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October 1984, Vol 41, No. 10 >
Article | October 1984

Diagnostic Efficiency and DSM-III

Margaret Gilmore, MD; John F. Clarkin, PhD; Allen Frances, MD; Stephen W. Hurt, PhD; Thomas A. Widiger, PhD
[+] Author Affiliations

Accepted for publication Feb 17, 1984.

Reprint requests to 115 Kastle Hall, Psychology Department, University of Kentucky, Lexington, KY 40506-0044 (Dr Widiger).


Arch Gen Psychiatry. 1984;41(10):1005-1012. doi:10.1001/archpsyc.1984.01790210087011
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References
Comments

• This study critiques and extends the DSM-III use of fixed and explicit criteria by applying principles and statistics common within actuarial decision theory (eg, conditional probabilities). The value and limitations of sensitivity and specificity rates are discussed and compared with an interesting but rarely used statistic, positive predictive power. The statistics and analyses provided herein also provide an empirical method for developing diagnostic criteria and determining when and how the DSM-III cutoff points might be adjusted, recognize the importance of base rates and utilities to efficient diagnosis, and provide an explicit, quantitative means by which to make optimal differential diagnoses and to make use of the overlap among psychiatric diagnoses. The issues are illustrated in the differential diagnosis of the Borderline Personality Disorder, but they have a relevance to the development and application of the other DSM-III diagnoses.

