DSM-IV Literature reviews: Rationale,process, and limitations

DSM-IV will benefit from the extensive research and interest in diagnosis generated in large part by DSM-III. The development of DSM-IV is proceeding through three stages of empirical documentation, including literature reviews, analysis of unpublished data sets, and field trials. This paper discusses the rationale, process, and limitations of the literature reviews. The purpose of the literature reviews is to provide and to document a comprehensive review of the clinical and empirical literature to facilitate objective and empirically based decisions. The review process is guided by the explicit and systematic methods developed within meta-analysis. Limitations of the reviews are also discussed.The opinions expressed in this paper are those of the authors and do not necessarily represent the position of the American Psychiatric Association and its Task Force on DSM-IV.     

Reconceptualizing personality pathology in DSM-5: limitations in evidence for eliminating dependent personality disorder and other DSM-IV syndromes

The DSM-5 Personality and Personality Disorders Workgroup proposed that five DSM-IV personality disorders be eliminated as formal diagnostic categories (paranoid, schizoid, histrionic, narcissistic, and dependent), because these syndromes purportedly have low clinical utility and minimal evidence for validity. Scrutiny of studies cited in support of this proposal reveals difficulties in three areas: (1) Inadequate information regarding parameters of the literature search; (2) Mixed empirical support for proposed changes; and (3) Selective attention to certain disorders and not others. Review of validity and clinical utility data related to dependent personality disorder indicates that evidence regarding this syndrome does not differ from that of syndromes proposed for retention in DSM-5. Limitations in the research base cited by the workgroup illuminates gaps in the personality disorder literature, and may serve as a starting point for systematic research on personality pathology so that adequate empirical data are available to decide which syndromes to retain, revise, or remove in future versions of the diagnostic manual.     

Deriving an empirical structure of personality pathology for DSM-5

The DSM-IV model of personality disorders is composed of trait sets arranged into 10 theoretically distinct, polythetically assessed categories, with little regard for how the traits comprising these disorders are interrelated and structured. Research since the publication of DSM-III has shown that this model is untenable. The question is not whether this model needs revision; rather, the question is how to move from the existing DSM-IV framework to a model better connected with data. Empirically-based models of personality trait variation provide a starting point for DSM-5, and ongoing research will be used to delineate further the empirical structure of personality traits in the pathological range. The ultimate goal is to frame future DSMs in a way that is maximally useful for clinicians as well as researchers. It is also critical to understand that the DSM-5 is intended to be a living document that will facilitate novel inquiry and clinical applications, as opposed to a document designed to promote and perpetuate a fixed set of constructs. Thus, we view a proposed trait system as a first step on a path to a well-validated, clinically-useful structure.     

An outsider-insider's views about revising the DSMs

After having a leadership role in the development of the 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association, 1980) and its revision (DSM-III-R; American Psychiatric Association, 1987), I now comment as an outsider-insider on the development of DSM-IV. Many features of the DSM-IV process, such as systematic literature reviews and focused field trials, represent significant advances that will increase the role of empirical findings in the decision-making process in this latest edition of the DSM. However, it is likely that when final decisions are made about DSM-IV, the decisions will still be based primarily on expert consensus, rather than on data, as was the case with DSM-III and DSM-III-R.     

Persönlichkeitsdiagnostik im DSM-5

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was published in May 2013 and features (in Section III) a new model for the diagnosis of personality disorders. The aim of this paper is to introduce this model to a broader German-speaking readership. The article begins by explaining why a new model seems necessary. Secondly, the different components of the new DSM-5 model are presented, the theoretical and empirical background is explained and it is shown how the model works using a clinical case example. Thirdly, several advantages of the new model as compared to the DSM-IV diagnostic categories (which will be retained in DSM-5 Section II) are discussed. Finally, the article highlights some open questions and problems that require further conceptual and empirical research.     

The MCMI-III: present and future directions

Both the original Millon Clinical Multiaxial Inventory (MCMI-I; Millon, 1977) and the Millon Clinical Multiaxial Inventory-II (MCMI-II; Millon, 1987) were refined and strengthened on a regular basis by both theoretic logic and research data. This aspiration has continued. The new Millon Clinical Multiaxial Inventory-III (MCMI-III; Millon, 1994) has been further coordinated with the most recent official diagnostic schema, the Diagnostic and Statistical Manual of Mental Disorders (4th ed., [DSM-IV]; American Psychiatric Association [APA], 1994) in an even more explicit way than before. Although the publication of the first version of the MCMI preceded the publication of the DSM-IV, its author played a major role in formulating the official manual's personality disorders, contributing thereby to their conceptual correspondence. The DSM-III-R (APA, 1987) was subsequently published in the same year as the MCMI-II; the inventory was modified in its final stages to make it as consonant as possible with the conceptual changes introduced in the then forthcoming official classification. The present version of the MCMI, the MCMI-III, strengthens these correspondences further by drawing on many of the diagnostic criteria of the DSM-IV to serve as the basis for drafting the inventory's items. This article reports on a select set of theoretical and empirical developments that are being carefully weighed for possible inclusion in future MCMIs, or as a guide in the refinement process of future MCMIs.     

