Diagnosis of Schizophrenia: A Critical Review of Current Diagnostic Systems

Transcription

1 452 Diagnosis of Schizophrenia: A Critical Review of Current Diagnostic Systems by Wayne S. Fenton, Loren R. Mosher, and Susan M. Matthews Abstract The data relevant to the evaluation of six systems for diagnosing schizophrenia are reviewed. They are summarized in terms of the reliability, predictive validity, specificity, and comprehensiveness of each system. Unfortunately, none of these systems (Schneider's First-rank Symptoms, New Haven Schizophrenia Index, Flexible System, Feighner Criteria, Research Diagnostic Criteria, and DSM-HI) have established construct validity. It is noted therefore that they are all, in a sense, arbitrary. Choosing one over another cannot be data-based. Because the elevation of any one diagnostic system to an official status is thought to be premature, clinicians and researchers alike are advised to exercise caution and openmindedness in their use of DSM-HI. There is as yet no evidence that its criteria for schizophrenia are either less arbitrary or better (in identifying a group of "true" schizophrenics) than those of other systems or DSM-II. In the late 1960s, traditional clinical methods of diagnosing schizophrenia began to fall into disrepute, creating an environment of receptivity from which several new approaches for diagnosing the condition have emerged. They have generally been used in research, but are also themselves the subject of a growing body of research on diagnosis per se. In this article, we will review the five most frequently used systems for diagnosing schizophrenia: (1) Schneider's First-rank Symptoms; (2) New Haven Schizophrenia Index; (3) Flexible System; (4) Feighner Criteria; and (5) Research Diagnostic Criteria. After briefly describing the development of each system, we will attempt to evaluate their relationship to DSM-4II and, based on available data, the degree to which they offer advantages over usual diagnostic practice. Criteria for Assessing Diagnostic Systems Objectivity. Diagnostic procedures in most of medicine are relatively objective because abnormalities elicited by history can be subsequently documented (or not) by physical examination and laboratory studies. In psychiatry, however, the situation may be complicated by at least nine nonillness-related factors that have been shown to influence the assessment of psychopathology for example, race, sex, socioeconomic status, context, theoretical views, type of interview, and religious and political beliefs of the patient (Grinker et al. 1961; Kendell 1968; Temerlin 1968; Katz, Cole, and Lowery 1969; Wenger and Fletcher 1969; Efron 1970; Lee and Temerlin 1970; Cooper et al. 1972; Rosenhan 1973; Simon et al. 1973; Braginsky and Braginsky 1974; Kuriansky, Deming, and Gurland 1974; Langer and Abelson 1974; Strupp 1975). That clinical diagnostic practice is susceptible to so many nonpsychopathology-based biasing factors suggests that objectivity in psychiatric assessment is difficult to ensure. Reprint requests should be sent to S. Matthews at Center for Studies of Schizophrenia, NIMH, Rm , 5600 Fishers Lane, Rockville, MD

2 VOL 7, NO. 3, Reliability. A necessary constraint on the validity of any diagnostic system is its reliability. There is no guarantee that a reliable system is valid, but validity can never be established for an unreliable system. Two types of reliability are measured most often: intertater and test-retest. Interrater agreement focuses on multiple raters' independent judgments of a diagnostic classification for a single patient; the patient is either interviewed by each rater in succession, or is observed during one interview by multiple raters. The latter method avoids potential problems in assessing reliability that result from information variance. Test-retest reliability looks at the ability of raters to agree on a categorization over time. Because symptomatology (the current basis for diagnosis) is known to vary markedly over time, this approach to assessing reliability is of limited utility for evaluating a particular diagnostic system. Beck (1962) and Zubin (1967) reviewed the major diagnostic reliability studies before They concluded that the overall picture was one of poor reliability, with an average rate of less than 50 percent interjudge agreement for a diagnosis of schizophrenia. In a subsequent review of reliability studies, Spitzer et al. (1967) pointed out that the lack of a uniform method of quantifying interjudge reliability contributed to the difficulty in comparing findings across studies. Further, they observed that the common ways of reporting reliability for example, proportion of overall agreement, proportion of specific agreement, and overall contingency coefficient in addition to not being comparable, suffered from one or more statistical and conceptual flaws. Because of chance agreement, they believed these statistics probably falsely elevated the level of agreement. They described a statistic, kappa, an intradass correlation that corrects for chance agreement, which provides a more stringent and accurate measure of interrater agreement. Kappa varies from negative values for less than chance agreement to +1.0 for perfect agreement. Spitzer and Fleiss (1974) reanalyzed published reliability studies where the data reported allowed calculation of kappa. Table 1 shows these values for the Table 1. Studies reporting reliability (kappa) of psychosis and schizophrenia using clinical diagnosis 1 Study Schmidt and Fonda (1956) Kreitman (1961) Becket al. (1962) Sandifer, Pettus, and Quade (1964) Cooper et al. (1972) Spitzer et al. (1974) Raters Psychiatric resident, senior psychiatrist Consulting psychiatrist, research psychiatrist Two of four experienced psychiatrists Each of 10 diagnosticians Hospital physician, member of research project Resident, supervising physician Independence Raters shared patient's chart and other data Independent: both had access only to patient, family, and letter of referral No source other than patient Resident presents case to all 10. One clinician interviews patient in presence of others. All 10 make individual diagnosis Independent interviews Cases discussed Mean kappa for six studies: Kappa (psychosis) (NY).43 (London) Kappa (schizophrenia) (NY).60 (London) 'As reviewed by Spitzer and Fleiss (1974).

3 454 SCHIZOPHRENIA BULLETIN diagnosis of schizophrenia. An average kappa of.55 for psychosis and.57 for schizophrenia is obtained. Kappa is seen to vary by the amount of information shared by the raters (Kreitman 1961; Spitzer et al. 1974). Ideally, interjudge reliability should be assessed independently from the same interview or with a minimum time lapse between interviews. Thus, the mean kappa value reported by Spitzer and Fleiss (1974) for schizophrenia should be considered generous since most of the reported pairs of diagnoses were, not made completely independently (e.g., raters shared information). With an error rate of at least 25 percent, the clinical diagnosis of schizophrenia has heretofore been quite unreliable. In discussing the reasons for diagnostic unreliability, Spitzer and Fleiss (1974) and Spitzer, Endicott, and Robins (1975) cite Beck et al. (1962), who identified at least two sources of variability among diagnosticians: variability due to differences in how they elicit and evaluate information information variance; and differences in the formal, but unstated, inclusion and exclusion criteria that clinicians used to summarize patient data into psychiatric diagnoses criterion variance. For example, Spitzer, Endicott, and Robins (1975) found kappa of.48 for two independent raters using the same diagnosis of schizophrenia. All the research diagnostic systems reviewed here define explicit operational criteria to help reduce criterion variance. Several (table 2) also include structured interview schedules in an attempt to improve their reliability by reducing information variance. Validity. Unlike other medical conditions in which morbid anatomy, etiologic agents, and measurable biochemical or physiologic anomalies serve to provide construct validity for the existence of a given illness, there are at present no independent noninterviewderived measures that have been able to provide construct validation for the term "schizophrenia." If, for example, low platelet monoamine oxidase was found only in patients receiving the diagnosis of schizophrenia, this enzyme assay would provide one means of establishing construct validity for schizophrenia as a disease in the usual medical sense. Traditionally, schizophrenia has been defined as an illness by the apparent clustering of signs and symptoms and/or a characteristic course. Kraepelin emphasized a longitudinal deterioration in defining dementia praecox, while Bleuler stressed the importance of symptoms found cross-sectionally. Since psychiatric illnesses have been shown to run in families (Zerbin-Rudin 1967; Reed, Hartley, and Anderson 1973), increased prevalence of the same disorder among close relatives of a group of patients has also been used in an attempt to provide an indirect measure of construct validity. Among the new operational definitions, some require only the presence of cross-sectional features, while others require both symptoms and evidence of duration (tables 2 and 3). Because construct validation is not possible, predictive validity is frequently studied. That is, similarly diagnosed patients are followed over time to see if they have similar outcomes or respond to a particular treatment. Poor outcome (as originally proposed by Kraepelin) has increasingly come to be considered as a validating criterion for "true schizophrenia." Unfortunately, predictive validity is of very limited utility (as compared with construct validity) in the precise definition of a concept. Specificity and Comprehensiveness. A clinically useful diagnostic Table 2. Comparison of the criteria for the diagnosis of schizophrenia Diagnostic system Symptoms Duration New Haven Schizophrenia Index Flexible System Feighner Criteria Taylor and Abrams 1 Criteria Schneider's FRS Research Diagnostic Criteria 'See World Health Organization (1973). 2 See Helzeret al. (1978). 'See Endicott and Spitzer (1976). X X X X X X X X X Structured Interview No Yes (PSE) 1 Yes 2 No No (included in PSE) SADS 3

