comprehensive handbook of personality …...of people worked just as diligently, behind the scenes,...

COMPREHENSIVE HANDBOOKOF

PERSONALITY AND PSYCHOPATHOLOGY

VOLUME 2

ADULT PSYCHOPATHOLOGY

Frank Andrasik

Volume Editor

Michel Hersen

Jay C. Thomas

Editors-in-Chief

John Wiley & Sons, Inc.

File AttachmentC1.jpg

COMPREHENSIVE HANDBOOKOF

PERSONALITY AND PSYCHOPATHOLOGY

VOLUME 2

ADULT PSYCHOPATHOLOGY

Frank Andrasik

Volume Editor

Michel Hersen

Jay C. Thomas

Editors-in-Chief

John Wiley & Sons, Inc.

This book is printed on acid-free paper.A

Copyright � 2006 by John Wiley & Sons, Inc. All rights reserved.

Published by John Wiley & Sons, Inc., Hoboken, New Jersey.Published simultaneously in Canada.

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Library of Congress Cataloging-in-Publication Data:

Comprehensive handbook of personality and psychopathology / Michel Hersen & Jay C. Thomas,editors-in-chief.

p. ; cm.Includes bibliographical references.

ISBN-13 978-0-471-47945-1 (cloth : alk. paper : set)ISBN-10 0-471-47945-4 (cloth : alk. paper : set) —ISBN-13 978-0-471-48837-8 (cloth : alk. paper : v. 1)ISBN-10 0-471-48837-2 (cloth : alk. paper : v. 1) —ISBN-13 978-0-471-48838-5 (cloth : alk. paper : v. 2)ISBN-10 0-471-48838-0 (cloth : alk. paper : v. 2) —ISBN-13 978-0-471-48839-2 (cloth : alk. paper : v. 3)ISBN-10 0-471-48839-9 (cloth : alk. paper : v. 3)

1. Psychology, Pathological—Handbooks, manuals, etc. 2. Child psychopathology—Handbooks, manuals, etc. 3. Personality—Handbooks, manuals, etc. 4. Psychology—Handbooks, manuals, etc. I. Hersen, Michel. II. Thomas, Jay C., 1951–

[DNLM: 1. Mental Disorders—therapy. 2. Personality. 3. Psychological Theory. WM 400C737 2006] 1951–RC456.C66 2006618.92�89—dc22

2005043981

Printed in the United States of America.

10 9 8 7 6 5 4 3 2 1

www.wiley.com

v

Contents

Handbook Preface ix

Preface to Volume 2 xi

Contributors xiii

P A R T O N EGENERAL ISSUES

1 DIAGNOSIS AND CLASSIFICATION 3James Langenbucher and Peter E. Nathan

2 RESEARCH CONSIDERATIONS: LATENT VARIABLE APPROACHES TO STUDYING THECLASSIFICATION AND PSYCHOPATHOLOGY OF MENTAL DISORDERS 21Laura Campbell-Sills and Timothy A. Brown

3 BEHAVIORAL AND COGNITIVE INFLUENCES 36Arthur M. Nezu, Christine Maguth Nezu, and Elizabeth R. Lombardo

4 GENETIC INFLUENCES 52Kerry L. Jang

5 SOCIOCULTURAL INFLUENCES 67Dorothy Chin and Velma A. Kameoka

6 BIOLOGICAL INFLUENCES 85Beverly E. Thorn and Kristine L. Lokken

P A R T T W OMAJOR DISORDERS AND PROBLEMS

7 GENERALIZED ANXIETY DISORDER 101Marilyn Holmes and Michelle G. Newman

8 PANIC AND AGORAPHOBIA 121Jasper A. J. Smits, Conall M. O’Cleirigh, and Michael W. Otto

9 SOCIAL ANXIETY DISORDER 138Meredith E. Coles and Betty Horng

10 SPECIFIC PHOBIAS 154Karen Rowa, Randi E. McCabe, and Martin M. Antony

vi Contents

11 OBSESSIVE-COMPULSIVE DISORDER 169David S. Riggs and Edna B. Foa

12 POST-TRAUMATIC STRESS DISORDER 189Richard A. Bryant

13 MAJOR DEPRESSIVE DISORDER 207Michael E. Thase

14 DYSTHYMIA AND MINOR DEPRESSION 231Karen B. Schmaling and Dolores V. Hernandez

15 BIPOLAR DISORDER 244Cory F. Newman

16 SCHIZOPHRENIA 262Kim T. Mueser, Elisa Bolton, and Susan R. McGurk

17 ORGANIC MENTAL DISORDER 278Drew Gouvier

18 BORDERLINE PERSONALITY DISORDER 299Timothy J. Trull, Stephanie D. Stepp, and Marika Solhan

19 OTHER PERSONALITY DISORDERS 316Kenneth N. Levy and Lori N. Scott

20 ALCOHOL ABUSE AND DEPENDENCE 337Marilyn J. Strada, Jennifer Karmely, and Brad Donohue

21 DRUG ABUSE AND DEPENDENCE 354Brad Donohue, Alisha M. Farley, and Samantha L. French

22 GAMBLING AND IMPULSE DISORDERS 370Alex Blaszczynski and Lia Nower

23 EATING DISORDERS 389Eric Stice, Joanne Peart, Heather Thompson-Brenner, Erin Martinez, and Drew Westen

24 PSYCHOPHYSIOLOGICAL DISORDERS: HEADACHE AS A CASE IN POINT 409Frank Andrasik

25 SEXUAL DYSFUNCTION 423Eric W. Corty

26 SEXUAL DEVIATION 436William D. Murphy and I. Jacqueline Page

27 MARITAL DYSFUNCTION 450Steven R. H. Beach, Charles Kamen, and Frank Fincham

Contents vii

P A R T T H R E ETREATMENT APPROACHES

28 PSYCHODYNAMIC PSYCHOTHERAPY 469Steven K. Huprich and Rachel A. Keaschuk

29 COGNITIVE BEHAVIORAL TREATMENT 487Alisa R. Singer and Keith S. Dobson

30 PSYCHOPHARMACOLOGICAL INTERVENTIONS 503Timothey C. Denko and Michael E. Thase

Author Index 519

Subject Index 535

ix

Handbook Preface

Remarkably, the linkage between personality and psycho-pathology, although extensive, has not been underscored inthe larger tomes on these subjects. In the last decade therehave been many books on personality, adult psychopathology,and child psychopathology, but none seems to have relatedthe three in an integrated fashion. In part, this three-volumeComprehensive Handbook of Personality and Psychopathol-ogy (CHOPP), with the first volume on Personality and Every-day Functioning, the second on Adult Psychopathology, andthe third on Child Psychopathology, is devoted to remedyingthis gap in the literature. Another unique feature of CHOPPappears in the volumes on Adult Psychopathology and ChildPsychopathology, where impact of adult and child psycho-pathology on family, work, school, and peers is highlighted,in addition to the relation of specific psychopathology to nor-mal development. Given the marked importance of such im-pact, contributors were asked to delineate the negative impactof psychopathology on the individual’s daily environments.

In light of the aforementioned features, we trust thatCHOPP is timely and that it will be well received in manyquarters in psychology. The work should stand as an entityas a three-volume endeavor. However, given the structure ofeach volume, we believe that it is possible to break up theset into individual volumes for relevant courses on person-ality, normal development, adult psychopathology, and childpsychopathology.

Volume 1 (Personality and Everyday Functioning) contains23 chapters divided into four parts (Foundations, Broad-RangeTheories and Systems, Mid-Range Theories, and Special Ap-plications). This volume is unique in that it encompasses boththe broad theories of personality and those theories with amore limited range, known as mid-range theories. Broad-range theories were originally developed to explain the be-havior of normal people in everyday situations. But it also isimportant to have a reference point for those individuals suf-fering from various sorts of psychopathology. Chapters inthis section follow a general format where possible:

A. Statement of the TheoryB. Developmental ConsiderationsC. Biological/Physiological RelationshipsD. Boundaries of the Theory

E. Evidence in Support of and against the TheoryF. Predictions for Everyday Functioning

1. Family Life2. Work or School3. Retirement4. Recreation

Thus, Volume 1 sets the stage for Volumes 2 and 3 whileat the same time standing on its own for understanding every-day life from the personality perspective.

