BOOK REVIEWS

Book reviewed in this article: DSM-III-R Tutorial. Davis Hayden and Michael Furlong. Practicum and Internship Textbook for Counseling and Psychotherapy. John C. Boylan, Patrick B. Malley, and Judith Scott.     

Language Generation in Schizophrenia and Mania: The Relationships Among Verbosity, Syntactic Complexity, and Pausing

We examined the relationships among verbosity, syntactic complexity, and pausing in the speech of 21 Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.) (DSM-III-R) diagnosed schizophrenic participants and 19 DSM-III-R diagnosed manic participants. We found that less verbosity was associated with both less syntactic complexity and greater pausing. In addition, less syntactic complexity was associated with greater pausing. The strength of these associations did not differ significantly between the two diagnostic groups. We propose that deficits in verbosity, syntactic complexity, and pausing are all related to a disturbance in message generation. We discuss the consistency of this hypothesis with previous research linking information processing and frontal lobe deficits to disturbances in verbosity, syntactic complexity, and pausing.     

Interrater reliability of the DSM-III-R with preschool children

Little attention has been paid to evaluating the use of DSM-III-R with preschool children. Children (N = 510) ages 2 to 5 years who were screened at the time of a pediatric visit were selected to participate in an evaluation which included questionnaires, a semistructured interview, developmental testing, and a play observation. Following the evaluation, two clinical child psychologists independently assigned DSM-III-R diagnoses. For each diagnostic category, kappa and Ycoefficients were calculated; Ycoefficients are less sensitive to base rates of disorders. For overall agreement, the weighted mean kappa (.61), and mean Y(.66) were moderately high. Overall agreement that the child had at least one of the disruptive disorders was substantial (kappa =.64; Y =.65);agreement that there was at least one of the emotional disorders was moderate for kappa (.54), but substantial for Y(.70). Kappa coefficients were higher for major categories of disorder than for specific disorders; however, Ycoefficients did not show a decline for specific disorders. Interrater reliability of DSM-III-R appears to be similar for preschoolers and older children.This study was supported by grant MH46089 from the National Institute of Mental Health.A preliminary report was presented at the Fifth Annual NIMH International Research Conference on the Classification and Treatment of Mental Disorders in General Medical Settings, Bethesda, Maryland, September 1991. We gratefully acknowledge the members of the Pediatric Practice Research Group who participated in this study.     

Prevalence of personality disorders among bulimics,nonbulimic binge eaters,and normal controls

We examined the comorbidity of bulimia and personality pathology among college women. Subjects included women (n=23) meeting DSM-III-R criteria for bulimia nervosa (bulimics), women (n=23) who reported binge eating but did not fulfill the criteria for bulimia nervosa (binge eaters), and women (n=23) who did not binge eat (normals). The subjects completed an assessment battery consisting of the Personality Disorders Examination and the SCID as well as the Beck Depression Inventory, the Rosenberg Self-Esteem Index, and measures of impulsivity and self-defeating tendencies. Fourteen of 23 bulimics (61%) met criterion for a personality disorder using DSM-III-R Axis II criteria. In comparison, 3 of 23 (13%) binge eaters and 1 of 23 (4%) normal subjects received an Axis II diagnosis. Borderline and self-defeating diagnoses were the predominant personality disorders in 96% of the bulimics exhibiting clinically significant personality pathology. Bulimics also exhibited significantly more depression, impulsivity, and self-defeating behavior and lower self-esteem than binge eaters and normals. The findings are discussed within a conceptual framework that posits an interaction between personality pathology and restrained eating.     

The Effects of Psychological Trauma on Children and Adolescents

In this review the authors examine the cognitive, affective, behavioral, and somatic-physiological effects documented in the literature as sequelae of overwhelming life events in children and adolescents. Findings from the literature are compared with the current formulations of Post-traumatic Stress Disorder (PTSD) in the Diagnostic and Statistical Manual of Mental Disorders, third edition, revised (DSM-III-R, American Psychiatric Association, 1987) as this diagnostic category applies to children. Responses likely to be observed in children and adolescents who have been exposed to traumatic events are discussed. Suggestions for future research and counseling practice are presented     

Validity of the DSM-III-R personality disorder Clusters

This study assessed the validity of the DSM-III-R personality disorder clusters (i.e., odd-eccentric, dramatic-emotional-erratic, and anxious-fearful) by examining the relationships between self-report measures that tap the core features shared by disorders from each cluster and Cluster scores established via a semistructured interview in a sample of 57 outpatients. Results indicated a high degree of correlation among the DSM-III-R personality disorder Cluster scores. In addition, a series of regression analyses revealed that self-report scores did not account for a significant amount of variance in their respective Cluster scores over and above that accounted for by other self-report measures and other Cluster scores. These results suggest that the current DSM-III-R cluster classification scheme may not be appropriate, and it is recommended that a more empirically justifiable classification of the personality disorders be adopted in DSM-IV.     