4 VOL 7, NO. 3, Table 3. Definition of diagnostic criteria New Haven Schizophrenia Index 1a. Delusions not specified or other than depressive (2 points); 16. Hallucinations auditory; 1c. Hallucinations visual; 1ef. Hallucinations other (2 points for b, c, or d) 2a. Bizarre thinking; 2b. Autism or grossly unrealistic private thoughts; 2c. Looseness of association, illogical thinking, overinclusion (2 points for a, b, or c); 2d. Blocking; 1 2e. Concreteness; 1 2f. Derealization; 2g. Depersonallzation (1 point each for I and g) 3. Inappropriate affect (1 point) 4. Confusion (1 point) 5. Paranoid ideation self-referential thinking, suspiciousness (1 point) 6. Catatonic behavior: 6a. Excitement; 6b. Stupor; 6c. Waxy flexibility; 6d. Negativism; 6e. Mutism; Bf. Echolalia; 6g. Stereotyped motor activities (1 point for any one of a through g) 1 Where the 4th point necessary for Inclusion in the sample is provided by 2d or 2e, these symptoms are not scored. Flexible System Restricted affect Poor Insight Thoughts aloud Poor rapport Widespread delusions Incoherent speech Unreliable information Bizarre delusions Nihilistic delusions Absence of early (1-3 hours) awakening Absence of depressed fades Absence of elation Schneider First-rank Symptoms Percent of schizophrenic* correctly diagnosed and nonschlzophrenlcs Incorrectly diagnosed Minimum number of symptoms Schizophrenic Nonschlzophrenlc A patient with one or more of these symptoms in the presence of a clear sensorium is considered schizophrenic: The patient hears voices speaking his thoughts aloud The patient experiences himself as the subject whom hallucinatory voices are discussing The patient hears hallucinated voices describing his activity as it takes place Somatic passivity-hallucinated somesthetic experiences Thought insertion as though thoughts were put In one's mind by an external force Thought withdrawal thoughts are being removed from patient's mind by an outside agent Thought broadcast the passive experience of one's thoughts being magically transmitted to others Affect... Impulses... Motor activity... experienced as imposed and controlled from outside one's body. Feighner Criteria A through C are necessary: A. Both of the following are necessary: 1. A chronic illness with at least 6 months of symptoms before the index evaluation without return to premorbid level of psychosoclal adjustment; 2. Absence of a period of depressive or manic symptoms sufficient to qualify for affective disorder or probable affective disorder

5 456 SCHIZOPHRENIA BULLETIN Table 3. Definition of diagnostic criteria Continued B. The patient must have had at least 1 of the following: 1. Delusions or hallucinations without significant perplexity or dlsorientation associated with them; 2. Verbal production that makes communication difficult because of a lack of logical or understandable organization (in the presence of muteness, the diagnostic decision must be deferred) C. At least 3 of the following for definite, 2 for probable: 1. Single (never married); 2. Poor premorbid social adjustment or work history; 3. Family history of schizophrenia; 4. Absence of alcoholism or drug abuse within 1 year of onset of psychosis; 5. Onset of illness before age 40 Taylor and Abrams' (1973) Criteria All of the following must be present for a diagnosis of schizophrenia: A. Duration of episode greater than 6 months B. Clear consciousness C. Presence of either delusions, hallucinations, or formal thought disorder (verblgeration, non sequitors, word approximations, neologisms, blocking and derailment) D. Absence of a broad affect E. Absence of signs and symptoms sufficient to make a diagnosis of affective disease F. Absence of alcoholism or drug abuse within 1 year of the index episode G. Absence of focal signs and symptoms of coarse brain disease or major medical illness known to produce significant behavioral changes (e.g., thyroid dysfunction, pernicious anemia, porphyria) Research Diagnostic Criteria A through C are required for the period of illness being considered: A. At least 2 of the following are required for definite and 1 for probable. (If the symptoms occur only during a period of alcohol or drug abuse or withdrawal from them, do not score here.) 1. Thought broadcasting, insertion, or withdrawal (as defined In the manual); 2. Delusions of being controlled (or Influenced), other bizarre delusions, or multiple delusions (as defined in the manual); 3. Delusions other than persecutor^ or jealousy, lasting at least 1 week; 4. Delusions of any type if accompanied by hallucinations of any type for at least 1 week; 5. Auditory hallucinations in which either a voice keeps up a running commentary on the subject's behaviors or thoughts as they occur, or two or more voices converse with each other. 6. Nonaffective verbal hallucinations spoken to the subject (as defined in the manual); 7. Hallucinations of any type throughout the day for several days or intermittently for at least 1 month; 8. Definite instances of marked formal thought disorder (as defined in the manual) accompanied by either blunted or inappropriate affect, delusions or hallucinations of any type, or grossly disorganized behavior B. Either 1 or 2: 1. The current period of illness has lasted at least 2 weeks from the onset of a noticeable change in the subject's usual condition; 2. The subject has had a previous period of illness lasting at least 2 weeks in which he met the criteria and residual signs of the illness have remained, e.g., extreme social withdrawal, blunted or inappropriate affect, formal thought disorder, or unusual thoughts or perceptual experiences C. At no time during the active period of illness being considered did the subject meet the criteria for either probable or definite manic or depressive syndrome to such a degree that it was a prominent part of the illness Further subtyping of schizophrenia is done by course (Acute, Subacute, Subchronlc, Chronic) and clinical phenomenology (Paranoid, Disorganized, Confusional, Catatonic, and Undifferentiated or Mixed) system must be able to classify one diagnostic category. However, wider, reliability falls and patients most patients. In addition, a given patient's symptom picture should, as Blashfield (1973) has pointed out, in psychiatry the experience can be fitted into any one of sever- al categories. Thus far, highly speideally, place him or her in only has been that as coverage becomes tific, nonoverlapping systems are