Volume 2 (Adult Psychopathology) contains 30 chaptersdivided into three parts (General Issues, Major Disorders andProblems, Treatment Approaches). Volume 3 (Child Psy-chopathology) contains 27 chapters divided into three parts(General Issues, Major Disorders and Problems, TreatmentApproaches). As previously noted, a unique feature in thesevolumes is mention of the impact of psychopathology onthe family, work, school, and peers, often neglected in stan-dard works. In both Volumes 2 and 3, most of the contrib-utors have adhered to a relatively standard format for PartTwo. In some instances, some of the authors have opted tocombine sections.

A. Description of the DisorderB. EpidemiologyC. Clinical PictureD. EtiologyE. Course, Complications, and PrognosisF. Assessment and DiagnosisG. Impact on the Environment

1. Family2. Work or School3. Peer Interactions

H. Treatment Implications

In addition, authors in Volume 3 include the sections Per-sonality Development and Psychopathology and Implicationsfor Future Personality Development. We trust that the rela-tively uniform format in Part Two of Volumes 2 and 3 willmake for ease of reading and some interchapter comparisonswithin and across volumes.

Many individuals have worked very hard to bring this se-ries of volumes to fruition. First, we thank our editor at John

x Handbook Preface

Wiley, Tracey Belmont, for once again understanding theimport and scope of the project and having confidence in ourability to execute in spite of interfering hurricanes, other nat-ural events, and varied life events. Second, we thank oureditors of the specific volumes for planning, recruiting, andediting. Third, we thank our eminent contributors for takingtime out from their busy schedules to add yet one more writ-ing task in sharing their expertise. Claire Huismann, ourproject manager at Apex Publishing, deserves special rec-

ognition for her extraordinary efforts, competence, and pa-tience throughout the creation of this series. And finally, buthardly least of all, we thank all at John Wiley and PacificUniversity, including Carole Londeree, Linda James, AlisonBrodhagen, Greg May, and Cynthia Polance, for their excel-lent technical assistance.

Michel Hersen and Jay C. ThomasForest Grove and Portland, Oregon

xi

Preface to Volume 2

Volume 2 continues the themes articulated in the first volumeof this series. It contains 30 chapters, divided into three parts.Part One includes chapters that discuss diagnosis and clas-sification and pertinent research issues as well as separatechapters that discuss the behavioral, cognitive, genetic, socio-cultural, and biological factors that influence development.

Part Two includes 21 chapters that cover a broad spectrumof disorders, including anxiety, mood, schizophrenia, organic,personality, substance use, eating, psychophysiological, sex-ual dysfunction and deviation, and marital dysfunction. Thesechapters continue the focus on the linkage of personality andpsychopathology and how this impacts the individual’s socialunit (family and peers) and performance in work, school, andleisure settings. Although authors were asked to give equalweight to all of these specific impacts on the environment,the available literature demanded varied coverage, with au-thors left at times only to point out deficits in our currentknowledge and future avenues for research. These chaptersadditionally provide descriptions of the disorders and theclinical picture; review epidemiology and etiological theories;discuss the typical course, complications, and prognosis; out-line the approach to assessment and diagnosis; and review theliterature bearing on treatment and the attendant implications.

Part Three includes three individual chapters, each focus-ing more in depth on the most current general treatment ap-proaches for the conditions reviewed—psychodynamic, cog-nitive behavioral, and pharmacological.

A volume of this scope and size could not be possiblewithout the eminent scholars who gave so generously oftheir time, in the face of multiple competing demands, todraft the copy you see here. It is equally true that a numberof people worked just as diligently, behind the scenes, inorder to produce this volume. My first word of thanks to the“behind-the-scenes crew” goes to the series editors, MichelHersen and Jay C. Thomas, for affording me, and havingthe confidence in me, to serve as the volume editor and forproviding assistance beyond that normally needed whenIvan the Terrible raised its ugly head. I thank Gayle Beckand Tim Brown for their wise consultation as I was selectingauthors and topics. Prior to working on this volume, I felt Ihad a good handle on the editing process; however, workingclosely with Michel taught me that I had much to learn. Ioffer him my further thanks for teaching me so much moreabout the intricacies of successful editing. Final words ofthanks are owed to Tracey Belmont and Isabel Pratt, bothof John Wiley & Sons, for their patience, understanding,support, and flexibility; and to Claire Huismann, projectmanager at Apex Publishing, for her invaluable assistance,superb skills, and unflappable demeanor, all of which provedcritical in getting this volume to the finish line in polishedcondition.

Frank AndrasikPensacola, Florida

xiii

Contributors

Frank Andrasik, PhDUniversity of West FloridaPensacola, Florida

Martin M. Antony, PhD, ABPPMcMaster UniversityHamilton, Ontario

Steven R. H. Beach, PhDUniversity of GeorgiaAthens, Georgia

Alex Blaszczynski, PhDUniversity of SydneySydney, Australia

Elisa Bolton, PhDNH-Dartmouth Psychiatric Research CenterConcord, New Hampshire

Timothy A. Brown, PhDBoston UniversityBoston, Massachusetts

Richard A. Bryant, PhDUniversity of New South WalesSydney, Australia

Laura Campbell-Sills, PhDUniversity of California, San DiegoLa Jolla, California

Dorothy Chin, PhDUniversity of California, Los AngelesLos Angeles, California

Meredith E. Coles, PhDBinghamton University (SUNY)Binghamton, New York

Eric W. Corty, PhDPenn State Erie, The Behrend CollegeErie, Pennsylvania

Timothey C. Denko, MDUniversity of Pittsburgh Medical CenterPittsburgh, Pennsylvania

Keith S. Dobson, PhDUniversity of CalgaryCalgary, Alberta

Brad Donohue, PhDUniversity of Nevada, Las VegasLas Vegas, Nevada

Alisha M. Farley, BAUniversity of Nevada, Las VegasLas Vegas, Nevada

Frank Fincham, PhDFlorida State UniversityTallahassee, Florida

Edna B. Foa, PhDUniversity of Pennsylvania School of MedicinePhiladelphia, Pennsylvania

Samantha L. French, BSUniversity of Nevada, Las VegasLas Vegas, Nevada

Drew Gouvier, PhDLouisiana State UniversityBaton Rouge, Louisiana

Dolores V. Hernandez, MSUniversity of Texas at El PasoEl Paso, Texas

Marilyn Holmes, BAPennsylvania State UniversityUniversity Park, Pennsylvania

Betty Horng, MABinghamton University (SUNY)Binghamton, New York

Steven K. Huprich, PhDEastern Michigan UniversityYpsilanti, Michigan

Kerry L. Jang, PhDUniversity of British ColumbiaVancouver, British Columbia

xiv Contributors

Charles Kamen, BSUniversity of GeorgiaAthens, Georgia

Velma A. Kameoka, PhDUniversity of Hawaii at ManoaHonolulu, Hawaii

Jennifer Karmely, MAUniversity of Nevada, Las VegasLas Vegas, Nevada

Rachel A. Keaschuk, MSSUNY Upstate Medical UniversitySyracuse, New York

James Langenbucher, PhDRutgers, the State University of New JerseyPiscataway, New Jersey

Kenneth N. Levy, PhDPennsylvania State UniversityUniversity Park, Pennsylvania

Kristine L. Lokken, PhDUniversity of Alabama-BirminghamBirmingham, Alabama

Elizabeth R. Lombardo, PhD, PTPrivate PracticeDallas, Texas

Erin Martinez, BAUniversity of Texas at AustinAustin, Texas

Randi E. McCabe, PhDMcMaster UniversityHamilton, Ontario

Susan R. McGurk, PhDDartmouth Medical SchoolConcord, New Hampshire

Kim T. Mueser, PhDDartmouth Medical SchoolConcord, New Hampshire

William D. Murphy, PhDUniversity of Tennessee Health Science CenterMemphis, Tennessee

Peter E. Nathan, PhDUniversity of IowaIowa City, Iowa

Cory F. Newman, PhDUniversity of Pennsylvania, School of MedicinePhiladelphia, Pennsylvania

