Differences in DSM-III-R and DSM-IV Diagnoses in Eating

Disorder Patients
Suzanne R. Sunday, Carol B. Peterson, Karen Andreyka, Scott J. Crow, James E. Mitchell,
and Katherine A. Halmi
Two hundred eighty-eight eating disorder patients
were administered the DSM-III-R Structured Clinical
Interview (SCID) and the DSM-IV SCID for axis I and II.
Concordance between DSM-III-R and DSM-IV was ex-
cellent for the axis I affective and anxiety disorders,
bulimia nervosa, and substance abuse/dependence. It
was also excellent for axis II paranoid, schizoid, bor-
derline, and antisocial personality disorders. Agree-
ment between the two nosological systems was
lower for alcohol abuse/dependence with a kappa of
.63. Kappas were also poor for the following person-
ality disorders: schizotypal (.44), histrionic (.29), de-
pendent (.54), obsessive-compulsive (.62) and not oth-
erwise specied (.63). There was a substantial
difference in the diagnosis of anorexia nervosa be-
tween DSM-III-R and DSM-IV. Fourteen patients were
diagnosed with anorexia nervosa, binge/purge type,
using DSM-IV criteria, while only six received the di-
agnoses of anorexia nervosa and bulimia nervosa us-
ing DSM-III-R criteria. Kappa was .49 and the percent
agreement was 79%. While there are considerable
areas of overlap in DSM-IV and DSM-III-R, there are
also areas of substantial differences. Clinicians and
researchers must be very cautious when attempting
to compare data from the different nosologies.
Copyright 2001 by W.B. Saunders Company
T
HE DIAGNOSTIC and Statistical Manuals of
Mental Disorders (DSM), published by the
American Psychiatric Association, have reected
consensus among experts in the eld and the
changing knowledge base of psychiatry and psy-
chology. As such, these manuals have changed and
must continue to be modied over time. The pri-
mary goal of the DSM has been to provide descrip-
tions of diagnostic categories so that clinicians and
researchers are better able to diagnose, assess, and
treat people with psychiatric disorders. The evolv-
ing nature of the DSM has presented problems
because the diagnoses and their criteria have often
changed substantially from one nosological system
to the next.
The earliest versions of the DSM
1,2
did not in-
clude specic diagnostic criteria and were not em-
pirically based. This changed with the develop-
ment of DSM-III in 1980.
3
Diagnostic criteria were
explicitly stated and were based, in part, on empir-
ical data. Axis II was also added to diagnose per-
sonality disorders. Further, criteria were descrip-
tive and not specically linked to etiological
theories. These changes led to the development of
instruments to assess the specic criteria. One such
instrument was the Diagnostic Interview Schedule
(DIS),
4
a structured interview that could be admin-
istered by laypeople with little training. Using this
interview, researchers were able to assess psychi-
atric diagnoses, and many studies were published
using this measure.
5
The revision of DSM-III
6
further claried and
rened the diagnostic criteria. However, the
changes in denitions and diagnostic criteria also
presented problems. Recently, Regier et al.
7
dis-
cussed the impact of these changes on psychiatric
diagnoses of community-based samples in epide-
miological studies. In comparing the Epidemio-
logic Catchment Area (ECA) DSM-III studies with
the National Comorbidity Survey (NCS) DSM-
III-R study, they reported substantial increases in
the diagnosis of alcohol dependence, panic disor-
der, and social phobia based on the changes in the
criteria between the two nosological systems.
These changes reected inconsistencies in diag-
noses between the two systems rather than in-
creases in base rates.
Morey
8
compared axis II diagnoses between
DSM-III and DSM-III-R in 291 case reports from
clinicians. In general, the author found quite poor
agreement between the two systems; only border-
line personality disorder had a kappa value above
From the New York Presbyterian HospitalWeill Medical
College of Cornell University, White Plains, NY; Department of
Psychiatry, University of Minnesota, Minneapolis, MN; Neuro-
psychiatric Research Institute and University of North Dakota,
Fargo, ND.
