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Diagnostic Criteria ofAmerican and British Psychiatrists

United KingdomR. E. Kendell, MD, MRCP, DPM J.E.Cooper,MRCP,DPM

A.J.Gourlay,MAJ. R. M. Copeland, MRCP, DPM London

United StatesL. Sharpe, MB, DPM }NewYrokB. J. Gurland, MRCP, DPM

Videotapes of diagnostic interviewswith eight patients, three Americanand five English, were shown tolarge audiences of trained psychia-trists in the eastern United Statesand in different parts of the BritishIsles. The diagnoses made by theseaudiences were compared and forsome patients there were major dis-agreements between them. The over-all pattern of diagnostic differencesbetween the American and Britishraters indicates that the Americanconcept of schizophrenia is muchbroader than the British concept,embracing not only part of what inBritain would be regarded as de-pressive illness, but also substantialparts of several other diagnosticcategories\p=m-\manicillness, neuroticillness, and personality disorder.These serious differences in theusage of diagnostic terms have im-portant implications for transatlan-tic communication, and indeed forinternational communication in gen-eral.

THERE ARE striking differencesbetween the diagnostic contribu-tions of first admissions to the men-tal hospitals of the United Statesand those of England and Wales,1but these differences are greatly re-duced when cohorts of patients ad-mitted to hospital in the two coun-

tries are examined by a single teamof psychiatrists using consistentdiagnostic criteria.2,3 These findingsimply that there are systematic dif-ferences between the diagnostic cri-teria used by American and Britishpsychiatrists and that, in particular,the former have a broader conceptof schizophrenia and the latter abroader concept of manic depressive

illness. If this is so, one would ex¬

pect American and British psychia¬trists to make different diagnoseswhen both are confronted with thesame patients, and there is indeedsome evidence that this occurs.

Sandifer et al4 showed films of di¬agnostic interviews of a series ofAmerican patients to small groupsof psychiatrists in London, Glas¬gow, and North Carolina and foundsystematic differences between thethree centers. The British psychia¬trists tended to diagnose manic de¬pressive illness more readily, andthe North Carolina psychiatriststended to diagnose depressive neu¬

rosis more readily, and all with¬in national differences were over¬

shadowed by these cross-national dif¬ferences. In a similar study Katz etal5 showed a videotape of a diagnosticinterview of a young woman, an

aspiring actress, to two differentaudiences—42 American psychia¬trists at the 1964 annual meeting ofthe American Psychiatric Associa¬tion and 32 English psychiatrists atthe Maudsley Hospital in London. Athird of the American audience re¬garded this woman as schizophrenic,a third regarded her as neurotic, andthe remainder regarded her simplyas having a personality disorder. Bycontrast 60% of the English audi¬ence made a diagnosis of personali¬ty disorder and no one diagnosedschizophrenia.

The studies described here were

conceived against this background.Our intention was to define more

closely the areas in which the diag¬nostic criteria used by Americanand British psychiatrists differfrom one another by showing video¬tapes of diagnostic interviews withvarying types of patients, bothBritish and American, to large rep¬resentative audiences of psychia¬trists on both sides of the Atlantic.

Method

Eight videotapes were used. Eachwas an unstructured diagnostic inter¬view lasting between 20 and 50 min-

utes. Five of the patients (A, B, C, D,and E) were English and three (F, G,and H) American. Some were chosenin the expectation that they wouldhighlight diagnostic differences be¬tween the two countries, others were

chosen because their symptomatologywas typical of a well-known stereo¬type. Together they portrayed a widerange of symptoms and a variety ofdifferent clinical problems.

In the British Isles five of the tapeswere rated by an audience of 30 to 40psychiatrists mainly from the Maud¬sley Hospital, London, and the otherthree (patients A, B, and F) were

seen by 200 psychiatrists drawn fromall over the country. This large groupwas obtained by holding a series ofall-day meetings in different regions —two in London, two in Scotland, twoin Ireland, and one each in Birming¬ham and Manchester. Apart fromsome overrepresentation of clinicianstrained at the Maudsley Hospital, andthe inevitable problem that only thosewith an interest in diagnosis offered toparticipate, this group can reasonablybe regarded as broadly representativeof British psychiatry. In the UnitedStates it proved harder to obtain a

representative sample and eventuallyraters were obtained mainly from theNew York Psychiatric Institute andthe staffs of other state, city, andprivate hospitals supplying the NewYork metropolitan area. Audienceswere also assembled, though, in Balti¬more, Boston, and New Jersey and a

few raters were obtained at the 1968annual meeting of the American Psy¬chiatric Association. Altogether over

450 psychiatrists participated; twotapes (patients A and F) were rated byover 120 psychiatrists and the otherswere rated by between 30 and 60.