Toward a dimensional and psychometrically-informed approach to conceptualizing psychopathology

Most modern research on psychopathology is framed by the categorical model of mental disorders embodied in the Diagnostic and statistical manual of mental disorders, 4th edition (DSM-IV; American Psychiatric Association, 1994). Nevertheless, the categorical model of the DSM is incompatible with robust empirical observations about psychopathological variation, such as the tendency for multiple, putatively distinct mental disorders to occur in the same persons. The goal of this invited essay is to outline a potential alternative to the DSM's categorical approach: a dimensional and psychometrically-informed approach to conceptualizing and studying psychopathology. We discuss the advantages of the dimensional approach, some modern statistical technologies that can be recruited in the service of the dimensional approach, and ways of integrating the dimensional approach with a behavioral approach to psychopathology assessment and research.     

The Shedler-Westen assessment procedure (SWAP): evaluating psychometric questions about its reliability, validity, and impact of its fixed score distribution

The Shedler-Westen assessment procedure (SWAP) is a personality assessment instrument designed for use by expert clinical assessors. Critics have raised questions about its psychometrics, most notably its validity across observers and situations, the impact of its fixed score distribution on research findings, and its test-retest reliability. We review empirical data addressing its validity, emphasizing the multitrait-multimethod approach to evaluating test validity. To evaluate the hypothesis that the fixed, asymmetric score distribution artifactually inflates correlations between SWAP profiles, we conducted Monte Carlo simulations and also presented empirical data from a large patient sample. We observed a mean correlation of zero between simulated SWAP profiles, indicating that the score distribution does not impact the correlation coefficients. Empirical correlations between SWAP profiles of actual patients were small and similar to those obtained using Diagnostic and statistical manual of mental disorders, fourth edition (DSM-IV) personality disorder scales that had no fixed score distributions, suggesting that the correlations were not a methodological artifact of the SWAP. We report new test-retest reliability data (median coefficient > .85) for the SWAP's trait and personality disorder dimensions. The SWAP appears to be reliable and valid. The data do not support its primary psychometric critiques.     

Relationship between the DSM-IV and the ICD-10

The 10th revision of the International Classification of Diseases and Related Health Problems (ICD-10; World Health Organization, 1990) and the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) will both come into use in 1993 and be much more alike than the ICD-9 (World Health Organization, 1978) and the DSM-III (American Psychiatric Association, 1980). The American Psychiatric Association's controversial decision to publish a revision of the DSM-III in 1987 before setting up the Task Force to produce the DSM-IV impaired the association's ability to influence the format of the ICD-10, because by then major decisions had already been made by the World Health Organization. The DSM-IV will be more soundly based on a wider range of empirical data than any previous classification, national or international, and should not be revised again without compelling scientific reasons.     

Assessment of combat-related stress and physical symptoms of Gulf War veterans: criterion validity of selected hand test variables

We examined the utility of selected Hand Test (Wagner, 1983) variables in relation to posttraumatic stress and physical symptoms in Gulf War (GW) veterans. In this study, we sought to replicate and expand on prior empirical findings that have demonstrated efficacy of the Hand Test in the assessment of posttraumatic stress disorder (PTSD; Walter, Hilsenroth, Arsenault, Sloan, & Harvill, 1998). Based on this previous research, Hand Test variables were selected a priori and examined across three groups of veterans: (a) a control group of participants who were in a reserve unit not deployed to the GW theater of operations, (b) a subclinical group of deployed GW veterans who reported 1 to 5 Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994) criteria for PTSD, and (c) a group of deployed GW veterans who met DSM-IV criteria for PTSD. Analyses demonstrated significant differences across the three groups and significant relationships among selected Hand Test variables with the number of DSM-IV symptoms of PTSD reported in the interviews as well as with the number of physical problems reported by these veterans. We discuss these findings in relation to the assessment and treatment of posttraumatic stress symptomatology.     

