Samuel B. Guze’s research while affiliated with Washington University in St. Louis and other places

Clinic patients with diagnoses of either major depression or somatization disorder were given the MMPI. Women with somatization disorder had high scores on Keane's MMPI scale (PK) for posttraumatic stress disorder. Following the procedure for the MMPI-2 (46 of the 49 PK items and MMPI-2 norms), 59% of the women with somatization disorder and 21% of the women with major depression would have T scores > or = 65 on the MMPI-2 scale although none of them were known to have developed psychiatric disorder after exposure to a life threatening event. The PK scale has little use in the differential diagnosis of women patients with somatization disorder.

44 items on the MMPI were identified which appear to correspond to some of the symptoms in nine of the 10 groups on the Perley-Guze checklist for somatization disorder (hysteria). This list was organized into two scales, one reflecting the total number of symptoms endorsed and the other the number of organ systems with at least one endorsed symptom. Full MMPIs were then obtained from 29 women with primary affective disorder and 37 women with somatization disorder as part of a follow-up study of a consecutive series of 500 psychiatric clinic patients seen at Washington University. Women with the diagnosis of somatization disorder scored significantly higher on the somatization disorder scales created from the 44 items than did women with only major depression. These new scales appeared to be slightly more effective in identifying somatization disorder than the use of the standard MMPI scales for hypochondriasis and hysteria. Further development is needed.

The criteria for borderline personality disorder seem to select patients with very high rates of Briquet's syndrome (hysteria), somatization disorder, antisocial personality disorder, and substance abuse disorders. This study was undertaken to determine whether systematic assessment of patients with borderline personality disorder would reveal characteristic features of that condition which would distinguish it from these other disorders. Eighty-seven white female patients (75 in St. Louis and 12 in Milan, Italy) who had borderline personality disorder according to both the DSM-III-R criteria and the Revised Diagnostic Interview for Borderlines were further examined with the DSM-III-R Checklist and the Perley-Guze Hysteria Checklist to determine their patterns of psychiatric comorbidity. Every patient had at least one additional DSM diagnosis. Patients in St. Louis and Milan averaged five and four additional diagnoses, respectively. Eighty-four percent of the patients in St. Louis met criteria for either somatization disorder, Briquet's syndrome, antisocial personality disorder, or substance abuse disorders. Patterns of comorbidity for panic (51%), generalized anxiety disorder (55%), and major depression (87%) in St. Louis were consistent with those in other studies. The data indicate that the boundaries for the borderline condition are not specific and identify a high percentage of patients with these other disorders. Furthermore, the comorbidity profiles closely resemble the psychiatric profiles of patients with these disorders. If the borderline syndrome is meant to include all of these disorders, its usefulness as a diagnosis is limited. Until the fundamental features of borderline personality disorder that distinguish it from the others are identified, it is recommended that clinicians carefully assess patients for these other diagnoses. Efforts should be made to change the borderline personality disorder criteria by shifting away from overlap with the criteria for the other disorders.

New revisions of diagnostic categories have produced the most recent classification systems, namely DSM-IV and ICD-10. The diagnostic approaches exemplified by these two nomenclatures are very similar to one another and represent a return to descriptive psychiatry in which careful observation of symptoms, signs, and course of mental diseases become the diagnostic criteria themselves. In many ways, these newest classification schemata can be considered a return to phenomenological psychiatry perhaps best exemplified at the start of this century by Emil Kraepelin. Thus, recent developments in psychiatric diagnosis can be thought of as "neo-Kraepelinian". Because they represent a relatively radical change from psychodynamic approaches to evaluation and diagnosis, they can also be called "revolutionary." This paper traces the roots of current diagnostic systems and compares and contrasts these systems to the classification schema described by Kraepelin. Diagnostic criteria for schizophrenia are used as an example of how diagnostic conventions have changed dramatically over the past 50 years. Discussion of the implications of this neo-Kraepelinian revolution in psychiatric diagnosis is included.

The purpose of this study was to evaluate for APA a proposed strategy to diagnose somatization disorder for possible inclusion in DSM-IV. Five sites--Washington University, University of Kansas, University of Iowa, University of Arkansas, and Mount Sinai Medical Center in New York--participated in a collaborative field trial. Female subjects (N = 353) were recruited from several different services (psychiatry, internal medicine, and family practice) and were evaluated for the presence or absence of the disorder. This assessment was performed with a new instrument constructed by combining all the criteria for somatization disorder from the proposed criteria for DSM-IV, DSM-III, DSM-III-R, Perley-Guze, and proposed criteria for ICD-10. A high level of concordance was found between the proposed diagnostic strategy for DSM-IV and the current criteria (DSM-III-R), as well as the earlier criteria (Perley-Guze and DSM-III). The ICD-10 criteria agreed poorly with all other criteria sets. The level of experience of the rater (expert versus novice) with the earlier (Perley-Guze, DSM-III) and current (DSM-III-R) criteria did not influence the identification of cases by use of DSM-IV criteria. No racial effect was introduced by any of the criteria sets. The strategy for DSM-IV is an accurate and simpler method of diagnosing somatization disorder that does not require special expertise for proper use.

We describe the results of a follow-up study on patients with hysteria using the Minnesota Multiphasic Personality Inventory (MMPI) to evaluate the multiple complaints of these patients. MMPIs were obtained from 29 women with primary affective disorder and 37 women with Briquet's syndrome as part of a follow-up study of the St. Louis clinic 500. Patients with Briquet's syndrome were significantly less consistent and logical in answering MMPIs and were more likely to emphasize personal psychopathological conditions. They reported many more symptoms in many more problem areas than did women with primary affective disorder. Patients with Briquet's syndrome reported significantly more somatic symptoms and psychological/interpersonal problems than did the depressed group. It was suggested that such patients mimic multiple psychiatric and somatic disorders.

This report is limited to publications in English that deal with either Briquet's syndrome or DSM-III and DSM-III-R somatization disorder. The few reports dealing with hysteria defined as isolated conversion symptoms are omitted because of extensive previous work indicating clearly that such cases are very heterogeneous. The studies are presented chronologically, by year of publication.