All British raters were required topossess a Diploma in PsychologicalMedicine and American raters to havecompleted a psychiatric residency.Both were also required to have a

minimum of four years experience ofpsychiatry and the average for bothgroups was between 12 and 15 yearsexperience. Nearly all the British rat¬ers had received both their medicaland their psychiatric training in theBritish Isles. Half the American rat¬ers, however, had obtained their ini¬tial medical qualification abroad(mostly in Central Europe), but over

90% had received their psychiatric

Accepted for publication Nov 11, 1970.From the US-UK Diagnostic Project, Bio-

metrics Research, New York State Depart-ment of Mental Hygiene, New York (Drs.Sharpe and Gurland), and the Institute ofPsychiatry, London (Drs. Kendell, Cooper,and Copeland and Mrs. Gourlay).

Reprint requests to the Institute of Psychia-try, De Crespigny Park, London S.E. 5 (Dr.Kendell).

Downloaded From: http://archpsyc.jamanetwork.com/ by a SCELC - Loma Linda University User on 03/13/2014

training in the United States. Ahigher proportion of the British raterswere from university departments orthe psychiatric departments of gen¬eral hospitals, and a correspondinglyhigher proportion of the Americanswere from state hospitals. These dif¬ferences are probably due to the dif¬ferent manner in which raters wereobtained in the two countries. More ofthe American raters, on the otherhand, had received a formal trainingin psychotherapy, and more were cur¬

rently in private office practice. Theselatter differences probably reflect, oreven underreflect, genuine differencesbetween the two countries.

Apart from explanations of a fewslang phrases and allusions that mighthave been unfamiliar on the far sideof the Atlantic, raters were given noinformation other than that providedby the videotapes. After seeing eachtape every audience was required tocomplete three sets of ratings. Thefirst, Lorr's Inpatient Multi-dimension¬al Psychiatric Scale (IMPS)6 consistsof a series of 89 ratings, mainly on9-point scales, which are defined innontechnical language and cover mostof the varieties of abnormal behaviorlikely to be manifested in an inter¬view. The second was a check list of116 technical terms, culled from bothAmerican and British sources and in¬cluding most of the terms, like retar¬dation, blocking, flattening of affect,and so on, commonly used by psychia¬trists to describe abnormalities ofspeech and behavior. Lastly, raterswere required to make a diagnosis. Asthe main purpose of the study was tocompare the two sets of diagnoses itwas necessary for a common nomen¬clature to be used. For this reasonevery rater was provided with thepsychiatric section of the 8th editionof the International Classification ofDiseases and asked to restrict himselfto terms included therein. (ICD 8 isvery similar to the American Psychi¬atric Association's Diagnostic and Sta¬tistical Manual of Mental Disorders,ed 2 which was in fact modelled onICD 8). In addition to this main diag¬nosis, provision was made for a sub¬sidiary diagnosis, and also for an al¬ternative diagnosis, if either or bothwere felt to be needed by the rater.Finally, raters were invited to make apersonal diagnosis, using whateverterminology they wished. Because theinformation that can be included in a40-minute videotape is necessarily lim¬ited it was anticipated that ratersmight often feel that some vital piece

of information was lacking, and so beunable to make a confident diagnosis.For this reason a 5-point confidencescale was attached to the main diagno¬sis. In fact, these fears proved to belargely unjustified; over all eight tapes84% of American raters and 85% ofBritish raters made confidence ratingsof either 1 ("the patient's behavior ordescription of his subjective experi¬ence is pathognomonic") or 2 ("onthe evidence provided this is by far themost likely diagnosis").Results

This communication is concernedprimarily with Anglo-American di¬agnostic differences. An account ofthe relatively minor differences be¬tween psychiatrists within the Brit¬ish Isles is published elsewhere,7and an analysis of the IMPS andchecklist ratings is to be publishedshortly.

Patient A.—This 34-year-old En¬glish housewife had a long historyof mild depressive symptoms and hadrecently developed a florid psychoticillness in which both schizophrenic andaffective elements were prominent.She described feeling wonderfully hap¬py and feeling that she was beingforced to dance and sing and thatradio programs were purely for herbenefit; and then a few days laterfeeling "dirty and nasty" and thinkingpeople were laughing at her becauseshe was in hell. Table 1 lists thediagnoses given to her by 128 Ameri¬can and 211 British psychiatrists. Ineach country the majority regardedher illness as schizophrenic, mostly ei¬ther as paranoid schizophrenia or as aschizo-affective psychosis. However, asignificant minority (27%) of Britishclinicians regarded her illness as anaffective disturbance and a further11%, by listing an affective psychosisas an alternative diagnosis, impliedthat they regarded this as a seriouspossibility. The corresponding Ameri¬can figures were lower (7% and 9%,respectively).