Michelle G. Newman, PhDPennsylvania State UniversityUniversity Park, Pennsylvania

Arthur M. Nezu, PhD, ABPPDrexel UniversityPhiladelphia, Pennsylvania

Christine Maguth Nezu, PhD, ABPPDrexel UniversityPhiladelphia, Pennsylvania

Lia Nower, JD, PhDUniversity of Missouri-St. LouisSt. Louis, Missouri

Conall M. O’Cleirigh, PhDUniversity of MiamiCoral Gables, Florida

Michael W. Otto, PhDBoston UniversityBoston, Massachusetts

I. Jacqueline Page, PsyDUniversity of Tennessee Health Science CenterMemphis, Tennessee

Joanne Peart, BAEmory UniversityAtlanta, Georgia

David S. Riggs, PhDUniversity of Pennsylvania School of MedicinePhiladelphia, Pennsylvania

Karen Rowa, PhDMcMaster UniversityHamilton, Ontario

Karen B. Schmaling, PhD, ABPPUniversity of North Carolina at CharlotteCharlotte, North Carolina

Lori N. Scott, BAPennsylvania State UniversityUniversity Park, Pennsylvania

Alisa R. Singer, MScUniversity of CalgaryCalgary, Alberta

Contributors xv

Jasper A. J. Smits, PhDSouthern Methodist UniversityDallas, Texas

Marika Solhan, BSUniversity of Missouri-ColumbiaColumbia, Missouri

Stephanie D. Stepp, MAUniversity of Missouri-ColumbiaColumbia, Missouri

Eric Stice, PhDUniversity of Texas at AustinAustin, Texas

Marilyn J. Strada, MAUniversity of Nevada, Las VegasLas Vegas, Nevada

Michael E. Thase, MDUniversity of Pittsburgh Medical CenterPittsburgh, Pennsylvania

Heather Thompson-Brenner, PhDBoston UniversityBoston, Massachusetts

Beverly E. Thorn, PhDUniversity of AlabamaTuscaloosa, Alabama

Timothy J. Trull, PhDUniversity of Missouri-ColumbiaColumbia, Missouri

Drew Westen, PhDEmory UniversityAtlanta, Georgia

P A R T O N E

GENERAL ISSUES

3

CHAPTER 1

Diagnosis and Classification

JAMES LANGENBUCHER AND PETER E. NATHAN

A BRIEF OVERVIEW OF CONCEPTUALUNDERPINNINGS

The craft of psychiatric diagnosis is essential to nearly allclinical, research, and policy endeavors involving mentalhealth. For clinicians, diagnostic systems identify at-risk in-dividuals for prevention services; select other cases for re-ferral and brief treatment; in more serious cases they maysuggest special courses of treatment that have been empiri-cally tested; and of course they confer on third-party payersthe responsibility to honor charges for that treatment. Forscientists, well developed diagnostic systems protect the in-tegrity of human research samples; provide an important heu-ristic function by suggesting systematic relationships amongpsychiatric illnesses; allow scientists (and practitioners) fromdisparate backgrounds to communicate via a consensual no-menclature; and enable epidemiologists to find illness baserates, risk/resilience indicators, and other facts in the data.For policymakers, these rewards of well developed diagnos-tic systems provide the tools to apportion health and othersocial resources wisely. But probably most importantly, welldeveloped diagnostic systems provide nothing less than theessential structure for the storage and retrieval of new knowl-edge as it is gathered in the field (Blashfield & Draguns,1976), in all ways essential to the scientific enterprise.

Though some diagnostic systems are dimensional or oth-erwise noncategorical, and will be discussed briefly later,most are categorical or, like DSM-III, III-R, and IV, “class-quantitative” (Strauss, 1975). Such systems permit additionalnuance, such as severity ratings, codes for the presence/ab-sence of special features, and so on, but they require, aboveall, diagnostic classification. This is so for, as Raven, Berlin,and Breedlove (1971) observed in a seminal monograph inthe journal Science, “Man is by nature a classifying animal.. . . Indeed, the very development of the human mind seemsto have been closely related to the perception of discontinu-ities in nature” (p. 1210).

Raven and his colleagues used the term folk taxonomy toindicate the predisposition of subgroups, especially guildlike

groups of craftsmen, to establish categorical nomenclatures(folk taxonomies) for classifying objects in nature that are ofspecial interest to them. Thus, potters have extensive taxon-omies of clay, stonecutters of hardness and grain, and soforth. In a classic monograph, the cognitive psychologistEleanor Rosch (1973) extended this argument by observingthat, across human cultures, there are nonarbitrary or “natu-ral” categories that form around perceptually salient naturalprototypes. Such natural categories could, of course, serve asthe basis for the folk taxonomies described by Raven and hiscoauthors. Rosch explained the key attributes of natural cate-gories: (1) they are nonarbitrary; (2) they are partitioned fromcontinua; (3) they cannot, by use of normal language, be fur-ther reduced to simpler attributes; (4) they are easily learnedby novices; (5) they serve as natural structures for the orga-nization of more knowledge; and (6) they have indistinctboundaries, encompassing both clear-cut and marginal ex-amples. So, not only do human beings naturally tend to cate-gorize and classify things, as Raven and colleagues argue,Rosch would have it that human beings tend to categorizeand classify things in roughly the same way, across culturesand, presumably, across historical eras. It seems a character-istically human thing to do.

In a more recent monograph, Lilienfeld and Marino (1995)extended a Roschian analysis to psychiatric diagnosis, argu-ing that major psychopathologic entities such as schizophre-nia or bipolar illness are, like Roschian or natural prototypes,partitioned from the continuum of human behavior, irreduc-ible to simpler concepts, understood analogously across cul-tures, have good and bad examples, and so on. This viewcomplements the conceptualization of psychiatric diagnosisas a problem in prototype categorization (Cantor, Smith,French, & Mezzick, 1980). Cantor and her colleagues pro-posed that psychiatric diagnosis follows not a classic catego-rization model (universally accepted criteria, high agreementabout class membership, and within-class homogeneity ofmembers) but rather a prototype categorization model. Pro-totype categorization assumes (1) correlated—not necessar-

4 Diagnosis and Classification

ily pathognomonic—criteria for class membership, (2) highagreement among classifiers only when classifying cases thatdemonstrate most of the correlated criteria for class mem-bership (disagreement is expected when cases have a mar-ginal number of category features, or when they bear featuresfrom more than one category), and (3) heterogeneity of classmembership, because criteria are only correlated, not patho-gnomonic.

Thus, whereas systems of psychiatric diagnosis have theircritics—and many of their arguments will be reviewed later—there is nothing arcane, much less unprecedented, in the ac-tions of a mental health professional who, encountering a newcase, lifts a copy of the DSM from her desk, matches theproperties of the new case to one or more of the DSM cate-gories, and then uses the diagnostic result to select treatment,to make a referral, or to rule the case in or out of a researchprotocol. To the contrary, what the mental health professionalis doing is as old, as honored, as universal, and as essentiallyhuman as the crafts themselves (Nathan & Langenbucher,1999).

A BRIEF HISTORY OF DIAGNOSIS

Throughout the classical era, diagnoses were made on thebasis of presumed etiology, as when Hippocrates rooted theillnesses he diagnosed (mania, melancholia, and paranoia) invarious imbalances of black bile, yellow bile, blood, andphlegm (Zilboorg, 1941). Galen (A.D. 130–210), an influ-ential Greek anatomist who lived more than 500 years later,took much the same view in his descriptions of both normaland abnormal sensations and perceptions as products of aspirit or vapor he called pneuma psychikon. Basing diagnosticassessments on such etiologic conceits changed only whenthe Swiss physician and natural philosopher Paracelsus (1490–1541) developed the concept of syndromal diagnosis. Para-celsus defined the syndrome as a group of signs and symptomsthat co-occur in a common pattern and thereby, presumably,characterize a particular abnormality or disease state, but forwhich etiology is unknown, perhaps even unknowable. Syn-dromal diagnosis is epitomized today in the DSM, which con-tinues its focus on the signs and symptoms of diseases, ratherthan their presumed etiologies, which are unnecessary fordiagnostic purposes.