6 VOL. 7, NO. 3, unable to classify about 25 percent of patients, severely limiting their clinical usefulness (Strauss and Gift 1977). The Cross-Sectional Systems Schneider. In 1959, Kurt Schneider (1959) described 11 First-rank Symptoms (FRS) he believed were pathognomonic for schizophrenia. The FRS were derived from clinical experience and had no specific relationship to a theoretical conception of schizophrenia. While Schneider's views on the course and eventual outcome of schizophrenia were similar to those of Kraepelin, he felt that psychiatric diagnosis should be based on presenting symptoms rather than course of illness. Of the FRS, Schneider (1959) wrote: "When any of these modes of experience is undeniably present, and no somatic illness can be found, we may make the decisive clinical diagnosis of schizophrenia." The appeal of his concept of pathognomonic symptoms is lent credence by the widespread adoption of this system. It has had major influence on the British research system for diagnosing schizophrenia (Catego and the Present State Examination) and has been strongly recommended for use in the International Classification of Diseases (ICD) (World Health Organization 1973). Reliability. A diagnosis of schizophrenia based on FRS appears to be quite reliable. Brockington, Kendell, and Leff (1978), whose comparative study will be referred to in relation to several of the systems, found Schneider to have the highest interrater reliability with a kappa of.90 (table 4). Carpenter and Strauss (1974) also found the FRS to be reliable (mean intraclass r =.83). Validity. Table 5 lists several studies which have examined the predictive validity of FRS. In general, the results indicate that the FRS are poor predictors of patient outcome as measured by a variety of outcome variables at multiple followup intervals. In fact, Kendell, Brockington, and Leff (1979) showed that among a group of psychotics, Schneider's criteria were less effective than original clinical diagnosis in predicting outcome for schizophrenics rated as having made incomplete recovery from an index episode 6.5 years earlier. Schneider's criteria could not significantly predict a persistent "defect state," proportion of followup period spent in the hospital, subsequent employment, or social isolation. In addition, when an "outcome diagnosis" was made by studying all available data on each patient during the followup period, among the 39 patients with an index diagnosis of Schneiderian schizophrenia, 21 (55 percent) received a different outcome diagnosis (Brockington, Kendell, and Leff 1978). Specificity. Table 6 reviews studies measuring the prevalence of FRS. Among clinically diagnosed schizophrenics, a wide range of prevalence is seen: the lowest, 24 percent, among Silverstein and Harrow's (1978) young adult patients, early but in the postacute phase of their illness; the highest, 72 percent, among Mellor's (1970) chronic hospitalized patients. With the exception of Koehler, Wolfgang, and Grimm (1977), studies finding the greatest prevalence occurred outside the United States, perhaps reflecting the greater influence of Schneider's ideas and hence focus on them as determinants of a diagnosis in Europe. To summarize, the prevalence of FRS among clinically diagnosed schizophrenics is about 50 percent. They occur with sufficient frequency to be of diagnostic interest, but since they also occur with some frequency in other psychiatric disorders, particularly mania, they are clearly not pathognomonic. Prognostic and comparative studies indicate that the narrower diagnostic criteria of Schneider define groups of schizophrenics whose outcomes are not consistently different from those of patients defined more broadly by clinical judgment. Thus, while FRS-positive groups may be symptomatically more homogeneous at the time of index evaluation, there is no evidence to suggest that they are more "truly" schizophrenic. New Haven Schizophrenia Index (NHSI). Working from the assumption that an operational definition of schizophrenia should formalize the commonality of features used by clinicians, Astrachan et al. (1972) set out to determine empirically what these features were. As a first step, a panel reviewed the literature and abstracted a number of specific symptoms that were consistently identified as being associated with schizophrenia. Considering only those symptoms that could be reliably rated and easily retrieved from charts or clinical interview schedules, the panel initially agreed on minimal and sufficient criteria for a diagnosis. As Schneider had done, the

7 Table 4. Percent distribution of autistic (psychotic) population by study 1 Study System Judges Independence Brockington, Kendall, and Leff (1978) Heltzer et al. (1977) Spltzeret al. (1975) Spltzer, Endicott, and Robins (1975) Spitzer et al. (197B) Spitzer, Forman, and Nee (1979) Schneider & PSE NHSI & PSE Flexible & PSE Felghner & PSE Feighner & structured Interview RDC RDC (present episode) RDC (lifetime) RDC & SADS (lifetime) RDC& SADS (present episode) RDC& SADS (present episode) RDC& SADS (lifetime) DSM-III DSM-III A pair of clinicians A pair of clinicians A pair of clinicians A pair of clinicians A pair from: resident junior faculty senior faculty Senior author, 3 research assistants A pair of clinicians A pair of raters A pair of raters A pair of raters 2 independent raters 2 independent raters A pair of volunteer clinicians A pair of volunteer clinicians 1 interviewed patient as other observed 1 interviewed patient as other observed 1 Interviewed patient as other observed 1 interviewed patient as other observed 2 interviews 24 hours apart Case record review 1 interviewed patient as other observed 1 interviewed patient as other observed 1 interviewed patient as other observed 1 Interviewed patient as other observed 2 interviews at different times; no shared data 2 interviews at different times; no shared data 1 interviewed patient as other observed (letter of referral, etc., shared) 2 separate interviews (letter of referral, etc., shared) Kappa (schizophrenia) Kappa (other) Felghner:. 19, undiagnosed , schizoaffective.48, manic type;.86, depressive type Not stated, manic;.94, depressive type Not stated, manic;.87, depressive type Not stated, manic;.85, depressive type.79, manic type;.73, depressive Not stated, manic; 70, depressive.56, schizoaffective.53, schizoaffective ownloaded from at Pennsylvania State University on February 26, Less than 5 percent frequency by either rater.

8 Table 5. Summary of prognostic and comparative studies f Study Sample Schnelderlan FIrat-rank Symptoms Bland (1979) Bland and Orn (1980) Carpenter and Strauss (1973a) Kendell, Brockington, and Leff (1979) Mellor(1970) Hawk, Carpenter, and Strauss (1975) Prelser and Jeffrey (1979) Silverstein and Harrow (1978) 43 1st admission schizophrenics 103 schizophrenics, 39 affective psychoses, 23 neuroses and character disorders 134 patients with functional psychoses, mainly schizophrenic and affective psychoses 166 schizophrenic patients, both sexes, with a mean of 2.6 admissions to hospitals 131 patients initially, 60 patients evaluated at 5-year followup, of which 61 diagnosed as schizophrenic according to DSM-II 88 patients, 52 given discharge diagnosis of schizophrenia 72 schizophrenics and 54 nonschizophrenics in early phases of their disorder Followup period Outcome measures Results 14 years 12-month period preceding the 2-year followup 6 years Baseline symptoms and psychiatric history 5 years Admission, discharge, 6 months postdischarge for rehospitalization only Postacute phase Economic productivity, social adjustment, psychiatric condition Time In hospital, work adjustment social relationships, severity of symptoms Recovery from index episode, psychotic symptoms, presence of "defect state," time in hospital Symptomatology, admissions to hospital Hospitalization, social contacts, employment, symptomatology, ability to meet basic needs, fullness of life, overall level of functioning Psychotic Inpatient Profile, social interactions, impairment of functioning, rehospitalization Social and work adjustment, rehospitalization and a global composite ownloaded from at Pennsylvania State University on February 26, 2014 Assessment of presence or absence of symptoms unlikely to relate to outcome No relationship between presence or absence of FRS and individual outcome indices FRS less effective than clinical diagnoses in discriminating schizophrenics rated as having incomplete recovery from index episode, FRS successful in identifying patients with persistent symptoms, FRS did not predict time in hospital postdischarge Patients without FRS had been ill longer and hospitalized more than those with FRS No outcome differences between the 33 Schneider (+) and 28 Schneider (- ) patients The presence of FRS does not predict response to treatment A limited, nonsignificant tendency for schizophrenic patients with FRS to have a somewhat poorer outcome than patients with any psychotic features at followup

9 CO 2 R m z CD Table 5. Summary of prognostic and comparative studies Continued Study Sample Schnelderlan First-rank Symptoms (continued) Strauss and Carpenter (1974a) Taylor (1972) 142 patients at initial interview of which 105 diagnosed as schizophrenic; B5 schizophrenics seen at followup 78 male schizophrenics Abrams and Taylor 52 schizophrenics (1973) Silverstein and 107 schizophrenics Harrow (1981) and 76 nonschizophrenics New Haven Schizophrenia Index Astrachan et al. 132 patients dlag- (1974) nosed with NHSI Bland (1979) Kendell, Brockington, and Leff (1979) Stephens et al. (1980) Flexible System Hawk, Carpenter, and Strauss (1975) 43 1 st admission schizophrenics 134 patients with functional psychoses, mainly schizophrenia and affective psychoses 120 hospitalized patients, predominately diagnosed as schizophrenic 131 patients initially, 80 patients evaluated at 5 years, of which 61 were diagnosed as schizophrenic by DSM-II Followup period Outcome measures Results Admission, 2 Outcome scale consisting of social years post- contact, employment, sympdischarge tomatology and rehospitalizatlon; 14-item prognostic scale; Phillips Scale Admission, dis- Treatment response, disposition, charge use of somatic therapy Admission, dis- Symptomatology charge Admission and Psychotic Symptoms Inventory at average (PSI), Psychiatric Assessment 2.9 years Interview, FRS, Strauss and after hospital Carpenter, Levensteln and discharge Payne Scales 2 to 3 years after index hospitalization 14 years 6 years 10 years Psychotic symptoms Economic productivity, social adjustment, psychiatric condition Recovery from index episode, psychotic symptoms, presence of "defect state," time In hospital Social, work, symptomatic adjustment, time hospitalized 5 years Hospitalization, social contacts, employment, symptomatology, ability to meet basic needs, fullness of life, overall level of functioning Schneider ( + ) and Schneider (-) subgroups showed similar mean scores on prediction items except that Schneider schizophrenia subjects had significantly higher scores on the item rating hallucinations and delusions The presence of FRS identified patients who responded poorly to treatment, required more time in hospital and required more neuroleptics The presence of FRS did not predict poor outcome for manic patients FRS do occur more frequently in schizophrenics than nonschizophrenics at followup, although most schizophrenics did not show FRS at followup. FRS tend to Identify schizophrenics with a chronic course As a whole, patients diagnosed with NHSI are quite heterogeneous in regard to symptomatic outcome No correlation between NHSI scores and outcome measures The NHSI was less effective than clinical diagnosis in predicting poor symptomatic and social outcome Outcome was not significantly predicted by an NHSI diagnosis of schizophrenia No significant relationships between the presence or absence of discriminating symptoms and total outcome score