Supported by The McKnight Foundation, The New York
Community Trust established by DeWitt-Wallace, and the Min-
nesota Obesity Center Grant No. P30DK50456 from the Na-
tional Institute of Health.
Presented in part at the annual meeting of the Eating Dis-
order Research Society, November 21, 1997, Albuquerque, NM.
Address reprint requests to Suzanne R. Sunday, PhD, Weill
Medical College at Cornell University, 21 Bloomingdale Rd,
White Plains, NY 10605.
Copyright 2001 by W.B. Saunders Company
0010-440X/01/4206-0005$35.00/0
doi:10.1053/comp.2001.27896
448 Comprehensive Psychiatry, Vol. 42, No. 6 (November/December), 2001: pp 448-455
.75. Further, there were marked increases in some
disorders (e.g., an 800% increase for schizoid per-
sonality disorder) and an overall increase in over-
lap of axis II disorders using DSM-III-R. Blash-
eld et al.
9
compared the DSM-III and DSM-III-R
diagnoses of personality disorders among 72 pa-
tients using the Structured Interview for DSM-III
(SIDP) and for DSM-III-R (SIDP-R). Kappas for
all of the personality disorders were below .6.
Rates of paranoid, avoidant and, to a lesser degree,
obsessive-compulsive personality disorders all in-
creased with DSM-III-R; rates of schizotypal and
borderline personality disorders decreased.
After the introduction of DSM-III-R, many in-
vestigators and clinicians questioned whether ac-
curate psychiatric diagnoses could be assigned us-
ing a structured interview administered by
nonclinicians. In response to such criticisms, the
Structured Clinical Interview for DSM (SCID) was
developed.
10,11
This instrument has been shown to
be both reliable and valid.
11,12
The widespread use
of this semistructured, clinician-administered inter-
view in research studies led to an increase in the
description of comorbid psychiatric disorders
among numerous groups of psychiatric patients.
For example, Braun et al.
13
described comorbid
disorders among subgroups of eating disorder pa-
tients. Hundreds of articles have been published
describing typical axis I and axis II comorbidity
patterns for each of the axis I disorders, and re-
searchers and clinicians alike have incorporated
the ndings into their work. For example, those
who work with eating disorder patients expect to
nd comorbid major depression, obsessive-com-
pulsive disorder, and cluster C personality disor-
ders in anorectic and bulimic patients and comor-
bid alcohol and substance dependency, social
phobia and cluster B personality disorders (partic-
ularly borderline personality disorder) in bulimic
patients.
13
The publication of DSM-IV
14
represents further
modications of the diagnostic criteria. For the rst
time, the literature was closely reviewed, data were
reanalyzed, and extensive eld trials were con-
ducted so that changes in diagnostic criteria were
driven primarily by empirical data. For some diag-
noses (most notably axis II diagnoses), the new
criteria have led to major changes, such that a
person who was given a diagnosis in DSM-III-R
might not receive that diagnosis in DSM-IV. Con-
versely, patients might receive a diagnosis in
DSM-IV but not in DSM-III-R.
In axis I, two areas that did change substantially
were eating disorders and alcohol/substance abuse
and dependence. While the criteria for anorexia
nervosa did not change in DSM-IV, the subclassi-
cation into restricting and binge-eating/purging
types has been added. Previously in DSM-III-R an
anorexia nervosa patient who binged and purged at
least twice per month was given the additional
diagnosis of bulimia nervosa. However, research
ndings indicated that anorexia nervosa patients
who binge ate and/or purge regularly appeared to
be different from those who only restricted.
15,16
In
DSM-IV, individuals who meet criteria for an-
orexia nervosa and binge and purge are classied
in the binge-eating/purge subtype rather than given
an additional diagnosis of bulimia nervosa.
While the number of criteria required by
DSM-IV for substance dependence and abuse is
not different from DSM-III-R (three and one, re-
spectively), the items that can be considered for the
diagnoses are different. DSM-IV has different
questions that comprise the dependence and abuse
sections, generally resulting in lower rates of both
diagnoses than DSM-III-R. The agreement be-
tween DSM-III-R and IV concerning substance
abuse and dependence has been discussed recently
in the literature. Rounsaville et al.
