Differences in diagnostic patterns in Britain and America

Differences in Diagnostic Patterns in Britain and America Ronald

S

INCE

Gelfand

and

1935. it has been repeatedly

affective

disorders,

on first admission

Kline

noted that English

particularly

than American

Frank

manic

psychiatrists

depressive

psychiatrists.‘,’

diagnose

psychosis.

They

diagnose

more

often

schizophrenia

less frequently. The

first

systematic

review

1961 .‘i.’ He observed United

Kingdom

phrenia

was diagnosed

YOO% more In a study diagnosis lY51.Z

were

often

reasonably

than

at the

When

charts

York

observations

Are hospitalized diagnostic

criteria’?

sion diagnosis are different

diagnoses

reviewed

and

NIMH ent State falling

provided

it was

noted

by

that

the

about

a British-trained decreased.

or is the difference is the difference

in the two

These

questions

to study attitudes

the money mental

Examination.“”

asleep’?

If tablets

asleep without

forms

These

countries’?

one of

in first admisaberration

Is the major

to present

pathology.

and tolerance

only

of mental

seemed

patient

question

and

taken.

an excellent.

psychiatric

toward

OI

differcriteria

varying

forms

cjt

STUDIES

group

of researchers

rate did the patient

to each question

or reply

frequent

uncertainty.

an elaborate

but mild

finally.

would

could

to moderate

0

degree:

7

or incoherent.

Y if the question

have

check:

8 for no reply

inappropriate.

And.

feel they

the examiner

or persistent;

inaudible.

utilized

developed in England: “The prexreads, “Have you had difficulty

I for yes or abnormal,

rating

or not applicable.

;I

what

Next

and severe.

not understood,

(8) may also indicate

NATIONAL

status questionnaire A typical question

them’?”

for no or normal;

for yes or abnormal

asked

nearly

aberration.

computer-ratable

(zero)

in Britain

are different.

CROSS

fallen

and

schizo-

psychosis

lY4Os and peaked

rediagnosed

kept at home

and the cultural

in

States

Kingdom

as schizophrenia

of different

training’?

mental

in the

of toleration

opportunity

occurring

Kramer

to speculation.

different

naturally

United

depressive

Institute.

rapidly

ence in psychiatric for diagnosis.

Psychiatric

If the patients

by

States.

led naturally

the result

but in the

of cases diagnosed

patients

done

was

rates in the United

and manic

increased

were

the number

and other

close,

in the United New

differences

first admission

50% less often

of schizophrenia

psychiatrist,

of these

that overall

elicited. Eight was not

GELFAND

552

AND KLINE

Using this structured interview and interviews with the patient’s family, a diagnosis from the International Classification of Disease was chosen. A largescale comparison between nine hospitals in New York and nine in London was carried out by Zubin, Cooper, Gurland. et al. 7p11They found a high interrater reliability using standardized criteria for evaluation. Data from hospital diagnosis showed 61% of inpatients in New York were diagnosed schizophrenic by their psychiatrists while only 34% of inpatients in the London hospitals were so diagnosed. When patients were reviewed using project diagnostic techniques, the differences became insignificant: New York schizophrenia, 29%. London schizophrenia, 35%. They concluded that using standardized interviews and methods of diagnosis (in this case the London viewpoint), differences in the populations disappeared. It was demonstrated, therefore, that the differences were due substantially to diagnostic criteria and concepts. In addition, it was recommended that researchers in the field specify broad (U.S. type) or narrow (U.K. type) schizophrenia so that clinicians would know what population the findings apply to. In a related study, videotapes shown in Britain and America broadly confirmed the conclusions of previous cross-national comparisons.‘” Asking groups of psychiatrists on both sides of the Atlantic to rate the same videotaped patient interviews revealed that patients diagnosed as schizophrenic in the U.S. included some of those diagnosed in the U.K. as depressive illness, neurotic illness, personality disorder, and most of what the British called manic. Interestingly, some differences were found among U.S. centers suggesting that New York psychiatrists may diagnose schizophrenia more often than some other areas of the country: but there remains considerable evidence that the U.S.-U.K. differences are substantial. Another comparative study showed little difference in the stereotyped descriptions of schizophrenia by British and American psychiatrists, but significant differences were found in the amount and severity of psychopathology rated when viewing the same videotapes. I:)What, then, are the reasons for these repeatedly observed differences? ORIGIN OF DIFFERENCES A common explanation is the broadening of the concept of schizophrenia in the U.S. in the 1930s and 1940s because of the increased influence of psychoanalytic thinking. A prime example is the Hoch and Polatin concept of pseudo-neurotic schizophrenia” thatgained widespread recognition in the U.S., but not in Britain. Studies by Kelleher’” point to the influence of postgraduate training on the rating of abnormality. Beginning Maudsley (London) residents rated videotaped interviews for psychopathology during their first 3 days and at the end of 2 years of training. After 2 years, they rated less abnormality. In a corollary study, American medical undergraduates on a l-month elective at the Maudsley responded to a similar procedure by changing their rating habits in the direction of the British.“’ If this suggestion is valid, perhaps the British and American differences are related in part to the emphasis in psychiatric training. If, as some maintain, psychosis represents or results in a return of the denied

553

DIAGNOSES IN BRITAIN AND AMERICA or repressed, described

the nature

differently

sion is expected

of a given

in different

to be in moderation.

in the face of overwhelming should

“muddle

nonintrusive their

otijn

eccentric.

