The modern assessment of personality disorders. Part 1: definition and typology of personality disorders.

The general definition of personality disorders (PD) has found agreement in many classification systems and has remained relatively stable over many decades. However, a closer look at the history of the classification of various PD reveals that there are changes from generation to generation: a continuous variation in our cultural norms means that some types are 'renormalised' from time to time and that others are added. On the other hand, a comparison of the descriptions and classifications of PD by Schneider, the DSM and ICD systems shows substantial agreement on many types of PD.

Organic mental disorders (Fo). Results from the ICD-10 field trial of the Diagnostic Criteria for Research in German-speaking countries.

The results of the ICD-10 Diagnostic Criteria for Research (DCR) field trial in German-speaking countries concerning section F0 (organic mental disorders) are reported. On the comparatively small data basis of the study, acceptance and interrater-reliability cannot be estimated satisfactorily. Despite this general problem, it can be said that section F0 of ICD-10 DCR maintains a high degree of continuity with respect to ICD-10. Some categories caused diagnostic disturbances and needed further specification, especially the criteria regarding the temporal relationship between the onset of an organic disorder and the psychiatric symptomatology. The recently published definite DCR seem to avoid most of the problems of the earlier version used in this study.

Evaluating the new ICD-10 categories of depressive episode and recurrent depressive disorder.

The new ICD-10 categories of 'depressive episode' (F32) and 'recurrent depressive disorder' (F33) were evaluated on the levels of diagnoses, subtypes, syndromes and symptoms. Interrater reliability was analyzed from findings of four independent diagnosticians who rated 100 written psychiatric case records with the help of criteria-related checklists. Agreement was sufficient if patients with and without the diagnosis of a depressive disorder were included (kappa = 0.82), but low in the depressed subsample (kappa = 0.40). Unclear boundaries became apparent for the classification of depressive syndromes as moderate or severe. The results suggest that the ICD-10 concept of depressive disorder is very similar to the well-known international concept of 'major depression'.

Comparison of a diagnostic checklist with a structured interview for the assessment of DSM-III-R and ICD-10 personality disorders.

The International Diagnostic Checklists for the assessment of the DSM-III-R and ICD-10 personality disorders (IDCL-P) were compared with a structured interview, the International Personality Disorder Examination (IPDE), using a balanced test-retest design with forty psychiatric inpatients. The results, using pairwise kappa for the calculation of agreement, were as follows: any personality disorder versus no personality disorder 0.52 for DSM-III-R diagnoses and 0.75 for ICD-10 diagnoses. The range for the single personality disorders diagnosed at least five times was from -0.07 to 0.71 for DSM-III-R diagnoses and from 0.38 to 0.68 for ICD-10 diagnoses. Only for DSM-III-R diagnoses do figures exist from three other studies comparing two structured interviews with each other. The results of all four studies suggest that 60% of the variance in personality disorder diagnoses represents variance not attributable to the patients, which is scientifically unacceptable.

Routine psychiatric examinations guided by ICD-10 diagnostic checklists (International Diagnostic Checklists).

A systematic assessment of psychiatric diagnoses according to the new classification system ICD-10 can be guided and enhanced by the International Diagnostic Checklists (IDCL). This instrument was developed and evaluated primarily for use in routine clinical care. It consists of 30 separate lists in pocket form, each assigned to a specific disorder and allowing immediate and operationalized diagnostic decisions (without the need of computer assistance). Personality disorders are covered by a separate 12-page booklet (IDCL-P). Examples of the checklists are given together with possible areas of application. First studies have indicated good clinical practicability and satisfactory to excellent diagnostic reliability.

SIDAM--A structured interview for the diagnosis of dementia of the Alzheimer type, multi-infarct dementia and dementias of other aetiology according to ICD-10 and DSM-III-R.

