Use of Text Messaging for Postpartum Depression Screening and Information Provision.

OBJECTIVE: The objective of this study was to evaluate the feasibility of using text messages to enhance mental health screening and education of women in the immediate postpartum period. METHODS: A total of 937 postpartum women were recruited from an obstetrics and gynecology clinic of a large urban hospital. Participants received a text message containing a two-question screen for postpartum depression every two weeks and three text messages per week about postpartum mental health for the first 12 weeks postpartum. Those who screened positive were administered the Edinburgh Postnatal Depression Scale. They were matched with a subset of women who were also assessed with the Edinburgh Postnatal Depression Scale after screening negative for depression with the text messaging screen. At 12 to 13 weeks postpartum, all participants received an online survey assessing satisfaction with the text messages. RESULTS: Of 937 participants, 126 (13%) screened positive. Agreement between the texted screen and the Edinburgh Postnatal Depression Scale was moderate (κ=0.45), with good sensitivity (0.90, 95% confidence interval [95% CI]=0.81-0.96) and specificity (0.82, 95% CI=0.79-0.85). Nine hundred thirty (99%) participants responded to at least one of the six texted screens, whereas 632 (67%) responded to all six. Of the 589 (63%) who responded to the satisfaction survey, 459 (78%) recommended that all women be screened for postpartum depression via text messaging and that all women in the postpartum period be sent information texts about postpartum depression (N=504, 91%). CONCLUSIONS: Using text messaging technology to screen women for postpartum depression and provide information on postpartum mental health appears to be sensitive, feasible, and well accepted.

Psychotherapy Competency Milestones: an Exploratory Pilot of CBT and Psychodynamic Psychotherapy Skills Acquisition in Junior Psychiatry Residents.

OBJECTIVE: Psychiatry residents train in Psychodynamic Psychotherapy and Cognitive Behavioral Therapy (CBT), evidence-supported treatments used in mental health care that can facilitate clinical reasoning, foster therapeutic alliances, and improve clinical outcomes. However, empirically derived milestones are needed to evaluate competency. This exploratory pilot examined changes over 1 year of training in junior psychiatry residents' competency milestone elements in Psychodynamic Psychotherapy and CBT. METHODS: Seventy-nine randomly selected audio-recorded sessions from differing phases of Psychodynamic Psychotherapy and CBT with five junior residents and ten patients were rated using the Psychotherapy Process Q-sort (PQS). RESULTS: In both treatments, patient engagement with attention to in-session emotions improved. In CBT, residents were directive, supported patients' self-efficacy, emphasized patients' accepting responsibility for their problems, discussed homework such as thought records, and focused on termination in the concluding sessions. In Psychodynamic Psychotherapy, residents attended to emotional arousal and linked patients' feelings or perceptions to past situations or behavior. Growth and hierarchical linear modeling differentiated these treatments, with CBT v. Psychodynamic adherence to PQS modality-specific ideal elements being 52% v.19%. CONCLUSION: Teaching and observation using empirically derived observable psychotherapy practice behaviors is feasible and can be used to assess milestone elements for competency-based education of psychiatry trainees.

Improving physician-patient communication through coaching of simulated encounters.

OBJECTIVE: Effective communication between physicians and their patients is important in optimizing patient care. This project tested a brief, intensive, interactive medical education intervention using coaching and standardized psychiatric patients to teach physician-patient communication to family medicine trainees. METHODS: Twenty-six family medicine trainees (9 PGY1, 11 PGY2, 6 fellows) from five university-affiliated hospitals conducted four once-weekly, 30-minute videotaped interviews with "difficult" standardized patients. After each interview, trainees received 1 hour of individual coaching that incorporated self-assessment and skills-teaching from experienced psychiatrists. Two follow-up interviews with standardized patients occurred 1 week and an average of 6 months post-intervention. Trainee self-reported physician-patient communication efficacy was measured as a control 1 month before the intervention; during the month of the intervention; and an average of 6 months after the intervention. Coach-rated physician-patient communication competence was measured each week of the intervention. RESULTS: Improvements in physician-patient communication were demonstrated. Self-efficacy for physician-patient communication improved significantly during the intervention, in contrast to no improvement during the control period (i.e., training-as-usual). This improvement was sustained during the follow-up period. CONCLUSIONS: This innovative educational intervention was shown to be highly effective in improving trainee communication competence and self-efficacy. Future applications of this brief model of physician training have potential to improve communication competence and, in turn, can improve patient care.

