Gender, Race, DSM III

Gender, Race, and DSM-III: A Study of the Objectivity of Psychiatric Diagnostic Behavior
Author(s): Marti Loring and Brian Powell

Source: Journal of Health and Social Behavior, Vol. 29, No. 1 (Mar., 1988), pp. 1-22
Published by: American Sociological Association
Stable URL: http://www.jstor.org/stable/2137177
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Gender, Race, and DSM-III: A Study of the Objectivity of
Psychiatric Diagnostic Behavior*
MARTI LORING
Center for Mental Health and Human Development
BRIAN POWELL
Indiana University
Journal of Health and Social Behavior 1988, Vol. 29 (March):1-22
Sociologists have long been interested in the consequences of psychiatrists' and clients' social location
on diagnostic judgment. Previous research provided conflicting evidence on the effects of sex and race
on diagnosis, but it has been suggested that with the institution of a formalized diagnostic system, The
Diagnostic and Statistical Manual for Mental Disorders (Third Edition), the effects of gender and race
on diagnosis have become minimal. We assess the accuracy of this claim using an analogue approach
in which 290 psychiatrists evaluate two case studies. Case studies are manipulated so that
approximately one-fifth of the clinicians, using DSM-III-derived criteria, evaluate a white male, a white
female, a black male, a black female, or a client whose sex and race are not disclosed. Results indicate
that sex and race of client and psychiatrist influence diagnosis even when clear-cut diagnostic criteria
are presented. We conclude that it is premature to close the question of the influence of sex and race on
diagnostic assessments.
In this paper we question whether the the art for psychopathologic diagnosis" (Spitzer,
establishment of an objective nosological system Williams, and Skodol 1980, p. 152). The
with concrete diagnostic criteria succeeds in psychiatric community has become increasingly
eliciting objective evaluations by mental health diagnosis-conscious since the early 1960s;
professionals. More specifically, we ask this before that time the diagnostic tools used by
question: Using The Diagnostic and Statistical psychiatrists and other mental health profession-
Manual of Mental Disorders (Third Edition), do als were neither explicit nor complete. Although
psychiatrists provide differential evaluations of mental disorders were classified in manuals such
clients based on sex and race? as the World Health Organization's Interna-
tional Classification of Diseases, the descrip-
tions of the mental illnesses were incomprehen-
DEVELOPING AN OBJECTIVE sive, vague, and, as a result, underused by
DIAGNOSTIC SYSTEM OF MENTAL American clinicians. Not to be outdone by
DISORDERS: DSM-III international associations, the American Psychi-
atric Association initiated DSM-I, which was
The Diagnostic and Statistical Manual of not a sophisticated categorical system but a brief
Mental Disorders (commonly referred to as pamphlet providing nebulous guidelines for
DSM-III), published by the American Psychiat- diagnosis.
ric Association in 1980, represents "the state of Several small-scale research projects called at-
tention to the issue of reliable evaluations in psy-
chiatry. One of the most frequently cited, al-
* Direct all correspondence to Brian Powell, Depart-
ment of Sociology, Ballantine Hall Room 744, Indiana
though ridden with major methodological flaws,'
University, Bloomington, Indiana 47405. We appreciate is the work by Beck, Ward, Mendelson, Mock,
the suggestions of George Bohrnstedt, David Heise, and Erbaugh (1962). In this study, 153 patients
Marcella De Peters, Paul Sweeney, Lala Steelman, John
were diagnosed by two of the co-authors. After
Doby, and Herb Smith. Preparation of this paper was
supported by NIMH training grant 5-T32-MH-15789. each author made a separate diagnosis, the diag-
The authors are listed in alphabetical order. noses were compared and discussed. The con-
2 JOURNAL OF HEALTH AND SOCIAL BEHAVIOR
clusion drawn in the first article derived from sis were presented carefully in the manual. The
this study was that the level of consensus among comprehensive, explicit nature of the descrip-
psychiatrists was not unacceptably low but still tions was expected to facilitate agreement
mandated improvement. Even more interesting among clinicians and to minimize subjectivity in
was the follow-up article (Ward, Beck, Mend- diagnostic judgment. Second, a multiaxial
elson, Mock, and Erbaugh 1962), in which the system of diagnosis was recommended rather
authors gave three reasons for disagreement in than a unidimensional diagnosis. Five related
diagnosis. The first, "inconstancy on the part of diagnoses were to be determined, including the
the patient," placed the responsibility for dis- clinical syndrome (Axis 1) and the lifelong
sensus in judgment on the client. The second personality disorder (Axis 2).