Patient B.—This patient was a 33-year-old Londoner with more straightforward symptoms. He had heardvoices (talking about him and plottingto kill him) intermittently for severalyears and had had frequent admissionsto hospital. He was also a heavy drink¬er and commented that he could alwaysget rid of his voices by having a fewdrinks. For this man the American andBritish diagnoses were very similar

(Table 2). The majority, 83% of theBritish group and 76% of the smallerAmerican audience, regarded him as aschizophrenic. In each case, however,there was a dissenting minority whoregarded his illness as an alcoholicpsychosis. Eleven percent of the Amer¬ican and 6% of the British audiencemade a diagnosis of alcoholic halluci¬nosis or alcoholic paranoia and a fur¬ther 15% of the American audience and21% of the British listed one of theseas an alternative diagnosis.

Patient C.—This was a 37-year-old Cockney laborer who, like patientA, had both schizophrenic and affec¬tive symptoms. At the time of inter¬view he was euphoric and talkativeand revealed an elaborate series ofgrandiose delusions, centered on thebelief that he was "King David," buthe was prone to marked fluctuations ofmood and had had periods of deepdepression in the past. Again, mostraters in both countries regarded himas a schizophrenic but again a signif¬icant minority (20%) of the Britishraters regarded him as a manic de¬pressive and a further 17% gave thisas an alternative diagnosis (Table 3).By comparison, only 8% of the Ameri¬can raters even considered an affectiveillness as an alternative to schizophre¬nia.

Patient D.—This patient was an

unhappy 50-year-old woman who felt,with some justification, that her familywere treating her as a servant. Shehad been admitted after a suicidalattempt and wept during the inter¬view. She also had a longstanding fearof crowds and enclosed spaces andalways spent much of her time clean¬ing and polishing her house. Therewas almost universal agreement thatshe had a depressive illness (Table 4)but less agreement over what kind ofdepression it was. The majority (79%)of American raters favored a diagnosisof involutional melancholia. Forty-twopercent of the British raters did like¬wise, but nearly as many (39%) re¬

garded her as a manic depressive whilethe remaining 19% thought she had a

depressive neurosis. In addition, about40% of both American and Britishraters made a subsidiary diagnosis ofeither a neurotic illness or an anan-kastic personality disorder.

Patient E.—The last of the fiveEnglish patients presented a less fa¬miliar problem. She was a marriedwoman of 25 years of age who de¬scribed herself with some accuracy ashaving "gone back to being six." She


Table 1.—Diagnoses Given to Patient A

American Psychiatrists(N = 128)

British Psychiatrists(N = 211)

SchizophreniaHebephrenicCatatonicParanoidAcute schizophrenic episodeLatentResidualSchizo-affectiveUnspecified

112 (88%)52

60701

2611

148(70%)25

14328

11

427

Affective PsychosesInvolutional melancholiaManic depressive, manicManic depressive, depressedManic depressive, circularReactive depressive psychosisUnspecified

9 (7%)212400

56 (27%)1

169

171

12Other DiagnosesAlternative Diagnosis of

Affective Psychosis 11 (9%) 23 (11%)

Table 2.—Diagnoses Given to Patient



SchizophreniaHebephrenicParanoidAcute schizophrenic episodeLatentResidualSchizo-affective

35 (76%)0

320102

171 (83%)5

1593013

Paranoid StateParanoiaInvolutional paraphreniaUnspecified

5(11%)401

15 (7%)915

Alcoholic PsychosisAlcoholic hallucinosisAlcoholic paranoia

5(11%)41

12 (6%)93

Other Diagnoses 1Alternative Diagnosis of

Alcoholic Psychosis 7(15%) 44(2 1%)

denied knowing the date or how oldshe was and behaved and spoke in an

absurdly childlike manner, clutchingan empty egg carton and asking onlyto be allowed to sit on her husband'sknee and be cuddled. She describedhow this remarkable behavior hadbeen precipitated by the threat of herhusband's arrest on a criminal chargeand also gave a history of an earlier"breakdown" when, as a nursing stu¬dent, she had been required to assistat a delivery. The attitudes of theAmerican and British audiences to thisproblem were very different. Eighty-five percent of the American ratersregarded her as a schizophrenic (Ta¬ble 5) though there was no consensuson the type of schizophrenia involved.Only 7% of the British audienceagreed with this diagnosis. Fifty-two

percent of them thought that shehad a personality disorder and 38%thought that she had a neurotic ill¬ness. In fact, the most common diag¬noses were hysterical neurosis andhysterical personality, so 76% of theBritish raters were agreed that shewas a hysteric. In contrast, only oneAmerican rater mentioned the termhysteria.

