Diagnostic efficiency and DSM-III

Deriving alternative criteria sets for alcohol use disorders using statistical optimization: Results from the National Survey on Drug Use and Health

Much of the foundation of clinical practice, psychiatric epidemiology, and research into the etiology, course, prevention, and treatment of alcohol use disorder (AUD) rests on psychiatric diagnosis. However, existing research has failed to adequately exploit empirical techniques and existing databases to derive criteria considered optimal with respect to predicting external correlates. The current project adopts a novel approach to deriving new diagnostic criteria sets and rules for AUD. Utilizing the 2010 (N = 24,120) and 2013 (N = 23,627) National Survey on Drug Use and Health (NSDUH; Substance Abuse and Mental Health Services Administration [SAMHSA], 2011, 2014) data sets, we performed a statistical optimization procedure, using complete enumeration, on participants 21 or older who had consumed at least 1 alcoholic beverage in the past year. The goal was to maximize the distance (based on Cohen's d) between mean levels of the optimization criteria (i.e., consumption and functional impairment) in those with an AUD diagnosis versus those without. In contrast with current convention, AUD is derived transparently using a data-driven approach. The best solution included 9 criteria with a diagnostic threshold of 3, while the second-best solution comprised 5 criteria with a threshold of 2. External validation demonstrated both solutions perform similarly, suggesting it is appropriate to use either, depending on the goal of the diagnosis. Overall, statistical optimization approaches can yield highly efficient criteria sets and rules, although multiple, near equivalently performing solutions can be generated. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Coverage of the DSM-IV-TR/DSM-5 Section II Personality Disorders With the DSM-5 Dimensional Trait Model

Section III of DSM-5, for emerging measures and models, includes a five-domain, 25-trait model, assessed by the Personality Inventory for DSM-5. A primary concern with respect to the trait model is its coverage of the DSM-IV-TR personality disorder syndromes (all of which were retained in DSM-5). The current study considered not only total scale scores of three independent measures of DSM-IV-TR personality disorders but also the coverage of each diagnostic criterion included within six personality disorders: antisocial, borderline, avoidant, dependent, narcissistic, and obsessive-compulsive. Participants were 425 community adults, all of whom had received mental health treatment (36% currently; 75% within the past year). Results provided support for the coverage of the diagnostic criteria for the antisocial, borderline, avoidant, dependent, and narcissistic personality disorders. Coverage could perhaps be improved for a few of the criteria for obsessive-compulsive personality disorder.

Explanations for Common Responses to the Blue/Green Cab Probabilistic Inference Word Problem

Three explanations have been advanced to explain the most popular error on probabilistic inference word problems, which is the use of the reliability of the evidence p(E/H) as the response when p(H/E) is requested. Production system simulations of each explanation are applied to data from a study in which 265 subjects judged the probability of an hypothesis after receiving each of three pertinent pieces of information—the evidence, the baserate, and the reliability of the evidence—in all possible combinations. The explanation that subjects consider the baserate to be irrelevant is rejected. Data are consistent with both the explanation that 265 subjects confuse p(E/H) with p(H/E) and the explanation that they interpolate between the baserate probability and 1.0 and then select their response from among nearby numbers that are available in the word problem.

Detection of Random Responding in MMPI-2 Protocols

The present report represents a replication and extension of the Berry et al. (1991) study examining the utility of the standard second edition of the Minnesota Multiphasic Personality Inventory (MMPI-2) validity indices for detecting random responding. Specifically, relative to Berry et al., this study employs methodological improvements and investigates recently proposed alternative indices for detecting random responding. Another improvement includes the use of Bayesian statistics, including positive predictive power, negative predictive power, and hit rates, to select various cutting scores across three base rates of random responding. Results suggested that all validity indices studied differed significantly between random and valid protocols, although certain indices provided for more optimal hit rates in terms of classification. It is concluded that the alternative index, Variable Response Inconsistency ( VRIN) scale plus the Infrequency ( F) scale minus the Infrequency Back ( FB) scale ( VRIN + | F - FB|) provided for the highest hit rate across all examined base rates of random responding. However, VRIN also provided for highly accurate classification rates and has specific advantages including the scale's repeated validation in the literature, its ease of use, and empirical findings suggesting that the scale is insensitive to overreporting.

Assessment of Eating Disorders in Women

This article reviews current eating disorder self-report and interview measures and makes recommendations for choosing assessment devices for practice and research. The authors also incorporate overviews of related measures, such as body satisfaction and restrained eating. The presentation of women with eating disorders on measures of general psychological functioning (such as the Minnesota Multiphasic Personality Inventory) is also discussed. Implications and recommendations for practice are presented, as are recommendations for future research. The lack of validation of, and urgent need for, eating disorder assessment measures with ethnic minority women is discussed throughout.

Identity disturbance and problems with emotion regulation are related constructs across diagnoses

OBJECTIVE

This study examined the relation between identity disturbance and emotion dysregulation in a cross-diagnostic sample. We assessed whether these constructs are related and relevant beyond borderline personality disorder (BPD).