The impact of attachment insecurity and sleep disturbance on symptoms and sick days in hospital-based health-care workers.

OBJECTIVE: Adult attachment insecurity is associated with many health outcomes and may be associated with sleep disturbance. The purpose of this study was to test the hypothesis that sleep disturbance mediates the relationship between attachment insecurity and three measures of health (perceived general health, physical symptoms and sick days) in a group that is at high risk of sleep disturbance: hospital based health-care workers. METHODS: One hundred thirty-one nondepressed female hospital workers completed self-report measures of adult attachment, sleep disturbance, depressive symptoms (excluding sleep-related items) and health outcomes. The hypothesis of mediation was tested with sequential regression analyses. RESULTS: Both attachment anxiety and attachment avoidance were significantly associated with impairment in global sleep quality (ρ=.20 and .19, respectively, P<.05) and physical symptoms (ρ=.21 and .19, P<.05). Attachment anxiety was also associated with depressive symptoms (ρ=.33, P<.001) and sick days (ρ=.21, P<.05). For both physical symptoms and sick days, mediation analyses were consistent with global sleep quality acting as a partial mediator of the relationship between attachment anxiety and physical health. Non-sleep-related depressive symptoms were a stronger mediator. CONCLUSIONS: This study corroborates evidence that attachment insecurity is associated with sleep disturbance and extends this association to the occurrence of physical symptoms and time off work due to sickness among workers in a high-stress occupation.

Adult attachment measures: a 25-year review.

OBJECTIVE: Over the past 25 years, attachment research has extended beyond infant-parent bonds to examine dyadic relationships in children, adolescents, and adults. Attachment has been shown to influence a wide array of biopsychosocial phenomena, including social functioning, coping, stress response, psychological well-being, health behavior, and morbidity, and has thus emerged as an important focus of psychosomatic research. This article reviews the measurement of adult attachment, highlighting instruments of relevance to-or with potential use in-psychosomatic research. METHODS: Following a literature search of articles that were related to the scales and measurement methods of attachment in adult populations, 29 instruments were examined with respect to their utility for psychosomatic researchers. RESULTS: Validity, reliability, and feasibility were tabulated on 29 instruments. Eleven of the instruments with strong psychometric properties, wide use, or use in psychosomatic research are described. These include the following: Adult Attachment Interview (George, Kaplan, and Main); Adult Attachment Projective (George and West); Adult Attachment Questionnaire (Simpson, Rholes, and Phillips); Adult Attachment Scale (and Revised Adult Attachment Scale) (Collins and Read); Attachment Style Questionnaire (Feeney); Current Relationship Interview (Crowell and Owens); Experiences in Close Relationships (Brennan, Clark, and Shaver) and Revised Experiences in Close Relationships (Fraley, Waller, and Brennan); Parental Bonding Instrument (Parker, Tupling, and Brown); Reciprocal Attachment Questionnaire (West and Sheldon-Keller); Relationship Questionnaire (Bartholomew and Horowitz); and Relationship Scales Questionnaire (Grifiin and Bartholomew). CONCLUSION: In addition to reliability and validity, investigators need to consider relationship focus, attachment constructs, dimensions or categories of interest, and the time required for training, administration, and scoring. Further considerations regarding attachment measurement in the context of psychosomatic research are discussed.

Computer-assisted resilience training to prepare healthcare workers for pandemic influenza: a randomized trial of the optimal dose of training.

BACKGROUND: Working in a hospital during an extraordinary infectious disease outbreak can cause significant stress and contribute to healthcare workers choosing to reduce patient contact. Psychological training of healthcare workers prior to an influenza pandemic may reduce stress-related absenteeism, however, established training methods that change behavior and attitudes are too resource-intensive for widespread use. This study tests the feasibility and effectiveness of a less expensive alternative - an interactive, computer-assisted training course designed to build resilience to the stresses of working during a pandemic. METHODS: A "dose-finding" study compared pre-post changes in three different durations of training. We measured variables that are likely to mediate stress-responses in a pandemic before and after training: confidence in support and training, pandemic-related self-efficacy, coping style and interpersonal problems. RESULTS: 158 hospital workers took the course and were randomly assigned to the short (7 sessions, median cumulative duration 111 minutes), medium (12 sessions, 158 minutes) or long (17 sessions, 223 minutes) version. Using an intention-to-treat analysis, the course was associated with significant improvements in confidence in support and training, pandemic self-efficacy and interpersonal problems. Participants who under-utilized coping via problem-solving or seeking support or over-utilized escape-avoidance experienced improved coping. Comparison of doses showed improved interpersonal problems in the medium and long course but not in the short course. There was a trend towards higher drop-out rates with longer duration of training. CONCLUSIONS: Computer-assisted resilience training in healthcare workers appears to be of significant benefit and merits further study under pandemic conditions. Comparing three "doses" of the course suggested that the medium course was optimal.