17
reported high
levels of agreement and high kappa values (.85)
between the two systems for alcohol and substance
dependence; however, the kappa values for abuse
ranged from .56 for alcohol to .78 for sedatives.
Similar ndings were reported by others for alco-
hol and other substances.
18-22
Many of the personality disorders have under-
gone substantial changes from DSM-III-R to
DSM-IV. Some of the changes were minor, such as
requiring three rather than four criteria for antiso-
cial personality disorder and adding one additional
item to the criteria for borderline personality dis-
order. Other axis II disorders underwent major
changes. The denition of schizotypal personality
disorder was modied. In DSM-III-R, it included
excessive social anxiety, especially with unfamiliar
people; for DSM-IV it requires excessive social
anxiety that does not diminish with familiarity. For
histrionic personality disorder, the number of cri-
teria required for a diagnosis was changed from
four to ve and several criteria were changed. Both
DSM-III R/DSM-IV DIAGNOSES IN EATING DISORDERS 449
denitions and criteria were changed for narcissis-
tic, avoidant, and dependent personality disorders.
DSM-IV obsessive-compulsive personality disor-
der requires four rather than ve criteria, has a
different denition, and includes different criteria
than DSM-III-R. Thus, it should be expected that
the agreement between DSM-III-R and DSM-IV
should be lower for schizotypal, histrionic, narcis-
sistic, avoidant, dependent, and obsessive-compul-
sive personality disorders because of the degree of
change for those disorders.
Blais et al.
23,24
recently evaluated DSM-IV per-
sonality disorder criteria psychometrically. When
cluster B (narcissistic, histrionic, borderline, and
antisocial) personality disorders were examined
in 94 patients, improvements in divergence and
reliability were found. Diagnoses in DSM-IV
and DSM-III-R were also compared. Agreement
(kappa) was high for borderline and antisocial per-
sonality disorders but low for the other two. Over-
all, there was a decrease in axis II diagnoses using
DSM-IV. Poling et al.
25
also compared SCID II
DSM-III-R and DSM-IV personality disorder di-
agnoses by interviewing 370 substance abusing
or dependent patients. They reported very poor
agreement between the two systems for histrionic
(kappa .42) and dependent (kappa .34) per-
sonality disorders and only moderate kappas for
avoidant and obsessive-compulsive personality
disorders.
Despite the fact that reliability, validity, diver-
gence, and consistency are better with DSM-IV
than with DSM-III-R, discriminant validity re-
mains a problem. This problem leads to very high
levels of comorbidity between different personality
disorders. This issue was discussed in detail by
Clark et al.
26
Their review of the DSM-III-R liter-
ature revealed percentages of multiple axis II di-
agnoses between 76% and 100%; in other words,
greater than three quarters of the personality dis-
order patients had two or more personality disor-
ders. Personality disorder not otherwise specied
(PD-NOS) was generally the most common axis II
diagnosis. Such overlap between different person-
ality disorders reects a problem both with the
conceptualization of the disorders and in the oper-
ational denitions of the criteria.
The SCID has been revised to reect the
changes in DSM-IV for both axis I and axis II.
27,28
It was the purpose of the present study to examine
the differences in axis I and axis II diagnoses using
the SCID for DSM-III-R and the SCID for
DSM-IV in a sample of eating disorder patients.
METHOD
Two hundred eighty-eight female inpatients and outpatients
served as participants; 167 were patients in the Eating Disorder
Program at New York Presbyterian Hospital-Weill Cornell
Medical Center, White Plains, NY, and 121 were participants in
the Eating Disorder Research Program at the University of
Minnesota. The mean age of the patients was 29.2 years (SD
8.7). The racial groups of the patients were: Caucasian 91.7%
(n 264), Hispanic 3.1% (n 9), African-American 2.8%
(n 8), Asian 1.7% (n 5), and Native American 0.7% (n
2). Written informed consent was obtained from all subjects
(and from their parents if subjects were under 18 years of age)
at the time the study was explained. Subjects could withdraw
their consent at any time during the study.