METHOD

We recruited 127 participants who completed measures assessing identity disturbance, emotion dysregulation, anxiety, and depression. The sample included primarily depressed adults meeting criteria for multiple diagnoses as well as psychiatrically healthy participants.

RESULTS

Identity disturbance was significantly higher among psychiatric participants with and without BPD compared to healthy controls. Emotion dysregulation was a significant predictor of identity disturbance, even when controlling for BPD diagnosis, depression, and anxiety. In particular, clarity in emotional situations and problems using emotion regulation strategies were most closely related to identity disturbance.

CONCLUSION

The results of this study suggest that future research should examine identity disturbance and its relation with emotion regulation transdiagnostically.

Emotional versus cognitive rumination: are they differentially affecting long-term psychological health? The impact of stressors and personality in dental students

In the process of recovery from work, rumination is considered as an important mediating variable in the relationship between work demands and psychological health outcomes. Past research differentiated affective rumination from problem-solving pondering. The aim of the present study was to test a moderated mediation model for these two distinct ruminative states and to show how personality (i.e. neuroticism and conscientiousness) can alter the mediating effect. The present study is based on 119 surveys from dental students with a time lag of 6 months. Participants filled out questionnaires assessing specific study-relevant performance demands, rumination and personality and a screening measure for psychological health status. Neuroticism was found to moderate the demand-affective rumination association, but conscientiousness did not moderate the demand-problem-solving pondering association. Moderated mediation analysis revealed that affective rumination mediates the impact of demands on psychological health only for individuals low in neuroticism. Findings are discussed regarding potential interventions for dental students to prevent negative psychological health outcomes due to increased work-related demands in the long term.

Neuroticism and common mental disorders: meaning and utility of a complex relationship

Neuroticism's prospective association with common mental disorders (CMDs) has fueled the assumption that neuroticism is an independent etiologically informative risk factor. This vulnerability model postulates that neuroticism sets in motion processes that lead to CMDs. However, four other models seek to explain the association, including the spectrum model (manifestations of the same process), common cause model (shared determinants), state and scar models (CMD episode adds temporary/permanent neuroticism). To examine their validity we reviewed literature on confounding, operational overlap, stability and change, determinants, and treatment effects. None of the models is able to account for (virtually) all findings. The state and scar model cannot explain the prospective association. The spectrum model has some relevance, especially for internalizing disorders. Common causes are most important but the vulnerability model cannot be excluded although confounding of the prospective association by baseline symptoms and psychiatric history is substantial. In fact, some of the findings, such as interactions with stress and the small decay of neuroticism's effect over time, are consistent with the vulnerability model. We describe research designs that discriminate the remaining models and plea for deconstruction of neuroticism. Neuroticism is etiologically not informative yet but useful as an efficient marker of non-specified general risk.

Maternal trait personality and childbirth: the role of extraversion and neuroticism

BACKGROUND

anxiety during pregnancy and childbirth can increase risk of complications and interventions for both mother and infant. Although considerable work has explored fear of childbirth and anxiety during labour and subsequent birth outcomes there has been less consideration of the role of more stable maternal personality upon childbirth. Traits of neuroticism and extraversion are however predictive of health outcomes in other fields potentially through biological, psychological and social mechanisms. The aim of the current research was thus to examine the relationship between trait personality and childbirth experience.

METHODS

seven hundred and fifty-five mothers with an infant aged 0-6 months completed a self-report questionnaire including the Ten Item Personality Measure and descriptions of birth experience including mode of birth [vaginal vs. caesarean section] and complications [failure to progress, fetal distress, post-partum haemorrhage, assisted birth and severe tear].

FINDINGS

personality traits were significantly associated with birth experience. Specifically mothers scoring low in extraversion and emotional stability were significantly more likely to have a caesarean section and experience a number of complications during labour and birth including an assisted birth, fetal distress, failure to progress and a severe tear. Findings were independent of maternal age, education and parity.

CONCLUSIONS

the personality traits of extraversion and emotional stability appear to facilitate likelihood of normal birth. Potential explanations for this include biological (physiological reactivity, pain thresholds, oxytocin and dopamine release) and psychological (coping mechanisms, social support, self-efficacy) factors. The findings have important implications for antenatal education and support during labour.

An examination of the diagnostic efficiency of post-deployment mental health screens

OBJECTIVE

To conduct a blinded study to examine the diagnostic efficiency of the Department of Defense (DoD) Post-Deployment Health Reassessment (PDHRA) screens for major depressive disorder (MDD), posttraumatic stress disorder (PTSD), and alcohol abuse.

METHOD

Participants were 148 post-deployed soldiers who were completing the PDHRA protocol. Soldiers' mean age was 27.7 (standard deviation = 6.6) years, and 89.0% were male. Mental health professionals blinded to the PDHRA screening results administered the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition directly after the PDHRA assessment protocol.