Typically, psychiatric illnesses are organized hierarchi-cally, by the principles of descriptive similarity or sharedsymptom pictures. Thus, following Paracelsus, more com-prehensive and better organized hierarchical classificationsystems were soon developed, first by Thomas Sydenham(1624–1689), an English physician for whom a childhood

chorea is named, and a bit later by the French physicianFrançois de Sauvages (1706–1767). Shortly afterward, famedFrench hospital reformer Phillippe Pinel (1745–1826), pic-tured in almost every abnormal psychology textbook break-ing the chains of the insane in Paris’s Bicêtre and Salpêtrièrehospitals, proposed a system that included melancholia, mania,mania with delirium, dementia, and idiotism. The appearanceof this nomenclature coincided with the development of asy-lums for the insane, for which Pinel was partly responsible,and certainly contributed to both their humanity and theirsuccess. Building on this advance, both Pinel’s system andthe new availability of large numbers of diagnostically dif-ferentiated patients in asylums paved the way for the markedincrease in efforts to categorize psychopathology during thenineteenth century.

The victims of serious, chronic psychopathology—whatare today understood as organic mental disorders, severe de-velopmental disabilities, dementia, schizophrenia, and bipo-lar disorder (Nathan, 1998; Spitzer, Williams, & Skodol,1980)—were permanent residents of these asylums for thementally ill. The study of their essential features acceleratedwhen the German psychiatrist Karl Kahlbaum (1828–1899)discovered that understanding the premorbid course of de-mentia praecox (which today we call schizophrenia), and thefactors that conferred risk for it, helped predict its outcome.The roots of modern syndromal classification, including theDiagnostic and Statistical Manual of Mental Disorders, canbe traced to Kahlbaum and to fellow German taxonomistsGriesinger and Hecker. But no figure in descriptive psycho-pathology stands taller than Emil Kraepelin (1856–1926),whose successive textbook editions at the end of the nine-teenth and beginning of the twentieth centuries anticipatedmuch of what modern-day diagnosticians would find famil-iar, including detailed medical and psychiatric histories ofpatients, mental status examination, emphasis on careful ob-servation of signs and symptoms to establish diagnoses, andunderstanding the psychoses as largely diseases of the brain.Kraepelin’s taxonomy of mental illness has a strikingly con-temporary feel and includes many of the terms used today.

In the twentieth century, more and more mental healthpractice took place outside the mental asylums, to encompassthe military services, private clinics and office practice,company-supported mental health and substance abuse ser-vices, and educational institutions at all levels. As a result,nosologies grew broader and increasingly complex in in-struments published by the National Commission on MentalHygiene/Committee on Statistics of the American Medico–Psychological Association in 1917 and the American Psy-chiatric Association/New York Academy of Medicine (1933).This was both fortunate and necessary, for during World

Emergence of the Neo-Kraepelinian Tradition: DSM-III and DSM-III-R 5

War II, unexpectedly, most psychological casualties resultedfrom nonpsychotic, acute disorders like substance abuse, de-pression, and the anxiety disorders, with extraordinarily highbase rates among combat personnel. Clearly, the impact ofthese conditions on the war effort required development of anomenclature that provided substantially greater coverage ofthese conditions so that they could be accurately identified,treated, and their sufferers returned to service.

A COMMON U.S. NOMENCLATURE: DSM-I ANDDSM-II

Although the U.S. War Department worked hard to developsuch a system in response to the flood of wartime psychiatriccasualties, it was only in 1946 that representatives of the Vet-erans Administration, the War Department, and the civilianmental health community led by the American PsychiatricAssociation (APA) began to consider how to create a no-menclature that would meet their diverse needs. Their ef-forts led to the publication, in 1952, of the first edition ofthe APA’s Diagnostic and Statistical Manual of Mental Dis-orders (DSM-I).

The DSM-I (APA, 1952) was the first comprehensive syn-dromal system developed. As such, it was designed to offermental health professionals a common diagnostic languagethrough which to communicate about their patients and theirresearch findings. Its appearance sparked a similar effort inEurope that ultimately caused the World Health Organization(WHO) to add a mental disorders section to the eighth edi-tion of the International Classification of Diseases (ICD-8;WHO, 1967). Despite its promise, DSM-I (and DSM-II [APA,1968], which closely resembled it) shared serious problemsthat markedly compromised their diagnostic reliability, valid-ity, and utility.

Most obviously, the manuals contained relatively little tex-tual material: The DSM-I contained 130 pages and fewer than35,000 words; DSM-II was a mere four pages longer. As aconsequence, these early efforts provided only brief descrip-tions of each syndrome, insufficient for reliable diagnoses.Moreover, the signs and symptoms of each syndrome werenot empirically based. Instead, they represented the accu-mulated clinical wisdom of the small number of senior aca-demic psychiatrists who staffed the DSM task forces. As aresult, the diagnostic signs and symptoms that interested taskforce members were imperfectly related to the clinical ex-periences of mental health professionals working in publicmental hospitals, mental health centers, and the like. Con-sequently, clinicians very often failed to agree with one an-other when assigning diagnoses based on DSM-I and DSM-II,

whether they were presented with the same diagnostic infor-mation (interclinician agreement; Beck, Ward, Mendelson,Mock, & Erbaugh, 1962; Nathan, Andberg, Behan, & Patch,1969) or they reevaluated the same patient after a period oftime had passed (diagnostic consistency; Zubin, 1967).

Not surprisingly, the low reliability of DSM-I and DSM-II diagnoses affected both their validity and clinical utility. Ifclinicians could not agree on a diagnosis, they were unlikelyto be able to validate it against other measures (Black, 1971),to have confidence in predictions of the future course of di-agnosed disorders (Nathan, 1967), or to create the diagnos-tically homogeneous groups of patients necessary to spursubstantive advances in etiological or treatment research(Nathan & Harris, 1980).

Just as predictably, the low reliability and validity of DSM-I and DSM-II diagnoses raised ethical concerns among prac-titioners and scholars. Psychiatrist Thomas Szasz (1960)created a national furor over what he considered the dehu-manizing, stigmatizing consequences of psychiatric “labeling,”ultimately concluding that the modern categories of psychi-atric illness were mere “myths.” Szasz’s ideas gained empir-ical substance in 1973 when psychologist David Rosenhanpublished, in the world’s most prestigious journal, Science,one of the most widely cited studies in psychiatry, “On BeingSane in Insane Places.” At Rosenhan’s behest, eight peers,friends, and graduate students presented for treatment to vari-ous psychiatric hospitals in northern California, complainingof “hearing voices.” Auditory hallucinations are, of course,a “first-rank” symptom of schizophrenia (Schneider, 1959),and all eight pseudopatients were admitted to hospital. Im-mediately thereafter, they stopped complaining of the voicesand denied any other symptoms of psychosis. Nonetheless,all were diagnosed as psychotic, and their subsequent behav-ior was construed in light of that label. Quite normal reactionsthey manifested, such as being wary of strange and perhapsmenacing fellow patients, were characterized in chart notesand staff meetings as the products of paranoid and delusionalprocesses. Summarizing his findings, Rosenhan concluded,“The normal are not detectably sane” (1973, p. 252), a damn-ing assertion indeed. Clearly, psychiatric diagnosis had comeas far as it possibly could as an “art” practiced in an arcanefashion by an elite group of the initiated. The time was ripefor its transformation into a science.

EMERGENCE OF THE NEO-KRAEPELINIANTRADITION: DSM-III AND DSM-III-R

Antecedents

Beginning in the late 1960s, psychiatrist Robert Spitzer andcolleagues at the New York State Psychiatric Institute devel-


oped several structured diagnostic interviews, including theMental Status Schedule (Spitzer, Fleiss, Endicott, & Cohen,1967) and the Psychiatric Status Schedule (Spitzer, Endicott,Fleiss, & Cohen, 1970), in an effort to begin to gather em-pirical data on diagnostic syndromes. Spitzer and his col-leagues also developed computer programs called DIAGNOand DIAGNO-II that were designed to use the syndromalinformation gathered by the Mental Status Schedule to assignmore reliable clinical diagnoses (Spitzer & Endicott, 1968,1969).

