The Early Psychosis Screener (EPS): Item development and qualitative validation.

A panel of experts assembled and analyzed a comprehensive item bank from which a highly sensitive and specific early psychosis screener could be developed. Twenty well-established assessments relating to the prodromal stage, early psychosis, and psychosis were identified. Using DSM-5 criteria, we identified the core concepts represented by each of the items in each of the assessments. These granular core concepts were converted into a uniform set of 490 self-report items using a Likert scale and a 'past 30days' time frame. Partial redundancy was allowed to assure adequate concept coverage. A panel of experts and TeleSage staff rated these items and eliminated 189 items, resulting in 301 items. The items were subjected to five rounds of cognitive interviewing with 16 individuals at clinically high risk for psychosis and 26 community mental health center patients. After each round, the expert panel iteratively reviewed, rated, revised, added, or deleted items to maximize clarity and centrality to the concept. As a result of the interviews, 36 items were revised, 52 items were added, and 205 items were deleted. By the last round of cognitive interviewing, all of the items were clearly understood by all participants. In future work, responses to the final set of 148 items and machine learning techniques will be used to quantitatively identify the subset of items that will best predict clinical high-risk status and conversion.

The DSM revision process: needing to keep an eye on the empirical ball.

From DSM-III onward, successive DSM editions have strived to ground the diagnostic definitions in empirical evidence. DSM-IV established a three-stage process of empirical review, consisting of comprehensive and systematic literature reviews, secondary analyses of datasets, and field trials to provide reliability and validity data for the most substantial or controversial proposals. DSM-IV Work Group members were required to review the empirical literature to document explicitly the evidence supporting the text and criteria published in DSM-IV. As noted by Kendler and Solomon (2016), in contrast to the emphasis on systematic reviews in medicine which is a manifestation of the evidence-based medicine movement, such systematic evidence-based reviews have not been consistently integrated into the development of DSM-5, raising questions about empirical rigor underlying the DSM-5 revision. It is likely that this regression in terms of anchoring the revision process in a comprehensive review of empirical data stemmed from the emphasis during the DSM-5 revision process on trying to move DSM-5 from its categorical descriptive approach towards a more etiological dimensional approach. Although such a shift ultimately did not occur, the effort spent on trying to achieve a paradigm shift likely came at the expense of the hard work of conducting systematic empirical reviews. For the DSM to continue to remain credible in the current era of evidence-based medicine, it is essential that the developers of future editions of the DSM avoid taking their eye off the empirical ball and insure that the manual remains grounded in solid empirical evidence.

Performance characteristics and clinical utility of diagnostic criteria proposals in bereaved treatment-seeking patients.

BACKGROUND: Persistent complex bereavement disorder (PCBD) is a protracted form of grief included in DSM Section 3 indicating a need for more research. Two other criteria sets [prolonged grief disorder (PGD) and complicated grief (CG) disorder] are also currently in use by researchers. This study evaluates rates of diagnosis of each proposed criteria set in a clinical sample of bereaved individuals participating in clinical research. METHOD: Two groups in which persistent grief was judged to be present or absent completed an assessment instrument that included items needed to diagnose PCBD as well as PGD and CG. One group included grief treatment-seeking participants in our multicenter National Institute of Mental Health (NIMH)-sponsored study who scored ⩾30 on the Inventory of Complicated Grief (ICG) and the other comprised bereaved adults enrolled in clinical research studies who scored <20 on the ICG. Rates of diagnosis were determined for proposed PCBD, PGD and CG criteria. RESULTS: PCBD criteria diagnosed 70 [95% confidence interval (CI) 64.2-75.8] % of the grief treatment-seeking group, PGD criteria identified 59.6 (95% CI 53.4-65.8) % of these individuals and CG criteria identified 99.6 (95% CI 98.8-100.0) %. None of the three proposed criteria identified any cases in the bereaved comparison group. CONCLUSIONS: Both proposed DSM-5 criteria for PCBD and criteria for PGD appear to be too restrictive as they failed to identify substantial numbers of treatment-seeking individuals with clinically significant levels of grief-related distress and impairment. Use of CG criteria or a similar algorithm appears to be warranted.

Proposals for new standardized general diagnostic criteria for the secondary headaches.

Headache classification is a dynamic process through clinical testing and re-testing of current and proposed criteria. After publication of the second edition of the International Classification of Headache Disorders (ICHD-II), need arose for revisions in the classification of medication overuse headache and chronic migraine. These changes made apparent a further need for broader revisions to the standard formulation of diagnostic criteria for the secondary headaches. Currently, the fourth criterion makes impossible the definitive diagnosis of a secondary headache until the underlying cause has resolved or been cured or greatly ameliorated by therapy, at which time the headache may no longer be present. Given that the main purpose of diagnostic criteria is to enable a diagnosis at the onset of a disease in order to guide treatment, this is unhelpful in clinical practice. In the present paper we propose maintaining a standard approach to the secondary headaches using a set of four criteria A, B, C and D, but we construct these so that the requirement for resolution or successful treatment is removed. The proposal for general diagnostic criteria for the secondary headaches will be entered into the internet-based version of the appendix of ICHD-II. During 2009 the Classification Committee will apply the general criteria to all the specific types of secondary headaches. These, and other changes, will be included in a revision of the entire classification entitled ICHD-IIR, expected to be published in 2010. ICHD-IIR will be printed and posted on the website and will be the official classification of the International Headache Society. Unfortunately, it will be necessary to translate ICHD-IIR into the many languages of the world, but the good news is that no major changes to the headache classification are then foreseen for the next 10 years. Until the printing of ICHD-IIR, the printed ICHD-II criteria remain in place for all other purposes. We issue a plea to the headache community to use and study these proposed general criteria for the secondary headaches in order to provide more evidence for their utility-before their incorporation in the main body of the classification.

