VITA Shirley L. Campbell was born in Danville, Illinois on. She was reared in covington, Indiana and

Transcription

1 VITA Shirley L. Campbell was born in Danville, Illinois on January 6, She was reared in covington, Indiana and has lived there most of her life. She attended Danville Area Community College between 1980 and 1985, and received her Bachelor of Science degree, Magna Cum Laude, from Indiana State University in May, Ms. Campbell received full academic scholarships from , was awarded an American Psychological Association Dissertation Research Award in 1991, is a member of Phi Kappa Phi Honor Society, and is a student affiliate of the Indiana Psychological Association and the American Psychological Association. She is employed at the Danville, Illinois Veterans Administration Medical Center as a member of the Post Traumatic Stress Disorder Clinical Team.

2 SEX BIAS IN THE DIAGNOSIS OF NARCISSISTIC, HISTRIONIC, SADISTIC, AND BORDERLINE PERSONALITY DISORDERS A Doctoral Research Project Presented to The School of Graduate Studies Department of Psychology Indiana State University Terre Haute, Indiana In Partial Fulfillment of the Requirements for the Degree Doctor of Psychology by Shirley L. Campbell May 1994 / INDIANA STATE UNIVERSITY LIBRARY

3 ii Approval Sheet The doctoral research project of shirley L. Campbell, contribution to the School of Graduate Studies, Indiana State University, Series IV, Number 61, under the title Sex Bias in the Diagnosis of Narcissistic, Histrionic, Sadistic and Borderline Personality Disorders is approved as partial fulfillment of the requirements for the Doctor of Psychology Degree. tf/d2/~f... ~,L~ Date _hairperson cf!22,/9f Date For the School of

4 iii Abstract Recently, considerable attention has been given to sex bias in the diagnosis of personality disorders. Research has shown that clinicians will assign different diagnoses to case histories of males and females that contain identical symptoms. The present study attempted to examine sex bias in the diagnosis of Narcissistic, Histrionic, Borderline, and Sadistic personality disorders. Psychologists were presented with a male or female version of each of three audiotaped simulated interviews: a Narcissistic/Histrionic case, a Depression/Anxiety symptom case used as a "filler case," and a Borderline/Sadistic case. It was predicted that psychologists would assign more diagnoses of Borderline and Histrionic to the female versions of the cases, and Sadistic and Narcissistic to the male versions. The results showed that, while sex of the patient did not have a significant effect on diagnoses assigned, there was a trend for more Narcissistic and Sadistic diagnoses to be assigned to the male interviews and Borderline to the female interview by male psychologists only. Limitations of this study and directions for future research are discussed.

5 iv ACKNOWLEDGEMENTS This research project was partially supported by a Dissertation Research Award presented by the American Psychological Association, I would like to thank the members of my committee, Dr. Robert Levy and Dr. Michael Murphy, who have helped and encouraged me on numerous occasions. I would especially like to thank my chairperson, Dr. June Sprock, not only for her professional guidance, but for her unending encouragement and support throughout this project and my entire doctoral training. Dr. Sprock has been an inspiration to me in many ways, professionally and personally.

6 v TABLE OF CONTENTS Page LIST OF TABLES vii Chapter 1. INTRODUCTION 1 2. METHOD 11 subjects Materials. Procedure RESULTS Case 1 (Narcissistic and Histrionic Symptoms) Case 3 (Borderline and Sadistic Symptoms) DISCUSSION 37 REFERENCES 47 APPENDIXES A. Case Scripts 49 Case 1: Narcisistic-Histrionic Case 2: Depression-Anxiety Case 3: Borderline-Sadistic 58 B. Diagnostic Questionnaire 63 C. Demographic Questionnaire D. pilot Studies. 66 pilot Study