All patients were interviewed at, or shortly after, entry to the
program. To establish axis I diagnoses, SCID I for DSM-IV
27
and the H module (eating disorders) from SCID I for DSM-III-
R
10
were used. SCID I for DSM-IV interviews were recoded for
DSM-III-R criteria after each interview by the interviewer. In
order to minimize differences between DSM-III-R and DSM-IV
ratings due to interviewer biases, the same clinician conducted
both interviews. SCID II for DSM-IV
28
was conducted on the
same day as SCID II for DSM-III-R,
11
because test-retest reli-
ability for the DSM-III-R SCID II between 1 day and 2 weeks
apart is moderate to poor (kappas ranged from .24 to .74
12
).
SCID II questionnaires (for both DSM-IV and DSM-III-R)
were completed prior to the interviews for all participants. For
most subjects, SCID I and II interviews were conducted on
different days; however, all interviews were completed within a
2-week period. All interviews were conducted by either the rst
or the second author; both were experienced clinical and re-
search interviewers who had been extensively trained to admin-
ister the SCID I and II. The interviewers had initially received
training using the SCID for DSM-III-R; the rst author was
trained by one of the SCID coauthors (M. Gibbon) and the
second author was trained by an expert at her site and viewed
the DSM-III-R SCID tapes. Both interviewers conducted many
of these interviews before the inception of the current project.
When the DSM-IV SCID was released, the interviewers re-
ceived further training and taped all interviews. A subset of
these tapes were reviewed for both interviewing and scoring
procedures.
Percent agreement and kappas between DSM-III-R and
DSM-IV were computed for all axis II diagnoses and the
following axis I diagnoses: alcohol and substance abuse and
dependence, anorexia nervosarestricting type (AN-R), and an-
orexia nervosabinge-eating/purge type (AN-BP). For alcohol
and substances, data were analyzed separately for each sub-
stance but with abuse and dependence within a single analysis.
RESULTS
Axis I
Only 85 patients (29.5%) had no axis I disorders
other than the eating disorder. There was complete
450 SUNDAY ET AL
agreement between DSM-III-R and DSM-IV diag-
noses for all axis I disorders except anorexia ner-
vosa, alcohol abuse/dependence, and substance
abuse/dependence. Of the 14 patients who were
diagnosed as AN-BP using DSM-IV, only six were
diagnosed as meeting criteria for anorexia nervosa
and bulimia nervosa using DSM-III-R. Thirty-two
patients were diagnosed as only meeting criteria
for anorexia nervosa using the DSM-III-R criteria
while 24 received the diagnosis using DSM-IV.
Thus, there was a 79% agreement between DSM-
III-R and IV for anorexia nervosa but the kappa
value was only .485. One hundred seventy-two
patients were classied with bulimia nervosa and
78 with eating disorder not otherwise specied
(ED-NOS) using both systems.
Table 1 presents the occurrence of alcohol and
substance disorders. Percent agreement was high
throughout with greater variation among the kap-
pas. With the exception of alcohol abuse and de-
pendence (.63), all kappas were quite high (.75).
Axis IIPersonality Disorders
The majority of this sample (n 156 or 54%)
had no axis II pathology. The agreement between
DSM-III-R and DSM-IV varied by personality dis-
order; the data appear in Table 2. Again, percent
agreement was high for all disorders but kappas
varied widely with all but paranoid, schizoid, bor-
derline, and antisocial below .75. The prevalence
of the diagnoses was not dramatically different
between DSM III-R and IV except for substantial
decreases in schizotypal, histrionic, and dependent
personality disorders and a twofold increase in
obsessive-compulsive personality disorder. The
two most prevalent axis II disorders in both noso-
logical systems were borderline and avoidant.
