Diagnosis of posttraumatic stress disorder with the MMPI: PK scale scores in somatization disorder.

Clinic patients with diagnoses of either major depression or somatization disorder were given the MMPI. Women with somatization disorder had high scores on Keane's MMPI scale (PK) for posttraumatic stress disorder. Following the procedure for the MMPI-2 (46 of the 49 PK items and MMPI-2 norms), 59% of the women with somatization disorder and 21% of the women with major depression would have T scores > or = 65 on the MMPI-2 scale although none of them were known to have developed psychiatric disorder after exposure to a life threatening event. The PK scale has little use in the differential diagnosis of women patients with somatization disorder.

MMPI screening scales for somatization disorder.

44 items on the MMPI were identified which appear to correspond to some of the symptoms in nine of the 10 groups on the Perley-Guze checklist for somatization disorder (hysteria). This list was organized into two scales, one reflecting the total number of symptoms endorsed and the other the number of organ systems with at least one endorsed symptom. Full MMPIs were then obtained from 29 women with primary affective disorder and 37 women with somatization disorder as part of a follow-up study of a consecutive series of 500 psychiatric clinic patients seen at Washington University. Women with the diagnosis of somatization disorder scored significantly higher on the somatization disorder scales created from the 44 items than did women with only major depression. These new scales appeared to be slightly more effective in identifying somatization disorder than the use of the standard MMPI scales for hypochondriasis and hysteria. Further development is needed.

Clinical study of the relation of borderline personality disorder to Briquet's syndrome (hysteria), somatization disorder, antisocial personality disorder, and substance abuse disorders.

OBJECTIVE: The criteria for borderline personality disorder seem to select patients with very high rates of Briquet's syndrome (hysteria), somatization disorder, antisocial personality disorder, and substance abuse disorders. This study was undertaken to determine whether systematic assessment of patients with borderline personality disorder would reveal characteristic features of that condition which would distinguish it from these other disorders. METHOD: Eighty-seven white female patients (75 in St. Louis and 12 in Milan, Italy) who had borderline personality disorder according to both the DSM-III-R criteria and the Revised Diagnostic Interview for Borderlines were further examined with the DSM-III-R Checklist and the Perley-Guze Hysteria Checklist to determine their patterns of psychiatric comorbidity. RESULTS: Every patient had at least one additional DSM diagnosis. Patients in St. Louis and Milan averaged five and four additional diagnoses, respectively. Eighty-four percent of the patients in St. Louis met criteria for either somatization disorder, Briquet's syndrome, antisocial personality disorder, or substance abuse disorders. Patterns of comorbidity for panic (51%), generalized anxiety disorder (55%), and major depression (87%) in St. Louis were consistent with those in other studies. CONCLUSIONS: The data indicate that the boundaries for the borderline condition are not specific and identify a high percentage of patients with these other disorders. Furthermore, the comorbidity profiles closely resemble the psychiatric profiles of patients with these disorders. If the borderline syndrome is meant to include all of these disorders, its usefulness as a diagnosis is limited. Until the fundamental features of borderline personality disorder that distinguish it from the others are identified, it is recommended that clinicians carefully assess patients for these other diagnoses. Efforts should be made to change the borderline personality disorder criteria by shifting away from overlap with the criteria for the other disorders.

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.

The neo-Kraepelinian revolution in psychiatric diagnosis.

New revisions of diagnostic categories have produced the most recent classification systems, namely DSM-IV and ICD-10. The diagnostic approaches exemplified by these two nomenclatures are very similar to one another and represent a return to descriptive psychiatry in which careful observation of symptoms, signs, and course of mental diseases become the diagnostic criteria themselves. In many ways, these newest classification schemata can be considered a return to phenomenological psychiatry perhaps best exemplified at the start of this century by Emil Kraepelin. Thus, recent developments in psychiatric diagnosis can be thought of as "neo-Kraepelinian". Because they represent a relatively radical change from psychodynamic approaches to evaluation and diagnosis, they can also be called "revolutionary." This paper traces the roots of current diagnostic systems and compares and contrasts these systems to the classification schema described by Kraepelin. Diagnostic criteria for schizophrenia are used as an example of how diagnostic conventions have changed dramatically over the past 50 years. Discussion of the implications of this neo-Kraepelinian revolution in psychiatric diagnosis is included.

Briquet's syndrome (hysteria) is both a somatoform and a "psychoform" illness: a Minnesota Multiphasic Personality Inventory study.

We describe the results of a follow-up study on patients with hysteria using the Minnesota Multiphasic Personality Inventory (MMPI) to evaluate the multiple complaints of these patients. MMPIs were obtained from 29 women with primary affective disorder and 37 women with Briquet's syndrome as part of a follow-up study of the St. Louis clinic 500. Patients with Briquet's syndrome were significantly less consistent and logical in answering MMPIs and were more likely to emphasize personal psychopathological conditions. They reported many more symptoms in many more problem areas than did women with primary affective disorder. Patients with Briquet's syndrome reported significantly more somatic symptoms and psychological/interpersonal problems than did the depressed group. It was suggested that such patients mimic multiple psychiatric and somatic disorders.