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8 vii LIST OF TABLES Table Page 1 Subjects' Number of Years Experience as a Mental Health service Provider Frequency and Percentage of Psychologists Employed in Different Settings Frequency and Percentage of Clinicians Who Reported Commonly Treating specific DSM-III-R Disorders DSM-III-R criteria Used in the Narcissistic Histrionic Symptom Case (Case 1) DSM-III-R Criteria Used in the Borderline- Sadistic Symptom Case (Case 3) Mean Ratings of severity of Axis I Symptoms and Overall Axis I Pathology for the Narcissistic-Histrionic Case (Case 1) Frequency and Percentage of Clinicians Assigning specific DSM-III-R Personality Disorders to the Male and Female Versions of the Narcissistic Histrionic Case (Case 1) Percentage of Male and Female Subjects Assigning Specific Personality Disorder Diagnoses to the Two Versions of the Narcissistic-Histrionic Case (Case 1) Percentage of Subjects Recommending Treatment for the Narcissistic-Histrionic Case (Case 1) Mean Ratings of Likelihood of Improvement for the Three Treatment strategies for the Narcissistic Histrionic Case (Case 1) Mean Ratings of severity of Axis I Symptoms and Overall Axis I Pathology for the Borderline- Sadistic Case (Case 3) 30

9 viii Table Page 12 Frequency and Percentage of Clinicians Assigning Specific DSM-III-R Personality Disorders to the Male and Female Versions of the Borderline- Sadistic Case (Case 3) Percentage of Male and Female subjects Assigning specific Personality Disorder Diagnoses to the Two Versions of the Borderline Sadistic Case (Case 3) Percentage of Subjects Recommending Treatment for the Borderline-Sadistic Case (Case 3) Mean Ratings of Likelihood of Improvement for the Three Treatment Strategies for the Borderline Sadistic Case (Case 3) Number of Subjects Who Endorsed Symptoms and Mean Rating of severity for the Narcissistic-Histrionic Case (Case 1) Number of SUbjects Who Endorsed Symptoms and Mean Rating of severity for the Borderline-Sadistic Case (Case 3) Number of Subjects Who Assigned Disorders for Case 1 and Case Mean Ratings of Believability and Typicality of the Two Cases Mean Ratings of Typicality of Interviewer and Believability of the Interview for Cases 1 and

10 1 Chapter 1 INTRODUCTION Women are diagnosed and treated for mental disorders far more often than men, and the literature abounds with theories to account for this difference (carmen, Russo, & Miller, 1981; Gilligan, 1979; Gove & Tudor, 1973; Phillips & Segal, 1969). The proposed theories range from biological explanations to sex bias based on sex-role stereotyping and beliefs about what constitutes a healthy adult male and female (Broverman, Broverman, Clarkson, Rosenkrantz, & Vogel, 1970). Sex bias in the diagnosis of mental disorders has been a controversial topic which has received considerable attention over the last two decades, particularly in the diagnosis of depression and personality disorders. Lately, there has been considerable attention given to the possibility of sex bias in the criteria for personality disorders in the Diagnostic and Statistical Manual for Mental Disorders, third edition (DSM-III; American Psychiatric Association, 1980), and the Diagnostic and statistical Manual for Mental Disorders, third edition revised (DSM-III-R; American Psychiatric Association, 1987)

11 2 (Kaplan, 1983; Williams & Spitzer, 1983; Widiger & Nietzel, 1984; Hamilton, Rothbart, & Dawes, 1986; Sprock, Blashfield, s Smith, 1990). Kaplan (1983) argued that there are masculine biased assumptions built into DSM-III criteria which influence clinicians' diagnoses. These male biases influence the determination of which behaviors are considered healthy and which are considered pathological. women may be labeled as disordered. As a result, healthy The definitions of mental disorder and social deviance result in vague rules for differentiating between the two, and leave open the possibility for clinicians' values, which may reflect society's sexism, to influence their decision making. According to Kaplan, women are more frequently diagnosed with Histrionic, Dependent, and Borderline personality disorders (PD), and men are more frequently diagnosed with Paranoid, Antisocial, and Compulsive PD (from this point on "PD" will be used as an abbreviation for personality disorder when referring to the names of specific personality disorders). Williams and Spitzer (1983), who were both involved in the development of DSM-III, replied to Kaplan's article and stated that conscientious attempts were made to ensure that DSM-III did not manifest sex bias, and that Kaplan provided no data to back up her hypothesis. While they noted that certain personality disorders are diagnosed more often for women (i.e., Dependent and Histrionic), and others are