The number of personality disorders present ap-
pears in Table 3. The majority of patients who were
diagnosed with a personality disorder had one or
two diagnoses. There were few differences be-
tween DSM-IV and DSM-III-R. Table 4 presents
Table 1. Substance Abuse and Dependence Diagnoses in DSM-III-R and DSM-IV
Substance % Agreement Kappa
Absent
Both
Abuse
Both
Dependence
Both
Abuse III-R
Only
Abuse IV
Dependence III-R*
Alcohol 80% .63 177 36 48 10 17
Sedatives 99% .92 261 7 16 0 4
Cannabis 97% .89 242 18 12 1 7
Stimulants 99% .91 262 5 17 2 2
Opioids 99% .93 271 7 7 0 3
Cocaine 99% .95 256 6 23 2 1
Hallucinogens 98% .77 275 7 1 0 5
Other 97% .87 265 2 12 7 2
Poly-drug 99% .90 277 0 9 1 0
*The changes from DSM-III-R to DSM-IV in criteria for abuse and dependence were such that subjects were more likely to meet
dependence criteria using DSM-III-R than in DSM-IV. This column reects cases where subjects met dependence criteria for
DSM-III-R but only abuse criteria using DSM-IV.
Table 2. Axis II Diagnoses in DSM-III-R and DSM-IV
Personality Disorder % Agreement Kappa
Absent
Both
Present
Both
IV
Only
III-R
Only
% in
IV
% in
III-R
Paranoid 100% 1.00 261 27 0 0 9.4 9.4
Schizotypal 99% .44 284 1 0 3 .3 1.4
Schizoid 100% 1.00 285 3 0 0 1.0 1.0
Histrionic 95% .29 271 2 0 15 .7 5.9
Narcissistic 98% .71 274 8 3 3 3.8 3.8
Borderline 96% .88 235 52 10 1 21.5 18.4
Antisocial 100% .91 281 6 1 0 2.4 2.1
Avoidant 92% .72 227 39 12 10 17.7 17.0
Dependent 95% .54 261 11 1 15 4.2 9.0
Obsessive-compulsive 94% .62 252 20 20 0 13.8 6.9
PD-NOS 97% .63 271 8 5 4 4.5 4.2
DSM-III R/DSM-IV DIAGNOSES IN EATING DISORDERS 451
the co-occurrence of the personality disorders; that
is, for each personality disorder, the number of
subjects who had at least one other personality
disorder diagnosis. For all of the disorders, a ma-
jority of subjects had additional axis II comorbidity
and there were few differences between the two
diagnostic systems. Only obsessive-compulsive
personality disorder showed a substantial decrease
in axis II comorbidity from DSM-III-R to DSM-IV.
Several specic pairings of personality disorders
were found to occur. Borderline and avoidant co-
occurred (with or without additional personality
disorders) most frequently (for 28 subjects using
DSM-IV and for 23 using DSM-III-R), followed
by paranoid and borderline (21 and 17, respec-
tively), borderline and obsessive-compulsive (17
and 9), avoidant and obsessive-compulsive (12 and
9), borderline and dependent (7 and 17), and
avoidant and dependent (7 and 15).
A Comparison Between Subgroups of Eating
Disorders
DSM-IV axis I and II diagnoses were examined
for each of the eating disorder subgroups. Only
DSM-IV diagnoses are presented since this is the
current nosological system. Due to the small num-
bers in the two anorexia groups (24 for AN-R and
12 for AN-BP), detailed breakdowns of the diag-
noses will be presented only for the bulimics. Ap-
proximately one third of patients in each of the
groups had had no other axis I disorder than an
eating disorder (BN, n 63% to 37%; AN-R, n
8% to 33%; AN-BP, n 4% to 33%). Asubstantial
number of patients in each of the groups had had
some form of affective disorder (almost always
major depression)38% of BN (n 65), 29% of
AN-R (n 7), and 50% of AN-BP (n 7). Any
history of alcohol or drug dependence or abuse was
twice as prevalent in BN and AN-BP as in ANR
(42% and 43% as compared with 21%). The pres-
ence of any anxiety disorder was seen more in the
anorectic patients than in BN (50% for AN-R, 42%
for AN-BP as compared to 25% for BN). For BN,
obsessive-compulsive disorder was most prevalent
(n 22), followed by post-traumatic stress disor-
der (n 17), and social phobia (n 13). All other
anxiety disorders were found in fewer than 10 BN
patients.
