A self-report scale to help make psychiatric diagnoses: the Psychiatric Diagnostic Screening Questionnaire.

BACKGROUND: The Psychiatric Diagnostic Screening Questionnaire (PDSQ) is a brief, psychometrically strong, self-report scale designed to screen for the most common DSM-IV Axis I disorders encountered in outpatient mental health settings. In the present report, we describe the diagnostic performance (sensitivity, specificity, and positive and negative predictive values) of the PDSQ in an outpatient setting. METHODS: Six hundred thirty psychiatric outpatients presenting for treatment were evaluated with the Structured Clinical Interview for DSM-IV after completing the PDSQ. Patients arrived approximately 20 minutes before the scheduled time of the appointment to complete the scale. Diagnostic raters were blind to responses on the scale. RESULTS: The PDSQ's subscales' diagnostic performance varied in a predictable manner according to the cutoff score-as the threshold for case identification increased, subscale sensitivity decreased and specificity increased. Mean subscale sensitivities of 80%, 85%, and 90% resulted in mean subscale specificities of 78%, 73%, and 66%, respectively, and negative predictive values of 95%, 96%, and 97%. Receiver operating curves were determined for each subscale and all areas under the curve were significant. CONCLUSIONS: The PDSQ is a diagnostic aid designed to be used in clinical practice to facilitate the efficiency of conducting initial diagnostic evaluations. From a clinical perspective, it is most important that a diagnostic aid have good sensitivity, so that most cases are detected, and high negative predictive value, so that most noncases on the measure are indeed noncases. Our results indicate that most of the PDSQ subscales were able to achieve this goal.

Differences between clinical and research practices in diagnosing borderline personality disorder.

OBJECTIVE: It has been reported that clinicians are less inclined than researchers to use direct questions in ascertaining the presence of personality disorders, and questions have been raised about the validity of research on personality disorders in which diagnoses are based on semistructured diagnostic interviews. This study examined the influence of assessment method on the diagnosis of borderline personality disorder. METHOD: Diagnoses of borderline personality disorder derived from structured and unstructured clinical interviews were compared in two groups of psychiatric outpatients seen in the same practice setting. Five hundred individuals presenting to a general adult psychiatric practice for an intake appointment underwent a routine unstructured clinical interview. After the completion of that study, the method of conducting diagnostic evaluations was changed, and 409 individuals were interviewed with the borderline personality disorder section of the Structured Interview for DSM-IV Personality. RESULTS: Individuals in the structured interview group were significantly more often diagnosed with borderline personality disorder than individuals in the clinical group. When information from the structured interview was presented to the clinicians, borderline personality disorder was much more likely to be diagnosed by them. CONCLUSIONS: The method used to assess borderline personality disorder has a great impact on the frequency with which it is diagnosed. Without the benefit of detailed information from a semistructured diagnostic interview, clinicians rarely diagnose the disorder during a routine intake evaluation. Providing the results of a semistructured interview to clinicians prompts them to diagnose borderline personality disorder much more frequently. This is inconsistent with the notion that personality disorder diagnoses based on semistructured interviews are not viewed as valid by clinicians.

Frequency of anxiety disorders in psychiatric outpatients with major depressive disorder.

OBJECTIVE: The authors determined the frequency of anxiety disorders in a large group of depressed outpatients seeking treatment. METHOD: The Structured Clinical Interview for DSM-IV was administered to 373 depressed outpatients. RESULTS: More than one-half of the patients met the full criteria for a current anxiety disorder, and more than one-half of the patients with an anxiety disorder had more than one. When partial remissions and anxiety disorder diagnoses classified as "not otherwise specified" were included, two-thirds of the patients had a current anxiety disorder and three-quarters had a lifetime history of an anxiety disorder. CONCLUSIONS: The majority of patients with a principal diagnosis of unipolar major depressive disorder have a comorbid anxiety disorder. Because antidepressant medications have differential efficacies for anxiety disorders, knowledge of the presence of a comorbid anxiety disorder in a depressed patient may have treatment implications.

Gender differences in patients with posttraumatic stress disorder in a general psychiatric practice.

OBJECTIVE: This report examined gender differences in the clinical manifestations of current posttraumatic stress disorder (PTSD) in treatment-seeking patients. METHOD: Outpatients with PTSD (N=138) were interviewed with the Structured Clinical Interview for DSM-IV. RESULTS: Compared with male patients, female patients experienced more reexperiencing symptoms and were more likely to meet criteria for current PTSD and to report sexual trauma as their index trauma. Men with PTSD were more likely than women with PTSD to meet criteria for a substance use disorder and for antisocial personality disorder. No gender differences were found in the frequency of other types of comorbid disorders, the number of comorbid disorders, or the presence of PTSD as a primary disorder. CONCLUSIONS: Overall, male and female patients with current PTSD present with fairly comparable clinical profiles.