RESULTS

All screens exhibited excellent negative predictive power. Sensitivity metrics were lower, consistent with the relatively low base rates observed for MDD (10.1%), PTSD (8.8%), and alcohol abuse (5.4%). Metrics obtained for the PTSD screen were consistent with previous research with a similar base rate. A two-item screen containing PTSD reexperiencing and hyperarousal symptom items revealed excellent psychometric properties (sensitivity = .92; specificity = .79). The alcohol abuse screen yielded high sensitivity (.86), but very poor precision; these metrics were somewhat improved when the screen was reduced to a single item.

CONCLUSIONS

The PDHRA MDD, PTSD, and alcohol abuse screens appear to be functioning well in accurately ruling out these diagnoses, consistent with a population-level screening program. Cross validation of the current results is indicated. Additional refinement may yield more sensitive screening measures within constraints imposed by the low base rates in a typically healthy population.

Interpreting neuroticism scores across the adult life course: immutable or experience-dependent set points of negative affect?

Neuroticism (N) scores predict psychopathology. Therefore, it is important to know how to best interpret N-scores. This paper reviews prior interpretations, the item content of N-measures and relevant empirical studies. We propose that N-scores reflect person-specific negative affect set points. We distinguish three possible set point models. (1) The immutable set point model in which N-scores fluctuate with short-term perturbations in reaction to positive and negative experiences but always return to their person-specific set point. (2) The experience-dependent model in which an individual's set point can change during any life stage when prompted by far-reaching experiences. (3) The mixed model, a combination of the first two models, which separates the variation in neuroticism into stable and changing components. The changing component is experience-dependent. Current evidence provides little support for the immutable model. Rather, the evidence, though inconclusive, suggests that the experience-dependent or mixed model may help to explain between- and within-subject differences in N-scores across the life span. In particular, the observation that the differential consistency of N-scores tends to drop over time, but has not been shown to approach zero, is consistent with the mixed model. We discuss implications of the models and how to distinguish them empirically.

Screening for depressive disorders using the Mood and Anxiety Symptoms Questionnaire Anhedonic Depression Scale: a receiver-operating characteristic analysis

The present study examined the utility of the anhedonic depression scale from the Mood and Anxiety Symptoms Questionnaire (MASQ-AD scale) as a way to screen for depressive disorders. Using receiver-operating characteristic analysis, we examined the sensitivity and specificity of the full 22-item MASQ-AD scale, as well as the 8- and 14-item subscales, in relation to both current and lifetime Diagnostic and Statistical Manual of Mental Disorders (4th ed.) depressive disorder diagnoses in two nonpatient samples. As a means of comparison, the sensitivity and specificity of a measure of a relevant personality dimension, Neuroticism, was also examined. Results from both samples support the clinical utility of the MASQ-AD scale as a means of screening for depressive disorders. Findings were strongest for the MASQ-AD 8-item subscale and when predicting current depression status. Furthermore, the MASQ-AD 8-item subscale outperformed the Neuroticism measure under certain conditions. The overall usefulness of the MASQ-AD scale as a screening device is discussed, as are possible cutoff scores for use in research.

5-HTTLPR moderates effects of current life events on neuroticism: differential susceptibility to environmental influences

Research chronicling links between a polymorphism in the serotonin-transporter gene (5-HTTLPR) and neuroticism has yielded inconsistent results. One possible explanation for this inconsistency is that any gene-phenotype association is obscured by a gene-X-environment (GXE) interaction. We studied a healthy non-clinical sample (N=118) to determine whether the 5-HTTLPR interacts with current life events in predicting neuroticism. The differential-susceptibility hypothesis led to the prediction of such an interaction, reflecting the fact that individuals with short alleles would be affected more by both negative and positive life events than those homozygous for long alleles. Participants completed questionnaires concerning recent life events and neuroticism. The 5-HTTLPR was genotyped using a standard protocol with DNA extracted from oral fluid. For those homozygous for the short allele, more negative life events proved related to greater neuroticism, whereas more positive life events proved related to less neuroticism. No such association emerged in the case of those homozygous for the long allele. Whereas neuroticism is likely to be an especially stable trait in individuals homozygous for the long allele, this may be less so the case for those carrying short alleles.

A Study of the Predictive Validity of the Children’s Depression Inventory for Major Depression Disorder in Puerto Rican Adolescents

This study aims to evaluate the predictive validity of the Children’s Depression Inventory items for major depression disorder (MDD) in an outpatient clinic sample of Puerto Rican adolescents. The sample consisted of 130 adolescents, 13 to 18 years old. The five most frequent symptoms of the Children’s Depression Inventory that best predict the presence of MDD were “I worry about others’ aches and pains,” “I don’t have any friends,” “I have to push myself to do my schoolwork,” “I have trouble sleeping every night,” and “I do very badly in subjects I used to be good in.” Results demonstrated that the symptoms that best predict MDD in Puerto Rican adolescents are not necessarily the ones commonly described as characteristic of the disorder.