MMPI-2 Assessment of Varying Levels of Posttraumatic Stress in Vietnam Combat Veterans

The effectiveness of the MMPI-2 in the detection of posttraumatic stress (PTS) symptomatology was investigated. Forty-nine veterans at a VA posttraumatic stress clinic were evaluated for PTS symptomatology according to DSM-III-R criteria. The ability of the MMPI-2 to differentiate between Vietnam combat veterans (VCV) who met DSM-III-R criteria for posttraumatic stress disorder (PTSD; N = 36) and those who reported varying levels of posttraumatic stress symptoms (PTSS; N = 13) was examined. Overall, the MMPI-2 was effective in differentiating between the two groups of veterans. Of the 15 MMPI-2 scales used to evaluate PTS symptomatology, 12 significantly differentiated veterans with PTSD from those with PTSS. Diagnostic efficiency statistics for the MMPI-2 PTSD scales (PS and PK) were calculated at four cutoff points (T 65, 70, 75, and 80). The PS Scale was the most robust and effective index in differentiating between veterans with PTSD and those with PTSS. Implications for the assessment of varying degrees of PTS are discussed.     

Evidence for developmentally based diagnoses of oppositional defiant disorder and conduct disorder

This paper compares the validity of DSM-III-R diagnoses of oppositional defiant disorder (ODD) and conduct disorder (CD) and an alternative option which is subdivided into three levels according to developmental sequence and severity: modified oppositional disorder (MODD), intermediate CD (ICD), and advanced CD (ACD). Using a sample of 177 boys followed over 3 years, both the DSM-III-R and the alternative diagnostic constructs are evaluated on three criteria: symptom discriminative validity, and diagnostic external and predictive validity. Most DSM-III-R ODD and CD symptoms discriminated between ODD and CD, but exceptions are noted. Additional analyses demonstrated considerable overlap among DSM-III-R oppositional symptoms. The majority of the symptoms proposed for the alternative option could be assigned to a specific level based on acceptable symptom discrimination. External validity lent support to the distinctions between DSM-III-R ODD and CD, and between MODD, ICD, and ACD. MODD was a better predictor than ODD of which boys received a later diagnosis of CD. Suggestions are made for the inclusion and exclusion of symptoms for developmentally based diagnoses of oppositional and conduct disorders.This research was supported by a grant from the John D. and Catherine R. MacArthur Foundation to the American Psychiatric Association, and grant 1-RO1-MH42529-04 from the National Institute of Mental Health. The authors are indebted to Paul Frick for his advice with some of the statistical analyses, and particularly to Ms. Judith Navratil for her expert help in data collection.     

The Relationship Among Major Depression, Depressive Symptoms, and Self-Preoccupation

The present study investigates whether highly self-preoccupied people (exhibiting a tendency to focus primarily on the self and to maintain self-focused attention) were more likely to experience major depressive episodes (MDEs) than those without such tendencies. One hundred nineteen young community residents, aged 18 to 21, took part in semistructured interviews, during which we investigated their past and present history of mental illness, including MDEs, as delineated by the Diagnostic and Statistical Manual of Mental Disorders (3rd ed. rev.; DSM-III-R). Self-preoccupation was measured by the Self-Preoccupation Scale (SPS). Of the 119 participants interviewed, the lowest and highest quarters in the SPS scores formed the low- and high-self-preoccupation (SP) groups. The lifetime prevalence of the DSM-III-R MDE was significantly greater among those high in SP than in the low SP group. Moreover, the high-SP group had significantly more depressive symptoms than the low-SP group. The contributory role of self-preoccupation to suicide ideation and the interpersonal aspects of self-preoccupation were discussed.     

Double Depression in Men: Does It Exist?

Differences between male veterans diagnosed with major depression alone and male veterans diagnosed with both major depression and dysthymia (double depression) were investigated. Assessment instruments included the Structured Clinical Interview for DSM-III-R, the Beck Depression Inventory (BDI), and the Symptom Checklist-90-R (SCL-90-R). Consistent with prior literature, it was hypothesized that male veterans diagnosed with both major depression and dysthymia display more severe depressive symptomatology and other forms of psychopathology than male veterans diagnosed with major depression alone. Results did not corroborate these hypotheses. Patients with double depression (n = 17) yielded BDI and SCL-90-R scores which did not differ significantly from those of patients with major depression alone (n = 14). Our results call into question the existence of double depression among men, a disorder whose existence has been demonstrated primarily among women.     