REFERENCES

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Stengel E:  Classification of mental disorders . Bull WHO 1959;;21:601-663.
2 +
Feighner J, Robins E, Guze S, Woodruff R, Winokur G, Munoz R:  Diagnostic criteria for use in psychiatric research . Arch Gen Psychiatry 1972;;26:57-63.
3 +
Spitzer R, Endicott J, Robins E: Research Diagnostic Criteria . New York, Biometrics Research, New York State Department of Mental Hygiene, 1974;.
4 +
Spitzer R, Williams J, Skodol A:  DSM-III: The major achievements and an overview . Am J Psychiatry 1980;;137:151-164.
5 +
Spitzer R, Fliess J:  A reanalysis of the reliability of psychiatric diagnosis . Br J Psychiatry 1974;;125:341-347.
6 +
Kendall R:  The choice of diagnostic criteria for biological research . Arch Gen Psychiatry 1982;;39:1334-1339.
7 +
Spitzer R, Forman J, Nee J:  DSM-III field trials: Initial interrater diagnostic reliability . Am J Psychiatry 1979;;136:815-817.
8 +
Frances A, Cooper A:  Descriptive and dynamic psychiatry: A perspective on DSM-III . Am J Psychiatry 1981;;138:1198-1202.
9 +
Widiger T, Kelso K:  Psychodiagnosis of Axis II . Clin Psychol Rev 1983;;3:491-510.
10 +
Birnbaum A, Maxwell A:  Classification procedures based on Baye's formula . Appl Stat 1960;;9:152-169.
11 +
Edwards W, Lindman H, Savage L:  Bayesian statistical inference for psychological research . Psychol Rev 1963;;70:63-67.
12 +
Meehl P, Rosen A:  Antecedent probability and the efficiency of psychometric signs, patterns, or cutting scores . Psychol Bull 1955;;52:194-216.
13 +
Price R:  Bayes' essay towards solving a problem in the doctrine of chances . Philos Trans R Soc Lond 1763;;53:376-398.
14 +
Lusted L: Introduction to Medical Decision Making . Springfield, Ill, Charles C Thomas Publisher, 1968;.
15 +
McNeil B, Keeler E, Adelstein S:  Primer on certain elements of medical decision making . N Engl J Med 1975;;293:211-215.
16 +
Pauker S, Kassirer J:  The threshold approach to clinical decision making . N Engl J Med 1980;;302:1109-1117.
17 +
Shrout P, Fliess J:  Reliability and case detection , in Wing J, Pebbington P, Robins L (eds): What is a Case? London, Grant McIntyre, 1981;, pp 37-68.
18 +
Wing J, Cooper J, Sartorius N: Measurement and Classification of Psychiatric Symptoms . London, Cambridge University Press, 1974;.
19 +
Einhorn H, Hogarth R:  Behavioral decision theory: Processes of judgment and choice . Ann Rev Psychol 1981;;32:53-88.
20 +
Fischoff B, Beyth-Marom R:  Hypothesis evaluation from a Bayesian perspective . Psychol Rev 1983;;90:239-260.
21 +
Baldessarini R, Finklestein S, Arana G:  The predictive power of diagnostic tests and the effect of prevalence of illness . Arch Gen Psychiatry 1983;;40:569-573.
22 +
Rorer L, Dawes R:  A base-rate bootstrap . J Consult Clin Psychol 1982;;50:419-425.
23 +
Blashfield R, Draguns J:  Evaluative criteria for psychiatric classification . J Abnorm Psychol 1976;;85:140-150.
24 +
Spitzer R, Williams J:  Classification of mental disorders and DSM-III , in Kaplan H, Freedman A, Sadock B (eds): Comprehensive Textbook of Psychiatry , ed 3. Baltimore, Williams & Wilkins Co, 1980;, vol 1, pp 1035-1072.
25 +
Andreasen N:  Thought, language, and communication disorders: II. Diagnostic significance . Arch Gen Psychiatry 1979;;36:1325-1330.
26 +
Gunderson J, Kolb J:  Discriminating features of borderline patients . Am J Psychiatry 1978;;135:792-796.
27 +
Kernberg O, Goldstein E, Carr A, Hunt H, Bauer R, Blumenthal R:  Diagnosing borderline personality . J Nerv Ment Dis 1981;;169:225-231.
28 +
Kroll J, Sines L, Martin K, Lari S, Pyle R, Zander J:  Borderline personality disorder . Arch Gen Psychiatry 1981;;38:1021-1026.
29 +
Perry J, Klerman G:  Clinical features of the borderline personality disorder . Am J Psychiatry 1980;;137:165-173.
30 +
