On the threshold of disorder: a study of the impact of the DSM-IV clinical significance criterion on diagnosing depressive and anxiety disorders in clinical practice.
BACKGROUND
Two recent reanalyses of epidemiologic studies found that adding a clinical significance criterion reduced disorder prevalence. Patients presenting for clinical care are usually distressed or impaired by their symptoms; thus, the DSM-IV clinical significance criterion might have little impact on diagnosis in clinical practice. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examine the impact of the DSM-IV clinical significance criterion on diagnostic frequencies of depressive and anxiety disorders in psychiatric outpatients.


METHODS
1500 psychiatric outpatients were evaluated with the Structured Clinical Interview for DSM-IV. We determined the percentage of patients who met symptom criteria but did not meet the DSM-IV clinical significance criterion for major depressive disorder, posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), social phobia, specific phobia, panic disorder, and obsessive-compulsive disorder.


RESULTS
No patient who met the symptom criteria for current major depressive disorder or PTSD failed to meet the clinical significance criterion. Less than 2% of patients meeting the symptom criteria for current GAD did not meet the clinical significance criterion. There was variability among the remaining anxiety disorders in the percentage of symptomatic patients who met the clinical significance criterion.


CONCLUSIONS
In psychiatric patients, the clinical significance criterion had little impact on diagnosing major depressive disorder, GAD, and PTSD, disorders that are defined, in part, by disruptions of daily regulatory domains such as sleep, appetite, energy, and concentration. In contrast, the clinical significance criterion had a greater impact in determining whether phobic fears, obsessive thoughts, and panic attacks were sufficiently distressing or impairing to qualify for disorder status.
Zimmerman
Mark
M
Department of Psychiatry and Human Behavior, Brown University School of Medicine, Providence, RI, USA. mzimmerman@lifespan.org
Chelminski
Iwona
I
Young
Diane
D
D000328:Adult; D000553:Ambulatory Care / Q000706:statistics & numerical data; D001008:Anxiety Disorders / Q000145:classification / Q000175:diagnosis* / Q000453:epidemiology; D003865:Major Depressive Disorder / Q000145:classification / Q000175:diagnosis* / Q000453:epidemiology; D039721:Diagnostic and Statistical Manual of Mental Disorders; D005260:Female; D006801:Humans; D008297:Male; D009771:Obsessive-Compulsive Disorder / Q000145:classification / Q000175:diagnosis / Q000453:epidemiology; D010698:Phobic Disorders / Q000145:classification / Q000175:diagnosis / Q000453:epidemiology; D011569:Psychiatric Status Rating Scales / Q000706:statistics & numerical data*; D011594:Psychometrics; D011872:Radiology Department, Hospital / Q000706:statistics & numerical data; D012237:Rhode Island / Q000453:epidemiology; D013313:Stress Disorders, Post-Traumatic / Q000145:classification / Q000175:diagnosis / Q000453:epidemiology