Cognitive reactivity mediates the relationship between neuroticism and depression

Although neuroticism has long been established as an important risk factor for depression, the mechanisms through which this temperamental predisposition translates into the occurrence of symptoms are still relatively unclear. This study investigated cognitive reactivity, i.e. the ease with which particular patterns of negative thinking are reactivated in response to mild low mood, as a potential mediator. Individuals with (N = 98) and without a previous history of depression (N = 83) who had provided neuroticism scores six years previously were assessed for cognitive reactivity and current symptoms of depression using self-report questionnaires. Tendencies to respond to mild low mood with ruminative thinking mediated the relation between neuroticism and current symptoms of depression in both groups. Reactivation of hopelessness and suicidal thinking occurred as an additional mediator only in those with a history of previous depression. The results suggest that neuroticism predisposes individuals to depression by generally increasing the likelihood of ruminative responses to low mood. In those with a history of depression in the past, neuroticism additionally increases risk of recurrence by facilitating reactivation of previously associated patterns such as suicidal thinking and hopelessness. These findings suggest potential targets for interventions to help preventing the occurrence, or recurrence of depression in those who due to their temperamental predisposition are at an increased risk.

Factor structure and diagnostic efficiency of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for avoidant personality disorder in Hispanic men and women with substance use disorders

OBJECTIVE

This study examined the internal consistency, factor structure, and diagnostic efficiency of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), criteria for avoidant personality disorder (AVPD) and the extent to which these metrics may be affected by sex.

METHOD

Subjects were 130 monolingual Hispanic adults (90 men, 40 women) who had been admitted to a specialty clinic that provides psychiatric and substance abuse services to Spanish-speaking patients. All were reliably assessed with the Spanish-Language Version of the Diagnostic Interview for DSM-IV Personality Disorders. The AVPD diagnosis was determined by the best-estimate method. After evaluating internal consistency of the AVPD criterion set, an exploratory factor analysis was performed using principal components extraction. Afterward, diagnostic efficiency indices were calculated for all AVPD criteria. Subsequent analyses examined men and women separately.

RESULTS

For the overall group, internal consistency of AVPD criteria was good. Exploratory factor analysis revealed a 1-factor solution (accounting for 70% of the variance), supporting the unidimensionality of the AVPD criterion set. The best inclusion criterion was "reluctance to take risks," whereas "interpersonally inhibited" was the best exclusion criterion and the best predictor overall. When men and women were examined separately, similar results were obtained for both internal consistency and factor structure, with slight variations noted between sexes in the patterning of diagnostic efficiency indices.

CONCLUSIONS

These psychometric findings, which were similar for men and women, support the construct validity of the DSM-IV criteria for AVPD and may also have implications for the treatment of this particular clinical population.

A Latent Class Analysis of DSM-III-R Pathological Gambling Criteria in Middle-Aged Men: Association with Psychiatric Disorders

PURPOSE

: This study was designed to empirically derive latent classes based on PG criteria and to assess the association between nongambling psychiatric disorders and specific classes.

METHODS

: A total of 8138 community-based middle-aged men were surveyed, and 2720 were assessed for Diagnostic Interview Schedule, Version 3, Revised (DIS-III-R) pathologic gambling (PG). Latent class analysis (LCA) was applied to Diagnostic and Statistical Manual Version 3, Revised (DSM-III-R) criteria to identify gambling classes. χ and logistic regression models evaluated the association between gambling classes and lifetime psychiatric disorders.

RESULTS

: The final model included 4 classes: class 0 (ie, 5418 individuals who never gambled 25 or more times per year) and classes 1-3 (identified by the LCA and comprising 2720 respondents assessed for PG). For the 9 individual criteria of PG, endorsement percentages ranged from 2%-6%, 4%-58%, and 53%-100% for classes 1-3, respectively. Nongambling psychiatric disorders were differentially associated with the 4 gambling classes, and psychopathology was more common in groups more frequently acknowledging PG criteria.

CONCLUSIONS

: Empirical support is provided for distinct classes of gambling behaviors demonstrating differential associations with individual PG criteria and nongambling psychiatric disorders. The data-driven categorization of gambling behaviors provides direction for research on defining, preventing, and treating syndromal and subsyndromal PG.

A practical measure of impairment: psychometric properties of the impairment rating scale in samples of children with attention deficit hyperactivity disorder and two school-based samples

Assessing impairment is an explicit component of current psychiatric diagnostic systems. A brief parent and teacher rating scale for assessing impairment was developed and studied using attention deficit hyperactivity disorder (ADHD) as an exemplar disorder. The psychometric properties of the Impairment Rating Scale (IRS) were measured in 4 samples. Two included ADHD and matched comparison children and the other 2 a school sample. Overall, IRS ratings exhibited very good temporal stability. They correlated with other impairment ratings and behavioral measures and displayed evidence of convergent and discriminant validity. The IRS was highly effective in discriminating between children with and without ADHD. Evidence that the parent and teacher IRS accounted for unique variance beyond ratings of ADHD symptoms is also presented. The scale is brief, practical, and in the public domain. The results of the studies and implications for the assessment of impairment are discussed.