The prevalence of childhood adversity among healthcare workers and its relationship to adult life events, distress and impairment.

OBJECTIVE: We investigated the prevalence of childhood adversity among healthcare workers and if such experiences affect responses to adult life stress. METHODS: A secondary analysis was conducted of a 2003 study of 176 hospital-based healthcare workers, which surveyed lifetime traumatic events, recent life events, psychological distress, coping, social support, and days off work due to stress or illness. RESULTS: Sixty eight percent (95% CI 61.1-74.9) of healthcare workers had one or more experience of violence, abuse or neglect, 33% (95% CI 26.1-40.0) before the age of 13. Compared to healthcare workers who did not experience childhood adversity, those who did reported more recent life events (median 11 vs. 5 over the previous 6 months, p<.001) and greater psychological distress (median score 17 vs. 13, p<.001). The relationship between life events and psychological distress was not linear. Most healthcare workers without childhood adversity (73%) reported a low number of life events which were not associated with psychological distress. Most healthcare workers with childhood adversity (81%) reported a higher number of life events, for which the correlation between events and distress was moderately strong (Spearman's rho=.50, p<.001). Childhood adversity was also associated with more missed work days. Each of these outcomes was higher in 22 healthcare workers (13%) who had experienced more than one type of childhood adversity. CONCLUSIONS: Childhood adversity is common among healthcare workers and is associated with a greater number of life events, more psychological distress and impairment.

Family and patient predictors of symptomatic status in schizophrenia.

OBJECTIVE: To test an interactive hypothesis that, in schizophrenia, a combination of patients' and relatives' characteristics at 1-month postdischarge from hospital (Time 1 [T1]) better predicts the level of psychotic symptoms at follow-up (Time 2 [T2]), than do the characteristics of patients or relatives alone. METHODS: Male patients (n = 38) with a diagnosis of schizophrenia, without substance abuse, and in contact with their families, were recruited at the time of hospital discharge. Patients' psychotic symptom levels were monitored every 2 weeks until follow-up, while family measures were administered at T1 and T2. The 4 predictor variables in the regression analysis were T1 symptom levels of the patient and 3 measures of family interaction (expressed emotion, family burden, and family functioning). RESULTS: The model based on the family variable, family burden at T1, and the patient variable, patients' remitted levels of psychotic symptoms at T1, was found to significantly predict the level of psychotic symptoms at T2. These 2 T1 variables made independent and additive contributions to the level of psychotic symptoms at T2, predicting 19% of the variance. Neither expressed emotion nor family functioning at T1 added to the prediction. CONCLUSION: This finding suggests a patient-family interactional component to symptomatic relapse in schizophrenia.

Evaluation of a communication skills program for first-year medical students at the University of Toronto.

BACKGROUND: Effective doctor-patient communication has been linked to numerous benefits for both patient and physician. The purpose of this study was to evaluate the effectiveness of the University of Toronto's Therapeutic Communication Program (TCom) at improving first-year medical students' communication skills. METHODS: Data were collected during the 1996/97, 1997/98, 1998/99 and 1999/00 academic years. The study used a repeated measures design with a waiting list control group: students were randomly assigned to groups starting the educational intervention in either September (N = 38) or February (N = 41), with the latter being used as a control for the former. Communication skills were assessed at the pre- and post-intervention times and at the end of the academic year from the perspectives of student, standardized patient and external rater. RESULTS: Only the external rater, using an instrument designed to assess the students' empathy based on their written responses, showed a time x group interaction effect (p = 0.039), thereby partially supporting the hypothesis that TCom improved the students' communication skills. Students rated themselves less positively after participation in the program (p = 0.038), suggesting that self-evaluation was an ineffective measure of actual performance or that the program helped them learn to more accurately assess their abilities. CONCLUSION: The lack of strong findings may be partly due to the study's small sample sizes. Further research at other medical or professional schools could assess the effectiveness of similar courses on students' communication skills and on other capacities that were not measured in this study, such as their understanding of and comfort with patients, their management of the doctor-patient relationship, and their ability to give and receive feedback.