The majority of patients in each group (92 or
53% with BN, 17 or 71% with AN-R, and seven or
50% with AN-BP) did not meet criteria for any
personality disorder. Of the personality disorders
seen in these patients, any cluster Adiagnoses were
infrequent (8% of BN, 0% of AN-R, and 8% of
AN-BP). Cluster B disorders were found only
among those who binged and/or purged (26% of
BN, 25% of AN-BP, 0% of AN-R). Cluster C
disorders were most prevalent for all three groups;
however, AN-R had the lowest levels (17% as
compared with 30% for BN and 33% for AN-BP).
The most prevalent personality disorders for BN
were borderline (n 40), avoidant (n 33),
obsessive-compulsive (n 23), and paranoid (n
11). All other personality disorders occurred in
fewer than 10 BN patients.
DISCUSSION
Agreement between DSM-III-R and DSM-IV
diagnoses depended strongly on the disorders
themselves. Concordance between the two noso-
Table 3. Number of Personality Disorder Diagnoses in
DSM-III-R and DSM-IV
No. of
Personality
Disorders
DSM-IV DSM-III-R
n % n %
0 178 48.2 191 66.3
1 53 18.4 44 15.3
2 31 10.8 26 9.0
3 16 5.5 17 5.9
4 6 2.1 3 1.0
5 2 .6 2 .6
6 2 .6 3 1.0
7 0 0 2 .6
NOTE. Excludes PD-NOS diagnoses.
Table 4. Co-occurrence of Axis II Diagnoses in DSM-III-R
and DSM-IV
Personality
Disorder
DSM-IV DSM-III-R
No. With
at Least
One Other
Axis II
Diagnoses %
No. With
at Least
One Other
Axis II
Diagnoses %
Paranoid 24 88.9 19 70.3
Schizoid 2 66.7 3 100.0
Schizotypal 2 66.7 3 75.0
Histrionic 2 100.0 14 82.3
Narcissistic 8 72.7 10 90.9
Borderline 45 72.5 38 71.7
Antisocial 5 71.4 4 66.7
Avoidant 37 72.5 37 75.5
Dependent 10 83.3 23 88.5
Obsessive-compulsive 21 52.5 15 75.0
452 SUNDAY ET AL
logical systems was excellent on axis I for the
affective and anxiety disorders and bulimia ner-
vosa, very good for non-alcohol substance depen-
dence/abuse, and excellent on axis II for paranoid,
schizoid, borderline, and antisocial personality dis-
orders. Substantial differences arose for the re-
maining Personality Disorders, alcohol depen-
dence/abuse, and anorexia nervosa. These ndings
are consistent with previous research that has
found signicant differences between classication
systems.
7,8
The subtyping of anorexia nervosa in DSM-IV
is substantially different from the diagnosis of an-
orexia nervosa or the dual diagnosis of anorexia
nervosa and bulimia nervosa in DSM-III-R. Thus,
clinical descriptions of DSM-III-R anorexia ner-
vosa patients in the literature and other differences
between these groups (such as response to therapy)
should not be assumed to adequately describe ei-
ther DSM-IV restricting or binge-eating/purging
patients. It will be important to replicate much of
this previous work using DSM-IV anorectic sub-
types.
The convergence of axis II diagnoses was not
good between the two systems, except for para-
noid, schizoid, borderline, and antisocial personal-
ity disorders. This is especially interesting since
the completion of both the DSM-III-R and
DSM-IV SCID II questionnaires at the same time
may have actually increased convergence of the
two systems. The majority of personality disorders
did not yield consistent results between the two
systems. Our ndings concerning cluster B person-
ality disorders are similar to those of Blais et al.
23
and Poling et al.
25
; agreement was very good for
borderline and antisocial but less good for narcis-
sistic and poor for histrionic personality disorders.
The especially low kappa for histrionic personality
disorder may be the result of the increase in the
number of criterion responses required and the
changes in the content of the criteria in DSM-IV.