[The empirical development of transference-focused psychotherapy]

The author describes the stages of elaboration of Transference Focused Psychotherapy (TFP) : choice of theoretical model, observation and analyses of several sessions of psychotherapy led by experienced therapists, team discussions on problems encountered that rise both from the pathology itself and from the therapeutic approach applied, a quest of empirical data to explain as much the personality disorder as its neurological and psychological roots, etc. The author reviews the efforts made to arrive at the description in writing of a manual on TFP, a manual that meets the criteria of a treatment method. Finally, the author summarizes studies conducted to measure the psychotherapeutic efficacy of the method and the possibilities of generalizability.

Longitudinal diagnostic efficiency of DSM-IV criteria for borderline personality disorder: a 2-year prospective study

OBJECTIVE

To examine the longitudinal diagnostic efficiency of the DSM-IV criteria for borderline personality disorder (BPD).

METHODS

At baseline, we used semistructured diagnostic interviews to determine criteria and diagnoses; blinded assessments were performed 24 months later with 550 participants. Diagnostic efficiency indices (specifically, conditional probabilities, total predictive power, and kappa) were calculated for each criterion determined at baseline, with the independent BPD diagnosis at follow-up used as the standard.

RESULTS

Longitudinal diagnostic efficiencies for the BPD criteria varied, with the criteria of suicidality or self-injury and unstable relationships demonstrating the most predictive utility.

CONCLUSIONS

BPD criteria differ in their predictive utility for the diagnosis of BPD when considered longitudinally. These findings have implications both for clinicians who are considering diagnoses and for researchers concerned with forthcoming revisions of our nosological system.

An investigation of the validity of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition avoidant personality disorder construct as a prototype category and the psychometric properties of the diagnostic criteria

This study investigated several aspects of the validity of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition avoidant personality disorder (APD) construct, with emphasis on the psychometric properties of the diagnostic criteria and the prototype nature of the construct. A sample of 1,058 patients from the Norwegian Network of Psychotherapeutic Day Hospitals was examined by means of exploratory factor analysis, correlation, and diagnostic efficiency statistics, chi(2) analysis, and frequency distribution. The results indicated that APD is a 1-dimensional construct with good internal consistency. The criteria had acceptable diagnostic efficiency; criterion 3 performed poorest. Number of APD criteria showed no distinct threshold between No-APD and patients with APD. Sixty-two different combinations of any 4 APD criteria occurred. It can be concluded that the prototype model fitted the data well and that the APD diagnostic criteria perform well in the current classification system. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition hierarchy of criteria was not supported.

Diagnosing major depressive disorder VI: performance of an objective test as a diagnostic criterion

Considerable research has evaluated biological and psychological tests for various psychiatric disorders; however, few objective tests are included in DSM-IV as diagnostic criteria. It was recently suggested that existing tests are insufficiently accurate to be included as diagnostic criteria. While it is true that there are limitations in the sensitivity and/or specificity of such tests, this should not rule them out as effective diagnostic criteria. Studies examining the diagnostic efficiency of the DSM criteria sets demonstrate that the individual criteria vary in their sensitivity and specificity. In the present article, we suggest that the same standard should be applied to the evaluation of objective tests. That is, we suggest changing the perspective used to evaluate the performance of biological and psychological measures from the traditional one examining them as diagnostic tests to one in which these measures are evaluated as diagnostic criteria. To our knowledge, no previous investigators have compared the psychometric performance of an objective test to the psychometric performance of the DSM-IV symptom criteria. The recent report from the committee to develop a research agenda for the initial planning phase for DSM-V discussed the use of self-report symptom scales as possible diagnostic criteria in nonpsychiatric settings. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we examined the performance of a self-report depression questionnaire as a diagnostic criterion for major depressive disorder (MDD). We compared the performance of the Diagnostic Inventory for Depression to the performance of the DSM-IV MDD symptom criteria in 1138 psychiatric outpatients. The results indicated that the diagnostic efficiency of the Diagnostic Inventory for Depression was similar to the loss of interest or pleasure criterion, and superior to all of the remaining DSM-IV MDD symptom criteria except low mood. We discuss issues related to the possible use of a self-administered depression symptom scale as a diagnostic criterion.

Discriminant efficiency of antisocial and borderline personality disorder criteria in Hispanic men with substance use disorders

The authors examined the discriminant efficiency of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition ( DSM-IV ) criteria for borderline personality disorder (BPD) and antisocial personality disorder (APD). Subjects were 74 men admitted to an outpatient substance abuse program for monolingual Hispanic adults. All were reliably assessed with the Spanish-language version of the Diagnostic Interview for DSM-IV Personality Disorders. Conditional probabilities were calculated to determine the diagnostic efficiency and discriminant efficiency of BPD and APD symptoms. Twenty-five (34%) subjects met diagnostic criteria for BPD, and 16 (22%) met criteria for APD. The diagnostic co-occurrence of these disorders was statistically significant. Whereas the diagnostic efficiency of the BPD criterion set was comparable to that reported in other clinical studies, these criteria were not significantly more efficient in diagnosing BPD than APD. By contrast, the APD criteria were more efficient in diagnosing APD than BPD; this was true for both the "adult" and the "conduct disorder" APD criterion subsets. In male Hispanic outpatients with substance use disorders, BPD and APD show significant diagnostic overlap. The APD criteria are useful in discriminating these 2 disorders, whereas the BPD criteria are not. These findings have implications for the discriminant validity of the BPD and APD criteria and support the value of the conduct disorder criteria in predicting APD in adulthood.