Psychotic subtyping of major depressive disorder and posttraumatic stress disorder.

BACKGROUND: Many studies have established that a large percentage of patients with posttraumatic stress disorder (PTSD) have comorbid major depressive disorder. Other studies have found that patients with PTSD or a history of childhood trauma have an increased rate of psychotic symptoms. In the present report from the Rhode Island Methods to Improve Diagnosis and Services project, we examine whether an association exists between psychotic subtyping of major depressive disorder and PTSD. METHOD: Five hundred psychiatric outpatients were interviewed with the Structured Clinical Interview for DSM-IV. RESULTS: Almost half of the 500 patients had nonbipolar major depressive disorder (N = 235, 47.0%), 45 (19.1%) of whom had PTSD. Nineteen patients had psychotic depression, 216 had nonpsychotic depression. Compared with patients with nonpsychotic depression, the patients with psychotic depression were nearly 4 times more likely to have PTSD (57.9% vs. 15.7%, Fisher exact test, p = .0001). CONCLUSION: The results of the present study suggest that the presence of psychosis in psychiatric outpatients with major depressive disorder is associated with concurrent PTSD. It is hypothesized that the poorer longitudinal course of psychotic versus nonpsychotic depression may be due to the underrecognition of PTSD in psychotically depressed patients.

The reliability and validity of a screening Questionnaire for 13 DSM-IV Axis I disorders (the Psychiatric Diagnostic Screening Questionnaire) in psychiatric outpatients.

BACKGROUND: The purpose of this study was to examine the reliability and validity of a new multidimensional screening instrument for 13 DSM-IV Axis I disorders. METHOD: The Psychiatric Diagnostic Screening Questionnaire (PDSQ) is a 90-item self-administered questionnaire that screens for 13 DSM-IV disorders in 5 areas (eating, mood, anxiety, substance use, and somatoform disorders). A consecutive series of 500 psychiatric outpatients completed the PDSQ immediately before their intake evaluation. Seventy-four patients completed the scale a second time less than a week after the initial administration, and 51 patients completed a booklet of questionnaires that included established measures of the same symptom domains assessed by the PDSQ. RESULTS: The PDSQ subscales achieved moderate-to-high levels of internal consistency (mean Cronbach's alpha coefficient = 0.82) and test-retest reliability (mean correlation coefficient = 0.84). Subscale scores were significantly associated with blind clinical diagnoses, and individual PDSQ items correlated much more highly with their own subscale than with other subscales. The PDSQ subscales were much more highly correlated with established measures of the same symptom domain (mean correlation coefficient = 0.72) than with measures of other types of psychopathology (mean correlation = 0.17). CONCLUSION: The PDSQ is a reliable and valid measure of multiple DSM-IV disorders that is brief enough to be incorporated into routine clinical outpatient practice without disruption, yet lengthy enough to be a psychometrically sound instrument.

The revised Stroop color-naming task in social phobics.

Information processing was examined in a sample of social phobic individuals using a revised version of the Stroop color-naming task. In the first of two experiments, the response latencies of social phobics and matched community controls were compared when color-naming socially threatening words, physically threatening words and color words. Social phobics demonstrated greater response latencies regardless of type of stimulus word and additional interference in color-naming social threat words compared to the control group. The second experiment examined the cognitive structural change that has been hypothesized to accompany successful treatment of individuals with an anxiety disorder. Social phobics who were treated with cognitive-behavioral group therapy, phenelzine or pill placebo were classified as treatment responders or nonresponders, and their latencies to color-naming on the Stroop task were compared. Treatment responders showed a significant reduction in latencies to color-name social threat words (vs matched control words) while nonresponders did not. This effect was not demonstrated with color words or physically threatening words. Clinical implications and future research directions are discussed.

Principal and additional DSM-IV disorders for which outpatients seek treatment.