Prospective assessment of late-luteal phase dysphoric disorder

This investigation evaluated a method for the prospective assessment of the symptoms of premenstrual syndrome (PMS). The American Psychiatric Association has proposed a diagnostic category for PMS in the DSM-III-R entitled late-luteal phase dysphoric disorder (LLDD). The criteria for this disorder include prospective documentation of at least two symptomatic cycles. Two groups of women were studied, one group that met the DSM-III-R diagnostic criteria for LLDD and a comparison group that did not. Subjects recorded symptoms related to PMS for two menstrual cycles. A clinically significant worsening of symptoms was defined as a symptom increase during the premenstruum of greater than one standard deviation above normal. These effect sizes were then used to determine if the subject met the DSM-III-R criteria for prospective confirmation. Data analysis showed that although the LLDD group showed evidence for PMS in several symptom groups, only a minority (31%) met the requirement of prospective confirmation of significant PMS symptoms for the two cycles recorded. These results were discussed in terms of the need for prospective behavioral assessment of LLDD and the implications of these findings for past and future research.Portions of this paper were derived from the master's thesis of the first author.     

The effects of different types of interpretation on outcome in group psychotherapy

Interpretations in three psychodynamic therapy groups were rated according to Yalom's typology. Results indicated that here-and-now interpretations were employed over four times as often as historical ones. Outcome results, as measured by the DSM-III-R, indicated that interpretations of a client's present patterns of behavior were most effective in changing pathology, followed by interpretations of the impact of the client's behavior on others, then by historical interpretations. Interpretations of motivation tended to make clients worse. Client session satisfaction ratings demonstrated the same pattern as the outcome results.     

Comorbid Substance Use and Anxiety Disorders in Adolescents

To explore the coexistence of substance use disorders and anxiety disorders in adolescents, we assessed adolescents presenting for treatment to an inpatient substance abuse treatment facility (SUH), an inpatient psychiatric treatment facility (IPH), and a community-based psychiatric facility (CMHC) for comorbid substance use and psychiatric diagnoses. Thirty subjects from each facility (N=90) were interviewed using the revised Child Schedule for Affective Disorders and Schizophrenia (K-SADS) and the Structured Clinical Interview DSM-III-R (SCID-R) for substance use diagnoses. Overall, comorbidity (anxiety and substance use disorders) prevalence was 67% (20/30) of adolescents in the SUH group, 33% (10/30) of the CMHC adolescents, and 33% (10/30) of the IPH adolescents. Alcohol and marijuana were the most frequently abused substances. Anxiety disorders commonly coexist with substance use disorders in adolescents. Early identification and treatment of anxiety disorders may in fact prevent substance abuse in this population.     

Anxiety disorders in African-American and white children

There are little available data on African-American children with anxiety disorders. Treatment-seeking African-American (n=30) and white children (n=139), with a current DSM-III-R anxiety disorder, were compared on sociodemographic background variables, clinical characteristics, and lifetime rates of specific DSM-III-R anxiety disorders. Overall, results suggested that the anxiety-disordered African-American and white children who sought treatment from an outpatient mental health facility were more similar than different. The two groups did, however, differ somewhat on several variables (trend only), including rates of school refusal, severity of primary anxiety disorder, lifetime prevalence of posttraumatic stress disorder, and total scores on the Fear Survey Schedule for Children-Revised. More specifically, white children were more likely to present with school refusal and higher severity ratings, while African American children were more likely to have a history of posttraumatic stress disorder and score higher on the FSSC-R. The impact of these findings and the need for additional research are discussed.This study was supported in part by MH grant 40021 from the National Institute of Mental Health.     

Review, critique, and synthesis of personality theory in motivation to sexually assault

A widely-cited meta-analysis of recidivism amongst adult male perpetrators or sexual assult [Hanson and Bussiere, J. Consult. Clin. Psychol. 66 (1998) 348–362] found that the presence of any personality disorder (APA, Diagnostic and Statistical Manual of Mental Disorders: DSM-III-R. (1987); [APA, Diagnostic and Statistical Manual of Mental Disorders: DSM-IV (1994)] was the only variable to significantly predict sexual recidivism in a category measuring “Psychological Maladjustment” (r₊=.16, n=315). The relationship between personality disturbance and new sexual offenses is undoubtedly a dynamic relationship that deserves exploration. This review and critique of theory covers two theories of personality: (1) a psychoanalytic theory of rapist personality offered by Groth [Men Who Rape: The Psychology of the Offender. (1979), New York: Plenum] and (2) a general biosocial theory or personality disturbance offered by Millon [Disorders of Personality: DSM-IV and Beyond. (1996). New York: Wiley]. Theory offered by Groth is critiqued and limitations considered. Theory offered by Millon is offered and the two approaches are synthesized to suggest possible causes of characteristic psychological disturbance associated with perpetration of sexual assault. Applications for research and practice are considered, and implications of this line of research for risk assessment and sexual assault prevention are reviewed.     