Predicting Future Antisocial Personality Disorder in Males From a Clinical Assessment in Childhood

It is essential to identify childhood predictors of adult antisocial personality disorder (APD) to target early prevention. It has variously been hypothesized that APD is predicted by childhood conduct disorder (CD), attention-deficit/hyperactivity disorder (ADHD), or both disorders. To test these competing hypotheses, the authors used data from a single childhood diagnostic assessment of 163 clinic-referred boys to predict future APD during early adulthood. Childhood Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.; American Psychiatric Association, 1987) CD, but not ADHD, significantly predicted the boys' subsequent APD. An interaction between socioeconomic status (SES) and CD indicated that CD predicted APD only in lower SES families, however. Among children who met criteria for CD, their number of covert but not overt CD symptoms improved prediction of future APD, controlling for SES.

Essential Paul Meehl lessons for personality assessment psychology

The author presents four essential Meehl lessons for personality assessment. First, Meehl's particular form of the integration of science and practice is described. Second, by outlining Meehl's Hedonic Capacity conjecture, Meehl's contribution to the inclusion of personality individual differences in generating the full clinical picture and in planning treatment is recognized. The third Meehl lesson is on the nature and importance of theory in test development and application programs. The fourth Meehl lesson is a more general epistemological lesson for psychology. Meehl's role in destroying the fantasy of an easy methodological formula for a scientific psychology is described. His program of taxometric research is shown to be an example of demanding greater material implications from theory. Meehl's corroboration index is described and contrasted with the p value of statistical significance testing.

Symptoms of major depression in people with spinal cord injury: implications for screening

OBJECTIVES

To provide psychometric data on a self-report measure of major depressive disorder (MDD) and to determine whether somatic symptoms are nonspecific or count toward the diagnosis.

DESIGN

Survey.

SETTING

Data from the National Spinal Cord Injury Statistical Center representing 16 Model Spinal Cord Injury Systems.

PARTICIPANTS

Eight hundred forty-nine people with spinal cord injury who completed a standardized follow-up evaluation 1 year after injury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The Patient Health Questionnaire-9 (PHQ-9), a measure of MDD as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition . We computed descriptive statistics on rates of depressive symptoms and probable MDD, evaluated internal consistency and construct validity, and analyzed the accuracy of individual items as predictors of MDD.

RESULTS

Exactly 11.4% of participants met criteria for probable MDD. Probable MDD was associated with poorer subjective health, lower satisfaction with life, and more difficulty in daily role functioning. Probable MDD was not related to most demographic or injury-related variables. Both somatic and psychologic symptoms predicted probable MDD.

CONCLUSIONS

The PHQ-9 has promise as a tool with which to identify probable MDD in people with SCI. Somatic symptoms should be counted toward the diagnosis and should alert health care providers to the likelihood of MDD. More efficient screening is only one of the quality improvement efforts needed to enhance management of MDD.

Neuroticism: a non-informative marker of vulnerability to psychopathology

BACKGROUND

Neuroticism measures are very popular in psychopathological research, but it is unclear how useful neuroticism is in studies of the aetiology of psychopathology.

METHOD

A conceptual examination was made of the literature on the association of neuroticism and psychopathology, the ontological status of neuroticism, the purport of neuroticism questionnaires, and causal issues.

RESULTS

The research on which neuroticism is built has historically been based solely on the factor analyses of the common adjectives used to describe usual behaviours. An abundance of studies have shown that neuroticism scores predict life stress, psychological distress, emotional disorders, psychotic symptoms, substance abuse, physical tension-related symptoms, medically unexplained physical symptoms, and health care utilisation. This evidence suggests that neuroticism scales index vulnerability to many forms of negative affect and psychiatric disorder. However, the associations do not clarify the nature of this vulnerability nor the underlying psychobiological mechanisms. We present evidence that neuroticism scores reflect a person's characteristic (or mean) level of distress over a protracted period of time. In this perspective, even prospective associations of neuroticism with mental health outcomes are basically futile, and largely tautological since scores on any characteristic with substantial within-subject stability will predict, by definition, that characteristic and related variables at later points in time.

CONCLUSION

Neuroticism is not an explanatory concept in the aetiology of psychopathology, since it measures a person's characteristic level of distress over a protracted period of time. This situation will not change until knowledge becomes available about: (i) the mechanisms that produce high neuroticism scores (and, therefore, also psychopathology) and (ii) its neurobiological substrate. Only then will we understand why neuroticism appears to "predict" the outcomes it predicts.