10 Gunderson, Carpenter, and Strauss (1975) Kendell, Brockington, and Left (1979) Fclghner Criteria Morrison et al. (1972) Morrison et al. (1973) Tsuang and Winokur (1974) Tsuang, Dempsey, and Rauscher (1976) Original cohort of 135 patients, from whom 24 borderline patients and 35 schizophrenic patients were drawn 134 patients with functional psychosis, mainly schizophrenia and affective psychoses 874 patients clinically diagnosed as manic-depressive (n = 286), Involutional melancholia (n = 84), schizophrenia (n = 504) 525 patients of which 225 diagnosed as unipolar affective, 100 as bipolar affective, and 200 as schizophrenic 200 schizophrenics diagnosed using Feighner Criteria of which 115 subtyped as hebephrenic, 62 as paranoids, 23 as other types 200 schizophrenics, 100 bipolar (mania), 225 unipolar (depression), 85 atypical schizophrenics 2 years posthospitalization 6 years years 5 followup periods: 2.2 years, bipolar affective; 2.6 years, schizophrenia; 3.2 years, schizophreniform; 4.3 years, unipolar depression Mean followup period = 2.6 years Mean followup period = 2.6 years Symptomatology based on PSE items, 14-ltem prognostic scale, social relationships, hospitalization, employment Recovery from index episode, psychotic symptoms, presence of "defect state," time in hospital Clinical diagnoses vs. research diagnoses (Feighner Criteria) years later Recovery rate (symptoms, occupational status, social recovery, self-maintenance), hospitalizatlon Examination of hospital charts regarding marital status, employment, symptomatology Recovery (well or social recovery) and nonrecovery (chronic institutlonalization or incomplete recovery) ownloaded from at Pennsylvania State University on February 26, 2014 No significant differences between schizophrenia and borderline samples on outcome measures at 2 years The Flexible System superior to original clinical diagnosis in predicting incomplete recovery, the presence of a "defect state." Flexible System successful in identifying patients with persistent delusions or hallucinations and time In hospltal postdischarge 25% originally diagnosed as affective disorder were discarded. Of original 504 schizophrenics, 63% discarded, primarily because of acute onset. Of the 3 study groups, the majority of chart diagnoses were in agreement with the stringent research diagnostic criteria After 10 years, nearly all affective disorder patients recovered. Only 8% of schizophrenics ever recovered compared to 22% of schizophreniform patients. 20% of schizophrenics were continuously hospitalized after 10 or more years vs. only 5% of schizophrenitorm and 0% affective disorder patients. Overall, paranoids had more favorable outcome than hebephrenics (more likely to be married, to be employed; less likely to be secluslve, to have defective memory, and orientation or motor symptoms) 44% of atypical schizophrenics recovered vs. 8% of schizophrenics. "Atypicals" were young, mostly female, had definite precipitant to illness, and were likely to have a family history of affective disorder

11 R 1 Table 5. Summary of prognostic and comparative studies Cont/nued Study Sample Mean lollow- up = 18.2 months (98% had a 1- to 2%-year followup) Admission Felghner Criteria (continued) Robins et al. 314 psychiatric emer- (1977) gency room patients Taylor and Abrams (1975) Bland (1979) Initial sample of 247, of which 89 schizophrenics and 22 manics were studied 43 1st admission schlzophenics Research Diagnostic Criteria (RDC) Kendell, Brockington, and Left functional 134 patients with (1979) psychosis, mainly schizophrenia and affective psychoses Brocklngton, Kendell, and Left (1978) Two samples: st admission psychotic patients years of age; patients (mixed 1st and subsequent admissions with functional psychosis) Followup period Outcome measures Results 14 years Diagnosis at admission vs. diagnosis at followup Comparison of Felghner vs. authors' own criteria Economic productivity, social adjustment, psychiatric condition 6 years Recovery from index episode, psychotic symptoms, presence of "defect state," time in hospital 6.5 years Social state (occupational record and social involvement) final diagnosis and outcome diagnosis Followup showed the prediction based on initial diagnoses was 84% correct Of 89 patients, 11% satisfied Feighner Criteria for schizophrenia, and 10% satisfied authors' criteria. Diagnostic agreement was found in only 5 of these patients Feighner Criteria significantly correlated with outcome in terms of economic productivity, psychiatric condition, and a combined outcome score RDC somewhat better than clinical diagnoses In predicting incomplete recovery from Index episode, persistent delusions or hallucinations, development of a "defect state" and social isolation, less successful than clinical diagnoses in predicting time spent in hospital during followup and unemployment RDC had concordances with outcome and final diagnosis as high or higher than the project diagnosis. A diagnosis of "probable" schizophrenia was superior to "definite" schizophrenia in predicting social outcome

12 VOL 7, NO. 3, Table 6a. Schneider's First-rank Symptoms: Prevalence among clinically diagnosed schizophrenics Study Prospective Mellor(1970) Carpenter and Strauss (1973a) 1 Carpenter and Strauss (1974) 1 Strauss and Gift (1977) Silverstein and Harrow (1978) Bland and Parker (1978) Kendell, Brockington, and Left (1979) Preiser and Jeffrey (1979) Case record Huber(1967) Taylor (1972) Abrams and Taylor (1973) Koehler, Wolfgang, and Grimm (1977) 'Used only 8 FRS. 'Concordance. n Nationality England U.S.A. International U.S.A. U.S.A. Canada England U.S.A. Germany U.S.A. U.S.A. Germany % with FRS Table 6b. Schneider's First-rank Symptoms: Prevalence in other psychiatric disorders Study Taylor and Abrams (1973) Carpenter and Strauss (1974) Carpenter and Strauss (1973a) Taylor and Abrams (1975) Silverstein and Harrow (1978) Taylor (1972) (chart review) Preiser and Jeffrey (1979) Patient's clinical diagnosis 52 manics 66 manic psychosis 119 depressive psychosis 123 neurosis and personality disorders 39 manic depressives 53 manic (distinct from above) 54 nonschizophrenics (depressives, personality disorders) 16 personality disorders \ 2 neurosis I 8 depression I 7 mania ) 11 schizophreniform 36 nonschizophrenics %wlth FRS n U 14 panel also described exclusionary factors such as overt organic symptomatology. In using this preliminary checklist, Astrachan et al. (1972) required subjects to attain a total score of 4 points (maximum = 13), of which at least 1 point had to be scored on the symptoms delusions, hallucinations, or bizarre thinking to be considered schizophrenic. The checklist was then applied to a sample of 422 charts which carried the diagnosis of schizophrenia as well as 100 charts carrying other diagnoses, but selected to confuse the diagnosis of schizophrenia (e.g., borderline states, psychotic depression). A point system was derived to give greater weight to highly discriminating symptoms and to eliminate nondiscriminating symptoms. A sample of 522 cases was then rescored according to the final Index. Using a cutoff of 4 or more points, the checklist correctly identified 87.6 percent of the schizophrenics and gave false positive diagnoses to 15.6 percent of the cases. Reliability. A reliability study was conducted in which three nonclinicians reviewed material from 25 randomly selected cases. Interrater agreement for a checklist diagnosis of schizophrenia was 84 percent. Kappa was not reported. Brockington, Kendell, and Leff (1978) found the NHSI to be comparatively difficult to apply reliably. Validity. As shown in table 5, the four studies examining the predictive validity of the NHSI consistently reveal it to be ineffective in predicting outcome. Kendell, Brockington, and Leff (1979) reported that the New Haven criteria were less effective than clinical di-