Is cognitive-behavioural therapy more effective than psychoeducation in bipolar disorder?

OBJECTIVE: Psychosocial research in bipolar disorder (BD) has not yet assessed the relative benefits of a short course of psychoeducation (PE), compared with a longer course of cognitive-behavioural therapy (CBT) containing psychoeducational principles. This pilot study evaluated the efficacy and added benefit of adding a course of CBT to a standard course of brief PE, as maintenance therapy for BD. METHOD: Seventy-nine consenting adult men and women with BD on stable medication regimens, who were in full or partial remission from an index episode (BD I = 52; BD II = 27), were randomized to receive either 7 sessions of individual PE, or 7 sessions of PE followed by 13 additional individual sessions of CBT. Weekly mood and medication adherence was rated using the National Institute of Mental Health's Life Chart Method, while psychosocial functioning and mental health use were assessed monthly. RESULTS: Forty-six participants completed the entire study. Participants who received CBT in addition to PE experienced 50% fewer days of depressed mood over the course of one year. Participants who received PE alone had more antidepressant increases compared with those who received CBT. There were no group differences in hospitalization rates, medication adherence, psychosocial functioning, or mental health use. CONCLUSIONS: Pilot data from this real-world study suggest that even after medication treatment has been optimized, a longer course of adjunctive CBT may offer some additional benefits over a shorter course of PE alone for the maintenance treatment of BD. Larger randomized controlled trials with equal treatment lengths are indicated.

Prevalence of psychiatric disorders among Toronto hospital workers one to two years after the SARS outbreak.

OBJECTIVE: This study aimed to determine the incidence of psychiatric disorders among health care workers in Toronto in the one- to two-year period after the 2003 outbreak of severe acute respiratory syndrome (SARS) and to test predicted risk factors. METHODS: New-onset episodes of psychiatric disorders were assessed among 139 health care workers by using the Structured Clinical Interview for DSM-IV and the Clinician-Administered PTSD Scale. Past history of psychiatric illness, years of health care experience, and the perception of adequate training and support were tested as predictors of the incidence of new-onset episodes of psychiatric disorders after the SARS outbreak. RESULTS: The lifetime prevalence of any depressive, anxiety, or substance use diagnosis was 30%. Only one health care worker who identified the SARS experience as a traumatic event was diagnosed as having PTSD. New episodes of psychiatric disorders occurred among seven health care workers (5%). New episodes of psychiatric disorders were directly associated with a history of having a psychiatric disorder before the SARS outbreak (p=.02) and inversely associated with years of health care experience (p=.03) and the perceived adequacy of training and support (p=.03). CONCLUSIONS: Incidence of new episodes of psychiatric disorders after the SARS outbreak were similar to or lower than community incidence rates, which may indicate the resilience of health care workers who continued to work in hospitals one to two years after the SARS outbreak. In preparation for future events, such as pandemic influenza, training and support may bolster the resilience of health care workers who are at higher risk by virtue of their psychiatric history and fewer years of health care experience.

Psychobiological subtypes of ulcerative colitis: pANCA status moderates the relationship between disease activity and psychological distress.

INTRODUCTION: Studies of psychological factors in ulcerative colitis (UC) have produced inconsistent findings. This study sought to determine whether perinuclear antineutrophil cytoplasmic antibody (pANCA) demarcates subtypes which differ with respect to psychobiological interactions. METHODS: In 148 outpatients with UC, the strength of the relationship between current UC disease activity and psychological distress was assessed. pANCA was determined by ELISA and immunofluorescence, disease activity was determined by symptoms, physical examination, and endoscopy using the St. Mark's index, and depressive symptoms and health anxiety were measured with self-report scales. Pearson correlations between disease activity and depressive symptoms and between disease activity and health anxiety were calculated. RESULTS: In 74 pANCA negative subjects, the relationship between disease activity and measures of psychological distress was significant for disease activity-depression (partial correlation = 0.48, p < 0.001) and for disease activity-health anxiety (partial correlation = 0.64, p < 0.001), whereas in 74 pANCA positive subjects, no relationships were found (disease activity-depression: partial correlation = 0.18, p= 0.14; disease activity-health anxiety: partial correlation = 0.20, p= 0.09). The differences in the strength of correlation between pANCA positive and pANCA negative subjects were statistically significant for both disease activity-depression (z = 2.0, p= 0.02) and activity-health anxiety (z = 3.3, p < 0.001). CONCLUSIONS: pANCA status demarcates psychobiologically distinct subtypes of UC, such that the absence of pANCA is associated with greater psychobiological interaction. These findings have implications for clinical care and understanding the pathophysiology of intestinal inflammation.