There were several dramatic decreases in the fre-
quencies of some personality disorders, notably
schizotypal, histrionic, and dependent.
Similar decreases in histrionic and dependent
personality disorders were also reported by Poling
et al.
25
Blais et al.
23
reported similar decreases in
the diagnosis of histrionic personality disorder in
DSM-IV as compared with DSM-III-R and noted
that the correlations with borderline and narcissis-
tic personality disorders had decreased as well.
Only obsessive-compulsive personality disorder
rates increased in DSM-IV, perhaps because the
threshold for diagnosis was lowered from ve to
four items; it will be important to examine this
personality disorders overlap with other axis II
disorders. Although Poling et al.
25
did report sim-
ilar kappas for obsessive-compulsive personality
disorders, they found only slight increases in the
prevalence in DSM-IV rather than the twofold
increase that we found. This nding may be spe-
cic to eating disorder patients and may not gen-
eralize to substance abusers.
Co-occurrence of personality disorders was no
different with both nosological systems. For all but
one personality disorder (obsessive-compulsive),
axis II comorbidity was present for more than two
thirds of the patients. Similarly, the number of
patients with two or more personality disorders
was not very different between the two systems.
Despite the expressed interested in decreasing the
number of mixed or atypical categorizations (PD-
NOS) in DSM-IV, we obtained very similar num-
bers of patients who received this diagnosis using
both systems. However, for both DSM-III-R and
DSM-IV, the use of PD-NOS was not particularly
high (about 4%) for our sample. This is in contrast
to the ndings of Clark et al.
26
and may reect
differences using an eating disorder sample or dif-
ferences in interviewer usage of the PD-NOS cat-
egory between the two studies.
The amount of psychopathology found in the
current study among subjects with BN, AN-R, and
AN-BP using DSM-IV criteria was somewhat less
than what has been previously reported using
DSM-III-R.
13
For example, Braun et al.
13
reported
that 82% of the eating disorder patients had axis I
comorbidity, 69% had axis II comorbidity, and
65% of their BN patients had had an affective
disorder. In contrast, we found that less than two
thirds of our subjects had axis I comorbidity, less
than half had axis II comorbidity, and only 38% of
bulimics had had an affective disorder. The former
study examined inpatients, whereas our study ex-
amined outpatients; this could account for the dif-
ferences. There were also similarities between our
ndings and those of Braun et al.
13
Levels of
substance/alcohol problems and anxiety disorders
were very similar, as were the levels of cluster C
DSM-III R/DSM-IV DIAGNOSES IN EATING DISORDERS 453
personality disorders for all groups and cluster B
personality disorders for BN.
One potential limitation of this study is that the
same interviewer conducted both the DSM-III-R
and DSM-IV interviews, which may have inated
the correlations between the two interviews. How-
ever, the decision to have the same interviewer
conduct both interviews was made in order to
minimize differences due to examiner variance.
Thus, the differences between the two nosological
systems found in this study may actually be an
understatement of the differences as measured by
the SCID. Future studies should attempt to repli-
cate the ndings of this investigation using inde-
pendent raters for diagnostic system.
In conclusion, the results of this study suggest
that while there is considerable overlap between
DSM-III-R and DSM-IV diagnoses, there are also
substantial differences, especially on axis II. Be-
cause of these differences, researchers and clini-
cians must use caution in generalizing from one
system to another. For example, a patient who
received a DSM-III-R diagnosis may have the
same diagnosis, a different diagnosis, or no diag-
nosis at all according to DSM-IV. The differences
between the two classication systems suggest that
previous ndings using DSM-III-R require repli-
cation using DSM-IV criteria. The inconsistencies
between DSM-III-R and DSM-IV have signicant
implications to investigations of treatment out-
come and comorbidity, which also need to be con-
sidered in future revisions of DSM criteria. While
it is important to improve the clarity and accuracy
of axis II criteria, the diminished ability to conrm
or disconrm classic studies and track changes in
the epidemiology of personality disorders across
time suggests that further substantive changes in
DSM criteria need to be carefully considered.
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