13 464 SCHIZOPHRENIA BULLETIN agnosis in predicting poor symptomatic and social outcome 6.5 years later. Bland (1979) found no correlation between patients' scores on the NHSI during an index hospitalization and social, symptomatic, or work status 14 years later. Astrachan et al. (1974) found symptomatic outcome in 132 patients diagnosed with the NHSI to be quite heterogeneous. Stephens et al. (1980) found no correlation between NHSI and outcome in several areas. Specificity. The specificity of the system was rechecked by Astrachan et al. (1974) applying the checklist to 100 consecutive emergency room psychiatric patients and 50 current inpatients. Among the 39 patients in this group who received a clinical diagnosis of schizophrenia, 89.7 percent were correctly scored as schizophrenic on the checklist. An acceptably low false positive rate of 14.4 percent (16/111) was achieved. Comparative studies have consistently shown the NHSI to be the broadest definition of schizophrenia, and as such, it has been recommended for screening purposes. Flexible System for Diagnosis of Schizophrenia. Pointing out that signs and symptoms have traditionally been the key criteria in defining psychiatric classification, Carpenter and Strauss (19736) described a "Flexible System" for the diagnosis of schizophrenia. Other systems (e.g., Feighner et al. 1972) were seen by the authors as reflecting the views of particular diagnostic schools with their individual conceptual approaches. What seemed desirable was an empirically derived system for identifying patients diagnosed as schizophrenic by investigators representing many schools of thought from many nations. Data from the International Pilot Study of Schizophrenia (IPSS), in which the Present State Examination (PSE) (World Health Organization 1973) was used to rate patients' signs and symptoms, were examined. A total of 1,121 psychiatric patients from nine different countries were both evaluated with the PSE and assigned clinical diagnoses by local psychiatrists using the ICD. Using half of the total patient cohort, and beginning with the 360 signs and symptoms rated on the PSE, investigators used discriminant function analysis to derive the 12 symptoms most frequently found in patients receiving a clinical diagnosis of schizophrenia. The ability of various numbers of these symptoms to discriminate clinically diagnosed schizophrenics was tested on the patient cohort not involved in their derivation. The authors found that 91 percent of clinically diagnosed schizophrenics exhibited four or more of the symptoms, but 38 percent of those receiving other clinical diagnoses also did. When the minimum number of symptoms for research diagnosis was raised to five, six, seven, or eight or more symptoms, the ratios became 81/22, 63/6, 39/1 and 20/0 (all percents), respectively. Thus, at any cutoff point for a diagnosis, an estimate of incorrect inclusion (false positives) is provided. As generally applied, the presence of five or six symptoms is used as a cutoff. Reliability. The overall reliability of the Flexible System was demonstrated in the IPSS study showing a similar incidence of schizophrenia at each level of certainty in the two randomly split halves of the original patient group cohort. Adequate interrater reliability was confirmed by Brockington, Kendell, and Leff (1978) (table 4). Validity. Table 5 reports four studies examining the predictive validity of the Flexible System. As part of their participation in the IPSS project, Carpenter and Strauss (and others) studied the nature and predictors of outcome in the Washington, D.C., cohort of patients. By applying a number of different diagnostic systems to the patients when they were first seen, they had the opportunity to ascertain, "Does schizophrenia as defined by characteristic symptoms have a predictable outcome that validates these symptoms as constituting a particular disorder?" (Hawk, Carpenter, and Strauss 1975, p. 343). The predictive validity of Langfeldt's, Schneider's, and the Flexible System of diagnosis all crosssectional, symptom-based systems was studied. Among symptoms, only restricted affect was significantly associated with outcome, but the authors attributed the predictive value of this symptom to its relationship to established chronicity (Strauss and Carpenter 1978). Outcome was also looked at in terms of hospitalization, social function, and work function during the year before followup evaluation, and severity of symptoms during the month before followup. The findings suggested that outcome in these areas was not a single phenomenon, but rather, several semi-independent processes of outcome in all areas (Strauss and Carpenter 1974b). A later study (Gunderson, Carpenter, and

14 VOL 7, NO. 3, Strauss 1975), which used the Flexible System to distinguish schizophrenic from borderline patients, confirmed discrepant symptom pictures in the two groups, but did not find between-gtoup differences in prehospitalization functioning or 2-year posthospitalization outcome. While Stephens et al. (1980) found that outcome was not significantly predicted by the Flexible System of diagnosis, Kendell, Brockington, and Leff (1979) reported that the Flexible System was among the best studied in predicting outcome. This often cited comparative study showed, however, that in each outcome area investigated, no greater than 65 percent of patients meeting the most predictive criteria exhibited the poor outcome characteristics in question. Thus, while certain systems' predictive abilities were significant statistically, their usefulness in making individual predictions was quite limited. Specificity. As noted in the background section on this system, its specifity (i.e., rates of false positive and negative diagnoses) is variable but known, depending on the cutoff point used. Longitudinal Approaches Feighner Criteria. In 1972, Feighner and a gtoup of researchers at the Washington University in St. Louis described operational criteria for schizophrenia and 13 other psychiatric illnesses (Feighner et al. 1972). In doing so, they revived Kraepelinian diagnostic practice by including longitudinal features as a criterion for making the diagnosis of schizophrenia. Their theoretical position, based on previous research, was that a homogeneous outcome and the occurrence of similar disorders in the family defined diseases. Based on the then available data, they concluded that good and poor prognosis schizophrenia were, in fact, two different diseases (Robins and Guze 1970). Their criteria are explicitly designed to diagnose the "true" or poor prognosis gtoup of schizophrenics and, as such, contain longitudinal features (e.g., insidious onset, more than 6 months' duration of symptoms, poor premorbid adjustment) found to be associated with poor prognosis. They also include some strictly cross-sectional features (symptoms) and exclusion criteria designed to differentiate schizophrenia from affective disorders and psychosis associated with alcoholism and drug abuse. The criteria were espoused as having been "sufficiently validated by precise clinical description, followup and family studies to warrant their use in research as well as in clinical practice" (Feighner et al. 1972, p. 57). Publication of the Feighner criteria generated a great deal of interest and enthusiasm. Among all the systems reviewed here, this is the most frequently cited and the one for which most research data are available (Blashfield, unpublished). The impact of this system is evidenced by the incorporation of many of its features into DSM-IH. (American Psychiatric Association 1980). Table 7 highlights the similarities between the Feighner criteria and DSM-IH schizophrenia. Reliability. Studies reporting the reliability of the Feighner criteria are shown in table 4. Reliability for Feighner schizophrenia is about as good as that previously described for clinical diagnosis; but because percent of patients tend to fall into an undiagnosed category, the St. Louis system includes a large group of patients for whom diagnostic reliability is very low. In addition to the studies summarized in table 4, Helzer et al. (1978) examined the "concurrent diagnostic validity" of the Feighner system applied with a structured interview. The diagnostic concordance between a Feighner diagnosis made during a structured interview and one applied only after a chart review was calculated. The authors argued that one approach to measuring concurrent validity when no absolute standard exists is to ascertain whether independent techniques for making a diagnosis arrive at the same conclusion (a reliability measure utilizing two sources of information). Although concordance (kappa) for some diagnoses was high (mania:.75), the value for schizophrenia was.37, suggesting that when information variance is not controlled, the reliability of the St. Louis schizophrenia diagnosis is quite low. In a second study (Helzer et al. 1977), test-retest reliability was assessed by comparing initial diagnosis among 314 psychiatric emergency room patients with an independent diagnosis made 18 months later at a followup examination. Both diagnoses were based on data obtained in a structured interview. A kappa of.89 was reported for the diagnosis of schizophrenia. This high value is difficult to interpret, however, since the initial diagnosis for the schizophrenic patients, when checked against the followup diagnosis, was described as incorrect in 38 percent of the cases.