Patient F.—This 30-year-old bach¬elor from Brooklyn had been hos¬pitalized briefly several times, had noclose friends, and had rarely held a

steady job. He described having oncehad a hysterical paralysis of his armand gave a vivid account of the fluc¬tuations in his mood and morale andof his willingness to abuse alcohol ordrugs whenever the opportunity arose.Table 6 shows the diagnoses made by

133 American and 194 British psychia¬trists. Again, there is a striking dif¬ference between the two. Sixty-ninepercent of the American audience, butonly 2% of the British audience, diag¬nosed some form of schizophrenia. Themost common American diagnoseswere schizo-affective psychosis andparanoid schizophrenia, but many ofthe psychiatrists concerned indicatedthat pseudoneurotic schizophrenia, aterm not recognized in the Interna¬tional Classification, was the diagnosisthey would normally have made. Onlythree British psychiatrists even men¬tioned this term. Instead, 75% of theBritish audience made a diagnosis ofpersonality disorder, and the majorityspecified that this was of hystericaltype. By comparison, only 8% of theAmerican group diagnosed a personal¬ity disorder of any kind.

The striking differences between theAmerican and British diagnoses forthe previous patient (E) might per¬haps be discounted on the grounds thather behavior, and the situation thathad precipitated it, were both unusualand that, in any case, the diagnosticdiscrepancy summarized in Table 5was derived from a comparativelysmall number of raters. But neither ofthese pleas can be made here. Thegeneral tenor of the patient's historyand his behavior in the interview werefamiliar enough to psychiatrists onboth sides of the Atlantic and bothgroups of raters were large. For thisreason the discrepancy was studied inmore detail.

If the patient's account of his prob¬lems had been vague and incomplete,or if the interviewer had left impor¬tant areas uncovered, the raters wouldnot have been able to make confidentdiagnoses and the discrepancy wouldlose much of its significance. But thisdoes not seem to have been the case.Eighty-three percent of both theAmerican and the British audiencesmade ratings of 1 or 2 on the 5-pointconfidence scale and when the two au¬diences were compared again after ex¬

cluding all those who had rated 3, 4 or

5, the discrepancy was as great asever. Sixty-eight percent of the Amer¬icans, but only 2% of the British,diagnosed schizophrenia; 79% of theBritish, but only 6% of the Ameri¬cans, diagnosed a personality disorder.An examination of the alternative di¬agnoses offered pointed to the sameconclusion. Fifty-nine percent of theAmerican audience and 62% of theBritish audience offered no alternativediagnosis, a further indication of their


British ConceptsAmerican Concept of Schizophrenia

The differences between American and British concepts of schizo¬phrenia.

confidence in their main diagnoses. Ofthe 92 American psychiatrists who re¬garded the patient as schizophrenic,only three offered a personality disor¬der as an alternative; and of the 146British psychiatrists who regarded thepatient as having a personality disor¬der, only three mentioned schizophre¬nia as an alternative. In short, themajority of American psychiatristswas confident that the patient wasschizophrenic and did not seriouslyconsider any other diagnosis; the ma¬

jority of British psychiatrists, on theother hand, insisted that he simplyhad a personality disorder and thatthere was really no question of hishaving a psychotic illness.

Because of this persisting discrep¬ancy, the personal information provid-

ed by all participating psychiatristswas analyzed in an attempt to identifytypes of psychiatrists particularlyprone to make a diagnosis of schizo¬phrenia rather than personality disor¬der, or vice versa. Age, length of psy¬chiatric experience, country of medicalqualification, and formal psychothera-peutic training exerted no significantinfluence. In the United States therewas a significant (P<0.05) tendencyfor raters who had either been trainedin, or were currently working in, statehospitals to diagnose schizophreniamore commonly than those from uni¬versity departments or other settings,but by far the most important vari¬ables were which country the raterworked in, Britain or America, andwhich he had received his psychiatric

training in. The two could not be dis¬tinguished because they were nearlyalways the same.

Patient G.—This patient was a26-year-old American who spent mostof the interview describing his illogi¬cal and incomprehensible schemes forworld domination. He rocked in hischair, giggled repeatedly, and twicestopped speaking in midsentence andstared blankly for several seconds be¬fore continuing. This tape was seen by34 psychiatrists in each country andtheir diagnoses are listed in Table 7.Nearly everyone agreed that he was

schizophrenic but there was muchpoorer agreement on the type of schizo¬phrenia involved. Eight of the ninesubtypes recognized in the Interna¬tional Classification were mentionedand none commanded a majority ofeither American or British raters.