12 3 diagnosed more often for men (i.e., Schizoid, Antisocial, Passive-Aggressive), they also pointed out that differential frequency of diagnosis is not sufficient evidence for gender bias. A number of studies have attempted to look at gender bias in the way that clinicians assign personality disorder diagnoses. These studies utilized the methodology of manipulating the gender in case vignettes while holding the symptoms constant. Generally, these studies have found that clinicians will assign different personality disorder diagnoses to male and female versions of a case even though the cases are otherwise identical. One of the earliest studies on gender bias in the diagnosis of personality disorders was conducted by Warner (1978). The results of this study suggested that the diagnosis assigned by clinicians is affected by the gender of the patient. Warner presented two versions of an identical case showing a variety of symptoms of psychopathology. In one version the patient was portrayed as female, and in the other, the patient was portrayed as male. The female patient was most frequently diagnosed as Hysterical PD, while for the male patient, Antisocial and Hysterical PD diagnoses were assigned equally. Henry and Cohen (1983) conducted a study looking at Borderline PD and found that a labeling process may be in effect when clinicians diagnose this disorder. As a part of their study, they asked male and female college students to

13 self-report symptomatology on a questionnaire that included 4 the DSM-III criteria for Borderline PD. Based on their findings that normal men report more Borderline characteristics than women, they suggested that clinicians may view these characteristics as more consistent with male sex roles and, as a consequence, find them more tolerable in men. In women these characteristics may not fit the typical female sex role and may be more likely to prompt a diagnosis of Borderline PD. Further support for sex bias in diagnosis was presented by Hamilton, Rothbart, and Dawes (1986). They suggested that vague diagnostic descriptions promote sex bias, and that sex bias is more likely to be evident when diagnostic categories describe personality traits as opposed to behaviors. They had 65 licensed clinical psychologists independently rate the applicability of personality disorder diagnoses to 18 written case studies based on 10 DSM-III categories, including Antisocial and Histrionic. Clinicians received either the male or female version of each case. Applicability of diagnosis was rated on a Likert-type scale from 1 (diagnostic category is not applicable) to 11 (diagnostic category is applicable). The results showed that the Histrionic case was rated as significantly more Histrionic when it was presented as female than as a male. However, they did not find the same sex bias for Antisocial; clinicians did not rate the male version of the case as showing more Antisocial pathology than the female version.

14 5 They proposed that the reason for the difference between the two diagnoses is that the diagnostic criteria for Antisocial are behaviorally anchored while the Histrionic criteria are trait dominated. Ford and Widiger (1989) conducted a study looking at sex bias in the diagnoses of Antisocial and Histrionic PO in which they also used rating scales. As part of their study they presented 266 psychologists with three brief case histories (Histrionic, Antisocial, or balanced) which were presented as either a male, a female, or sex unspecified patient. The balanced symptom case was used because it was believed that bias would be most evident in an ambiguous case such as the one used in the Warner (1978) study. SUbjects responded by rating the extent to which the patient had each of four specified Axis I disorders and five specified Axis II disorders (Narcissistic, Histrionic, Passive-Aggressive, Antisocial, and Borderline PO). The results suggested that sex biases were evident for diagnoses of Antisocial and Histrionic POi however, the cases that were most affected by the sex of the patient were the least ambiguous ones. They also found no differences in diagnosis between male and female subjects. A different approach in looking at gender bias in personality disorder diagnoses was presented by Sprock, Blashfield, and Smith (1990). They examined gender weighting for the OSM-III-R diagnostic criteria for personality disorders using a card sorting methodology.