OBJECTIVE: Epidemiological studies indicate that most patients in the community do not get treatment for psychiatric disorders. It is unknown whether persons who present for outpatient psychiatric services seek treatment for all the disorders they have or only for the principal disorder for which they are seeking treatment. The goal of this study was to determine which axis I psychiatric disorders motivate patients to seek treatment. METHODS: Four hundred outpatients at a hospital-affiliated, community-based, psychiatric clinical practice were interviewed with the Structured Clinical Interview for DSM-IV (SCID). For patients with more than one disorder, the diagnoses were assigned as principal or additional according to the DSM-IV convention of whether it was the patient's stated primary reason for presenting for treatment or was an additional disorder. For all current disorders, patients were asked whether the symptoms of each diagnosed disorder were a reason, or one of the reasons, for seeking treatment. RESULTS: Nearly all patients with major depression wanted treatment for this disorder, and more than 85 percent of patients with panic disorder, posttraumatic stress disorder, and generalized anxiety disorder indicated that the symptoms of these disorders were a reason for seeking treatment. Half to two-thirds of patients with social phobia, obsessive-compulsive disorder, intermittent explosive disorder, body dysmorphic disorder, and substance use disorders reported that the symptoms of these disorders were a reason for seeking treatment. Only 30 percent of those with specific phobia indicated that their phobic fears were a reason for seeking treatment. CONCLUSIONS: Patients often seek treatment for symptoms of disorders that are diagnosed as comorbid, rather than principal, conditions. It is important for clinicians to conduct thorough diagnostic interviews in order to diagnose disorders that are not related to the patient's chief complaint, as patients often desire treatment for these additional diagnoses.

Psychiatric diagnosis in clinical practice: is comorbidity being missed?

The recognition of comorbidity has important clinical significance. Comorbidity predicts a poorer outcome for patients with depressive and anxiety disorders, and the presence of multiple psychiatric disorders is associated with greater psychosocial impairment. In routine clinical settings, an unstructured interview is typically used to assess patients. However, unstructured interviews may result in missed diagnoses, with potential negative clinical consequences. The goal of the present study was to examine whether diagnostic comorbidity is less frequently identified during a routine clinical evaluation versus a semistructured diagnostic interview. Axis I diagnoses derived from structured and unstructured clinical interviews were compared in two groups of psychiatric outpatients in the same practice setting. Five hundred individuals presenting for an intake appointment to a general adult psychiatric practice underwent a routine unstructured clinical interview. Subsequent to completion of the first study, the method of conducting diagnostic evaluations was changed and 500 individuals were interviewed with the Structural Clinical Interview for DSM-IV Axis I Disorders (SCID). The two groups had similar demographic characteristics and scored similarly on symptom questionnaires. Individuals interviewed with the SCID were assigned significantly more axis I diagnoses than individuals assessed with an unstructured interview. More than one third of the patients interviewed with the SCID were diagnosed with three or more disorders, in contrast to fewer than 10% of the patients assessed with an unstructured interview. Fifteen disorders were more frequently diagnosed in the SCID sample, and these differences occurred across mood, anxiety, eating, somatoform, and impulse-control disorder categories. The results suggest that in routine clinical practice, clinicians underrecognize diagnostic comorbidity. Anxiety, somatoform, and not otherwise specified (NOS) disorders were the most frequently underdetected disorders. The implications of underdiagnosis for the treatment outcome are discussed.

Body dysmorphic disorder in psychiatric outpatients: recognition, prevalence, comorbidity, demographic, and clinical correlates.

The prevalence of Body Dysmorphic Disorder (BDD), based on structured and unstructured clinical interviews, was compared in two samples of psychiatric outpatients drawn from the same practice setting. In the first sample, 500 patients were diagnosed according to a routine, unstructured clinical interview. In the second sample, 500 subjects were diagnosed according to information obtained by the Structured Clinical Interview for DSM-IV (SCID). No patient was diagnosed with BDD in the clinical sample, whereas 16 (3.2%) patients were diagnosed with BDD in the SCID sample. Compared with patients without BDD, patients with BDD received significantly more current axis I diagnoses, and were more likely to be diagnosed with current obsessive-compulsive disorder (OCD) and social phobia. Both groups were diagnosed with major depression at similar rates. Patients with BDD, versus those without, tended to be sicker and more functionally impaired. It appears that BDD is an infrequent disorder in an outpatient setting, which is rarely recognized when clinicians conduct their routine diagnostic interview. Although it was not usually a patient's principal reason for seeking treatment, the majority of patients with BDD in this sample wanted their treatment to address these symptoms.

Axis I diagnostic comorbidity and borderline personality disorder.