Patient H.—The last patient wasan American woman of 47 who re¬garded herself as the queen of En¬gland. She was flippant and preoccu¬pied with her sexual needs and herspeech was full of puns and clang as¬sociations. Her symptomatology hadprominent schizophrenic and maniccomponents and she gave rise to asimilar pattern of diagnoses to patientA. That is, in both countries the ma¬

jority diagnosis was schizophrenia, ofeither paranoid or schizo-affectivetypes, and in both there was a dissent¬ing minority who felt she had a manic-depressive illness (Table 8). Again,like patient A, the proportion of Amer¬ican raters diagnosing schizophreniawas higher than that of the Britishraters (78% vs 66%), and the propor¬tion diagnosing an affective psychosiscorrespondingly lower (22% vs 34%).

Comment

Three different patterns of diag¬nostic agreement or disagreementare portrayed by these eight pa¬tients. Patients B, D, and G all ex¬hibited symptoms which were fairlytypical of classical stereotypes andfor all three there was substantialagreement between American andBritish psychiatrists. For patient agreement was very close, not onlyfor the main diagnosis of paranoidschizophrenia but also for the alter¬native diagnosis of an alcoholic psy¬chosis. Similarly, there was almostcomplete agreement that patient Dhad a depressive illness and thatpatient G had a schizophrenic ill-


TaWe 3.—Diagnoses Given to Patient C



SchizophreniaHebephrenicParanoidAcute schizophrenic episodeResidualSchizo-affectiveUnspecified

37(95%)0

321121

23 (77%)1

153031

Manic Depressive PsychosesManic depressive, manicManic depressive, circular

6 (20%)24

Other Diagnoses 1Alternative Diagnosis of

Affective Psychosis 3 (8%) 5(17%)

Table 4.—Diagnoses Given to Patient D



Involutional melancholiaManic depressive, depressedReactive depressive psychosisDepressive neurosisSchizophrenia, schizo-affective tyne

23 (79%)1221

13 (42%)12(39%)06 (19%)0

Subsidiary DiagnosesAnxiety, phobic or obsessive

compulsive neurosisAnankastic personality

Table 5.—Diagnoses Given to Patient E

American Psychiatrists(N-27)

British Psychiatrists(N=29)

SchizophreniaSimpleHebephrenicCatatonicParanoidAcute schizophrenic episodeResidualSchizo-affectiveUnspecified

23 (85%)12224174

2 (7%)01000100

NeurosesAnxiety neurosisHysterical neurosis

1 (4%)01

11 (38%)1

10

Personality DisordersSchizoidHystericalAntisocialUnspecified

1 (4%)1000

15(52%)0

1212

Other Diagnoses

ness. There was poor agreement,however, both between and withincountries, on the variety of depres¬sion or schizophrenia involved. Pa¬tients A, C, and H all exhibiteda mixture of schizophrenic andaffective symptoms and had beenchosen for that reason. All threewere regarded as schizophrenic bythe majority of both American andBritish raters, but for each between

20% and 34% of the British audi¬ence made a diagnosis of anaffective psychosis (mainly manic-depressive illness) and a further15% or so suggested this as a seri¬ous alternative to schizophrenia. Afew American psychiatrists did thesame, but in each case the propor¬tion was much lower. Patients Eand F had originally been includedto offset a preponderance of psy-

chotic patients rather than to high¬light any particular diagnosticproblem but, in the event, it wasthese two who gave rise to the mostserious disagreement. For both, themajority of American psychiatristsdiagnosed some form of schizophre¬nia while British psychiatrists di¬agnosed either a personality disor¬der or a neurotic illness.

The differences between theAmerican and British diagnoses forpatient A, C, and H are consistentwith the many other indications1-3·8that American psychiatrists have abroader concept of schizophrenia andBritish psychiatrists have a corre¬spondingly broader concept of manicdepressive illness, and are not ofsufficient magnitude to prevent themajority diagnosis from being thesame on both sides of the Atlan¬tic. The problem is familiar, and ofmanageable proportions. The samecannot be said of the almost totaldisagreement revealed by patients Eand F, which has more serious im¬plications. The basic design of thestudy ensured that all raters were

provided with exactly the same in¬formation and it has already beenshown that both sets of raters hadconfidence in their conflicting diag¬noses. The different interpretationsplaced on patient E's behaviormight perhaps be discounted, forreasons that have been discussedpreviously, but the same cannot bedone for patient F. The essentialfeatures of his problem—a long his¬tory of failure to develop lastingrelationships or to cope with thedemands of everyday life, but with¬out florid psychotic symptoms—-were commonplace. Perhaps signif¬icantly, Katz's aspiring actress5showed these same general charac¬teristics and the majority of En¬glish raters considered that she hada personality disorder ; while a thirdof the American audience regardedher as schizophrenic.