15 6 They defined gender weighting as the degree to which the individual criteria for personality disorders varied along a male-female dimension. Individual personality disorder criteria were typed on index cards and subjects were asked to sort them along a male-female dimension. Differences in gender weighting may reflect sex role stereotyping, and if this stereotyping affects criteria for personality disorders, then non-clinicians would be expected to show gender weighting in their ratings of the criteria. The results revealed differences in gender weighting of criteria, with Dependent and Histrionic criteria viewed as feminine and Sadistic and Antisocial seen as strongly masculine. Although the authors had expected to find an Antisocial-Histrionic dimension, consistent with past research showing these disorders to be male and female prototypes, subjects in the study saw the criteria as occurring along a Sadistic-Dependent dimension. Another somewhat surprising finding was that Borderline PD did not show a gender weighting. The explanation for this finding was that all of the criteria for this disorder were seen as feminine except one, which was seen as strongly masculine, pulling the mean toward the middle of the dimension. Much of the past research on sex bias and personality disorders has focused on differential diagnosis of disorders such as Antisocial and Histrionic, or has examined sex bias in individual disorders, such as Borderline or Dependent. Although the methodology has varied, the personality

16 7 disorders under investigation have varied little. Most of the past attention has focused on Antisocial, Dependent, Histrionic, and Borderline PD. The present study attempted to examine sex bias in differential diagnosis involving two personality disorders which have received less attention, Narcissistic, and the newly proposed category listed in the appendix of DSM-III-R, Sadistic. Narcissistic PD is characterized by an exaggerated sense of self-importance. Narcissistic individuals crave constant attention and admiration, are self-centered, intolerant of criticism, feel that they are entitled to special favors, and are interpersonally selfish. Sadistic PD is characterized by a pervasive pattern of cruel, demeaning, and aggressive behavior toward others. for dominance and power. Sadistic individuals feel a need They lack respect and empathy for others, and take pleasure in others' pain or suffering. Sadistic PD was included in the appendix of DSM-III-R, rather than listed with Axis II personality disorders, because of the controversy surrounding it. Critics opposed to including Sadistic PD stated that there has been no systematic research on the disorder, and that it was included only to counterbalance the proposed Masochistic (Self-Defeating) PD (Holden, 1986). Both Narcissistic and Sadistic PD have been shown to be diagnosed more often for males than females (Philipson, 1985), and Sadistic was seen as the most masculine personality disorder in the Sprock et ale (1990) study.

17 In the present study, Narcissistic and Sadistic PD were 8 contrasted with Borderline and Histrionic PD. Both are more likely to be diagnosed for females (Ford & Widiger, 1989; Kass, spitzer, & williams, 1983; Williams & spitzer, 1983), and Histrionic had a feminine gender weighting in the Sprock et ale (1990) study. Borderline PD is characterized by affective instability, including depression and anger which is often inappropriate and intense, impulsivity, physically destructive acts, unstable and intense relationships, identity confusion, intolerance of being alone, and chronic feelings of emptiness. The characteristics of Histrionic PD include dramatic and exaggerated emotions, irrational angry outbursts, chronic need for attention, and overreaction to minor events. These individuals show disturbances in interpersonal relationships and are seen by others as superficial, demanding, inconsiderate, dependent, and manipulative. The first case contained a mixture of symptoms from Histrionic and Narcissistic PD while the second contained a mixture of symptoms from Sadistic and Borderline PD. Histrionic was paired with Narcissistic because some research has suggested that there is diagnostic overlap and confusion between these two disorders (Blashfield, McElroy, Davis, & Sprock, 1991). Borderline was selected as the feminine alternative to Sadistic because some symptoms (e.g., intense anger, physically destructive acts) overlap with symptoms seen in Sadistic personality disorder. Cases