Sharing a similar commitment to developing an empiri-cally based, more reliable diagnostic system, researchers atWashington University in Saint Louis published an importantarticle in 1972 (Feighner et al., 1972) that set forth explicitdiagnostic criteria—the so-called Feighner criteria—for 16major disorders. Their intent was to replace the vague andunreliable descriptions of DSM-I and DSM-II with system-atically organized, empirically based diagnostic criteria, help-ing researchers to establish the diagnostically homogeneousand predictively valid experimental groups for which theyhad long striven in vain. The format of the Feighner criteriagreatly influenced the format for diagnostic criteria adoptedin DSM-III. A derivative of Feighner’s work, the ResearchDiagnostic Criteria (RDC), developed jointly by the NewYork State Psychiatric Institute and Washington Universitygroups (Spitzer, Endicott, & Robins, 1975), was published in1975. Designed to permit empirical testing of the presumablygreater reliability and validity of the Feighner criteria, theRDC criteria yielded substantially greater diagnostic reli-ability than the equivalent DSM-II disorders (Helzer, Clayton,et al., 1977; Helzer, Robins, et al., 1977), and so constituteda great step forward.

This work, rooted in the idea of psychiatric diagnosis asa rigorously developed and universally applied scientific tool,defined what came to be known as the neo-Kraepelinianschool of U.S. psychiatry (Blashfield, 1984). Drawing largelyfrom the groups that formulated the RDC—psychiatry facultyat the Washington University School of Medicine in SaintLouis and the Columbia University College of Physiciansand Surgeons in New York—neo-Kraepelinian diagnostic re-search during the 1970s laid the groundwork for the revolu-tionary advances of DSM-III. Like Kraepelin himself, theneo-Kraepelinians endorsed the existence of a boundary be-tween “pathological functioning” and “problems in living,”viewed mental illness as the purview of medicine, and be-lieved in the importance of applying the scientific method sothat the etiology, course, prognosis, morbidity, associated fea-tures, family dynamics, predisposing features, and treatmentof psychiatric illnesses could be elucidated more clearly.

Diagnostic Criteria

Five years after the RDC criteria were published, DSM-IIIappeared (APA, 1980), heralding substantial advances in thereliability, validity, and utility of syndromal diagnosis. Basedin large part on the RDC, the inclusion in DSM-III of rigor-ously designed diagnostic criteria and, in an appendix, di-agnostic decision trees, represented the new instrument’smost significant advance. The criteria were designed to or-ganize each syndrome’s distinguishing signs and symptomswithin a consistent format—they were, in scientific parlance,operationalized, so that each clinician who used them woulddefine each sign and symptom the same way, and process theresulting diagnostic information in a consistent manner. Thisdegree of detail in the diagnostic information available toDSM-III’s users contrasted sharply with the paucity of suchdetail in DSM-I and DSM-II.

Several structured and semistructured diagnostic inter-views based on the DSM-III, very distant descendants of theMental Status Schedule and the Psychiatric Status Schedule,were published around the time DSM-III appeared, in a re-lated effort to enhance diagnostic reliability and, especially,to spur research. The best known of these was the NIMH Di-agnostic Interview Schedule (DIS; Robins, Helzer, Croughan,& Ratcliff, 1981), a structured interview designed for non-clinician interviewers. The semistructured Structured ClinicalInterview for DSM-III (SCID; Spitzer, 1983; Spitzer &Williams, 1986), designed for use by clinicians, was alsopublished around the same time. These important, and inmost ways unprecedented, new instruments provided thedata-gathering structure both for major new epidemiologicefforts (e.g., Epidemiologic Catchment Area study [Regieret al., 1984], National Comorbidity Survey [e.g., Kessler,Sonnega, Bromet, Hughes, & Nelson, 1995; Kessler, Stein,& Berglund, 1998]) and for a host of clinical and preclinicalstudies, because they insured the internal validity of the re-search by helping ensure that the samples of human psycho-pathology were well characterized diagnostically. DSM-III-R,published in 1987, was a selective revision of DSM-III thatretained the advances of the 1980 instrument and incorpo-rated generally modest changes in diagnostic criteria thatnew clinical research (to a great extent dependent on find-ings produced by the application of the DIS and SCID tohuman research samples) suggested should be a part of thediagnostic system. It was in this way that diagnostic re-search “bootstrapped” its way from the dismal days ofRosenhan to the well-regarded science it is today, and itsproducts, although not universally successful, have been im-pressive indeed.

Emergence of the Neo-Kraepelinian Tradition: DSM-III and DSM-III-R 7

Utility and Validity

DSM-III and DSM-III-R addressed their predecessors’ dis-appointing diagnostic validity and utility in several ways(Spitzer et al., 1980). To begin with, both volumes are muchlarger than their predecessors, in part to accommodate inclu-sion of more than three times as many diagnoses, in part toprovide detailed information on each syndrome along withits defining diagnostic criteria. The expansion of syndromedescriptions made it easier for clinicians to describe moreprecisely their patients’ behavior, and to understand their suf-fering in the context of their milieu.

Another advantage of DSM-III and DSM-III-R was thatthey assessed patients along five dimensions, or axes: Psy-chopathology was diagnosed on Axes I and II; medical con-ditions impacting on the mental disorders were noted on AxisIII; the severity of psychosocial stressors affecting the pa-tient’s behavior was noted on Axis IV; and the patient’s high-est level of adaptive functioning was noted on Axis V. Theadditional information available from multiaxial diagnosiswas presumed to be more useful for treatment planning anddisposition than the single diagnostic label available fromDSM-I and DSM-II.

Reliability and Stability

A very substantial number of reliability studies of the DSM-III and DSM-III-R diagnostic criteria were published. Almostwithout exception, they pointed to much greater diagnosticstability and interrater agreement for these instruments thanfor their predecessors, DSM-I and DSM-II. Enhanced reli-ability was especially notable for the diagnostic categories ofschizophrenia, bipolar disorder, major depressive disorder,and substance abuse and dependence; the reliability of thepersonality disorders, some of the disorders of childhood andadolescence, and some of the anxiety disorders has been lessencouraging (e.g., Fennig et al., 1994; Klein, Ouimette,Kelly, Ferro, & Riso, 1994; Mattanah, Becker, Levy, Edell,& McGlashan, 1995), but this has been due to a variety ofreasons, including conceptual underspecification (in the caseof the personality disorders), and the inherently transitory ofself-correcting nature (diagnostic stability problems) of someothers (disorders of childhood and adolescence and someforms of anxiety).

Thus, despite these explicit efforts to enhance the diag-nostic utility and validity of DSM-III and DSM-III-R, it didnot prove easy to document the impact of these efforts. Theabsence of documented etiological mechanisms, with asso-ciated laboratory findings, by which the diagnoses of many

physical disorders are confirmed—the “gold standard”—made establishing the construct validity of many DSM-III andDSM-III-R diagnoses difficult (Faraone & Tsuang, 1994). Asnoted later in this chapter, the same problem continues tostand in the way of attempts to validate DSM-IV diagnoses.

Although the DSM-III and DSM-III-R diagnostic criteriaenhanced the instruments’ diagnostic reliability, diagnosticstability continued to be an issue for diagnosticians becauseof changes in patient functioning over time. Thus, in a studyof the six-month stability of DSM-III-R diagnoses in first-admission patients with psychosis, Fennig et al. (1994) re-ported that whereas affective psychosis and schizophrenicdisorders showed substantial diagnostic stability, stability forsubtypes of these conditions was less stable. Changes in pa-tient functioning were seen as responsible for 43 percent ofthese diagnostic changes. In like fashion, Nelson and Rice(1997) reported that the one-year stability of DSM-III lifetimediagnoses of obsessive-compulsive disorder (OCD) turnedout to be surprisingly poor: Of OCD subjects in the ECAsample they followed, only 19 percent reported symptoms ayear later that met the OCD criteria. Mattanah and his col-leagues (1995) reported that the diagnostic stability of severalDSM-III-R disorders was lower for a group of adolescentstwo years after hospitalization than for the same diagnosesgiven adults. These and similar studies of diagnostic stabilityemphasized the extent to which diagnostic reliability is de-pendent not only on the validity of diagnostic criteria but onthe inherent symptom variability of disorders over time aswell.