Autonomic response to standardized stress predicts subsequent disease activity in ulcerative colitis.

OBJECTIVES: Prospective studies of the role of psychological stress in ulcerative colitis are inconsistent or show a modest relationship. We tested the hypothesis that individual differences in autonomic function are associated with differences in the disease course of ulcerative colitis. METHODS: The spectral power of heart rate variability, an indirect marker of autonomic function, was measured during a standardized stress protocol in 93 ulcerative colitis patients. Patients were categorized as typical or atypical by an increase or decrease, respectively, in the high frequency band of heart rate variability from a period of acute stress to recovery 5 min later. Disease activity was measured at baseline (time 1) and a second time point (time 2) 7-37 months later. RESULTS: An atypical pattern of heart rate variability at time 1, present in 29% of patients, was associated with lower mean disease activity at time 2 (atypical, 0.56+/-0.93; typical, 2.27+/-2.56, P=0.001). The contribution of heart rate variability pattern to explaining time 2 disease activity was independent of the contributions of other factors that differed between groups, including time 1 disease activity and lifetime corticosteroid use. DISCUSSION: An atypical pattern of autonomic reactivity may be a marker of individual differences in stress regulation that has prognostic significance in ulcerative colitis.

The relationship of attachment insecurity to subjective stress and autonomic function during standardized acute stress in healthy adults.

OBJECTIVE: The purpose of this study was to test predicted relationships between adult attachment and stress using subjective and physiological measures. METHODS: Sixty-seven healthy adults completed measures of adult attachment and perceived chronic stress. Subjective stress and the high-frequency (HF) and low-frequency (LF) spectral bandwidths of heart rate variability (HRV) were measured during a standardized stress protocol. RESULTS: Attachment anxiety is associated with between-subject differences in chronic perceived stress (P=.001) and subjective acute stress (P=.01). There is a main effect of attachment avoidance on between-subject differences in HF HRV (P=.004). Attachment avoidance is inversely associated with HF HRV, independent of age and variability in respiration. CONCLUSION: Attachment anxiety is associated with self-reported distress. Attachment avoidance is inversely associated with HF HRV, a marker of vagal influence on cardiac activity, but is not associated with subjective stress.

Long-term psychological and occupational effects of providing hospital healthcare during SARS outbreak.

Healthcare workers (HCWs) found the 2003 outbreak of severe acute respiratory syndrome (SARS) to be stressful, but the long-term impact is not known. From 13 to 26 months after the SARS outbreak, 769 HCWs at 9 Toronto hospitals that treated SARS patients and 4 Hamilton hospitals that did not treat SARS patients completed a survey of several adverse outcomes. Toronto HCWs reported significantly higher levels of burnout (p = 0.019), psychological distress (p<0.001), and posttraumatic stress (p<0.001). Toronto workers were more likely to have reduced patient contact and work hours and to report behavioral consequences of stress. Variance in adverse outcomes was explained by a protective effect of the perceived adequacy of training and support and by a provocative effect of maladaptive coping style and other individual factors. The results reinforce the value of effective staff support and training in preparation for future outbreaks.

Attachment insecurity moderates the relationship between disease activity and depressive symptoms in ulcerative colitis.

BACKGROUND: Among people with ulcerative colitis, depression occurs more frequently when inflammation is active. We hypothesized that individual differences in interpersonal style affect the risk that active disease will be accompanied by depressive symptoms. METHODS: In this study, disease activity, depressive symptoms, and 2 dimensions of interpersonal style, attachment anxiety and attachment avoidance, were measured in 146 ulcerative colitis outpatients at time 1 and in 99 of these patients at a second time-point, 7 to 37 months later. Test-retest correlations of attachment anxiety (r = 0.83, P < 0.001) and attachment avoidance (r = 0.76, P < 0.001) confirmed that these dimensions are stable. RESULTS: There was a stepwise increase in the correlation between time 2 disease activity and depression from the lowest tercile of attachment anxiety (r = 0.00, P = 0.99), through the middle tercile (r = 0.36, P = 0.05), to the highest tercile (r = 0.52, P = 0.002). For attachment avoidance, disease activity and depression were only significantly correlated in the highest tercile (r = 0.49, P = 0.005). CONCLUSIONS: Attachment anxiety meets all tested criteria as a moderator of the relationship between disease activity and depressive symptoms. Further attention to interpersonal style as a moderator of depressive risk in ulcerative colitis is warranted.