18 9 with mixed symptomatology were used because research has shown increased bias in situations of uncertainty and ambiguity (Warner, 1978; Hamilton et al., 1986). In this study, licensed psychologists were presented with three tape recorded simulated intake interviews. One interview (Case 1) presented a client with an equal number of symptoms each from Narcissistic and Histrionic PD. The second interview (Case 2) presented symptoms of depression and anxiety, served only as a filler case, and was not analyzed for the purpose of this study. The third interview (Case 3) presented an equal number of symptoms each from Sadistic and Borderline PD. The sex of the clients was manipulated by using male and female actors to play the part of the client. The scripts were identical and the actors practiced to achieve as similar voices as possible. The psychologists received either the male or female version of each case and the order of presentation was partially counterbalanced. For Case 1, it was hypothesized that clinicians who received the female version of the case would be more likely to assign a diagnosis of Histrionic PD than those who received the male version of the case. Clinicians who received the male version of the interview were expected to assign a diagnosis of Narcissistic PD more often than those who received the female version of the case. For Case 3, it was hypothesized that clinicians would be more likely to assign a diagnosis of Borderline PD when the client in the

19 10 interview was a female than a male, while they would be more likely to assign a diagnosis of Sadistic PD when the client in the interview was a male than a female.

20 11 Chapter 2 METHOD SUbjects Approximately 221 licensed psychologists, who were current members of the Indiana Psychological Association, were contacted first by mail and then telephone and asked to participate in the study. They were told that the study was about clinical judgment in assigning diagnoses and involved listening to three audiotaped intake interviews and completing a diagnostic questionnaire for each interview. Of the 221 clinicians contacted, a total of 70 (32%) agreed to participate in the study. SUbjects were randomly assigned to one of the four experimental groups, and the materials were mailed to them. Thirty-three psychologists (47%), of the 70 who agreed to participate, actually completed and returned the questionnaires. An additional six psychologists were recruited from the researchers' internship sites making a total of 39 subjects. Although there was no significant difference in mean ages between the original group (mean = 45.91, SD = 8.29) and the additional 6 subjects (mean = 39.00, SD = 5.62), t(37) = 1.95, R >.05, the original group

21 12 of subjects was significantly more experienced (mean = 15.97, SO = 8.37) than the six additional subjects (mean = 7.17, SO = 5.64), ~(37) = 2.46, R <.05. There were no significant differences between the original group and the additional six in terms of personality disorder diagnoses for Case 1 (X = 1.68) or Case 3 (X = 3.69); therefore, the results from all 39 subjects were grouped together for the analyses of the cases. It should also be noted that there were no significant differences between subjects recruited the two ways in their Axis I ratings, Axis II pathology ratings, or ratings of the effectiveness of different treatment strategies for either of the two cases. However, the original group rated Case 1 as more chronic (mean = 5.25 SO =.88) than the additional group of subjects (mean = 4.00 SO = 1.79), ~(36) = 2.66, R <.05. The 39 subjects, 21 males (54%) and 18 females (46%), ranged in age from 31 to 62 years old (mean = 44.85, SO = 8.27), and were relatively experienced with an average of (SO = 8.57) years as a mental health service provider (HSPP) in psychology. Licensed psychologists qualify for the designation of HSPP in Indiana after two years postdoctoral clinical experience. The males were significantly older (mean = 48.29, SO = 7.19) than the females (mean = 40.83, SO = 6.90), t(37) = 3.11, R <.05, and were more experienced (mean = 19.00, SO = 7.97), t(37) = 4.11, R <.05 than the females (mean = 9.50, SO = 6.18). Table 1 presents the breakdown of subjects in terms of years of experience.

22 13 Table 1. Subjects' Number of Years Experience as g Mental Health Service Provider Years Frequency Percent Psychologists must be endorsed as a HSPP in order to independently diagnose and treat mental disorders. The subjects were employed in a wide variety of settings as illustrated in Table 2. The largest number were employed in private practice, followed by community mental health centers, and general hospitals. The therapeutic orientation of the subjects was also varied. The majority (54%) described themselves as eclectic, 12 (29%) as cognitive-behavioral, three (8%) as psychodynamic, one (3%) each as social learning and humanistic, and one did not report therapeutic orientation. Most of the subjects in the sample reported that they generally treat three or more types of disorders in their clinical practice, indicating that the clinical experience of the subjects is broad. Table 3 provides a list of the DSM-III-R disorders they most commonly treat. The majority of the subjects reported that they treat mood and anxiety disorders, the most frequent disorders seen by mental health professionals. Approximately one-third of the subjects