In a situation such as this, wheretwo groups of equally experiencedpsychiatrists, both provided withthe same data, disagree as to wheth¬er or not a patient is schizophrenicthere is a natural temptation to askwho is right. It is important to


Table 6.—Diagnoses Given to Patient F



SchizophreniaSimpleCatatonicParanoidLatentResidualSchizo-affectiveUnspecified

92 (69%)01

2783

3320

4 (2%)1010011

Personality DisorderParanoidAffective (cyclothymic)ExplosiveHystericalAsthénieAntisocialUnspecified

10 (8%)1104013

146 (75%)282

10528

19Affective Psychosis 10(8%) 7 (4%)Neurosis 19 (14%) 37(19%)Alcoholism or Drug Dependence

Table 7.—Diagnoses Given to Patient G


SchizophreniaSimpleHebephrenicCatatonicParanoidAcute schizophrenic episodeResidualSchizo-affectiveUnspecified


33 (97%)0

110

153013

32 (94%)1

12870103

Other Diagnoses 1

Table 8.—Diagnoses Given to Patient H



SchizophreniaHebephrenicCatatonicParanoidResidualSchizo-affectiveUnspecified

47 (78%)51

171

1211

27 (66%)60

100

110

Affective PsychosesManic depressive, manicManic depressive, depressedManic depressive, circularUnspecified

13 (22%)8113

14(34%)7052

Alternative Diagnosis ofSchizophrenia 6(10%) 8 (20%)

Alternative Diagnosis ofAffective Psychosis 7(12%) 5(12%)

realize, though, that in our presentstate of knowledge such a questionis not only unanswerable, it is in¬herently meaningless. Schizophre¬nia, like all other varieties of func¬tional mental illness recognized in

our nomenclature, is defined interms of its clinical picture. InScadding's terminology,9 its de¬fining characteristic is its syn¬drome, and so the decision whetheror not an individual patient has

schizophrenia can only be made bythe 'Hippocratic procedure' of com¬paring his symptoms with those ofthe illness and deciding whether theresemblance is adequate. In conse¬quence, though one may discusswhose concept of schizophrenia ismore useful, or closer to Bleuler'soriginal description, one cannotmeaningfully discuss which is right,for we have no external criterion toappeal to—no morbid anatomy, no

etiological agent, no biochemical or

physiological anomaly.But disagreements as glaring as

this have serious implications. Di¬agnoses are the most important ofall our technical terms because theyare the means by which we identifythe subject matter of most of ourresearch. They identify the types ofpatients who received the drug wewere assessing, or whose family dy¬namics or sodium metabolism wewere studying. If these terms areused by different groups of psychia¬trists in widely differing ways, thetwo will, at best, fail to communi¬cate with each other, and may wellactively mislead one another.

The fact that these Anglo-Ameri¬can differences have arisen in spiteof a common language and numer¬ous cultural and professional tieshas unhappy implications for inter¬national communication in general.Certainly the opportunities forgroups of psychiatrists who lackthese advantages to diverge fromone another without realizing itmust be much greater. Only recentlyhave attempts been made to studydifferences in diagnostic criteria onthis wider stage, and so far onlytwo multinational comparisons havebeen reported, both based on writ¬ten case histories rather than onfilms or videotapes. In the first ofthese,10 a World Health Organiza¬tion pilot study involving a smallnumber of distinguished psychia¬trists from eight different coun¬

tries, cross-national differences wereno worse than those within a groupof British psychiatrists. However,in the second,11 which involved larg¬er groups of psychiatrists from theUnited States, the United Kingdom,and the Scandinavian countries, sev¬eral systematic differences were de-


tectable. American psychiatrists hada propensity for diagnosing schizo¬phrenia where Europeans diagnoseda depression or a paranoid psy¬chosis : Scandinavian psychiatristsused the term psychogenic psychosisto describe patients others regardedas neurotic; and American andSwedish psychiatrists diagnosed ce¬rebral arteriosclerosis and theirBritish, Norwegian, and Danishcounterparts diagnosed an affectivedisorder. Significantly, these dif¬ferences emerged in spite of the factthat the study was based solely onwritten transcripts, and these elimi¬nate one of the most importantsources of variation, the observer'sown perception of psychopathology.