Borderline personality disorder (PD) has been the most studied PD. Research has examined the relationship between borderline PD and most axis I diagnostic classes such as eating disorders, mood disorders, and substance use disorders. However, there is little information regarding the relationship of borderline PD and overall comorbidity with all classes of axis I disorders assessed simultaneously. In the present study, 409 patients were evaluated with semistructured diagnostic interviews for axis I and axis II disorders. Patients with a diagnosis of borderline PD versus those who did not receive the diagnosis were assigned significantly more current axis I diagnoses (3.4 v 2.0). Borderline PD patients were twice as likely to receive a diagnosis of three or more current axis I disorders (69.5% v 31.1%) and nearly four times as likely to have a diagnosis of four or more disorders 147.5% v 13.7%). In comparison to nonborderline PD patients, borderline PD patients more frequently received a diagnosis of current major depressive disorder (MDD), bipolar I and II disorder, panic disorder with agoraphobia, social and specific phobia, posttraumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), eating disorder NOS, and any somatoform disorder. Similar results were observed for lifetime diagnoses. Overall, borderline PD patients were more likely to have multiple axis I disorders than nonborderline PD patients, and the differences between the two groups were present across mood, anxiety, substance use, eating, and somatoform disorder categories. These findings highlight the importance of performing thorough evaluations of axis I pathology in patients with borderline PD in order not to overlook syndromes that are potentially treatment-responsive.

Is posttraumatic stress disorder underdiagnosed in routine clinical settings?

The goal of the present study was to examine whether posttraumatic stress disorder (PTSD) is underrecognized in routine clinical practice. One thousand patients were evaluated at the Rhode Island Hospital Department of Psychiatry outpatient practice. The first 500 patients completed a psychiatric diagnostic screening questionnaire that included a PTSD subscale. The next 500 individuals were interviewed with the Structured Clinical Interview for DSM-IV (SCID). In the first 500 patients, 36 (7.2%) patients were diagnosed by their clinicians with PTSD and an additional 18.6% of the sample screened positive on the questionnaire but were not diagnosed with PTSD. The patients who were diagnosed with PTSD and the patients who screened positive but were not given the diagnosis were significantly younger, had lower GAF scores, and less frequently graduated from college than the non-PTSD group. The frequency of suicidal thoughts was identical in the two PTSD groups and twice as high as the frequency in the non-PTSD group. Scores on 9 of the other 12 psychopathology dimensions assessed by the screening questionnaire were significantly higher in the two PTSD groups than the non-PTSD group. In the 500 patients interviewed with the SCID the prevalence of PTSD was two times higher than in the 500 patients diagnosed with an unstructured clinical interview (14.4% vs. 7.2%). The difference in prevalence rates of PTSD between the SCID and clinical samples was significant when considering PTSD as an additional diagnosis; there was no difference in prevalence rates when restricting the analysis to principal diagnoses. The results of this study suggest that PTSD is frequently overlooked in routine clinical practice when symptoms of PTSD are not the presenting complaint.

The Psychiatric Diagnostic Screening Questionnaire: development, reliability and validity.

The Psychiatric Diagnostic Screening Questionnaire (PDSQ) is a self-report scale designed to screen for the most common DSM-IV axis I disorders encountered in outpatient mental health settings. We report the results of four studies of the PDSQ involving more than 2,500 subjects receiving outpatient mental health care. In two studies we examined the understandability of the items on the PDSQ. Items that initially were less well understood were rewritten, and all items of the final version of the scale were understood by more than 90% of the respondents. In the other two studies, the reliability and validity of the PDSQ subscales was examined. A priori criteria were established to guide the revision of subscales. The final version of the questionnaire contains 13 subscales (major depressive disorder [MDD], bulimia, post-traumatic stress disorder [PTSD], panic disorder, agoraphobia, social phobia, generalized anxiety disorder [GAD], obsessive-compulsive disorder [OCD], alcohol abuse/dependence, drug abuse/dependence, somatization, hypochondriasis, and psychosis), each of which achieved good to excellent levels of internal consistency, test-retest reliability, and discriminant, convergent, and concurrent validity.

Clinical correlates of self-mutilation in a sample of general psychiatric patients.

The aims of this study were to examine whether certain axis I disorders characterized by impulsive aggression were associated with self-mutilative behavior and to evaluate the clinical correlates of self-mutilation in a sample of general psychiatric outpatients. Two hundred fifty-six outpatients were administered diagnostic interviews for axis I and axis II disorders. In addition, questionnaires that measured self-mutilative acts within the last 3 months, dissociation, and childhood abuse were completed. This study found that axis I disorders of substance abuse, posttraumatic stress disorder, and intermittent explosive disorder were significantly related to self-mutilative behavior, independent of borderline personality disorder and antisocial personality disorder. Also, a higher level of dissociation was related to self-mutilation, controlling for borderline personality disorder and childhood abuse. Outpatients with certain axis I disorders and those who dissociate may represent a sizable group of patients who are at risk for self-mutilative behavior.