15 466 SCHIZOPHRENIA BULLETIN Table 7. Comparison of DSM-III and Felghner Criteria Course DSM-III: The diagnosis of schizophrenia requires that continuous signs of the illness have lasted for at least 6 months at some time during the person's life. The 6-month period must include an active phase during which there were symptoms (as defined in criteria) with or without a prodromal or residual phase Feighner: A chronic illness with at least 6 months of symptoms before the index evaluation without return to the premorbid level of psychosocial development Absence of full affective syndrome DSM-III: The full depressive or manic syndrome is either not present or, if present, developed after any psychotic symptoms, or was brief relative to the duration of psychotic symptoms in A (as defined in criteria) Feighner: Absence of a period of depressive or manic symptoms sufficient to qualify for affective disorder or probable affective disorder Characteristic symptoms DSM-III: Symptoms 1-5 refer to delusions and auditory hallucinations. Symptom 6 refers to incoherence, poverty of speech content. Of the 6 symptoms, only 1 must be present during a phase of the illness Feighner: Symptom 1 refers to delusions or hallucinations. Symptom 2 refers to verbal production which makes communication difficult due to a lack of logical or understandable organization. At least 1 of the 2 above symptoms is required Age of onset DSM-III: Onset of prodromal or active phase of illness before age 45 Feighner: Onset of illness before age 40 Validity. Although it may be tautological (see below) to speak of the predictive validity of the Feighner diagnosis of schizophrenia / outcome has been offered as proof of its validity. Studies of the Iowa 500 (Morrison et al. 1972, 1973) are often cited as support for its predictive validity. In a review of the records of patients admitted to the Iowa State Psychopathic Hospital between 1934 and 1944, 515 patients receiving the clinical diagnosis of schizophrenia were identified. Among these, 220 met the Feighner criteria for schizophrenia. The authors hypothesized that those who did not meet the criteria (referred to as schizophreniform) would do comparatively better at followup. Sources of followup information for the schizophrenics included interviews with the patient in 17 percent of cases, information from a close friend or relative in 25 percent, and a letter or chart review in 53 percent. Overall, some information was available for 94 percent of the patients. Length of followup ranged from 1 to 20 years, the mean being 2.6 years. As predicted, the schizophreniform patients were three times more likely to have made a complete recovery and twice as likely to be socially recovered as the Feighner schizophrenics. Ninety-two percent of the latter group remained chronically ill with process schizophrenia for the entire followup period. It was concluded that the criteria were able to predict recovery by their absence and continued dysfunction by their presence, and that patients meeting these hard criteria would be more likely to require continuous care than those who failed to meet the criteria. The fact that the Feighner criteria can identify patients with poor prognosis has remained undisputed and, as such, they have been used effectively by numerous investigators (Tsuang and Winokur 1974; Tsuang, Dempsey, and Rauscher 1976; Robins et al. 1977; Tsuang and Dempsey 1979). What has been disputed is whether prognosis can be considered a validating criterion for a system that reserves the diagnosis of schizophrenia for patients who have already manifested established chronicity (e.g., for inclusion, patients must have demonstrated more than 6 months of symptoms). Since it has been repeatedly shown (Vaillant 1964; Brown et al. 1966; Strauss and Carpenter 1974; Mintz, O'Brien, and Luborsky 1976) that established chronicity predicts future chroniciry for most psychiatric disorders, Strauss and Carpenter (1974b) and others have pointed out that the requirement of chronicity as a diagnostic criterion negates the utility of poor outcome as an independent validator. Taylor and Abrams (1975) compared a group of patients who satisfied their own research criteria for mania. Among the individual

16 VOL. 7, NO 3, Feighner criteria, only duration of illness and the exclusion criteria of diagnosable affective disease distinguished the two groups. Symptoms of delusions, hallucinations, or lack of understandable speech were equally frequent in the two groups. Bland (1979), using records from a first index admission, applied the Feighner criteria to 43 patients with a chart diagnosis of schizophrenia. Those who, except for insufficient duration, could otherwise meet the criteria were classified as probable schizophrenic. Outcome 14 years later was rated on 0-3 scales for employment, social adjustment, and psychiatric condition. Certainty of diagnosis (nonschizophrenic n = l, probable n=22; schizophrenic n = 20) correlated positively with outcome except in the area of social adjustment where no relationship was found. Assigning a "Feighner score" based on the number of criteria satisfied also resulted in significant correlations. This should be of no surprise since several of the Feighner criteria tap poor past functioning. Tsuang, Dempsey, and Rauscher (1976), using data from the Iowa 500, confirmed the Feighner system's identification of poor prognosis patients by comparing outcome in a group of schizophrenics who met the criteria with a group of atypical schizophrenics who were excluded due to insufficient duration of symptoms or presence of affective symptoms at index admission. Fully 85 percent of these atypical patients showed the schizophrenic symptoms manifest in the typical group, again suggesting that duration was the principal predictor of poor outcome. Strauss and Carpenter's (1977) suggestion that the predictive validity of the Feighner system may be largely accounted for by the requirement of 6 months of symptoms is supported by the studies cited above. Among the original Iowa 500 good prognosis schizophreniform patients who had chart diagnoses of schizophrenia but could not meet the Feighner criteria, the most frequent reason for failure to do so was insufficient duration of symptoms (Tsuang, Dempsey, and Rauscher 1976). Gift et al. (1980) have shown that the other reason (presence of affective symptoms) alone has little predictive value. Attributing predictive validity in this way to a system that requires established chroniciry as a diagnostic criterion is merely stating a tautology that results in a misleading impression of validity. Some data are now available which indirectly address the issue of construct validity in Feighner schizophrenia. Several studies have reported the prevalence of schizophrenia among relatives of patients diagnosed with the Feighner system. Tsuang, Dempsey, and Rauscher (1976) found that the prevalence of schizophrenia in parents and sibs of patients meeting the criteria was identical to that of the atypical patients who did not meet the criteria, although the latter patients' families showed more affective disease. Taylor and Abrams (1975) studied 89 patients who received a clinical diagnosis of schizophrenia and found that 11 (12 percent) satisfied the Feighner criteria. Among 19 first-degree relatives of these patients, two had diagnosable affective disorders, but none could be found with schizophrenia. Winokur et al. (1972) reviewed the family history records of patients in the Iowa 500 sample and not only reported a low morbidity risk for schizophrenia (2.11 percent) among first-degree relatives of patients diagnosed with the Feighner system, but also found a higher morbidity risk for affective disease (5.5 percent) among these relatives. In another study which subtyped patients meeting the Feighner criteria, Winokur et al. (1974) found a relatively low morbidity risk for schizophrenia among the first-degree relatives of hebephrenic patients (2.75 percent) and a risk among the relatives of paranoid patients (.83 percent) that was no greater than the risk for schizophrenia in the general population. These studies suggest that the Feighner criteria, while generally able to select those without an increased familial incidence of affective disorders, are not validated by their ability to define patients with a specifically increased risk of schizophrenia in the family. A recent study (Tsuang, Winokur, and Crowe 1980) did find a higher morbidity risk of schizophrenia (3.2 percent) among first-degree relatives of schizophrenic patients personally interviewed compared to the risk among patients with mania (1.0 percent), depression (.9 percent) and nonpsychiatric controls (.6 percent). The risk of affective disorders among these Feighner diagnosed schizophrenic relatives was 7.0 percent. The critical question, however, is whether a particular diagnostic approach is more successful than others in maximizing heritability. Since studies done before the advent of the modem systems of research diagnostic criteria (Kessler 1980) have shown that among first-