Also, researchers using DSM-III and DSM-III-R diagnos-tic criteria undertook research during the years followingtheir appearance to validate several of the manual’s majordiagnostic categories, including schizophrenia and major de-pressive disorder, despite the absence of a gold-standard cri-terion of validity. Our brief mention of validation studiesincludes only Kendler’s familial aggregation and coaggre-gation research findings, both because they represent a par-ticularly powerful approach to validation and because thefindings generally mirror those found by others, but manyothers could be adduced.

When Kendler, Neale, and Walsh (1995) examined thefamilial aggregation and coaggregation of five hierarchicallydefined disorders—schizophrenia, schizoaffective disorder,schizotypal/paranoid personality disorder, other nonaffectivepsychoses, and psychotic affective illness—in siblings, par-ents, and relatives of index and comparison probands, theyreported that although schizophrenia and psychotic affectiveillness could be clearly assigned to the two extremes of theschizophrenia spectrum, the proper placement of schizoaf-


fective disorder, schizotypal/paranoid personality disorder,and other nonaffective psychoses could not be clearly made.In a companion report, Kendler and his coworkers (1995)found that probands with schizoaffective disorder differedsignificantly from those with schizophrenia or affective ill-ness in lifetime psychotic symptoms as well as outcome andnegative symptoms assessed at follow-up. Moreover, relativesof probands with schizoaffective disorder had significantlyhigher rates of schizophrenia than relatives of probands withaffective illness.

Although Kendler’s family research method validated onlya portion of schizophrenic spectrum disorder diagnoses, heand his colleagues (Kendler et al., 1996; Kendler & Roy,1995) were able by the same methods to strongly support thevalidity of the DSM-III major depression diagnostic syn-drome. However, when Haslam and Beck (1994) tested thecontent and latent structure of five proposed subtypes of ma-jor depression, clear evidence for discreteness was found onlyfor the endogenous subtype; the other proposed forms lackedinternal cohesion or were more consistent with a continuousor dimensional account of major depression.

Criticisms

Although DSM-III and DSM-III-R represented major ad-vances, they were widely criticized. This was particularly sofor DSM-III, the first manual to truly shatter the mold inwhich prior nosologies had been cast. One major source ofconcern was that DSM-III incorporated more than three timesthe number of diagnostic labels in DSM I. Prominent clinicalchild psychologist Norman Garmezy (1978) expressed theconcern that this proliferation of diagnostic labels wouldtempt clinicians to pathologize unusual but normal behaviorsof childhood and adolescence, a criticism more recently di-rected at DSM-IV (Houts, 2002). In a similar vein, socialworkers Kirk and Kutchins (1992) accused the instrument’sdevelopers of inappropriately labeling “insomnia, worrying,restlessness, getting drunk, seeking approval, reacting to criti-cism, feeling sad, and bearing grudges . . . [as] possible signsof a psychiatric illness” (p. 12).

Thus, the definition of mental disorder developed forDSM-III (and retained in DSM-III-R and DSM-IV) has beencriticized for being both too broad and encompassing of be-haviors not necessarily pathological, and for offering poorguidance to clinicians who must distinguish between uncom-mon or unusual behavior and psychopathological behavior.Addressing these concerns, Spitzer and Williams (1982) de-fended the DSM-III approach (and by extension, the entireensuing DSM tradition) by noting that the intention of theframers was to construct a nomenclature that would cast as

wide a clinical net as possible, in order that persons sufferingfrom even moderately disabling or distressing conditionswould receive the help they needed.

But overdiagnosis was not the only rifle leveled at theDSM tradition. Schacht and Nathan (1977), Schacht (1985),and others questioned the frequent emphasis in DSM-III ondisordered brain mechanisms in its discussions of etiology,as well as its apparent endorsement of pharmacological treat-ments in preference to psychosocial treatments for many dis-orders. In response, Spitzer (1983) noted that the DSM-IIItext simply reflected the state of knowledge of etiology andtreatment. Similar concerns have been voiced about DSM-IVby Nathan and Langenbucher (1999).

DSM-III and its successors have also been criticized fortheir intentionally atheoretical, descriptive position on etiol-ogy. In a debate on these and related issues (Klerman, Vaillant,Spitzer, & Michels, 1984), these critics charged that an atheo-retical stance ignored the contributions of psychodynamictheory to a fuller understanding of the pathogenesis of mentaldisorders, as well as to the relationship between emotionalconflict and the ego’s mechanisms of defense. But in the samedebate, Spitzer questioned the empirical basis for the claimthat psychodynamic theory had established the pathogenesisof many of the mental disorders. Clearly, these are matterson which much has still to be written and argued, as it surelywill be.

THE PRESENT EMPIRICALLY BASEDNOMENCLATURE: DSM-IV

The DSM-IV Process

The principal goal of the DSM-IV process was to create anempirically based nomenclature that improved in importantways on DSM-III and DSM-III-R (Frances, Widiger, & Pincus,1989; Nathan, 1998; Nathan & Langenbucher, 1999; Widiger& Trull, 1993). To achieve this goal, a three-stage processwas used. The process began with the appointment of 13 four-to six-person work groups of experts on the major diagnosticcategories. Each work group began by undertaking system-atic literature reviews designed to address unresolved diag-nostic questions. When the literature reviews failed to resolvethem, the work groups sought clinical data that might be ca-pable of casting more light on outstanding questions; 36 rean-alyses of existing patient data sets were ultimately completed.The work groups also designed and carried out 12 large-scalefield trials involving more than seven thousand participantsat more than 70 sites worldwide.

The Present Empirically Based Nomenclature: DSM-IV 9

The DSM-IV development process is thoroughly chroni-cled in four Sourcebooks edited by Thomas Widiger and col-leagues (Widiger et al., 1994, 1996, 1997, 1998). There,important literature reviews are archived and findings fromdata reanalyses and field trials are summarized. Most of thefield trials contrasted the diagnostic sensitivity and specificityof alternative sets of existing diagnostic criteria, includingthose of ICD-10, DSM-III-R, and DSM-III, with one or moresets of new criteria, the DSM-IV Options. Many of the “op-tions” explored the impact on diagnostic reliability of changesin the wording of criteria or the minimum number requiredto meet diagnostic threshold and permit formal diagnoses tobe made.

Reliability and Validity

Most of the early data on the reliability and validity of DSM-IV diagnoses came from the field trials. Generally, the datasuggested modest increases in the reliability of a few diag-nostic categories (e.g., oppositional defiant disorder and con-duct disorder in children and adolescents, substance abuseand dependence) and validity (e.g., autistic disorder; oppo-sitional defiant disorder in childhood and adolescence). Un-fortunately, they also reported no real progress in addressingthe substantial reliability problems of the personality disor-ders, the sleep disorders, the disorders of childhood and ad-olescence, and some of the disorders within the schizophrenicspectrum. These continue to be thorny problems that scien-tists developing DSM-V are now hard at work to solve.

Because estimates of diagnostic reliability reflect, at leastin part, the stability of the disorder’s symptoms, a number ofstudies of DSM-IV symptom stability have been undertaken.To this end, Koenigsberg and his colleagues (2002) exploredthe instability of affective symptoms in borderline personalitydisorder; Mataix-Cols and his coworkers studied symptomstability in adult obsessive-compulsive disorder (2002), andShea and her fellow investigators (2002) explored the short-term diagnostic stability of schizotypal, borderline, avoidant,and obsessive-compulsive personality disorders. It is not ac-cidental that in all three instances the temporal stability ofdisorders with typically unstable symptom patterns was stud-ied. Interestingly, in all three studies, the investigators foundgreater than anticipated symptom stability.