In contrast. tivity.

is preferred

A piece

of confirming and their

British

raters as it was found raters.

likely

This

Americans

and this would families

from

in. He will cultural conformity nosed

more

psychiatrist

may

American Thus.

“It

we suspect

as pathologic

psychiatrist

that

great part. ;I reflection

than

ac-

Brooklyn

frequently

than

attitudes

patients

of the

interviewed are more

argue

use more

that

since

phenothiazines

But it cannot

account

deviance

system

in these

frowned

upon.

European

the seeming

sensitive values

accepted

States

where

schizophrenia

of mood

in diagnostic

A British

and affect.

An

behavior.

practices

shared by patients

has social is diag-

countries.“”

to odd or withdrawn

differences

of the cultural

with

of schizophrenia

that in the United

to disturbances

be more

he lives and works

in accordance

in the field

in most

sensitive

may

the

it represents

those of the social

is interesting

be more

they

likely.

and eccentricity

psychiatrist

to

One could

often.

as is

standard.

reflect

frequently

He noted more

of the patients.

More

A prominent

is expected

much

more

upon.

meaningless

the calm and placid

causalities.

and behavior

England.

of lead

to calm acceptance.

in the 49 Brooklyn

that in America

cultural

values

label affect

from

equally

attributable

for the calmness

the usual

standards.

written

is not

of the parents.

The psychiatrist’s

are tolerant

even

by Kende]l.li

schizophrenia

account

for the calmness

and

feel they

to let others

is frowned

activity.

as calm and placid

as psychiatric

diagnose

States

is presented

suggests

to be identified

United Frequent

rated

difference

American

They

lip.”

Americans

cheerfulness

were

by British

upper

and desperate

evidence

This

down

the British

than

is

exprrs-

is played

catastrophe,

a “stiff willing

behavior.

parents

patients.

affect

in the

to thought.

patients

Consequently,

emotional

lives.

eccentricity

and withdrawn

why decompensation

society,

even

and keep and more

withdrawn

real

may explain In British

adversity,

through”

eccentricity

introverted

culture places.

are.

in

psychiatrist\

ad

alike. The

International

views

and diagnostic

differences areas.

and

schizophrenia in only

on Schizophrenia’”

procedures Denmark,

major

illness

cultural

illness

differences

restricted

between

Northern

continued

=

study

if this is a true

with

that

there

(N

Latin

similar

found

of study Columbia,

affective

disorders

was schizophrenia

it will

be found

American

for diagnosis

striking in some

in 41%

129). In Cali,

are responsible

criteria

inter-

disorders

and major

1201). Perhaps culture

study

diagnosed =

in all nine centers

that

culture for

and a more

these

and larger

67% obvious

differences. samples

will

difference. FUTURE

We fee]

was

in 34%

an emotive

European

standardized

and affective

in 79% of the sample

14% (N

using

to the U.S.-U.K.

schizophrenia

affective

was reported

similar

of schizophrenia

4% (N = 127). The average

and affective

Only

Study

in the reporting

In Aarhus.

patients

reveal

Pilot

are

two

major

STRATEGIES aspects

that

have

been

overlooked

in

preliminary work. These are therapeutic response and longitudinal fo]]on’-up studies. For example: Do manic-depressive patients diagnosed in Britain re-