Factorial structure and diagnostic efficiency of DSM-IV criteria for avoidant personality disorder in patients with binge eating disorder

This study examined the factorial structure and diagnostic efficiency of the DSM-IV criteria for avoidant personality disorder (AVPD). Two hundred and twenty-eight consecutive outpatients (181 females and 47 males) with a primary diagnosis of binge eating disorder were reliably assessed with diagnostic interviews. Internal consistency of AVPD criteria was good, as suggested by coefficient alpha of 0.87, the pattern of inter-item correlations (range 0.41 to 0.64), and the lack of changes in alpha if any criteria are deleted. Exploratory factor analysis revealed a one-factor solution (56% of variance) supporting the unidimensionality of the AVPD criteria. Diagnostic efficiency indices (conditional probabilities, total predictive power, and kappa coefficients) were calculated for each AVPD criterion, for the entire study group and separately by gender. Overall, the best inclusion criterion was 'fears being ridiculed,' which was also the best predictor overall. These psychometric findings did not differ by gender. The findings support certain important aspects of the AVPD diagnosis.

Diagnostic Efficiency of DSM-IV Criteria for Borderline Personality Disorder: An Evaluation in Hispanic Men and Women With Substance Use Disorders

This study examined diagnostic efficiency of Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), criteria for borderline personality disorder (BPD). One hundred thirty monolingual Hispanic adults (90 men, 40 women) at an outpatient psychiatric and substance abuse clinic were assessed with the Spanish-Language Version of the Diagnostic Interview for DSM-IV Personality Disorders (C. M. Grilo, L. M. Anez, & T. H. McGlashan, 2003). The BPD diagnosis was determined by the best-estimate method. Diagnostic efficiency indices were calculated for all BPD criteria, for the entire study group, and separately by gender. Overall, the best exclusion criterion was affective instability, whereas suicidality or self-injury was the best inclusion criterion and the best predictor overall. These findings did not differ by gender, are similar to those reported elsewhere in the literature, and have implications for the refinement of diagnostic systems.

Diagnostic utility of DSM-IV-TR symptoms in the prediction of DSM-IV-TR ADHD subtypes and ODD

OBJECTIVE

Examined the diagnostic utility of DSM-IV-TR symptoms in the prediction of DSM-IV-TR ADHD subtypes and ODD to: (a) Assess the relative utility of parent and teacher ratings, and (b) Examine the utility of individual symptoms as inclusion and exclusion criteria.

METHOD

Parent and teacher versions of the Disruptive Behavior Disorders Rating Scale were completed for 440 children (217 boys; 223 girls) ranging in age from 9 to 13 years and were used to classify children into groups. Individual symptoms were used to compute corrected conditional probability statistics.

RESULTS

Corrected positive predictive power (cPPP) statistics indicated that parent and teacher ratings had similar diagnostic utility in the prediction of the presence of ADHD, Inattentive Type and ADHD, Hyperactive/Impulsive Type, and that their combination did not provide incremental utility over either informant alone. However, cPPP statistics for ADHD, Combined Type, and ODD indicated that teacher ratings, and the use of combined parent and teacher ratings, provided an advantage over parent ratings alone. Results support the use of a multi-method, multi-informant assessment approach.

A comparison of GMS-A/AGECAT, DSM-III-R for dementia and depression, including subthreshold depression (SD)--results from the Berlin Aging Study (BASE)

BACKGROUND

Empirical evaluation of the agreement between different diagnostic approaches is crucial for the understanding of epidemiological results in geriatric psychiatry.

OBJECTIVES

In this paper, we analyse differences between widely used diagnostic approaches of dementia and depression and offer evidence that diagnostic thresholds vary substantially on quantitative dimensions, but that conceptual and other differences between approaches must also been taken into account.

METHODS

In an epidemiological study of n = 516 persons, aged 70-103 years, we compared psychiatric diagnoses of dementia and depression obtained by GMS-A/HAS-AGECAT, DSM-III-R and clinician's diagnoses of subthreshold depression (SD).

RESULTS

For depression, cumulative prevalence of clinician's diagnosis (including SD, GMS-A/HAS-AGECAT and DSM-III-R defined forms) was highest, followed by GMS-A/HAS-AGECAT-diagnosis and DSM-III-R, while for dementia DSM-III-R was followed by GMS-A/HAS-AGECAT. Overall agreement between DSM-III-R and GMS-A/HAS-AGECAT was moderate. Adapting thresholds for AGECAT resulted in slightly better diagnostic efficiency. Diagnostic disagreement was found predominantly for cases with intermediate symptom severity, supporting the hypothesis of differing thresholds between DSM-III-R and GMS-A/HAS-AGECAT, while cases with lower or higher symptom severity were similarly seen as cases or non-cases.

CONCLUSION

Disagreement is not only caused by conceptual differences, but also different thresholds of diagnostic algorithms. Adaptation of threshold levels should be feasible, depending on the purpose of the analysis.

Diagnostic efficiency of symptoms in the diagnosis of DSM-IV: generalized anxiety disorder in youth

BACKGROUND

Evaluated five probability indices, including odds ratios, to determine relative contribution of Uncontrollable Excessive Worry (DSM-IV criterion A and criterion B) and Physiological Symptoms associated with uncontrollable excessive worry (DSM-IV criterion C) for diagnosing DSM-IV generalized anxiety disorder in youth.