suggested that the diagnosticians were the appro- Perhaps the most significant accomplishment
priate focus for the variance in response. These in the development of DSM-III was the
two explanations, however, were cited less fre- introduction of field trials of reliability. Before
quently than the third: "inadequacies of the noso- the research on DSM-III was conducted, the
logy." The explanation offered for these inade- empirical tests for reliability in diagnostic
quacies was that the lack of clear criteria for judgment were of questionable quality by any
diagnosis precluded high reliability in diagnosis. standard of experimental work. In contrast, the
The means by which the authors reached their field trials for DSM-III constituted the most
conclusion, however, should be viewed with extensive and most methodologically sophisti-
reservation. After both psychiatrists made a cated study to date of the reliability of
diagnosis, they would discuss the case and psychiatric judgment. The sample of several
decide why they disagreed. Thus it is not hundred psychiatrists was the largest study of
surprising that they found it easier to make an reliability ever conducted. Moreover, in view of
external attribution (i.e., the absence of an the magnitude of the study, the manipulation
adequate diagnostic scheme) than an internal checks and alternative methods were executed
attribution (i.e., errors of observation or inter- competently. Although there are reasonable
pretation on the part of the psychiatrist). grounds for criticism of the research design,2
Nevertheless, this article had a profound effect most observers conclude that the study provided
on the movement to generate an improved solid evidence of the diagnostic reliability
diagnostic system. among raters when using DSM-III.
As a group, psychiatrists began to recognize DSM-III-based diagnoses have become com-
that the lack of an agreed-upon categorical monplace in the mental health community.
system of mental disorders jeopardized the Although psychologists initially challenged the
psychiatric profession. Without a shared set of American Psychiatric Association's categoriza-
operational definitions of mental disorders, tion of mental disorders as medical (which was
reliability in diagnosis could not be adequate, removed in the final publication of DSM-III)
and without a reasonable degree of reliability, and questioned what they considered the APA's
the value of psychiatric assessment in terms of attempt to claim primacy over other mental
treatment could be questioned (Kendell 1975). health professionals (Schact and Nathan 1977),
Moreover, the psychiatrists' inability to offer they used the DSM-III diagnoses. DSM-III-
reliable and valid diagnosis led to criticism from derived categories now are required for certain
outside the psychiatric community (Ennis and third-party payments and are being used in a
Litwack 1974). series of hospital reports on mental illness. The
For the past two decades, classification influence of DSM-III extends beyond the
schemes have been formulated; each improved medical community by redefining "the nature
on the previous one by being more exhaustive and categories of 'mental illness' for another
and more lucid. DSM-I was followed by generation of police, social workers, judges,
DSM-II, which was a precursor to the Research lawyers, counselors of all kinds and laypersons"
Diagnostic Criteria (RDC); this scheme gave (Light 1982, p. 35).
rise to DSM-III, the most recent system. No One hopes that the success of the initial
earlier classification system had received as DSM-III field trials will inspire further work not
much critical acclaim or public attention as only on reliability but also on validity in
DSM-III. Its achievements were manifold. First, diagnostic assessment. In part this has been the
detailed operational definitions for each diagno- case (for example, Thakshan, Mellsop, Nelson,
GENDER, RACE, AND DSM-III 3
Pearce, and Wilson 1986), but a series of response to the actual hostility directed toward
unanswered questions remains, which should be them (Kleiner, Tuckman, and Lavell 1960;
of particular interest to sociologists. For exam- Ridley 1984).