23 reported treating patients with personality disorders, which is of particular interest to the present study. 14 Table 2. Frequency and Percentage of psychologists Employed in Different settings Employment Setting Frequency Percent Private Practice CMHC 7 18 General Hospital 6 15 outpatient Facility 4 10 VA Hospital 3 8 State Hospital 2 5 Private Hospital 1 3 University 1 3 Government Agency 1 3 Additionally, one subject reported treating all disorders, one subject reported treating nonpsychotic disorders, and one subject reported not currently being in clinical practice. However, this latter subject was kept in the study because of his 15 years of clinical experience. Materials Taped intake interviews: The simulated intake interviews were performed by seven volunteer students from the Theater Department at Indiana State University. One female acted as the "therapist" for all the cases, and three males and three females acted as the "patients" in the three cases. The interviews followed prepared scripts and each lasted approximately eight minutes. The first taped

24 15 Table 3. Frequency and Percentage of Clinicians Who Reported Commonly Treating Specific DSM-III-R Disorders Disorders Treated Frequency Percent Mood Anxiety Adjustment & V Codes Personality Childhood Psychotic 8 21 Organic 3 8 Substance Abuse 2 5 Impulse Control 1 2 Dissociative 1 2 Sexual Disorders 1 2 interview (Case 1) consisted of an equal number of symptoms (four each) from Narcissistic and Histrionic PD based on criteria in DSM-III-R (see Table 4). The criteria selectedwere those felt to overlap between the two disorders in order to present ambiguous cases which are more likely to elicit bias. The second taped interview (Case 2) presented an equal number of symptoms of depression and anxiety and was used only as a filler for the two cases of interest. The third taped interview (Case 3) consisted of an equal number of symptoms (four each) from Sadistic and Borderline PD based on criteria in DSM-III-R (see Table 5). Again, the symptoms that overlapped between the two disorders were selected in order to increase the ambiguity of the case. The interview scripts were written by the researcher and designed to follow the flow of a typical intake interview.

25 16 Table 4. DSM-III-R Criteria Used in the Narcissistic Histrionic Symptom Case (Case ~) Narcissistic Symptoms 1. Is interpersonally exploitative: takes advantage of others to achieve his or her own ends. 2. Has a sense of entitlement: unreasonable expectation of especially favorable treatment. 3. Requires constant attention and admiration. 4. Lack of empathy: inability to recognize and experience how others feel Histrionic Symptoms 1. Expresses emotion with inappropriate exaggeration. 2. Is overly concerned with physical attractiveness. 3. Is uncomfortable in situations in which he or she is not the center of attention. 4. Is inappropriately sexually seductive in appearance or behavior. See Appendix A for the scripts used for Cases 1, 2 and 3. Two pilot studies were conducted using graduate students in the Indiana State University Doctoral Program in Clinical Psychology. The first study evaluated whether the scripts contained the intended symptoms and were believable, while the second focused on the realism and sound quality of the audiotapes and whether the male and female versions of the cases were similar. Generally these pilot studies demonstrated that the cases contained the intended symptoms, were realistic and clear, and that the male and female versions were comparable. See Appendix D for pilot study information and results.

26 Table 5. DSM-III-R criteria Used in the Borderline-Sadistic symptom Case (Case 1) Borderline Symptoms 1. A pattern of unstable and intense interpersonal relationships. 2. Inappropriate, intense anger or lack of control of anger. 3. Affective instability: marked shifts from baseline mood to depression, irritability, or anxiety, usually lasting a few hours and rarely more than a few days. 4. Relationships characterized by alternating between extremes of overidealization and devaluation. Sadistic Symptoms 1. Is amused by, or takes pleasure in, the psychological or physical suffering of others. 2. Has lied for the purpose of harming or inflicting pain on others. 3. Restricts the autonomy of people with whom he or she has a close relationship. 4. Humiliates or demeans people in the presence of others. 17 Diagnostic questionnaire: The diagnostic questionnaire was based largely on the one developed by Perlick and Atkins (1984) for their study looking at age bias in the diagnosis of depression and dementia. It contained questions aimed ateliciting the subjects' diagnostic impressions of the client, and was constructed to become increasingly specific about the type of judgments the subjects would make. The subjects were first asked about Axis I pathology in the interview. They were asked to assign a DSM-III-R diagnosis and then rate the severity of the pathology for several