METHOD

One hundred eleven youths (6 to 17 years old) and their parents who presented to a childhood anxiety disorders specialty clinic were administered a semi-structured diagnostic interview schedule. Separate evaluations were conducted for children and adolescents.

RESULTS

Results showed that symptoms comprising DSM-IV's generalized anxiety disorder diagnosis vary relative to one another in the degree to which they contribute to the diagnosis, with certain symptoms having relatively higher diagnostic value than other symptoms. The relative value of symptoms also appeared to vary with children's and adolescents' reports, and parents' reports about their children and adolescents.

CONCLUSIONS

Despite variations in symptoms' values, with only a few exceptions, almost all symptoms were still quite useful for diagnosis, whether reported by children, adolescents, or their parents.

Inpatient diagnostic assessments: 3. Causes and effects of diagnostic imprecision

Preceding studies found that clinicians using the Traditional Diagnostic Assessment (TDA, the standard of clinical practice) often made imprecise diagnoses, compared with gold standards. Those same studies found excellent diagnostic agreement (kappa>0.75) between Computer Assisted Diagnostic Interview (CADI) and gold standards, thus warranting CADI's use as the standard for data collection and diagnosis in this study. When TDA and CADI users independently examined 106 inpatient-subjects, TDA users agreed only 45.3% (48/106) with CADI's primary diagnosis and found only 50.5% as many total diagnoses. This study searched for the causes and effects of those differences. To test the hypothesis that insufficient data collection was the cause, the 106 TDA write-ups were analyzed word-by-word. Only 46.2% (49/106) of the TDA write-ups listed enough symptom criteria (e.g. hallucinations, depression) to meet DSM-IV requirements for diagnosis, a likely cause of TDA's inaccuracy. TDA write-ups evaluated only 52.9% of the 18 Key Criteria necessary to screen for 10 diagnostic groups, a likely cause of TDA's incompleteness. TDA's diagnostic imprecision had effects on (1) length of stay (LOS) for hospitalized patients and (2) associated costs. Patients evaluated with TDA had a mean LOS of 12.5 days versus 7.7 days for CADI patients, a reduction of 4.8 days (12.5-7.7). If CADI replaced TDA, then annual savings of 3,000,000 dollars system-wide could be projected for inpatient care. Remedies for TDA's diagnostic imprecision are proposed.

Assessing ADHD across settings: contributions of behavioral assessment to categorical decision making

Adapted methods of behavioral assessment to assess home and school functioning in a way that maps directly to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., [DSM-IV]; American Psychiatric Association, 1994). The study was conducted in a school-based sample with 5- to 12-year-old children referred to a school intervention team. A multigate set of procedures was used to assign children to one of 3 groups: attention deficit hyperactivity disorder (ADHD), inattentive group; ADHD, combined group; and a non-ADHD control group. The ADHD Rating Scale-IV was used to assess parent and teacher ratings of ADHD symptoms as delineated in DSM-IV. The findings suggest that the use of a fixed cutoff point (i.e., 6 or more symptoms), which is employed in the DSM-IV, is often not the best strategy for making diagnostic decisions. The optimal approach depends on whether diagnostic information is being provided by the parent or teacher and whether the purpose of assessment is to conduct a screening or a diagnostic evaluation. Also, the results indicate that a strategy that aggregates symptoms in the order in which they are accurate in predicting a diagnosis of ADHD is a more effective strategy than the approach used in DSM-IV, which aggregates any combination of a specific number of items. Implications for using methods of behavioral assessment to make diagnostic decisions using DSM-IV criteria are discussed.

Assessing ADHD and comorbid disorders in children: the Child Behavior Checklist and the Devereux Scales of Mental Disorders

Evaluated discriminant validity and clinical utility of selected subscales of the Devereux Scales of Mental Disorders (DSMD; Naglieri, LeBuffe, & Pfeiffer, 1994) and the Child Behavior Checklist (CBCL; Achenbach, 1991a) in 228 children referred to a clinic for the evaluation and treatment of attention deficit hyperactivity disorder (ADHD). The DSMD is a multiaxial behavior rating scale that measures symptomatology for a broad range of child psychopathology as described in the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev. [DSM-R-III] and 4th ed. [DSM-IV]; American Psychiatric Association, 1987, 1994). Discriminant function analyses as well as sensitivity, specificity, and predictive power analyses were computed to evaluate the discriminant validity and clinical utility of selected DSMD and CBCL subscales for assessing ADHD, oppositional defiant disorder (ODD), and anxiety disorders. Results indicated that the DSMD compared very favorably with the CBCL in the ability to discriminate between children with ADHD and those without ADHD and between children with comorbid ODD and anxiety disorders and children who did not meet criteria for these disorders. The DSMD Attention subscale may be somewhat better at ruling in ADHD combined subtype (ADHD-C) and ADHD inattentive subtype (ADHD-I) than the CBCL Attention Problems subscale, but the CBCL Attention Problems subscale may have slightly better utility than the DSMD Attention subscale in ruling out these subtypes. Both the CBCL and DSMD were more useful for ruling out than for ruling in ODD and anxiety disorders.