Comorbid personality disorder and treatment use in a community sample of youths: a 20-year follow-up.

OBJECTIVE: The impact of comorbid personality disorder (PD) on subsequent treatment and psychotropic drug use was examined in a representative sample of over 700 individuals. METHOD: Axis I disorders and PD were assessed by self- and mother-report at mean ages 13 and 22 years, and by self-report at mean age 33. Mothers reported treatment use by participants before mean age 33; participants reported treatment and psychotropic drug use at mean age 33. RESULTS: Individuals with multiple axis I disorders without PD, axis I disorder-PD comorbidity, and single disorders were compared simultaneously to individuals not diagnosed. Overall, odds of subsequent and past year treatment or psychotropic drug use or both were highest when PD co-occurred with a mood, an anxiety, a disruptive, or a substance use disorder. CONCLUSION: Co-occurring personality pathology may contribute to elevated mental health service use, including use of psychotropic drugs, among young adults in the community.

Nosology of chronic mood disorders.

In attempting to assess the complex relationship of chronic depression with other conditions to which it may be a predisposition, an accompaniment, or a consequence of, a few concluding caveats may be useful. It must be recognized that chronic depression has a wide variety of different presentations and causes. Current definitions of major depressive disorder and dysthymic disorder may create a misleading distinction of what may be two aspects of the overall course of a depressive disorder. Furthermore, much of what is considered to be comorbidity of other disorders with chronic depression actually may be a complex syndrome with a common pathogenesis.

Results of the DSM-IV mood disorders field trial.

OBJECTIVE: The DSM-IV mood disorders field trial, a multisite collaborative study, was designed to explore the reliability of a course-based diagnostic classification system for major depression, evaluate the symptom criteria for dysthymia, and explore the need for additional diagnostic categories for milder forms of mood disorder (e.g., minor and recurrent brief depression). METHOD: Five hundred twenty-four depressed subjects were recruited from inpatient, outpatient, and community settings at five sites and evaluated with structured interviews according to DSM-III and DSM-III-R criteria, with careful attention to longitudinal course. Within- and across-site interrater reliability studies and 6-month test-retest reliability studies were also conducted on subsets of the sample. RESULTS: For evaluations of major depression and dysthymia, intrasite reliability was good to excellent and intersite reliability was fair to good; 6-month test-retest reliability was fair for dysthymia and poor to fair for major depression. Interrater reliability for six course of illness specifiers was fair to good, and almost all subjects could be assigned to a specific type of course. CONCLUSIONS: The results supported the use of a course-based classification system for major depression. They also suggested that the content validity of the DSM-III-R symptom criteria for dysthymia could be improved by emphasizing cognitive and social/motivational symptoms, although such changes are unlikely to sharpen the distinction between dysthymia and major depression. Finally, 91% of the subjects met the criteria for current or lifetime major depression or dysthymia, suggesting that additional categories for milder forms of depression are not needed.

DMS-IV meets philosophy.

The authors discuss some of the conceptual issues that must be considered in using and understanding psychiatric classification. DMS-IV is a practical and common sense nosology of psychiatric disorders that is intended to improve communication in clinical practice and in research studies. DSM-IV has no philosophic pretensions but does raise many philosophical questions. This paper describes the development of DSM-IV and the way in which it addresses a number of philosophic issues: nominalism vs. realism, epistemology in science, the mind/body dichotomy, the definition of mental disorders, and dimensional vs. categorical classification.

The reliability of three definitions of bizarre delusions.

OBJECTIVE: This study was conducted to determine whether the interjudge reliability of the DSM-III-R concept of bizarre delusions could be improved by alternative definitions of the concept. METHOD: Twelve raters evaluated 180 delusions of separate psychiatric patients according to the DSM-III-R and two alternative definitions of bizarre delusions. RESULTS: The kappas for the DSM-III-R definition and for one of the alternative definitions were 0.64 and 0.65, respectively; for the other alternative definition it was 0.45. All three definitions were highly intercorrelated, largely identifying the same cases. CONCLUSIONS: Neither of the alternative definitions of bizarre delusions was more reliable than the DSM-III-R definition. The reliability of the DSM-III-R definition, although only fair, is comparable to that of other important clinical concepts that play a major role in the DSM-III-R diagnostic criteria for psychotic disorders.