GELFAND

554

AND KLINE

spond to lithium to the same degree as patients diagnosed as manic-depressives in the United States? Or do they respond better to phenothiazines? The authors conducted a random sampling of 25 of the 70 patients hospitalized in 1974 at the Maudsley with a diagnosis of manic-depressive-manic and manic-depressive-circular illness. It was found that 20% of the patients were admitted on therapeutic levels of lithium. This is a conservative estimate as lithium levels were not often drawn on admission. On discharge, only 27% were on lithium alone and 59% were on phenothiazines or phenothiazines and lithium. These data suggest that treatment practices do not match diagnostic concepts as closely as might be expected. At the Los Angeles County, University of Southern California Medical Center, manic depressive-manic and circular types are routinely tapered from antipsychotic medication and discharged on lithium alone. Since many of the manic patients in Britain would be called schizophrenic in the U.S. and are treated in roughly the same way, perhaps similar patients seen at the Maudsley or our Medical Center would be described or diagnosed differently but given the same treatment. Another advantage to looking at treatment response is that it may indicate a different biologic target and etiology of a particular illness. This procedure would, in our opinion, add a meaningful and clinically useful basis for diagnostic discrimination. Finally, a word about longitudinal studies and classification. We believe in the philosophy of diagnosis strongly advocated by Woodruff et al”’ that classification should serve the function of prediction. Without adequate follow-up, studies diagnostic categories remain a temporal description without a consistent natural history. We sincerely hope that the U.S.-U.K. Cross National Study and the International Pilot Study on Schizophrenia publish follow-up studies on the initially described patients. Only when diagnosis can lead to the most effective form of treatment and prediction of prognosis will it indeed be useful. REFERENCES I. Slater ETO: The incidence of mental disorder. Ann Eugenics, 6:172-186, 1935 2. Lewis AJ: Aging and senility. a major problem in psychiatry. J Ment Sci 92: 150- 170, 1946 3. Kramer M: Some probiems for international research suggested by observation on differences on first admission rate to mental hospitals of England and Wales and of the United States. Proceedings of the Third World Congress of Psychiatry, Montreal. McGill University Press 3:153-160. 1961 4. Kramer M, Pollack ES, Redlich RW: Studies of the incidence and prevalence of hospitalized mental disorders in the United States. current status and future goals. in Hoch PH. Zubin J (eds): Comprehensive Epidemiology of Mental Disorders. New York, Grune & Stratton. 1961. pp X-100

5. Kuriansky

JB.

Demmg

EW.

Gut-land

B:

On trends in the diagnosis of schizophrenia. Am J Psychiatry I3 I :402-408. 1974 6. Wing JK, Birley JLT. Cooper JE. et al: Reliability of a procedure for measuring and classifying present psychiatric state. Br J Psychiatry I13:499-515. 1967 7. Kramer M: Cross national study of diagnosis of the mental disorders: origin of the problem. Am J Psychiatry 125: l-l I. 1969 (Suppl) 8. Zubin J: Cross national study of diagnosis of the mental disorders: methodology and planning. Am J Psychiatry 125: 12-20, 1969 (Suppl) 9. Cooper JE. Kendel RE. Gurland BJ, et al: Cross national study of diagnosis of the mental disorders: some results from the first comparative investigation. Am J Psychiatry 125:21-29. 1969 (SuppI) IO. Gurland BJ. Fleiss JL. Cooper JE, et al:

DIAGNOSES

IN BRITAIN

AND AMERICA

555

Crc)ss national

study of diagnosis of mental dis-

training on the rating of mental ahnormality.

orders:

some

comparisons

J Psychiatry

criteria

from

the

Psychiatq

I I.

first Staff

Project: in

Bulletin

Diagnostic

York

of

Cross of

and

I I:35-7Y.

Sharpe

criteria

psychiatrists.

J

psy-

London.

IY74

L. Looper

American

JE et al: Briti\h

25: 13-

IIt).

IYil I!.

Hodel-n A. Sandifer Jiagnwis:

can conc~lrdance

Hr J Psychiatry

1-i. Hoch forms 276. IS.

I’,

MG. Green 1.M. et ;II:

British and North

on stereotype\

of schizophrenia.

P:

.Ameri-

of mental

Il4:Y35-Y44.

Polatln

ill-

iYt%

Pwudo-neurotic

Psychiatr

0

23:24X-

lY4Y Kelleher

rewlt\ Med

Influence

of postgraduate

of teaching

h!

Psychiatry IX.

Psychiatr). Kent.

national

l25:4l-43.

Clinical

Schizi>phrcnia 20. vrrsit!,

preaentaion

Woodl-uff

Brothel-s.

N. Shapiro

RA. lY74

and B (txl\).

IYhY. p

R. Jablensky

1

A. ct

pilot study on cchi~ophrenla.

Bulletin

DiagnoG~.

Press.

J

in (‘ontrmpwar~

T. Barraclough

Headley

al: The international

4ni

lY6Y (suppI

Silverstone

19. Sartorius

the HI-J

of the pr~c)hlrm\ stuJic\.

of schizophrenia

England.

et

hv medical student\:

DiscusGon

crws F:

HG

on the ohser-vatton

1974

RE:

Fish

BG. Harwin

teaching expel-iment.

Educ X:26-30.

raised

HI-

1972

MJ. Gardner

of a videotape

Psychlntric MJ:

160-163,

of mental ahnormalities

cla\sifcation

Psychiatric nes\.

16. Kelleher

17. Kendel

and

Arch Gen P\ychiatl-y

IX:

al: The intlurnce

diagnosis

New

RE.

Am

of the US-UK

The

Schizophrenia Krndel

diagnwtic

1969 (SuppI)

chopathology I?.

the

investigations.

13:70-39.

Profc5sional

National

of

I1:21-75. GoodL\in

Winier DW.

NC\& Yorh.

1Y71

GII/S

S:

Out’ord I n-