„Shedler-Westen Assessment Procedure“ (SWAP-200)

International research on operationalization of psychoanalytical constructs has brought up several instruments which are often refused by non-psychoanalytical research because they stick too close to psychoanalytical terms. Furthermore, for all of these instruments intensive training is needed to achieve reliability, and some of them pertain only to certain parts of personality functioning. Recently, a new diagnostic instrument, the Shedler-Westen assessment procedure (SWAP-200) gained strong influence on the US American research on personality disorders. The SWAP authors claim to create a universal and empirically derived language to describe personality pathology. The Q-sort-based procedure is supposed to bridge the gap between empirical research and clinical practice, to overcome DSM-IV with its reduction to symptoms while ignoring inner psychic phenomena, as well as to build a foundation for psychoanalytic case formulation. The relevance of SWAP-200 for the German speaking region is discussed and its procedure is demonstrated by the presentation of one case. Due to positive outcomes of previous validation studies it could be reasonable to implement SWAP in Germany after further independent testing.     

A Psychodynamic Treatment for Severe Personality Disorders: Issues in Treatment Development

We describe a psychodynamic treatment modified for patients with severe personality disorders identified as borderline personality disorder in DSM-IV, Axis II, and understood as borderline personality organization from a psychoanalytic perspective. This treatment is labeled transference-focused psychotherapy (TFP) in order to highlight the centrality of working with these patients in the here-and-now treatment interaction. The empirical development of TFP is described, including the generation of a treatment manual, the utility of various methods to teach the treatment, and preliminary data on efficacy. The latest step in the development of this treatment is an ongoing randomized clinical trial comparing the efficacy of TFP to a cognitive-behavioral and a supportive treatment.     

Does the Beck Anxiety Inventory measure anything beyond panic attack symptoms?

The Beck Anxiety Inventory (BAI) has become a popular measure in anxiety assessment and the BAI does not overlap in content with measures of depression. There is also some factor analytic evidence to support this distinction. However, an inspection of the BAI's content indicates that many of its items resemble, or are identical to, the symptoms of panic attacks listed in the DSM-IV. Further empirical support for this suspicion is provided from the results of a factor analysis of the BAI items and the individual DSM-IV panic symptoms contained in the Panic Attack Questionnaire, using data from a sample of 157 panic disorder patients. A three-factor model (dizziness related, catastrophic cognitions/fear, cardiorespiratory distress) emerged that replicated a three-factor model of panic symptoms identified in earlier work with another panic disorder sample. All but one of the BAI items loaded highly on the three panic symptom clusters and no separate BAI factor was obtained. The BAI appears to be confounded with, or actually measures, panic attacks rather than anxiety in general. Several implications of this finding are discussed.     

Confirmatory factor analyses of DSM-IV Cluster C personality disorder criteria

Notwithstanding its research and clinical relevance, the dimensionality and validity of the DSM-IV avoidant, dependent, and obsessive-compulsive personality disorders (PDs) criteria is still a largely unexplored topic. The aim of this study was to test the factor structure for DSM-IV Cluster C PD criteria in a sample of 641 consecutively admitted outpatients. Factor analysis results suggested that avoidant, dependent, and obsessive-compulsive PDs share a common latent dimension, and supported the three-factor structure of both observer and self-report ratings of DSM-IV Cluster C PD criteria. The pattern of factor loadings, however, was different from the one expected according to the DSM-IV classification.     

Acquisition, development, and maintenance of online poker playing in a student sample.

To date there has been very little empirical research into Internet gambling and none relating to the recent rise in popularity of online poker. Given that recent reports have claimed that students may be a vulnerable group, the aim of the current study was to establish basic information regarding Internet poker playing behavior among the student population, including various motivators for participation and predictors of problematic play. The study examined a self-selected sample of student online poker players using an online survey (n=422). Results showed that online poker playing was undertaken at least twice per week by a third of the participants. Almost one in five of the sample (18%) was defined as a problem gambler using the DSM-IV criteria. Findings demonstrated that problem gambling in this population was best predicted by negative mood states after playing, gender swapping whilst playing, and playing to escape from problems.     

