Interpreting the structure of diagnosis in initial evaluations: primary, auxiliary and rule out patterns

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.

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.

Sociocultural and clinical characteristics of patients with comorbid depressions: a comparison of substance abuse and non-substance abuse diagnoses

Patients with three varieties of major depression (MD) were compared with respect to sociocultural and clinical characteristics. The patients sought psychiatric evaluation in an intake setting during a 6-year interval. The groups that were compared included MD (sole axis I diagnosis; N = 3,913); MD with a comorbid non-substance abuse ([MD-nonSA] N = 594); and MD with a comorbid substance abuse ([MD-SA] N = 690). Prominent demographic differences were found in the three groups, with males, lower social class status, younger age, and African American ethnicity being more prominent in MD-SA. The four demographic variables, axis I status, axis II diagnosis, and axis III diagnosis constituted the independent variable in an analysis of variance (ANOVA) main-effects comparison of social function (during last year and currently in three areas) and type of depression symptoms (somatic and psychological). Of the demographic variables, age and social class proved to have significant effects on social function and psychological symptoms. Each of the three "syndromic" axes (Axis I, Axis II, and Axis III) had a significant impact on social function and psychological symptoms. Only Axis III produced differences in somatic symptoms. The social and cultural implications of these results are discussed.

Do Caucasian and black adolescents differ at psychiatric intake?

A large sample of adolescents brought for psychiatric evaluation to a public University based facility are the subjects of the study. Material incorporated in a DSM-III multiaxial formulation plus symptoms constituted the dependent variables. Analyses concentrated on ethnic differences, with variation associated with gender and social class controlled statistically. Caucasians showed comparatively greater clinical morbidity: higher number of Axis I definite diagnoses and level of symptoms. Eating disorder diagnoses were more common in Caucasians. There were no significant differences pertaining to level of stress or social impairment. Blacks showed higher levels of symptoms scored as "social aggression" and diagnosed as conduct disorders. The pattern of results raised the question of a possible referral bias, with blacks shunted to the psychiatric facility with lower levels of standard clinical psychopathology, but higher levels of social oppositional behavior. Further research is needed to verify if such a bias does exist.

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.

Females and males in an intake psychiatric setting

It is generally acknowledged that some psychiatric disorders are more commonly found among members of one sex rather than the other (e.g., Dohrenwend and Dohrenwend 1976; Gove and Tudor 1973; Kass et al. 1983; Robins et al. 1984; Rosenfield 1980; Weissman and Klerman 1977). Females, moreover, are consistently overrepresented in treatment populations of different sorts, and various reasons involving responses to illness and inclination to seek treatment have been offered to account for this (Finkler 1984; Kessler et al. 1981; Nathanson 1975; Verbrugge and Wingard 1987). In contrast to accepted gender differences in prevalence, incidence and inclination to use services, a prevailing view about psychopathology is that the actual content or manifestations of a disorder should be "culture free" or universal. In the theory of psychopathology (e.g., implicit in DSM-III), general descriptors of the person (i.e., demographic and cultural) play a comparatively minor role in the stipulation of the manifestations of psychiatric illness. Among socially and culturally oriented psychiatrists, on the other hand, such descriptors are considered important clues to origins of psychopathology. However, in such analyces, sociocultural is usually equated with altogether different symbolic/language traditions (e.g., Finkler 1985; Lieban 1978), although reports exist of sex differences in symptom expression in Western societies (Brown and Harris 1976; Hinkle et al. 1960; Nathanson 1979). Feminist critics assert that even within the sociocultural tradition linked to Anglo-American society, a bias exists with respect to how psychopathology is shaped, defined and handled (Kaplan 1983; Showalter 1985). The topic of gender differences in psychiatric morbidity is thus of considerable general interest and one that can be approached from a number of different perspectives. In this study we compare psychopathology in males and females who were referred to an intake setting. The DSM-III formulations and level and type of symptoms were the focus of analysis. The results are interpreted in light of findings in psychiatric epidemiology and social psychiatry.