17 468 SCHIZOPHRENIA BULLETIN degree relatives of a schizophrenic proband, the average risk for schizophrenia is between 8 and 10 percent, the Feighner criteria may in this regard be less valid. Ideally, if a blind study could demonstrate that the families of schizophrenics, as defined by the Feighner system, have a higher prevalence of schizophrenia than families of patients defined by other systems, this finding could be taken as evidence of validity of the system. Until such a study is conducted, however, the validity of the Feighner system, measured in this way, remains unsupported. Specificity. By design, certain diagnoses in the Feighner system are mutually exclusive (affective disorder and schizophrenia, alcoholism and schizophrenia) while others may be made in the same patient (affective disorder and alcoholism; anxiety neurosis and depression). The criteria allow for the coexistence of most syndromes. Thus, in the study of Robins et al. (1977), a total of 477 diagnoses were applied to 314 patients (1.5 diagnosis per patient). One hundred and ninety patients received one diagnosis; 90 patients, two diagnoses; 30 patients, three diagnoses; three patients, four diagnoses; and one patient, four and five diagnoses, respectively. In the Washington University reliability study of 101 psychiatric inpatients, the average number of diagnoses made per patient was 2.5 (Helzer et al. 1977). Allowing multiple diagnoses, but calculating kappa on the basis of them singly, may have elevated the kappa values reported in these studies. What is certain is that the diagnostic categories overlap considerably. Another consequence of the Feighner approach is the necessity of an "undiagnosed psychiatric disorder" category for those patients who do not meet any of the criteria for the specified diagnoses. The size of this gtoup when the criteria are used is a direct measure of how specific and comprehensive the system is. Among the 101 psychiatric inpatients mentioned above, 18 percent were classified in the undiagnosed category. This is more than three times the rate diagnosed schizophrenic in these groups. Spitzer and Fleiss (1974) reported that the Feighner undiagnosed category is applied to percent of newly admitted inpatients. Comparative studies have all found Feighner criteria to define patients most narrowly. Strauss and Gift (1977) applied the Feighner criteria to a sample of patients first hospitalized for a psychiatric disorder. Of the 272 patients in the sample, 122 (44.8 percent) were classified schizophrenic by at least one set (of six) of criteria. The Feighner criteria diagnosed nine (3.3 percent) patients as schizophrenic. Further, 71 (26 percent) of the patients were classified in the undiagnosed category using the Washington University system. The size of this latter group suggested to the authors that it was analogous to the old schizophrenia category (e.g., same patients labeled differently). Thus, only a small subset of the old schizophrenia category the new Feighner schizophrenia group was defined more clearly by the system. The remainder of the group was placed in a negative category (undiagnosed) with minimal communication value for clinical research or theoretical purposes. On the other hand, a large undiagnosed category may be viewed positively as accurately reflecting current knowledge (Guze 1980). To conclude, the Feighner criteria are successful in defining a narrow group of patients who are homogeneous with regard to the specified criteria used to assemble them. As a diagnostic system defining schizophrenia, there is no evidence that it represents a substantial improvement over previous methods. It improves diagnostic reliability slightly for a very restricted subgroup of the former schizophrenia category while decreasing it for the remainder of this group. It is neither comprehensive nor nonoverlapping. Its validity can only be defined prognostically, and since evidence suggests that past function predicts future functioning regardless of diagnosis or symptoms, this axis is basically tautological, and of limited usefulness. Various attempts to establish its construct or concurrent validity suggest that Feighner schizophrenics are no more suffering from a "true disease" or "true" schizophrenia than those defined in any other way. Research Diagnostic Criteria. As part of a collaborative project on depressive disorders sponsored by the Clinical Research Branch of the National Institute of Mental Health, Spitzer, Endicott, and Robins (1978) developed the Research Diagnostic Criteria (RDC). They are described as an elaboration, expansion, and modification of the Feighner criteria. For schizophrenia, the RDC inclusion criteria rely heavily on the presence of Schneidarian firstrank symptoms. In addition, 2 weeks' duration is required, and those with a prominent affective component are excluded and clas-

18 VOL 7, NO. 3, sified separately under schizoaffective disorder. The RDC can be used with direct examination or with detailed case records. A structured interview, the Schedule for Affective Disorders and Schizophrenia (SADS), has been developed (Endicott and Spitzer 1978, 1979) and is designed to reduce information variance when making an RDC diagnosis. Using different versions of the SADS, researchers can assign a diagnosis for the current episode or a lifetime diagnosis. An additional feature of the RDC is the flexibility of rating according to varying degrees of certainty: illness not present, probable, or definite (Spitzer, Endicott, and Robins 1978). Reliability. Spitzer, Endicott, and Robins (1975, 1978) and Spitzer et al. (1975) have reported the reliability of the RDC under various testing conditions. These studies, as shown in table 4, demonstrate varying degrees of reliability with an overall trend toward higher kappas than have been reported for other diagnostic systems. As might be expected, reliability is affected by the amount of information shared by the raters and the use of the structured interview. One difficulty in interpreting the data is the fact that in all studies ratings of "illness probable" or "illness definite" were collapsed to indicate concordance for "illness present." The effect of this manipulation on the reported kappas cannot be ascertained from the published studies. Validity. Although the RDC have been used extensively to define populations for research, the validity of RDC schizophrenia has been studied only in terms of outcome prediction. As described in relation to the other diagnostic approaches, Kendell, Brockington, and Leff (1979) and Brockington, Kendell, and Leff (1978) followed up 134 patients diagnosed by various operational definitions an average of 6.5 years after index examination. All six definitions were more successful at predicting poor symptomatic outcome than a social outcome, and the RDC, one of the most predictive systems, could only be described as about as good as clinical diagnosis in predicting outcome. Even in the area of persistent delusions or hallucinations, where it was shown to be statistically most predictive, only 43 percent of the RDC schizophrenics demonstrated the poor outcome characteristic in question. Further data on the validity of the RDC must await the results of various genetic, psychobiologic, and treatment outcome studies currently underway (Spitzer, Endicott, and Robins 1978; Alexander, Van Kammen, and Bunney 1979; Mandell and Knapp 1979). Specificity and Comprehensiveness. As distinct from the Feighner criteria where 6 months' duration of symptoms is required, the RDC requires only 2 weeks. While this change might be expected to broaden the definition, this tendency is counterbalanced by the RDC's not considering schizophrenic any patients with an important affective component to their symptomatology. Kendell, Brockington, and Leff (1979) found that among 134 patients, 59 of whom met at least one of six operational definitions of schizophrenia, 34 (25 percent) were considered such by the RDC. Overall and Hollister (1979) found that 73.5 percent of 166 clinically diagnosed schizophrenics met the RDC. Strauss and Gift (1977) applied five systems to a group of 272 patients and found the RDC to be the most narrow of definitions, considering only four (1.4 percent) of the patients schizophrenic. In this study 53 were defined as schizophrenic by clinical (DSM-1I) criteria. Feighner's criteria used a negative (undiagnosed) category for the large group that could not fit the narrow schizophrenia definition, but with the RDC system, Strauss and Gift found that many of these met the criteria for the new schizoaffective category. Sixty-eight patients or 25 percent of the sample were classified as schizoaffective, depressed a group comparable in size to the old schizophrenia category. A recent study (Stephens et al. 1980) found almost complete concordance between collapsed RDC schizophrenia and schizoaffective disorder and DSM-II schizophrenia. The disparate picture of the relative narrowness or breadth of the RDC apparent from the three studies just described may be attributed to the fact that hallucinations scored for RDC schizophrenia do not include those having a clearly depressive theme. As Overall and Hollister (1979) point out, this distinction is one of the more nebulous that users of the system must make. While reliability studies between research gtoups might shed more light on this question, it is apparent that at least within one research group, the RDC can fairly reliably identify both the small "true" schizophrenic group and the large new schizoaffective one (table 4). By creating new categories such as schizoaffective, the RDC is able to maintain a narrow definition of