A critique of the proposed prototype rating system for personality disorders in DSM-5

The DSM-5 Personality and Personality Disorders (PDs) Work Group has recommended a reformulation of the PD section, one component of which is a replacement of specified operational criteria with a prototype matching dimensional rating system. The Work Group indicated that prototype ratings have been demonstrated to have good interrater reliability. No study was cited to support this statement, and a review of the reliability literature does not support this claim. The one study that directly compared the reliability of prototype and DSM-IV criteria counting approaches found the DSM-IV approach was much more reliably applied. The Work Group cited 2 studies supporting the validity of the prototype matching approach, one of which had significant methodological limitations and the other changed the a priori threshold on the PD prototype dimensional rating scale to categorize patients into PD positive and negative groups. The Work Group also cited 2 studies suggesting that prototype matching approaches are preferred by clinicians. Several studies have raised concerns about the adequacy of psychiatric diagnostic evaluations conducted in routine clinical practice thereby raising questions about the value of studies of clinicians' preferences in comparing different diagnostic practices. In conclusion, if the prototype matching dimensional approach described in the DSM-5 draft proposal is adopted, then it will have been adopted with essentially no empirical support demonstrating improved reliability or validity. In fact, there is evidence that reliability will be worse than the DSM-IV approach.     

The Strengths and Difficulties Questionnaire (SDQ): the Factor Structure and Scale Validation in U.S. Adolescents

The Strengths and Difficulties Questionnaire (SDQ) is one of the most commonly used instruments for screening psychopathology in children and adolescents. This study evaluated the hypothesized five-factor structure of the SDQ and examined its convergent validity against comprehensive clinical diagnostic assessments. Data were derived from the National Comorbidity Survey - Adolescent Supplement (NCS-A), a nationally representative sample of U.S. adolescents aged 13 to 18 years. Parents/parent surrogates (n=6,483) was asked to complete a self-administered questionnaire including the SDQ and DSM-IV comprehensive diagnostic information on the participating adolescents. Confirmatory factor analysis (CFA) was conducted to assess the factor structure of the SDQ. The five-factor solution of the SDQ (including emotional, conduct, hyperactivity-inattention, peer relationship, and prosocial) provided a satisfactory fit to the data, and was invariant across sex, age, race/ethnicity and income subgroups. SDQ scores predicted a significantly increased probability of meeting criteria for a DSM-IV disorder, with better prediction for behavior disorders than for mood disorders. Decreasing the SDQ cutoffs to the 80th percentile significantly increased the sensitivity from 39% to 63% for the SDQ Total Difficulties Score, with an expected decrease in specificity from 93% to 87%. This work confirms the five-factor structure of the SDQ in an ethnically and sociodemogrpahically diverse community sample of adolescents. Our findings strengthen empirical evidence for the use of the parent-reported SDQ as a screening tool for DSM-IV behavioral and emotional disorders in adolescents identified in the general population.     

Predicting DMS-IV cluster B personality disorder criteria from MMPI-2 and Rorschach data: a test of incremental validity

Despite their frequent conjoint clinical use, the incremental validity of Rorschach (Rorschach, 1921/1942) and MMPI (Hathaway & McKinley, 1943) data has not been adequately established, nor has any study to date explored the incremental validity of these tests for predicting Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994) personality disorders (PDs). In a reanalysis of existing data, we used select Rorschach variables and the MMPI PD scales to predict DSM-IV antisocial, borderline, histrionic, and narcissistic PD criteria in a sample of treatment-seeking outpatients. The correlational findings revealed alimited relation between Rorschach and MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) variables, with only 5 of 30 correlations reaching significance (p <.05). Hierarchical regression analyses showed that both the MMPI and Rorschach data add incrementally in the prediction of DSM-IV borderline and narcissistic PD total criteria scores. The findings were less clear for the incremental value of Rorschach and MMPI-2 data in predicting the total number of DSM-IV histrionic PD criteria, which were best predicted by Rorschach data, and antisocial PD criteria, which were best predicted by MMPI-2 data. In addition to providing evidence of the incremental validity of Rorschach data, these findings also shed light on the psychological characteristics of the DSM-IV Cluster B PDs.     

How should we revise diagnostic criteria for substance use disorders in the DSM-V?

This article reviews literature on the validity and performance characteristics of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) diagnostic criteria for substance use disorders (SUDs) and recommends changes in these criteria that should be considered for the next edition of the DSM (DSM-V). Substantial data indicate that DSM-IV substance abuse and substance dependence are not distinct categories and that SUD criteria are best modeled as reflecting a unidimensional continuum of substance-problem severity. The conceptually and empirically problematic substance abuse diagnosis should be abandoned in the DSM-V, with substance dependence defined by a single set of criteria. Data also indicate that various individual SUD criteria should be revised, dropped, or considered for inclusion in the DSM-V. The DSM-V should provide a framework that allows the integration of categorical and dimensional approaches to diagnosis. Important areas for further research are noted.