Of the relatively few very recent reliability studies ap-pearing in the literature—their paucity reflects the substantialnumber of such studies already published in the Sourcebooks,as well as agreement among scholars and researchers thatdiagnostic reliability for most DSM-IV diagnostic categoriesis satisfactory—one reported good interrater agreement amongexperienced psychiatrists for DSM-IV diagnoses of bipolar II

disorder (Simpson et al., 2002), whereas a second found“good to excellent reliability” for the majority of currentand lifetime DSM-IV anxiety and mood disorder diagnoses(Brown, Di Nardo, Lehman, & Campbell, 2001). In addition,four recent pieces attested to the predictive validity of a di-verse group of DSM-IV disorders. Kim-Cohen and her col-leagues (2003) reported that between 25 percent and 60percent of a large sample of British adults with a currentpsychiatric diagnosis had a history of conduct and/or oppo-sitional defiant disorder, making the latter particularly pre-dictive of adult disorder. Assessing psychiatric disorders ina random community sample of U.S. adolescents, Johnson,Cohen, Kotler, Kasen, and Brook (2002) found that depres-sive disorders during early adolescence were associated withelevated risk for the onset of eating disorders, and disruptiveand personality disorders were independently associated withelevated risk for specific eating or weight problems. Yen andher colleagues (2003) reported that the diagnosis of border-line personality disorder (BPD) among patients in a morevariegated group, when combined with a history of drug use,significantly predicted suicide attempts during a two-yearfollow-up; when BPD was controlled, a worsening in thecourse of major depressive disorder and of substance use dis-orders in the month preceding the suicide attempt was also asignificant predictor of suicide. Following the five-year clini-cal course of almost 600 men and women with diagnoses ofalcohol abuse or alcohol dependence, Schuckit and colleagues(2001) observed that the DSM-IV diagnosis of alcohol de-pendence predicted a chronic disorder with a relatively severecourse, whereas DSM-IV alcohol abuse predicted a less per-sistent, milder disorder that did not usually progress to de-pendence. Results from these four studies support a growingconsensus that the enhanced reliability of a number of DSM-IV diagnoses, reflecting more accurate diagnostic criteria, hasled to their greater predictive validity.

In a thoughtful recent article that asked clinicians to dis-tinguish between the concepts of diagnostic validity and di-agnostic utility that also has relevance to the continuingdimensional/categorical controversy, Kendell and Jablensky(2003) observed that, despite historical assumptions to thecontrary, little evidence demonstrates that most currently rec-ognized mental disorders are separated by natural boundaries.Although these authors make the case that diagnostic syn-dromes should be regarded as valid only if they have beenshown to be discrete entities with natural boundaries, theymake a strong case for believing that many of these entitiesnonetheless possess high utility because they do providevaluable information on outcome, treatment response, andetiology. That is, with reference to the points with which webegan this chapter, Kendell and Jablensky believe that DSM-


IV diagnoses are useful folk taxonomies in the sense de-scribed by Raven and colleagues, even if they do not meetthe standard of natural prototypes described by Eleanor Rosch.

Gender and Cultural Bias

In response to the controversy surrounding DSM-III-R’s es-timates that more women than men merit the diagnoses ofhistrionic PD and dependent PD, the DSM-IV text nowavoids specifying gender prevalence rates for these disor-ders. DSM-IV has also added three PDs (schizoid, schizoty-pal, and narcissistic) to the three (paranoid, antisocial, andobsessive-compulsive) that DSM-III-R indicated were diag-nosed more often in males than in females. In reviewing thesechanges, Corbitt and Widiger (1995) asked whether DSM-IVhas unintentionally introduced diagnostic bias, in a laudableeffort to combat it, by going beyond the modest empiricaldata on gender prevalence rates for the histrionic and depen-dent PDs.

Two recent studies examined the impact of ethnicity onrates of psychiatric disorders, in a continuing expression ofinterest in ethnicity and diagnosis stimulated in part by DSM-IV’s Appendix I. Minsky, Vega, Miskimen, Cara, and Escobar(2003) reported significantly higher rates of major depressionfor Latinos in a survey of differential diagnostic patternsamong Latino, African American, and European Americanpsychiatric patients drawn from a large behavioral health ser-vice delivery system in New Jersey. However, these authorswere unsatisfied with the range of possible explanations forthis unexpected finding. Canino and her colleagues (2004)examined rates of child and adolescent disorders in PuertoRico, finding prevalence rates “that were generally compa-rable with those found in previous surveys” and broadly inline with previous surveys of children and adolescents on theU.S. mainland.

Criticisms

Although there is widespread agreement about the enhancedempirical base that underlies DSM-IV, many persons involvedin the development of the instrument acknowledge limita-tions on full utilization of the extensive empirical databasebecause of unavoidable, biased or misleading interpretationsof the data (e.g., Kendler, 1990; Widiger & Trull, 1993). Re-sponding to related criticisms that professional issues over-shadowed scientific ones in the creation of DSM-IV (e.g.,Caplan, 1991; Carson, 1991; Kirk & Kutchins, 1992), Widigerand Trull (1993) defended attention by the drafters of DSM-IV to issues of utility that sometimes preempted issues ofvalidity, as when a valid diagnosis was de-emphasized be-

cause so few patients met its criteria. Nonetheless, eventhough the DSM-IV Task Force had to be sensitive to a varietyof forensic, social, international, and public health issues,Widiger and Trull described the result as largely an empiri-cally driven instrument. The DSM tradition, and the muchenhanced approach to diagnostic inquiry it helped promul-gate, has had impressive impact on how scientists conductresearch and, thus, on how clinicians approach their patients.

TWO CRITICAL CASES OF DIAGNOSIS

Epidemiology: The CIDI in the NCS

Prior to the arrival in 1980 of a rule-guided diagnostic system,DSM-III, the basic fact of mental illness was appreciated, andsome preliminary studies in psychiatric epidemiology—suchas the New Haven Study (Hollingshead & Redlich, 1955)and the Midtown Manhattan Study (Srole, Langer, Michael,Opler, & Rennie, 1962)—were conducted. However, not eventhe best-informed scientist of the time knew much about howprevalent mental illnesses were, how they co-occurred, howthey were concentrated in certain age ranges, what factorsseemed to predispose to their presence and absence (e.g., riskand resiliency factors), and so on. Firm findings require re-liable diagnoses, and these were impossible in the absence ofrule-guided diagnostic systems like DSM-III. This gap in di-agnostic methodology made investment in large-scale epi-demiologic research by the U.S. government unattractive.Consequently, because health policymakers had little basison which to make informed judgments, groups of underiden-tified persons affected by psychiatric conditions—PTSD pa-tients, patients with mild depression, children with learningdisorders, and so on—may well have suffered needlessly.

This situation changed with the development of the Epi-demiologic Catchment Area study, which deployed an im-portant tool, the structured diagnostic interview, for the firsttime in a large-scale epidemiologic study. The ECA involvedface-to-face interviews of a stratified sample of more than18,000 adult community respondents in five states during theearly 1980s. Its goal was to establish the prevalence of a verywide range of mental and substance use disorders in theUnited States. This goal became possible with the develop-ment of the Diagnostic Interview Schedule, based on DSM-III diagnostic categories, and structured to permit speciallytrained non-mental-health professionals to interview and di-agnose respondents reliably. The DIS was an early exampleof what became, during the late 1980s and 1990s, a large andsophisticated family of fully and semistructured or “guided”diagnostic interviews—including the CIDI (Robins et al.,

Future Directions 11

1988), SCID (Spitzer, Williams, Gibbon, & First, 1992),SADS (Endicott & Spitzer, 1978), PRISM (Hasin et al.,1996), and many others—developed by numerous indepen-dent research teams to facilitate both clinical and epidemio-logical research. It is true that most of these instrumentsrequire extensive interviewer training and can take severalhours to complete, but they are designed to do something thatwas never before possible: to yield full knowledge of thatrespondent’s psychiatric state and past history, formal diag-noses of illnesses that meet diagnostic threshold, and even thepresence of individual symptom, symptom severity, symptomonset and offset patterns, and subclinical states.

Between September 1990 and February 1992, using a de-scendant of the DIS called the CIDI-UM, Kessler and col-leagues undertook the successor to the ECA, the NationalComorbidity Study (NCS). The NCS gathered data on dem-ographics, psychiatric and health functioning, quality of life,and many other domains from a stratified national sample ofmore than 8,000 Americans aged 15 to 54 years. Like theECA before it, the NCS dataset has generated scores of im-portant epidemiologic and descriptive studies on issues asdiverse as adolescent depression (Kessler, Avenevoli, &Merikangas, 2001), generalized anxiety disorder (Wittchen,Zhao, Kessler, & Eaton, 1994), symptom progression of al-cohol dependence (Nelson, Little, Heath, & Kessler, 1996),and many others. Because of such studies, we now under-stand, within the limitations of our current concepts, howprevalent psychiatric illnesses are, how they onset, what ge-netic and other factors seem to predispose to them, and manyother matters of crucial public concern. In fact, data derivedfrom the NCS—and thus directly derived from the DSM-IVand the structured interviews it made possible—are con-stantly appealed to by mental health administrators and pol-icymakers charged with assessing and predicting service andresearch requirements prior to distributing resources that areincreasingly scarce and hard to come by.