There is probably no easy way ofremoving entrenched differences indiagnostic usage of the kind thathave been demonstrated here. Ifpsychiatrists detected the same ab¬normalities in patients to whomthey attributed different diagnosesthe problem would be relatively sim¬ple. Patients could be identified bytheir symptoms instead of by diag¬nosis, and different schools of psy¬chiatry might even be persuaded toagree on common definitions fortheir diagnoses. But in this study atleast the evidence (to be reported indetail elsewhere) is that Americanand British psychiatrists often de¬tect quite different symptoms in pa¬tients whom they diagnose dif¬ferently. Patient F, for instance,was rated by 67% of the Americanaudience as having delusions, by63% as having passivity feelings,and by 58% as showing thoughtdisorder. The corresponding per¬centages for British raters were12%, 8%, and 5%, a contrast everybit as striking as the difference indiagnosis. Even the IMPS ratings,which are couched in nontechnicallanguage and purport to bestraightforward descriptions of de¬viations from normal behavior,showed several significant dif¬ferences, with American raters per¬ceiving more symptomatology in allareas, particularly in those with astrong schizophrenic connotation.Whether clinicians make differentdiagnoses because they perceivedifferent symptoms, or whether they

perceive different symptoms becausethey have already recognized a fa¬miliar illness is an important andintriguing issue. But either way thefact that serious perceptual dif¬ferences are involved makes it verydifficult for someone who has beentrained in one frame of reference tochange to another.

Probably the most importantcause of the Anglo-American dis¬crepancies revealed here is that theAmerican concept of schizophreniahas expanded greatly in the last 30years without any correspondingenlargement of the British concept.The reasons for this divergence arecomplex, but the greater influenceof the psychoanalytic movement inNorth America, and influentialteachers on both sides of the Atlan¬tic, have probably been more impor¬tant than any factual discoveries.The evidence provided by these andearlier videotape studies4·6 and com¬parisons of hospital populations inLondon and New York2·3·8 make itclear that the concept of schizophre¬nia held on the east coast of theUnited States now embraces notonly part of what in Britain wouldbe regarded as depressive illness butalso substantial parts of severalother diagnostic categories—manicillness, neurotic illness and per¬sonality disorder (Figure).

Other less important differencescan also be seen. The diagnoses givento patients E and F (Tables 5and 6) indicate that British psychi¬atrists are more prone to use theterm hysteria than their Americancounterparts, a finding presumablyrelated to the omission of hysteriafrom the American Psychiatric As¬sociation's 1952 classification (DSM1). Similarly, the diagnoses givento patient D (Table 4) and theresults of the hospital populationcomparisons referred to above2·3 in¬dicate that American psychiatristsdiagnose involutional melancholia inmiddle-aged women whom manyBritish psychiatrists would regardas manic depressives. Of all thesedifferences, the overlap between theAmerican concept of schizophreniaand the British concept of manicdepressive illness is the most widelyrecognized, but the additional over-

lap with the British concept of per¬sonality disorder probably repre¬sents the most serious problem,particularly where ambulant pa¬tients are concerned.

Although, as was stressed above,no concept of schizophrenia can beeither right or wrong it does seem,at least to a European observer,that the diagnosis is now made sofreely on the east coast of the Unit¬ed States that it is losing much ofits original meaning and is ap¬proaching the point at which it be¬comes a synonym for functionalmental illness. Seven of the eightpatients in this study were diag¬nosed as schizophrenic by over twothirds of the American psychia¬trists, although between them theypresented a variety of differentsymptoms and problems. Similarly,in a recent random sample of 192patients below the age of 60 admit¬ted to public mental hospitals inNew York City, 82% of those withnonorganic conditions were diag¬nosed as schizophrenic by the hospi¬tal psychiatrists.8·8 But doubtlessthe situation looks very differentwhen seen through North Americaneyes and any major changes in ei¬ther the British or American con¬cepts of schizophrenia will probablyoccur only after, and as a conse¬quence of, therapeutic innovationsor biochemical or physiological dis¬coveries. Changes currently takingplace in the American concept ofmania illustrate this quite well. Thediagnosis of mania was in dangerof disappearing, at least in NewYork, until lithium salts were intro¬duced as a specific treatment of man¬ic illnesses. The interest arousedby this new drug has, however,caused patients who five years agowould have been regarded as schizo¬phrenics to be diagnosed now asmanic depressives in order that theymay be given lithium salts.1218

Finally, one last issue needs to beraised. Although the British raters,at least of tapes A, B, and F, canreasonably be regarded as geo¬graphically representative of Brit¬ish psychiatry, the same is not trueof the American raters, the majori¬ty of whom worked in or near NewYork. At present we do not know


how representative New York psy¬chiatrists are of American psychia¬try as a whole, but there are anumber of indications that theirconcept of schizophrenia may bebroader than that of their col¬leagues elsewhere. The 1968 tablesof first admissions to public mentalhospitals compiled by the BiometryBranch of the National Institute ofMental Health show that, for thewhole of the United States, 18% ofadmissions are diagnosed as schizo¬phrenics, or 31% of all admissionsother than organic brain syndromesand addictive states. For Californiaand Illinois, two large states of sim¬ilar size and population distributionto New York state, the correspond¬ing proportions are very similar.For New York state, though, theyare considerably higher—25% and52%. These high percentages might,of course, be due to a higher preva¬lence of schizophrenia in New York,but they certainly raise the possibil¬ity that schizophrenia is diagnosedmore readily there. The preliminaryresults of videotape comparisons be¬tween New York and other centerson the Pacific coast and in the Mid¬west suggest the same. It is prob¬ably also significant that several ofthe ideas that have been instrumen¬tal in enlarging the Americanconcept of schizophrenia, like theintroduction of the concept of pseu-doneurotic schizophrenia14 and thedictum that "even a trace of schizo¬phrenia is schizophrenia"15 origi¬nated in New York, and so can beexpected to have been more in¬fluential there than elsewhere.

