing a psychiatric classification to a psychological test. Structurally, diagnostic criteria are like test items; diagnostic categories are like scales; and classification are like tests. Analytically, the ideas of reliability and validity are the primary concepts invoked in the empirical evaluation of both classifications and tests. However, when the metaphor is explored in more detail, the differences between classifications and tests become clear. These differences are discussed in terms of the structural and analytical relations between tests and classifications. This metaphorical analysis of classifications as tests suggests that certain issues that have been discussed in regard to psychological tests, particularly reliability and validity, may require modification when applied to psychiatric classification.

Psychotropic medication and priapism: a comprehensive review.

Numerous reports have emphasized the association between priapism and the ingestion of psychotropic medication. Clinicians are becoming increasingly aware of this association and its subsequent severe morbidity. Review of the literature reveals that medications possessing alpha-adrenergic blocking properties are most frequently associated with priapism. These medications include trazodone, several antipsychotics, and the antihypertensive agent, prazosin. Awareness of these associations and an appreciation of potentially serious consequences of this disorder may assist clinicians in choosing psychotropic agents that minimize the risk of developing priapism. It is essential that patients who are to receive psychotropic medications be forewarned about priapism. In addition, patients should be questioned concerning prior occurrence of prolonged erections, since a past history of delayed detumescence is present in approximately 50% of subsequent cases of priapism.

An American view of the ICD-10 personality disorders.

The 1986 version of the ICD-10 diagnostic criteria for the personality disorders was analyzed. In one part of the study, clinicians in the United States were asked to assign the ICD-10 criteria to the ICD-10 categories. In a second part, the ICD-10 criteria were assigned to DSM-III-R categories. In the first part, the face validities of the ICD-10 criteria were highly variable. Thirty percent of the criteria were assigned to the correct parent category by over 80% of the clinicians. In contrast, 34% of the criteria failed to be correctly assigned by at least half of the clinicians. Concerning the correspondence between ICD-10 and DSM-III-R categories, only anankastic (ICD) and obsessive-compulsive (DSM) showed a high level of correspondence. The correspondences of anxious (ICD) with avoidant (DSM), impulsive (ICD) with borderline (DSM), and histronic (ICD) with histrionic (DSM) were poor.

Gender weighting of DSM-III-R personality disorder criteria.

This study explored the gender weighting of the diagnostic criteria for personality disorders. Gender weighting was defined in terms of how 33 female and 17 male nonclinicians ranked the diagnostic criteria along a male-female dimension. Although the a priori expectation was that antisocial would be the prototypically masculine personality disorder and histrionic the feminine, the subjects ranked criteria from the sadistic category as the most masculine and those from the dependent category as the most feminine. These results and the subjects' gender weighting of criteria for borderline, obsessive-compulsive, and self-defeating personality disorders are analyzed in detail.

Suggested guidelines for including or excluding categories in the DSM-IV.

A set of guidelines is proposed for the possible inclusion or exclusion of diagnostic categories in the DSM-IV. For possible inclusion, a new category should meet all of the following five guidelines: adequate literature, specified diagnostic criteria, acceptable interclinician reliability, evidence that the criteria forms a syndrome, and differentiation from other categories. For possible exclusion, a category should possess an inadequate literature, extremely low coverage, or evidence of diagnostic bias. None of the exclusionary guidelines would be invoked if the category refers to a demonstrable disease.

Face validity of the DSM-III-R personality disorders.

A list of the 142 diagnostic criteria for the DSM-III-R personality disorders was sent to a national sample of psychiatrists and clinical psychologists. The criteria were presented in randomly scrambled order, and clinicians were asked to assign the criteria to their parent categories. The average clinician assigned 66% of the criteria to the actual parent categories. These results suggest that the face validity of many of the DSM-III-R personality disorder criteria is low. Moreover, it appears that there are high levels of overlap in meaning among the criteria for the histrionic/narcissistic, avoidant/dependent, and schizotypal/paranoid pairs of personality disorders.

Variations on the family resemblance hypothesis as applied to personality disorders.

Diagnosis and classification of the personality disorders is controversial and problematic. Diagnostic reliability is uneven because of overlapping of traits and the lack of clear boundaries between categories. This study demonstrates that personality disorder diagnosis is dependent on the total number of defining features. Clinicians tend to ignore the presence of conflicting features when making a diagnosis. A new research instrument, artificially created case histories that allow the specific manipulation of defining features (i.e., diagnostic criteria), is described.

The family resemblance hypothesis applied to psychiatric classification.

The prototype model, an alternative to the classical view of classification theory, has recently been advocated for the study of the personality disorders. A central assumption of the prototype model is the family resemblance hypothesis. This hypothesis states that the more features of a category that a patient possesses, the more prototypical the patient is of the category. In previous research, results from applying this hypothesis to psychiatric classification have been mixed. The present study investigates the family resemblance hypothesis by examining the relationship between diagnostic agreement and the number of features in personality disorder cases.

Masochistic personality disorder. A prototype analysis of diagnosis and sex bias.

The Work Group of the American Psychiatric Association to revise DSM-III in 1985 proposed a new personality disorder titled Masochistic Personality Disorder (MPD). This study concerns the clinical relevance and possible sex bias of MPD. The study was performed with clinicians who analyzed 15 case histories, five of which represented masochistic personality. The results led to the rejection of two hypotheses: a) masochistic personalities can be subsumed under existing DSM-III categories and b) there is a sex bias in the diagnostic use of MPD.

MMPI scales for DSM-III personality disorders: a preliminary validation study.

A preliminary investigation of the external validity of MMPI scales designed to measure certain DSM-III Personality disorders (N = 108) is reported. Results indicate that many of these scales are effective for discriminating clinically diagnosed personality disorders from control subjects (N = 640).