Pope H, Jonas J, Hudson J, Cohen E, Gunderson J:  The validity of DSM-III borderline personality disorder . Arch Gen Psychiatry 1983;;40:23-30.
31 +
Rieder R:  Borderline schizophrenia: Evidence of its validity . Schizophr Bull 1979;;5:39-46.
32 +
Spitzer R, Endicott J, Gibbon M:  Crossing the border into borderline personality and borderline schizophrenia . Arch Gen Psychiatry 1979;;36:17-24.
33 +
Clarkin J, Widiger T, Frances A, Hurt S, Gilmore M:  Prototypic typology and the borderline personality disorder . J Abnorm Psychol 1983;;92:263-275.
34 +
Cronbach L, Gleser G: Psychological Tests and Personnel Decisions . Urbana, University of Illinois Press, 1965;.
35 +
Wiggins J: Personality and Prediction: Principles of Personality Assessment . Reading, Mass, Addison-Wesley Publishing Co Inc, 1973;.
36 +
Dawes R:  A note on base rates and psychometric efficiency . J Consult Psychol 1962;;26:422-424.
37 +
Dawes R:  How clinical probability judgments may be used to validate diagnostic signs . J Clin Psychol 1967;;23:403-410.
38 +
Dawes R, Meehl P:  Mixed group validation: A method for determining the validity of diagnostic signs without using criterion groups . Psychol Bull 1966;;66:63-67.
39 +
Yerushalmy J:  Statistical problems in assessing methods of medical diagnosis, with special reference to X-ray techniques . Public Health Rep 1947;;62:1432-1449.
40 +
Gunderson J, Siever L, Spaulding E:  The search for a schizotype . Arch Gen Psychiatry 1983;;40:15-22.
41 +
Frances A, Clarkin J, Gilmore M, Hurt S, Brown R:  Reliability of criteria for borderline personality disorder: A comparison of DSM-III and DIB . Am J Psychiatry , in press.
42 +
Kolb J, Gunderson J:  Diagnosing borderline patients with a semistructured interview . Arch Gen Psychiatry 1981;;38:1021-1026.
43 +
Widiger T:  Prototypic typology and borderline diagnoses . Clin Psychol Rev 1982;;2:115-135.
44 +
Carey G, Gottesman I:  Reliability and validity in binary ratings . Arch Gen Psychiatry 1978;;35:1454-1459.
45 +
Finn S:  Base rates, utilities, and DSM-III: Shortcomings of fixedrule systems of psychodiagnosis . J Abnorm Psychol 1982;;91:294-302.
46 +
Widiger T:  Utilities and fixed diagnostic rules: Comments on Finn . J Abnorm Psychol 1983;;92:495-498.
47 +
Rorer L, Hoffman P, Hsieh K:  Utilities as base-rate multipliers in the determination of optimum cutting scores for the discrimination of groups of unequal size and variance . J Appl Psychol 1966;;50:364-368.
48 +
Vaillant G, Perry J:  Personality disorders , in Kaplan H, Freedman A, Sadock B (eds): Comprehensive Textbook of Psychiatry , ed 3. Baltimore, Williams & Wilkins Co, 1980;, vol 2, pp 1562-1590.
49 +
Fenton W, Mosher L, Matthews S:  Diagnosis of schizophrenia: A critical review of current diagnostic systems . Schizophr Bull 1981;;7:452-476.
50 +
Young M, Tanner M, Meltzer H:  Operational definitions of schizophrenia: What do they identify? J Nerv Ment Dis 1982;;170:443-447.
51 +
Meehl P, Golden R:  Taxometric methods , in Kendall P, Butcher J (eds): Handbook of Research Methods in Clinical Psychology . New York, John Wiley & Sons Inc, 1982;, pp 127-181.
52 +
Rorer L, Widiger T:  Personality structure and assessment . Ann Rev Psychol 1983;;34:431-463.
53 +
Spitzer R, Andreasen N, Endicott J:  Schizophrenia and other psychotic disorders in DSM-III . Schizophr Bull 1978;;4:489-509.
54 +
Finn S:  Utility-balanced and utility-imbalanced rules: Reply to Widiger . J Abnorm Psychol 1983;;92:499-501.
55 +
Stone S: The Borderline Syndromes . New York, McGraw-Hill Book Co, 1980;.
56 +
Millon T: Disorders of Personality: DSM-III Axis II . New York, John Wiley & Sons Inc, 1981;.
57 +
Hare R:  Diagnosis of antisocial personality disorder in two prison populations . Am J Psychiatry 1983;;140:887-890.
58 +
Wulach J:  Diagnosing the DSM-III antisocial personality disorder . Prof Psychology: Res Pract 1983;;14:330-340.