Treatment Research: SCID in Randomized Trials

Prior to the 1980s, researchers charged with the design ofclinical trials—say, studies of patients with recurrent majordepression who could be used in the test of a new medica-tion—suffered as a group from two important limitations:First, without a fairly long conversation with the doctor ordiagnostic technician who admitted the subject to trial, noindependent observer could have confidence that any partic-ular case indeed met criteria for major depression as devel-oped in DSM-II; and, second, no independent observer couldhave confidence that any particular case did not meet criteriafor other psychiatric illnesses in addition to the illness of

interest, perhaps much more serious ones, ones that would“wash out” the effects of treatment on the less severe illness.Subjects in such trials were typically deemed eligible for re-search on the basis of clinician judgment, chart review, andperhaps some narrow-band assessments directed at scalingthe severity of the illness of interest, such as the Beck De-pression Inventory (BDI; Beck, Ward, Mendelson, Mock, &Erbaugh, 1961), the State-Trait Anxiety Inventory (Speil-berger, Gorsuch, & Lushene, 1970), and many others. It isinevitable that some, perhaps many, such cases did not sufferfrom the illness of interest at all and that a great many othersuch cases suffered from additional illnesses that confoundedthe results of the study. To use an analogy, it was as thoughchemists were charged with developing a new line of anti-cancer drugs while being blind to the identity of the powdersand fluids on their workbenches and unsure of the illnessesfrom which their experimental subjects suffered.

But just as epidemiologic research was transformed by theavailability of a host of fully structured and semistructuredor “guided” diagnostic interviews in the 1980s, so, at thesame time, did these same diagnostic interviews transformclinical research. Beginning in the 1980s with the develop-ment of the SCID, in particular, and continuing more vigor-ously now, editorial opinion governing the publication ofclinical research involving psychiatric groups has requiredthe administration of guided diagnostic interviews to pro-spective participants in order to protect the integrity of sam-ples. It is difficult—impossible, in most venues—to publishtreatment research results when participants have not been“SCID-ed,” that is, thoroughly interviewed prior to trial en-rollment by skilled diagnosticians using a diagnostic inter-view like the SCID or one of its close cousins. Is this withoutcost? No. Initial, preenrollment assessments regularly requirehours, even days, to thoroughly characterize the prospectiveenrollee’s history and current clinical state. But, is it worth it?We need cite nothing more than the recent development ofparity between medical and mental health coverage (Goldman,Rye, & Sirovatka, 1999), a result based on the greater respectaccorded research findings in the latter field to assert that it issurely so.

FUTURE DIRECTIONS

Although theoretical and methodological advances havedriven forward much of the very clear advantages of DSM-IV over its predecessors, application of still other, emergent,research techniques are poised to do much to aid the under-standing of, not only what psychiatric illnesses look like, buthow they develop over time, what are their essential versus


nonessential characteristics, how they might be further splitinto meaningful subgroups, and so on. Following, a few ofthe more promising techniques are briefly reviewed.

New Research Tools

As reviewed previously, the 1970s saw the emergence of anempirical, atheoretical approach to psychiatric diagnosis thatblossomed in the work of the neo-Kraepelinian school of U.S.psychiatry. The neo-Kraepelinian movement argued that psy-chiatric diagnosis, like any branch of medicine, should bebased solidly on empirical research (Compton & Guze, 1995).To fulfill this demand, and seeking a strong methodologicaland empirical base, diagnostic research in the 1970s came toborrow heavily from classical test theory (CTT), wherebysuch parameters as reliability, internal consistency, and pre-dictive power grew in interest (Baldessarini, Finkelstein, &Arana, 1983). Precisely because of the nature of the method-ological problems inherent in diagnostic research, researchershave been required to develop or import from other fieldsempirical approaches as well, such as epidemiologic conceptsand methods, advanced quantitative approaches, and others.

The neo-Kraepelinians formed the core group whose workresulted in the DSM-III and later versions of the DSM. Theirearly and important contribution to diagnostic validationmodels (e.g., Robins & Guze, 1970) is one of the most widelycited papers in psychiatry. The Robins and Guze validationmodel proposed testing or validating diagnostic categoriesagainst five criteria: (1) clinical description (the degree towhich the symptoms of the disorder cohere and logically con-nect); (2) laboratory studies (the degree to which the disordercan be seen to covary with physiological markers); (3) delim-itation from other disorders (the degree to which the disordercan be distinguished from others, even though some featuresmay overlap); (4) follow-up studies (the degree to which thedisorder is stable across time); and (5) family studies (thedegree of heritability of the disorder). To this basic model,Andreasen (1995), believing that psychiatry’s neurosciencebase is key to its future, added neurophysiological and neu-rogenetic tests. Contemporary validation efforts deploy a mixof clinical, epidemiological, genetic-familial, and neurobio-logical strategies, some of which will be reviewed in the fol-lowing sections.

To fulfill the research needs of validation models such asthis, a number of powerful advances in quantitative methodssharpened nosological research in the past quarter century.These included both traditional exploratory as well as con-firmatory factor analysis (CFA; Cole, 1987; Jöreskog &Sörbom, 1989), to study the presumed internal coherence orunidimensionality of criterion arrays for such diagnoses as

borderline personality (e.g., Sanislow et al., 2002) or soma-tization (Robbins, Kirmayer, & Hemami, 1997); cluster anal-ysis (e.g., Ward, 1963), to discover in the data naturallyoccurring groups of respondents who may represent subtypemanifestations of such disorders as mania (Dilsaver, Chen,Shoaib, & Swann, 1997), schizophrenia (Dollfus et al., 1996),or personality disorders (Morey, 1988); receiver/operatorcharacteristic analysis (ROC; Murphy, Berwick, Weinstein,& Borus, 1987), to correct a shortcoming of the DSM tradi-tion (the promulgation of clinical thresholds or “cut-points”for formal diagnosis arrived at by expert consensus ratherthan by quantitative means) by plotting sensitivity againstspecificity, thus suggesting optimally balanced diagnosticthresholds for such disorders as mania (Cassidy & Carroll,2001), ADHD (Mota & Schachar, 2000) or traumatic grief(Prigerson et al., 1999), and others. Additional advancedquantitative methods will be reviewed in the following sec-tions. The efforts of all have borne concrete benefits in manyareas of research and service delivery.

Latent Class Analysis

Latent class analysis (LCA; McCutcheon, 1987) is a multi-variate method that, like the earlier method of cluster anal-ysis, finds structural relationships between cases in a datasetas a function of their status on a set of manifest variables.The assumption of users of LCA is that the manifest variables“. . . are imperfect indicators of an underlying latent variablewith a finite number of mutually exclusive classes” (Peralta& Cuesta, 2002, p. 415). Whereas latent profile analysis is avariation on LCA in which continuous rather than categoricalvariables are used, LCA itself uses categorical variables, ei-ther Likert-type scores or, more commonly, binomial vari-ables. As such, LCA is ideally suited to diagnostic research,where binomial variables—symptom present/absent—are ofcritical import, and is reviewed here.

Latent classes (they are referred to as latent because theyare not directly observed, but inferred from the status ofgroups of cases on the manifest variables) fully structure thecases in a dataset with respect to the manifest variables. LCAuses maximum-likelihood estimates in an iterative way toproduce model parameters, such as the number of latentclasses, or the proportion of cases that fall into each latentclass, that best model, or account for, the observed relation-ships between cases and between manifest variables. An ad-vantage over older cluster analystic techniques is that LCAfinds the ideal number of latent classes by testing goodness-of-fit for models with increasing numbers of classes, with theminimum number of latent classes still showing a significantfit by likelihood ratio chi-square (and other methods) being,

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