19 470 SCHIZOPHRENIA BULLETIN schizophrenia and still classify most patients. The "other psychiatric disorder" category, for those who do not meet any of the specific criteria, is needed for about 5 percent of an inpatient population (Spitzer, Endicott, and Robins 1975). It is possible, however, that by splitting off a relatively small group of schizophrenics and creating new large categories, both the RDC and Feighner systems have shifted the problem more than solved it (Strauss and Gift 1977). Whether atypical patients defined on the basis of short duration and/or the presence of affective symptoms should be classified as schizophrenic, manic-depressive, or considered to have a third psychosis is at present being heatedly debated (Pope and Lipinski 1978; McGlashan and Carpenter 1979; Overall and Hollister 1979). DSM-III Schizophrenia. Although DSM-111 is a new and to some extent unknown entity, far from being created in a vacuum, it has evolved directly from the Feighner criteria and the RDC. Spitzer, Endicott, and Robins (1975, 1978) and Spitzer, Williams, and Sokdol (1980) describe DSM-III as a modification of the RDC, which is itself described as a modification and elaboration of the Feighner criteria (Feighner et al. 1972). It is therefore properly grouped with longitudinal systems. For the diagnosis of schizophrenia, the similarities between the Feighner criteria and DSM-III are highlighted in table 7. Data exist only about the reliability of draft versions of DSM-III. Nevertheless, on the basis of its derivation from the RDC and Feighner criteria, some predictive statements about its validity and specificity can be made. Reliability. Spitzer, Forman, and Nee (1979) have recently reported field trials on the reliability of DSM-III (draft version). The clinician sample was recruited by notices appearing in mental health publications. Pairs from 274 clinician participants evaluated 281 adult patients falling within 15 major diagnostic categories seen in various settings. Diagnosticians did half of the evaluations jointly (both present at the same evaluation interview) with the remainder conducting separate interviews. Although 40 percent of the testretest interviews were done within 1 day of each other, almost half were done more than 3 days apart. Both clinicians were to have access to the same materials such as case records, letters of referral, nursing notes, and family informants. Kappa is reported for agreement as to whether or not the patient has a disorder within a diagnostic class (e.g., the diagnosis of paranoid and catatonic schizophrenia by two clinicians is considered agreement on schizophrenia). As shown in table 8, under these testing conditions adequate reliability for schizophrenia and somewhat less reliability for schizoaffective disorders are demonstrated. A study which maintained totally independent judgments would more definitively evaluate the reliability of DSM-III. Validity. By requiring 6 months' duration of "disturbance or impairment" for the diagnosis of schizophrenia, it is almost certain that DSM-III will have a predictive validity similar to that found for the Feighner criteria. However, this cannot be construed as supporting the notion that DSM-III schizophrenia is validated by outcome as a medical entity. Previous studies on the RDC and Feighner criteria provide no reason to believe that the DSM-III criteria will be more valid than DSM-II type clinical diagnosis in predicting treatment response or a specifically higher prevalence of schizophrenia in the family (Alexander, Van Kammen, and Bunney 1979). Comprehensiveness. Like the Feighner criteria and RDC, DSM- III defines schizophrenia quite narrowly. Similarly, it is likely that at least among newly hospitalized patients, DSM-III schizophrenia will be uncommon. As described, those in the "old" schizophrenia category not able to meet the Feighner and RDC criteria tend to be classified by these systems as "undiagnosed" or "schizoaffective," respectively. While Strauss and Gift (1977) have suggested that creating these large groups may only be shifting the problem, DSM-III, when used as intended, may turn out to diffuse it. Presumably these patients will tend to be classified in one of four other major DSM-III groups: paranoid, other psychotic (schizophreniform, brief reactive, and schizoaffective), affective (especially "mood incongruent"), or personality disorders (especially schizotypal, schizoid, avoidant, and borderline). By including so many categories, DSM-III is likely to be comprehensive, but whether these and the multiple subcategories can be assessed reliably, much less validated, remains to be seen. Discussion This review has attempted to assess systematically the relative merits of five diagnostic methods

20 VOL 7, NO 3, Table 8. Kappa coefficients of agreement for DSM-IH diagnostic classes for 281 adults 1 Diagnostic class Disorders of infancy, childhood, or adolesence Mental retardation Disorders characteristic of late adolescence Eating disorders Organic mental disorders Senile and presenile dementias Substance-induced organic brain syndromes Organic brain syndrome with unknown etiology Substance use disorders Schizophrenic disorders Paranoid disorders Schizoaffective disorders Affective disorders Major affective disorders Chronic minor affective disorders Psychoses not elsewhere classified Anxiety disorders Factitious disorders Somatoform disorders Dissociative disorders Psychosexual disorders Paraphilias Psychosexual dysfunctions Adjustment disorders Disorders of impulsive control not elsewhere classified Overall kappa for major classes, axis I Overall kappa for personality disorders, axis II of total Interview method Joint (n=150) Test-retest (n=131) 'Reprinted, with permission from Spltzer, Forman, and Nee (1979), Copyright American Psychiatric Association. 'Percent of all subjects given diagnosis by at least 1 clinician. Because some subjects received diagnoses from 2 minor classes within a major class (e.g., a major affective disorder and a chronic minor affective disorder), the total percent of subjects in minor classes may exceed the percent of total subjects In the major class. Only in the case of substance use disorders was there an appreciable difference in percentages between the groups (joint %, test-retest = 14.5%). that provide explicit criteria for diagnosing schizophrenia. Because of its derivation from two of them, the DSM-III schizophrenia category is also included despite its relative newness and hence a paucity of data with which we could assess its merit. Most of the important issues have already been covered in the text. However, several points deserve emphasis: It is possible to identify, define, and obtain consensus as to the presence of a set of behaviors that can be labeled schizophrenia. The size of the group of persons fitting into diagnostic categories will depend on the criteria used. For example, the NHSI casts a relatively wide "net," while the Feighner criteria yield a much smaller "catch." Because none of these systems

21 472 SCHIZOPHRENIA BULLETIN have construct validity, they are arbitrary. That is, until one or another of them (or a new one) is able to meet the criteria used for defining other medical diseases, one cannot say that schizophrenia defined by system "A" is "true schizophrenia" while that defined by system "B" is not. Until such a system is found, it would seem wise to heed the advice of Sir Aubrey Lewis: "To set up sharp distinctions in the interests of academic accuracy, when the distinction is not found in nature, is no help to thought or action" (Mosher 1978). DSM-III differs from the other diagnostic systems reviewed because it is an official nomenclature and thus will be taught to both current practitioners and trainees, resulting over time in a new schizophrenia diagnostic "culture" in the United States. For schizophrenia, this review of diagnostic approaches suggests that the elevation of a single approach as official may be premature. In the absence of empirical evidence for superiority, the reasons for the elevation and prescription of one diagnostic approach must be looked for elsewhere. Overall and Hollister's (1979) recent study is particularly germane to the question of premature closure: They applied several sets of diagnostic criteria to a group of 166 clinically diagnosed schizophrenics and found that the different criteria, narrow or broad, defined only partially overlapping groups and that no objective criteria could precisely map the clinical population of schizophrenia. They suggest that the relative merits of each be examined before any one set is accepted as superior to current clinical diagnosis. To facilitate the needed empirical comparisons, they developed a Composite Diagnostic Checklist for Schizophrenia (CDC-Schizo) that can be used to determine how many, and which, among several sets of criteria a given patient meets. Another example of the limitations in DSM-III's extremely narrow definition of schizophrenia can be found in the elegant diagnostic study of Gottesman and Shields (1972). They reported that either very narrow or very broad definitions of schizophrenia reduced the concordance rates among identical twins in the Maudsley series. Ergo, "middle of the road" diagnosis produced higher rates of heritabiliry. Few would deny that improved reliability and a multiaxial approach are the major praiseworthy achievements of DSM-III (Spitzer, Williams, and Skodol 1980). At the same time, because cross-sectional symptomatology and longitudinal features are largely independent of each other, we believe they should not be confounded in a single axis, and consider this feature of DSM- III's criteria for schizophrenia to be its most serious potential methodological flaw. We recognize the very great difficulties in developing and revising a diagnostic system. However, we are concerned that the DSM-III schizophrenia category will be attributed powers it lacks, leading to its reification despite evidence of arbitrariness. The last word on diagnosis has yet to be spoken. Studies addressing the question of comparative validity will promote the acquisition of good scientific data relevant to the many questions that remain unanswered. References Abrams, R., and Taylor, M. Firstrank symptoms, severity of illness, and treatment response in schizophrenia. Comprehensive Psychiatry, 14: , Alexander, P.E.; van Kammen, D.P.; and Bunney, W.E., Jr. Serum calcium and magnesium levels in schizophrenia. Archives of General Psychiatry, 36: , American Psychiatric Association. DSM-III: Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. Washington, DC: APA, Astrachan, B.M.; Brauer, L.; Harrow, M.; and Schwartz, C. Symptomatic outcome in schizophrenia. 31: , Astrachan, B.M.; Harrow, M.; Adler, D.; Brauer, L.; Schwartz, A.; Schwartz, C; and Tucker, G.A. A checklist for the diagnosis of schizophrenia. British Journal of Psychiatry, 121: , Beck, A.T. Reliability of psychiatric diagnoses: I. A critique of systematic studies. American Journal of Psychiatry, 119: , Beck, A.T.; Ward, C.H.; Mendelson, M.; Mock, J.E.; and Erebaugh, J.K. Reliability of psychiatric diagnoses: II. A study of consistency of clinical judgments and ratings. American Journal of Psychiatry, 119: , Bland, R.C. Schizophrenia: Diagnostic criteria and outcome. British Journal of Psychiatry, 134:34-38, Bland, R.C, and Orn, H. Schizophrenia: Schneider's first-rank symptoms and outcome. British Journal of Psychiatry, 137:63-68, 1980.

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