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1 +
Stengel E:  Classification of mental disorders . Bull WHO 1959;;21:601-663.
2 +
Feighner J, Robins E, Guze S, Woodruff R, Winokur G, Munoz R:  Diagnostic criteria for use in psychiatric research . Arch Gen Psychiatry 1972;;26:57-63.
3 +
Spitzer R, Endicott J, Robins E: Research Diagnostic Criteria . New York, Biometrics Research, New York State Department of Mental Hygiene, 1974;.
4 +
Spitzer R, Williams J, Skodol A:  DSM-III: The major achievements and an overview . Am J Psychiatry 1980;;137:151-164.
5 +
Spitzer R, Fliess J:  A reanalysis of the reliability of psychiatric diagnosis . Br J Psychiatry 1974;;125:341-347.
6 +
Kendall R:  The choice of diagnostic criteria for biological research . Arch Gen Psychiatry 1982;;39:1334-1339.
7 +
Spitzer R, Forman J, Nee J:  DSM-III field trials: Initial interrater diagnostic reliability . Am J Psychiatry 1979;;136:815-817.
8 +
Frances A, Cooper A:  Descriptive and dynamic psychiatry: A perspective on DSM-III . Am J Psychiatry 1981;;138:1198-1202.
9 +
Widiger T, Kelso K:  Psychodiagnosis of Axis II . Clin Psychol Rev 1983;;3:491-510.
10 +
Birnbaum A, Maxwell A:  Classification procedures based on Baye's formula . Appl Stat 1960;;9:152-169.
11 +
Edwards W, Lindman H, Savage L:  Bayesian statistical inference for psychological research . Psychol Rev 1963;;70:63-67.
12 +
Meehl P, Rosen A:  Antecedent probability and the efficiency of psychometric signs, patterns, or cutting scores . Psychol Bull 1955;;52:194-216.
13 +
Price R:  Bayes' essay towards solving a problem in the doctrine of chances . Philos Trans R Soc Lond 1763;;53:376-398.
14 +
Lusted L: Introduction to Medical Decision Making . Springfield, Ill, Charles C Thomas Publisher, 1968;.
15 +
McNeil B, Keeler E, Adelstein S:  Primer on certain elements of medical decision making . N Engl J Med 1975;;293:211-215.
16 +
Pauker S, Kassirer J:  The threshold approach to clinical decision making . N Engl J Med 1980;;302:1109-1117.
17 +
Shrout P, Fliess J:  Reliability and case detection , in Wing J, Pebbington P, Robins L (eds): What is a Case? London, Grant McIntyre, 1981;, pp 37-68.
18 +
Wing J, Cooper J, Sartorius N: Measurement and Classification of Psychiatric Symptoms . London, Cambridge University Press, 1974;.
19 +
Einhorn H, Hogarth R:  Behavioral decision theory: Processes of judgment and choice . Ann Rev Psychol 1981;;32:53-88.
20 +
Fischoff B, Beyth-Marom R:  Hypothesis evaluation from a Bayesian perspective . Psychol Rev 1983;;90:239-260.
21 +
Baldessarini R, Finklestein S, Arana G:  The predictive power of diagnostic tests and the effect of prevalence of illness . Arch Gen Psychiatry 1983;;40:569-573.
22 +
Rorer L, Dawes R:  A base-rate bootstrap . J Consult Clin Psychol 1982;;50:419-425.
23 +
Blashfield R, Draguns J:  Evaluative criteria for psychiatric classification . J Abnorm Psychol 1976;;85:140-150.
24 +
Spitzer R, Williams J:  Classification of mental disorders and DSM-III , in Kaplan H, Freedman A, Sadock B (eds): Comprehensive Textbook of Psychiatry , ed 3. Baltimore, Williams & Wilkins Co, 1980;, vol 1, pp 1035-1072.
25 +
Andreasen N:  Thought, language, and communication disorders: II. Diagnostic significance . Arch Gen Psychiatry 1979;;36:1325-1330.
26 +
Gunderson J, Kolb J:  Discriminating features of borderline patients . Am J Psychiatry 1978;;135:792-796.
27 +
Kernberg O, Goldstein E, Carr A, Hunt H, Bauer R, Blumenthal R:  Diagnosing borderline personality . J Nerv Ment Dis 1981;;169:225-231.
28 +
Kroll J, Sines L, Martin K, Lari S, Pyle R, Zander J:  Borderline personality disorder . Arch Gen Psychiatry 1981;;38:1021-1026.
29 +
Perry J, Klerman G:  Clinical features of the borderline personality disorder . Am J Psychiatry 1980;;137:165-173.
30 +
Pope H, Jonas J, Hudson J, Cohen E, Gunderson J:  The validity of DSM-III borderline personality disorder . Arch Gen Psychiatry 1983;;40:23-30.