Factors associated with the psychological impact of severe acute respiratory syndrome on nurses and other hospital workers in Toronto.

OBJECTIVES: A survey was conducted to measure psychological stress in hospital workers and measure factors that may have mediated acute traumatic responses. METHODS: A self-report survey was completed by 1557 healthcare workers at three Toronto hospitals in May and June 2003. Psychological stress was measured with the Impact of Event Scale. Scales representing attitudes to the outbreak were derived by factor analysis of 76 items probing attitudes to severe acute respiratory syndrome. The association of Impact of Event Scale scores to job role and contact with severe acute respiratory syndrome patients was tested by analysis of variance. Between-group differences in attitudinal scales were tested by multivariate analysis of variance. Attitudinal scales were tested as factors mediating the association of severe acute respiratory syndrome patient contact and job role with total Impact of Event Scale by linear regression. RESULTS: Higher Impact of Event Scale scores are found in nurses and healthcare workers having contact with patients with severe acute respiratory syndrome. The relationship of these groups to the Impact of Event Scale score is mediated by three factors: health fear, social isolation, and job stress. CONCLUSIONS: Although distress in response to the severe acute respiratory syndrome outbreak is greater in nurses and those who care for patients with severe acute respiratory syndrome, these relationships are explained by mediating variables that may be available for interventions to reduce stress in future outbreaks. In particular, the data suggest that the targets of intervention should include job stress, social isolation, and health fear.

Psychoanalytic patients in the U.S., CANADA, and Australia: I. DSM-III-R disorders, indications, previous treatment, medications, and length of treatment.

To determine the demographics, DSM-III-R disorders diagnosed, indications used in recommending psychoanalysis, previous treatment histories, use of medication, and length of treatment in patients in psychoanalysis in the U.S., Canada, and Australia, a mail survey of practice was sent to every other active member of the American Psychoanalytic Association and every member of the Australian Psychoanalytical Society. This supplemented an earlier survey sent to all Ontario psychoanalysts. The response rates were 40.1 % (n = 342) for the U.S., 67.2% (n = 117) for Canada, and 73.9% (n = 51) for Australia. Respondents supplied data on 1,718 patients. The employment rate for patients increases as analysis progresses (p < .0001). The mean number of concurrent categories of disorders (Axis I, Axis II, and Disorders First Evident in Childhood) per patient at the start of treatment is 5.01 (SD = 3.66; median = 4; mode = 3). There are no statistically significant differences across countries. Mood, anxiety, sexual dysfunction, and personality disorders are most common. American Psychiatric Association / American Psychoanalytic Association peer review criteria for indicating psychoanalysis are followed for 86.5% of patients. Over 80% of patients in all three countries had undergone previous treatments prior to analysis. In the U.S., 18.2% of analysands are on concurrent psychoactive medication; in Australia, 9.6%. The mean length of analyses conducted in the U.S. is 5.7 years, in Australia 6.6, and in Canada 4.8. Psychoanalytic patients in all three countries have similar rates of DSM-III-R psychopathology, and many indications of chronicity.

Psychoanalytic patients in the U.S., Canada, and Australia: II. A DSM-III-R validation study.

A study was conducted to validate our previous work on the DSM-III-R disorders diagnosed in patients in psychoanalysis in the U.S., Canada, and Australia and to determine which specific mood, anxiety, and personality disorders were the most common in these patients. The earlier study consisted of three surveys of psychoanalytic practice that together obtained data on 1,718 patients, through extensive mail surveys to analysts in the three countries. In the validation study, 206 patients were diagnosed using a different technique. Analysts similar in important respects to those who participated in the original surveys rated patients diagnostically before and after DSM-III-R training. After training, no significant changes appeared in the rates for any of the specific mood disorders. For the thirty disorders examined, training effects decreased the identification of the generalized anxiety disorder, and increased the identification of three personality disorders: avoidant, dependent, and personality disorder not otherwise specified. Thus, analysts slightly underdiagnosed the number of personality disorders, and some "anxious" patients appear to have qualified for personality disorders. Some limitations of the DSM-III-R notion of narcissistic personality are discussed, as are the importance and stability of the self-defeating (masochistic) personality disorder. The most common Axis I disorder in psychoanalytic patients was dysthymia, followed by major depression, recurrent. This study reinforces the findings of the original three surveys. Minor corrections were developed to adjust the original three surveys.