It is possible, therefore, that fu¬ture work will show that these com¬parisons between predominantlyNew York psychiatrists and Britishpsychiatrists have given a mislead-ingly alarming picture of overallAnglo-American differences. It isimportant to realize, though, that ifthis does happen an equivalent com¬munication difficulty will necessarilybe revealed between New York psy¬chiatrists and their colleagues else¬where in the United States. Themagnitude of the diagnostic dispar¬ity, and hence of the communicationproblem, would not be affected, onlyits geographical location—within

the United States instead of be¬tween the United States and Brit¬ain. In view of the confusion whichinconsistent diagnostic criteria cancause, the sooner this question isanswered the better.

This work was supported by Public HealthService grant No. MH-09191 from the Na¬tional Institute of Mental Health.

Without the help of the hundreds of psy¬chiatrists, British and American, who ratedthese videotapes for us, and the hospitalsand university departments who allowed us touse their facilities, this study could not havebeen carried out.

References

1. Kramer M: Some problems forinternational research suggested byobservations on differences in first ad-mission rates to the mental hospitalsof England and Wales and of theUnited States, in Proceedings of theThird World Congress of Psychiatry.Montreal, McGill University Press,1961, vol 3, pp 153-160.

2. Cooper JE, Kendell RE, GurlandBJ, et al: Cross-national study of di-agnosis of the mental disorders: Someresults of the first comparative investi-gation. Amer J Psychiat 125(suppl):21-29, 1969.

3. Cooper JE: The use of a pro-cedure for standardizing psychiatricdiagnosis, in Hare EH, Wing JK(eds): Psychiatric Epidemiology. Lon-don, Oxford University Press, 1970, pp109-131.

4. Sandifer MG, Hordern A, Tim-bury GC, et al: Psychiatric diagnosis:A comparative study in North Caro-lina, London and Glasgow. Brit J Psy-chiat 114:1-9, 1968.

5. Katz M, Cole JO, Lowery HA:Studies of the diagnostic process: Theinfluence of symptom perception, pastexperience and ethnic background ondiagnostic decisions. Amer J Psychiat125:937-947, 1969.

6. Lorr M, Klett CJ: Inpatient Mul-tidimensional Psychiatric Scale. PaloAlto, Calif, Consulting PsychologistsPress, 1967.

7. Copeland JRM, Cooper JE, Ken-dell RE, et al: Differences in usage ofdiagnostic labels amongst psychia-trists in the British Isles. Brit J Psy-chiat (in press).

8. Gurland BJ, Fleiss JL, CooperJE, et al: Cross-national study of di-agnosis of mental disorders: Hospitaldiagnoses and hospital patients inNew York and London. Compr Psy-chiat 11:18-25, 1970.

9. Scadding JG: Meaning of diag-nostic terms in broncho-pulmonarydisease. Brit Med J 2:1425-1430, 1963.

10. Shepherd M, Brooke EM, CooperJE, et al: An experimental approachto psychiatric diagnosis. Acta PsychiatScand, suppl 201, 1968.

11. Rawnsley K: An international

diagnostic exercise, in Proceedings ofthe Fourth World Congress of Psy-chiatry. Amsterdam. Excerpta MedicaFoundation, 1967, vol 4, pp 2683-2686.

12. Lipkin KM, Dyrud J, Meyer GG:The many faces of mania. Arch GenPsychiat 22:262-267, 1970.

13. Gattozzi AA: Lithium in theTreatment of Mood Disorders. Nation-al Clearinghouse for Mental HealthInformation, Publication No. 5033, USGovernment Printing Office, 1970, pp23-24.

14. Hoch P, Polatin P: Pseudoneu-rotic forms of schizophrenia. PsychiatQuart 23:248-276, 1949.

15. Lewis NDC, Piotrowski ZA:Clinical diagnosis of manic depressivepsychosis, in Hoch PH, Zubin J (eds):Depression. New York, Grune & Strat-ton Inc, 1954, pp 25-38.


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Diagnostic Criteria of and British Psychiatristsdepts.washington.edu/psychres/wordpress/wp-content/... · with eightpatients, three American and five English, were shown to large