27 18 major Axis I disorders and overall Axis I pathology using Likert scales ranging from 1 (not present) to 7 (extremely severe). A similar set of questions followed for Axis II personality disorder pathology. Finally, the subjects were asked to provide treatment and/or management recommendations in an open-ended format, followed by ratings on a scale of 1 (not likely) to 7 (extremely likely) that the patient would improve with specific treatment strategies (i.e., antidepressant medication, anti-anxiety medication, psychotherapy). See Appendix B for a copy of the diagnostic questionnaire used for all three cases. A pilot study was conducted to identify any problems with the questionnaire and to examine two alternative orderings of the items. The pilot study showed no difficulty with the questionnaire and the version rated easier to use was selected for the study (see Appendix B). Demographic questionnaire: The demographic questionnaire (see Appendix C) was developed to provide information about the subjects and their clinical experience. It included questions regarding the subjects' gender, age, theoretical orientation, employment setting, the disorders which they most commonly treat, and their number of years of clinical experience. Procedure Envelopes containing an informed consent form; printed instructions; the three tape-recorded interviews; the demographic questionnaire; three identical diagnostic

28 19 questionnaires labeled Case 1, Case 2, and Case 3; and a prestamped return envelope were mailed to each subject who agreed to participate in the study. Subjects were randomly assigned to one of four experimental conditions: (1) Case 1 (male), Case 2 (female), Case 3 (female); (2) Case 1 (female), Case 2 (male), Case 3 (male); (3) Case 3 (female), Case 2 (male), Case 1 (male); (4) Case 3 (male), Case 2 (female), Case 1 (female). One-half of the subjects received the male version of Case 1 and female version of Case 3, while the other half received the female version of Case 1 and the male version of Case 3. One-half of the subjects received Case 1 first while the other half received Case 3 first. The depression-anxiety filler case was always presented second and one-half received the male and one-half the female version. instructions read as follows: In all experimental conditions the printed The purpose of this study is to try to get at the processes or reasoning involved in making a diagnosis. We are particularly interested in the way in which symptoms are grouped or clustered in the diagnostic process. You will hear three different taped recordings of standard intake interviews lasting approximately eight minutes each. The tapes are labeled "Case #1," "Case #2," and "Case 3." After listening to each interview you are asked to diagnose the clients in the same way you would ordinarily diagnose any client and complete the diagnostic questionnaires. After you have completed the questionnaires, please return all materials in the envelope provided.

29 20 Chapter 3 RESULTS Case 1 (Narcissistic and Histrionic Symptoms) For Case 1, the Narcissistic and Histrionic symptom case, 16 subjects (7 female, 9 male) received the male version while 23 (11 female, 12 male) received the female version. The subjects were first asked to assign an Axis I diagnosis for the case. Only eight (21%) of the subjects assigned an Axis I diagnosis, and of these, seven also assigned an Axis II diagnosis. None of the psychologists diagnosed a major Axis I disorder; three assigned an adjustment disorder and five a V-Code (i.e., problems in living not associated with a mental disorder). They were then asked to rate the presence and severity of organic impairment, clinical depression, substance abuse, and anxiety disorder for the case, and to rate the overall Axis I pathology on Likert-type scales from 1 (not present) to 7 (extremely severe). Table 6 provides the mean ratings of Axis I pathology for both the male and female versions. Results suggest that the subjects did not see the case as an Axis I disorder. SUbjects' ratings were analyzed by means

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