Three forms of stress in Cambodian adolescent refugees

Sixty-nine Cambodian adolescents and young adults were interviewed to determine their experience as children surviving the Pol Pot regime (1975–1979);their first-year experience of resettlement in this country; and their experience of stressful events during the past year. Current DSM-III-R diagnostic status was also determined. A strong relationship between earlier war trauma, resettlement strain, and symptoms of posttraumatic stress disorder (PTSD) was found. In contrast, the strongest relationship with depressive symptoms was found for recent stressful events. These results are discussed in light of current findings from stress and PTSD research.Dr. Clarke is Assistant Professor of Psychiatry in the Division of Child Psychiatry, Oregon Health Sciences University, Portland, Oregon. Dr. Sack is Director of the Division of Child Psychiatry and Principal Investigator of the Khmer Adolescent Project. Brian Goff is a Research Assistant.This project was supported by the National Institutes of Mental Health [NIMH] grant #5-RO1-MH42927-02, Dr. William H. Sack, M.D., Principal Investigator.     

Mental Health and Incarcerated Youth. II: Service Utilization

The incarceration of mentally ill youth is a serious problem not receiving the same attention as in adults. In this study, we examine the level of prior service utilization in incarcerated youth versus youth receiving community mental health services. We randomly recruited youth from middle South Carolina served by a local community mental health center (CMHC; n = 60), hospitalized in the state adolescent inpatient program (n = 50), and incarcerated in the S.C. Dept. of Juvenile Justice facilities (n = 75). We used a Services History to evaluate episodes of prior utilization of mental health, social service, educational, residential, and volunteer services, as well as the DISC-PC 2.3 to evaluate DSM-III-R diagnoses and symptoms and the CBCL and YSR to evaluate behavioral symptomatology. Incarcerated, hospitalized, and CMHC youth utilized similar levels of educational services and social services. Incarcerated youth had a significantly lower lifetime utilization of outpatient and acute mental health services and significantly higher utilization of out-of-home residential services than the other groups. These services utilization variables, along with gender and age, significantly distinguish incarcerated youth from the clinical groups, with clinical variables not serving to significantly distinguish them. Our results indicate the need to develop programs to prevent the entry of mentally ill/emotionally disturbed youth into the juvenile justice system. Youth who are at risk for incarcenation may benefit from intensive mental health services to prevent out-of-home placement and later incarceration.     

Social phobia features across the DSM-III-R anxiety disorders

One hundred sixty subjects meeting DSM-III-R criteria for the five major anxiety disorders were compared on the extent to which they reported features characteristic of social phobia. The results indicated that many patients in the anxiety disorder categories experience some degree of social anxiety. The differences between subjects with a primary diagnosis of social phobia and subjects with other anxiety disorders appear to be chiefly quantitative on this feature. Compared to the other anxiety disorders, social phobics report fear and avoidance in response to a greater number of social situations and report greater interference in their lives due to social phobic concerns. Among the anxiety disorders, generalized anxiety disorder appears to be associated with the greatest degree of social anxiety, and simple phobia with the least.     

Mental Health and Incarcerated Youth. I: Prevalence and Nature of Psychopathology

The incarceration of mentally ill youth is a serious problem not receiving the same attention as in adults. In this study, we examine the prevalence of psychopathology and level of behavioral symptomatology in incarcerated youth versus youth receiving community mental health services or hospitalization. We randomly recruited youth from middle South Carolina served by a local CMHC (n = 60), youth served by the state adolescent inpatient program (n = 50), and youth in the S.C. Dept. of Juvenile Justice facilities from the same region (n = 75). We used the DISC-PC 2.3 to evaluate DSM-III-R diagnoses and the CBCL and YSR to evaluate behavioral symptomatology. On the DISC, incarcerated youth had significantly higher mean number of diagnoses and symptoms than CMHC youth, but lower numbers than hospitalized youth. Level of caseness (at least one diagnosis) was 86% in hospital youth, 72% in incarcerated youth, and 60% in CMHC youth. The groups differed in CBCL mean total T, internalizing T, and externalizing T scores as well as mean YSR internalizing T scores. Our results indicate the comparability in level of psychopathology in incarcerated and community-treated populations of youth, and the need to develop diversionary programs to prevent the entry of such youth into the juvenile justice system.