Unipolar depression: diagnostic inconsistency and its implications.

Major depressive disorder using Feighner et al. (Arch. Gen. Psychiatry 26, 57-63, 1972) and DSM-III or DSM-III-R criteria has proven to be a heterogeneous diagnosis. It apparently includes a wide variety of clinical conditions. This report, based upon the results of a multi-year blind follow-up of 500 randomly selected psychiatric outpatients focuses on certain problems associated with the diagnosis of primary unipolar affective disorders. At index, 141 patients received diagnoses of primary unipolar depression. At follow-up, only 62 (44%) of these received the same diagnosis, with an additional 14 (10%) receiving a diagnosis of undiagnosed: questionable primary unipolar depression, and 5 (4%) a diagnosis of bipolar disorder. Thus, about 43% received other diagnoses at follow-up: 35 (25%) diagnoses of secondary depression and 25 (18%) other diagnoses without indication of an affective component. Bipolar patients' stability was significantly better for those who were manic at intake.

The simulation of neurologic disease.

Conversion symptoms are defined as symptoms that suggest neurologic disease but have no explanation after appropriate evaluation including physical examination, laboratory studies, and appropriate radiographic and other imaging studies. Conversion symptoms are more common in young women as compared with other groups. Conversion symptoms may be seen in essentially all psychiatric illness categories and are especially common in Briquet's syndrome and antisocial personality disorder. They are also seen in patients with neurologic disorders, including seizure disorder, central nervous system tumor, head injury, and multiple sclerosis. Family members of patients with conversion symptoms have a heterogeneous mixture of psychiatric illnesses parallel to the heterogeneous conditions seen in the probands. Psychosocial stressors and compensation factors, including monetary and legal aspects, appear to play important roles in many cases of conversion symptoms. Most individual conversion symptoms resolve, but the individual patient may experience other conversion symptoms as well as experience difficulty as a result of comorbid psychiatric illness.

Convergence of American and Scandinavian diagnoses of functional psychoses.

One hundred ninety-nine case summaries of a consecutive sample of functional psychoses, which had been classified by Odegård, were diagnosed independently using DSM-III-R criteria by four experienced psychiatrists. Odegård's classification and DSM-III-R showed high concordance for schizophrenia and affective psychoses. Odegård's concept of reactive psychoses had high concordance with atypical psychoses in DSM-III-R. These findings imply that the results of genetic and follow-up studies from Scandinavia might be relevant for these diagnostic categories in DSM-III-R.

Secondary depression: observations in alcoholism, Briquet's syndrome, anxiety disorder, schizophrenia, and antisocial personality. A form of comorbidity?

This article deals with the diagnostic issue of secondary depression and relates it to the broader question of comorbidity. The primary focus of the article is to summarize certain data supporting the validity of the concept of secondary depression; these data are used to point up an appropriate strategy for studying comorbidity involving psychiatric disorders.

Psychotherapy and the etiology of psychiatric disorders.

This paper compares two broad views of psychotherapy, the etiological and the rehabilitative. The etiological view is based on the premise that the psychotherapeutic process provides a basis for laying bare the causal link between 'deeply repressed' unconscious forces and the patient's current condition. Spence's critique of this position is based on drawing a distinction between narrative truth and historical truth, pointing out the persuasive or rhetorical power of a coherent synthesis of the material presented by the patient, regardless of its historical veracity. Michels also draws attention to this difficulty by pointing to Freud's discovery that reports from childhood were based not on fact, but on fantasies which re-emerge in the transference relationship. The proposal that the therapist provides a context more conducive to the resolution of childhood trauma implies that the trauma was fact and not fantasy. Frank has drawn the parallel between confession in a cueless vacuum with brainwashing techniques which result in the confession of non-events. Besides these difficulties, the etiological approach cannot establish the direction of supposed causality linking childhood events, repressed psychological forces and the patient's condition. The apparently consistent pattern of expectations, perceptions, behavior and 'defenses' may themselves be the effects rather than the causes of the patient's condition. The psychotherapeutic process is intrinsically incapable of deciding objectively between these possibilities. Grunbaum has emphasized this epistemological weakness in the etiological position. The author therefore proposes a more pragmatic, rehabilitative, view of the psychotherapeutic process. Psychotherapy that deals with the personal and social life of the patient may help to alter the circumstances that contribute to discomfort, or change behavior that leads to dissatisfaction, without any commitment to unproven etiological theories. In this sense, psychotherapy, like physiotherapy and rehabilitation, is non-specific and can be applied without making any assumptions regarding specific causal conditions or pathogenetic factors.

Followup studies of schizophrenia: a comment.

This set of articles provides a thoughtful and valuable review of the literature dealing with the findings and implications of long-term followup studies of patients receiving a diagnosis of schizophrenia. The results show clearly that if one starts with a psychotic disorder in a clear sensorium, the followup results may be quite variable. The articles provide, in addition, valuable discussions concerning methods, statistical analyses, and conceptual issues in followup studies.