The SIDAM--a new instrument for the symptomatic diagnosis and measurement of dementia according to DSM-III-R and ICD-10--is described. It comprises a brief structured clinical interview, a range of cognitive tests (e.g. including the Mini-Mental State (Folstein et al. 1975)) which constitute a short neuropsychological battery and a section for clinical judgement and third party information. All items rely on DSM-III-R and ICD-10 algorithms. The SIDAM has a high overall test-retest reliability which equally holds true on the diagnostic, criterion and item level. It is a brief (average of 28 min), practical and easily scored diagnostic instrument, which reliably separates subjects with DSM-III-R and ICD-10 dementia from those without such a disorder. Good congruence was found between SIDAM diagnoses and corresponding ICD-9 expert diagnoses. Furthermore, the SIDAM-Score (SISCO) allows a detailed measurement of even low levels of cognitive impairment and provides quantification of severity grading of cognitive dysfunction.

Development of diagnostic checklists for use in routine clinical care. A guideline designed to assess DSM-III-R diagnoses.

To enhance diagnostic assessment in routine clinical care, the Munich Diagnostic Checklists have been developed for a systematic criteria-related evaluation of the most common psychiatric disorders according to DSM-III-R. Design, concept, and areas of application of the instrument are described. An initial test-retest study showed that satisfactory to excellent diagnostic agreement can be reached.

Summary of the qualitative criticisms made during the ICD-10 field trial and remarks on the German translation of ICD-10.

The 1987 draft of ICD-10 presents many new aspects of the psychiatric diagnostic evaluation. Some were readily accepted by the participants of the field study, including: the purely descriptive approach with the abautonment of many theoretical concepts; the more operationalized descriptions of the diagnoses; similarity in structure and terms to DSM-III-R. Others proved controversial: extension of the term dementia to include even mild and moderately severe organic psychosyndromes; inclusion of all forms of depression in one chapter, and their subdivisioning only by severity; different time criteria for the diagnosis of schizophrenia in DSM-III-R (6 months) and ICD-10 (1 month). Considerable criticism was levelled at the overly long and often tediously formulated text, and the lack of didactic organisation. A number of examples of translation difficulties are given, and the differences between a too literal and a technically correct equivalent translation disu-used.

ICD-10 field trial in German-speaking countries--summary, judgement and perspectives.

On the basis of the results of the field trial, the most important classificatory innovations of ICD-10, together with their advantages and disadvantages are described. The initial good acceptance of the new system could be further improved by structural modifications, such as a uniform and systematic description of the individual diagnostic categories. Criticism of content was focused on affective and neurotic disorders and adult personality disorders. When it is introduced, the psychiatric chapter of ICD-10 will surpass most of the hitherto existing psychiatric classification systems in size, differentiation and international testing.

A systematic evaluation of the DSM-III-R criteria for alcohol dependence.

The diagnostic efficiency of the nine DSM-III-R criteria (signs and symptoms) for alcohol dependence was systematically investigated in a sample of 215 psychiatric outpatients. Specificity was generally greater than 0.90, but two groups of criteria were distinguished according to high v moderate sensitivity rates. The diagnostic relevance of all DSM-III-R criteria was strongly supported by a comparison with additional characteristics of alcoholism. Features referring to impaired control over alcohol use and to physical dependence (tolerance and withdrawal) were found to be most clearly discriminating between subjects with and without alcohol dependence. There is strong evidence that two positive criteria are sufficient to reliably diagnose alcohol dependence. A computer-simulated analysis was performed to demonstrate predictive power of single symptoms under different base rate conditions, and results were promising for the most common settings in clinical research.

Divergence and convergence of diagnoses for depression between ICD-9 and DSM-III-R.

