Explaining diagnostic complexity in an intake setting

Hispanic Mental Health Research: A Case for Cultural Psychiatry

Contemporary research involving Hispanic mental health is critically e-xamined. Selected problem areas that span a spectrum covering folk/traditional conceptualizations of mental illness, standardized concepts and methods employed in epidemiology, approaches to psychiatric diagnosis in biomedical settings, and more basic epistemological assumptions involving psychiatric nosology and theory receive systematic attention. The idea is developed that a dominating and exclusive "establishment psychiatry " stipulates concepts and methods of mental health research, thereby setting priorities and legitimating distinctive modes ofpractice and reimbursement for treatment. The need to challenge and broaden establishment psychiatry's paradigms and biases with insights and knowledge drawn from culturally sensitive Hispanic facts in contemporary mental health paradigms pertaining to psychiatric theory and practice is seen to contribute to a truly representative cultural psychiatry. These and related issues are analyzed using a framework that centers on mental health research but includes ideas from social medicine, political economy, and social evolution.

Reliability and validity of the Global Assessment of Functioning Scale in clinical outpatients with depressive disorders

RATIONALE, AIMS AND OBJECTIVES

The Global Assessment of Functioning Scale (GAF) is widely used to assess psychological, social and occupational functioning. The validity and reliability of the GAF in clinical practice have only scarcely been studied in naturalistic samples.

METHODS

A total of 432 outpatients with a current major depressive disorder (MDD) were evaluated with routine outcome monitoring (ROM). At baseline the GAF score was assessed by the treating clinician and at ROM baseline and follow-up sessions also by a trained test nurse. Sociodemographic data, the Mini International Neuropsychiatric Interview Plus and scores on the Montgomery-Äsberg Depression Rating Scale, Beck Depression Inventory-revised, Brief Symptom Inventory and Short Form-36 were assessed.

RESULTS

At baseline, the mean GAF score by the clinician was 54.8 (range 35-85), and this was systematically lower than the mean GAF score by the test nurse of 57.5 (range 31-88). GAF scores by the clinician and test nurse correlated weakly (r = 0.26). The GAF scores of the clinicians correlated strongly with disease severity, and social and physical functioning.

CONCLUSION

The GAF showed rather poor inter-rater reliability as well as poor discriminant validity with disease severity and physical limitations in a large naturalistic sample of outpatients with MDD.

Adolescent personality disorders and conflict with romantic partners during the transition to adulthood

Longitudinal data were used to investigate the association of adolescent personality disorders with conflict between romantic partners during the transition to adulthood (i.e., age 17 to 27). Findings indicated that adolescent personality disorders (PDs) assessed at mean age 16 were associated with subsequent elevated partner conflict. Cluster B PD was associated with sustained elevations in partner conflict throughout the transition to adulthood. Cluster A and C PDs were associated with elevated partner conflict before age 23. Paranoid, schizoid, schizotypal, borderline, narcissistic, and obsessive-compulsive PD symptoms were independently associated with sustained elevations in partner conflict.

DSM III as a systemic culture pattern: studying intracultural variation among psychiatrists

DSM III is viewed as embodying a pool of information pertaining to a systemic culture pattern of psychiatry and attempts are made to describe how psychiatrists understand and apply it using ideas from cognitive anthropology. Each of seven psychiatrists evaluated a group of patients in an intake setting. Seven broad categories of Axis I diagnoses were formed and the frequencies with which psychiatrists used these categories were computed. In addition, twelve arithmetical measures pertaining to the five axes of DSM III and a current functioning axis and the decision regarding disposition were also computed. Using these dependent variables, the study analyzes the similarities and differences among psychiatrists in the way they formulate intake evaluations. Psychiatrists' selections of Axis I diagnoses were highly intercorrelated but they differed greatly among themselves in the way they coded many of the axes of DSM III. Group correlations among diagnostic measures indicated a patterning among diagnostic measures and the nature of this patterning is discussed. Each psychiatrists' set of correlations among the twelve diagnostic measures was itself correlated with that of others and this showed a very high level of interpsychiatrist agreement. Deductions drawn from the cultural consensus model suggest that psychiatrists share an underlying 'grammar' that references the pool of information pertaining to DSM III.

The influence of illness duration on syndrome clarity and stability in functional psychosis: does the diagnosis emerge and stabilise with time?

This review aims to examine the relationship between phase and duration of illness and the clarity and stability of syndromes in psychotic illness. Originating from clinical experience with first episode psychosis, where Neo-Kraepelinian templates and the underlying model have felt especially awkward and ill-fitting, a hypothesis that the clinical picture of functional psychosis might become clearer over time and stabilise in individual patients is proposed which involves the notion of differentiation. A broad range of psychopathological studies and historical papers which refer directly or indirectly to the evolution of the clinical picture in psychosis over time are reviewed. The findings are difficult to interpret, since few studies have focused directly on the issue; however there is evidence of evolution over time of the clinical picture, particularly within the schizophrenia spectrum, and instability beyond this. Further research is needed to clarify the longitudinal patterns of psychopathology in psychotic illness. The capacity for evolution and instability and consequent scope for reclassification of patients has important implications for research and psychoeducation in early psychosis.

Nonparametric mixture logistic regression models for clinical disposition

Psychiatric hospitalization is one of the most important decisions in the care of patients. This is attributed to the complexity and intensity of treatment and isolation of patients from the family and community into a typically highly controlled and supervised setting. Logistic regression models are fitted to assess the relationship between DSM-III axes and psychiatric hospitalization decisions. Since the apparent error rate tends to underestimate the true error rate, the estimate for the downward bias of the apparent error was computed. A generalization of the logistic regression model is fitted where the intercept is assumed to be a random parameter.

Culture, social structure, and quandaries of psychiatric diagnosis: a Vietnamese case study

In contemporary psychiatry diagnosis is arguably the most important concern of a clinical evaluation insofar as it operates as a scaffolding for therapeutic plans and recommendations. Implicit in the theory and lore of diagnosis is that disorders exist as naturalistic entities possessed of a distinctive form and course. In the event of a complex clinical presentation, a psychiatrist resorts to multiple diagnoses and the use of a rule-out diagnosis, (or several rule-outs). The first practice reflects the dictum of comorbidity. Rule-out diagnoses, on the other hand, support the idea that in some instances extensive anamnesis, observation, and laboratory examination are required in order to establish the true identity of a clinical presentation. The way psychiatrists use the system of diagnosis when examining persons from their own society has been shown to reveal commonalities that conform to a systemic culture pattern (Fabrega et al. 1990a). With these subjects, then, our system of diagnosis works in the sense that it supports widely held assumptions and rationales. In this paper we present a case of a Vietnamese male patient. Its analysis from the standpoint of culture and social structure is used to illustrate some of the problems of reaching diagnoses in persons from other societies and the limitations of our theory about diagnosis.

On the homogeneity of personality disorder clusters

This study was conducted using as subjects persons seeking psychiatric care in a public intake facility. Patients who received a diagnosis of a personality disorder (PD) on axis II constituted the study sample. The study is unique in that it attempts to analyze in a treatment population the relationships between all of the personality disorders (PD) stipulated in DSM-III with emphasis on their relationships to the associated features recorded in the remaining axes of DSM-III. The specific aim of the study was to determine the variation that exists with respect to clinical and demographic variables across the PD clusters categorized in DSM-III and across the PD types of each of the DSM-III PD clusters. In general, considerable inhomogeneity was shown within and across clusters in both demographic and clinical variables, although differences among clusters were noted as well. Cluster B differs prominently from its cohorts with respect to demographic and clinical characteristics. Some of the limitations of these results are emphasized.