31 +
Rieder R:  Borderline schizophrenia: Evidence of its validity . Schizophr Bull 1979;;5:39-46.
32 +
Spitzer R, Endicott J, Gibbon M:  Crossing the border into borderline personality and borderline schizophrenia . Arch Gen Psychiatry 1979;;36:17-24.
33 +
Clarkin J, Widiger T, Frances A, Hurt S, Gilmore M:  Prototypic typology and the borderline personality disorder . J Abnorm Psychol 1983;;92:263-275.
34 +
Cronbach L, Gleser G: Psychological Tests and Personnel Decisions . Urbana, University of Illinois Press, 1965;.
35 +
Wiggins J: Personality and Prediction: Principles of Personality Assessment . Reading, Mass, Addison-Wesley Publishing Co Inc, 1973;.
36 +
Dawes R:  A note on base rates and psychometric efficiency . J Consult Psychol 1962;;26:422-424.
37 +
Dawes R:  How clinical probability judgments may be used to validate diagnostic signs . J Clin Psychol 1967;;23:403-410.
38 +
Dawes R, Meehl P:  Mixed group validation: A method for determining the validity of diagnostic signs without using criterion groups . Psychol Bull 1966;;66:63-67.
39 +
Yerushalmy J:  Statistical problems in assessing methods of medical diagnosis, with special reference to X-ray techniques . Public Health Rep 1947;;62:1432-1449.
40 +
Gunderson J, Siever L, Spaulding E:  The search for a schizotype . Arch Gen Psychiatry 1983;;40:15-22.
41 +
Frances A, Clarkin J, Gilmore M, Hurt S, Brown R:  Reliability of criteria for borderline personality disorder: A comparison of DSM-III and DIB . Am J Psychiatry , in press.
42 +
Kolb J, Gunderson J:  Diagnosing borderline patients with a semistructured interview . Arch Gen Psychiatry 1981;;38:1021-1026.
43 +
Widiger T:  Prototypic typology and borderline diagnoses . Clin Psychol Rev 1982;;2:115-135.
44 +
Carey G, Gottesman I:  Reliability and validity in binary ratings . Arch Gen Psychiatry 1978;;35:1454-1459.
45 +
Finn S:  Base rates, utilities, and DSM-III: Shortcomings of fixedrule systems of psychodiagnosis . J Abnorm Psychol 1982;;91:294-302.
46 +
Widiger T:  Utilities and fixed diagnostic rules: Comments on Finn . J Abnorm Psychol 1983;;92:495-498.
47 +
Rorer L, Hoffman P, Hsieh K:  Utilities as base-rate multipliers in the determination of optimum cutting scores for the discrimination of groups of unequal size and variance . J Appl Psychol 1966;;50:364-368.
48 +
Vaillant G, Perry J:  Personality disorders , in Kaplan H, Freedman A, Sadock B (eds): Comprehensive Textbook of Psychiatry , ed 3. Baltimore, Williams & Wilkins Co, 1980;, vol 2, pp 1562-1590.
49 +
Fenton W, Mosher L, Matthews S:  Diagnosis of schizophrenia: A critical review of current diagnostic systems . Schizophr Bull 1981;;7:452-476.
50 +
Young M, Tanner M, Meltzer H:  Operational definitions of schizophrenia: What do they identify? J Nerv Ment Dis 1982;;170:443-447.
51 +
Meehl P, Golden R:  Taxometric methods , in Kendall P, Butcher J (eds): Handbook of Research Methods in Clinical Psychology . New York, John Wiley & Sons Inc, 1982;, pp 127-181.
52 +
Rorer L, Widiger T:  Personality structure and assessment . Ann Rev Psychol 1983;;34:431-463.
53 +
Spitzer R, Andreasen N, Endicott J:  Schizophrenia and other psychotic disorders in DSM-III . Schizophr Bull 1978;;4:489-509.
54 +
Finn S:  Utility-balanced and utility-imbalanced rules: Reply to Widiger . J Abnorm Psychol 1983;;92:499-501.
55 +
Stone S: The Borderline Syndromes . New York, McGraw-Hill Book Co, 1980;.
56 +
Millon T: Disorders of Personality: DSM-III Axis II . New York, John Wiley & Sons Inc, 1981;.
57 +
Hare R:  Diagnosis of antisocial personality disorder in two prison populations . Am J Psychiatry 1983;;140:887-890.
58 +
Wulach J:  Diagnosing the DSM-III antisocial personality disorder . Prof Psychology: Res Pract 1983;;14:330-340.

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