Contrasting the classification systems ICD-9 and DSM-III-R, a comparison of diagnoses for unipolar depressive disorders is presented from a sample of 168 psychiatric outpatients. A relatively clear correspondence existed between ICD-9 endogenous depression and DSM-III-R major depression. Neurotic depression (ICD-9) divided into either dysthymia or major depression in DSM-III-R. A generally greater variety of corresponding ICD-9 diagnoses was observed for DSM-III-R categories, since patients with eating disorders, alcohol or drug dependence, or with neuroses other than depressive type often received an additional specific DSM-III-R diagnosis for depression. For ICD-9 diagnostics, a decreased threshold was found for diagnosing depressive reaction, as compared with the equivalent DSM-III-R diagnosis of adjustment disorder with depressed mood. A new technique is introduced in order to adjust corresponding proportions according to base rate differences.

[Teaching psychopathology using the AMDP system in postgraduate education]. / L'enseignement de la psychopathologie à l'aide du système AMDP au cours de la formation postgraduée.

The presentation of a patient's differential diagnosis and treatment by a psychiatric trainee during a clinical conference is increasingly used at the postgraduate level, and psychopathology is--in Europe--one of the major aspects of these conferences. At the Department of Psychiatry of the Max-Planck Institute of Psychiatry in Munich, we successfully used the Psychopathology Scale of the AMDP-System, systemically discussing two to three items during a 3-4 h. conference. The advantage of the AMDP scale and glossary is that its psychopathological concepts and terminology are classically European and concise; for teaching purposes, the separation of the scale and of the Manual is another advantage.

Some problems concerning the reliability and structure of the scales in the inpatient multidimensional psychiatric scale (IMPS).

Two problems concerning the IMPS are revealed. First, the importance of an appropriate reliability measure is demonstrated in a sample of 124 inpatients. Widely divergent results are found using three different intraclass correlation coefficients. The one producing the highest results was used by Klett and McNair (1966) and by Behrends et al. (1971). However, the results from this measure only apply to certain types of investigation. A measure more applicable to most investigations in psychiatric research (the intraclass correlation coefficient of individual ratings with between-rater variance included) produced results that were clearly lower, although still acceptable, with an average correlation of 0.72 between the 12 scales. Secondly, the multiplication of item scores by 2 or 8 when forming the scale scores is shown to lead to unusual and undesirable scale distributions in a sample of 1932 inpatients. The resulting implications for assessing change scores on some of the IMPS scales are discussed.

The stability of the symptom groupings in the Inpatient Multidimensional Psychiatric Scale (IMPS).

A full set of data has been gathered on admission of 1654 inpatients and included information on all 90 items from the Inpatient Multidimensional Psychiatric Scale (IMPS). The sample was divided into two by means of an odd-even split and principal component analyses with Varimax rotation as well as Ward hierarchical cluster analyses of symptoms were run on both subsamples. Comparisons of results were than made between the two subsamples, between the two methods of analysis, and with the studies of Lorr and Klett and Behrends et al. In general, earlier results concerning the structure of the symptom groupings have been confirmed. However, by comparing all the different sets of results, those symptom groupings that are particularly stable or unstable have been identified. In addition, comparisons have been made between the results from analyses using the full range of scores on the items and those using dichotomized scores in order to determine whether the use of different rating scales for different items has an effect on the resulting item groupings.

[Agreement between traditional and computer diagnosis in psychiatric outpatients (author's transl)]. / Ubereinstimmung zwischen konventioneller und Computer-Diagnostik bei ambulanten psychiatrischen Patienten

Psychiatric diagnosis based on personal interviews with 100 clinic outpatients was made and the data thus obtained were documented in Spitzer's and Endicott's CAPPS (Current and Past Psychopathology Scales). Two clinicians and the computer program DIAL - a modification of the DIAGNO II program of the same authors - diagnosed the same patients independently of each other basing their diagnoses solely on the entries in the CAPPS. The diagnostic agreement between the different diagnoses was evaluated and results compared with earlier findings by Schmid et al. These authors had, however, used CAPPS data gathered from case histories and not from direct interviews of patients. The modification in the procedure of gathering the data resulted in a slight, but statistically insignificant improvement in diagnostic agreement. The possibility of improving diagnostic agreement by the use of another scale is discussed.