ple, do social factors confound DSM-III-derived An alternative interpretation does not assume
diagnoses? Is there agreement when the sex that blacks exhibit those qualities associated
and/or race of clinicians are not the same? Does with schizophrenia and paranoid personality
the sex or race of the client influence diagnostic disorders any more frequently than their white
judgments while still allowing for interjudge counterparts. Rather, clinicians attribute more
reliability? paranoid and psychotic qualities to their black
clients for reasons unrelated to the clients' actual
psychopathology. On the basis of this reason-
RACE AND PSYCHOPATHOLOGY ing, the differential racial patterns of mental
disorders may be due in part to overdiagnosis of
Sociologists and other social scientists have blacks (or underdiagnosis of whites) in such
not fully investigated racial differences in categories as schizophrenia and underdiagnosis
psychopathology, despite intriguing questions of blacks (or overdiagnosis of whites) in other
which have been posed by others. An unsettled categories such as personality disorders, with
debate continues over the racial difference in the emphasis on dependency and affective disor-
overall rates of mental illness (Adebimpe 1981; ders. Diagnoses influenced by race may lead to
Dohrenwend and Dohrenwend 1969; Kessler differential treatment or to what other research-
and Neighbors 1986; Owens 1980; Thomas and ers might view as mistreatment (Edwards 1982;
Sillen 1972; Warheit, Holzer, and Arey 1975; Pope and Lipinski 1978). Moreover, psychiatric
Welner, Liss, and Robins 1974; Yancey, assessments contaminated by the client's race
Rigsby, and McCarthy 1972). Of greater will be echoed in official reports on the
interest is the difference in diagnostic patterns prevalence of mental illness, which in turn could
between black and white patients: many studies perpetuate the racial stereotypes of psycho-
reiterate the tendency to diagnose blacks into pathology (Adebimpe 1981).
categories that connote dangerousness and The evidence supporting the last explanation
severity. On the basis of hospital admissions has been less than unequivocal. Simon, Fleiss,
records, blacks are more prone than whites to be and Garblans (1973) concluded that hospital
diagnosed as having schizophrenia and paranoid clinicians were predisposed to diagnose blacks
personality disorders (Steinberg, Pardes, Bjork, as having a schizophrenic disorder and were
and Sporty 1977). Although most studies do not reluctant to diagnose blacks as having an
distinguish between subtypes of schizophrenia, affective disorder. The few studies that followed
it has been found that black patients are more tended to concur with these findings (Adebimpe
than twice as likely as white patients to be 1981; Liss, Welner, and Robins 1973; Raskin,
diagnosed with paranoid schizophrenic disor- Crook, and Herman 1975).
ders. (Steinberg et al. 1977). In contrast, lower How can one account for the possible
rates of affective disorders (for example, discrepancy between the diagnoses of blacks
depression) generally are attributed to blacks and of whites with comparable symptoms?
than to whites. Although some authors posit racism as the
Several explanations for these patterns have answer (Owens 1980; Thomas and Sillen 1972),
been offered. Some researchers contend that others regard this response as far too simplistic.
these differences are a function not of race but Several believe that in any interpretive process
of social class (Warheit et al. 1975). Others (such as diagnosis), the evaluation will be
offer biological and/or genetic explanations for influenced by the characteristics of both the
racial variations. Others posit that the paranoid observer (in this case, the psychiatrist) and the
tendencies observed among blacks represent a actor (the client) or, more specifically, by how
healthy psychological reaction to racism in the well the observer can understand and empathize
United States (Ridley 1984). According to this with the actor's behavior. Mechanic (1962) and,
perspective, blacks express distrust, alienation, more recently, Rosenberg (1984) suggest that
and hostility (and other characteristics associ- when an observer fails to take the role of the
ated with paranoid personality disorders and actor and cannot understand the actor's actions,
schizophrenic disorders) as a logical and normal the observer will portray the actor as "abnor-
mal" or insane. Although neither Mechanic nor tested by only scant empirical evidence, save for
Rosenberg refers specifically to the sex or the some minor anecdotal reports (Adebimpe 1981).
race of the actor and the observer, Rosenberg Similarly, other researchers lament the scarcity
notes that different social locations on the part of sex-specific studies of the link between
of the actor and the observer may accentuate the mental health and race (Wilkinson 1980).
problem of understanding the actor's behavior. Even if the research presented a clear,
Conversely, congruent statuses of the actor and detailed picture of diagnosis as affected by the
observer should facilitate the latter's empathy race of the psychiatrist and the client, it could be
with the former. Scheff (1984), using a labeling argued persuasively that claims of racial bias or
orientation,3 agrees that the greater the social of differential psychiatric assessments based on
distance between the rule breaker (i.e., the research conducted before the advent of DSM-
client) and the agent of social control (i.e., the III are no longer pertinent. When required to
psychiatrist), the more severely the agent make diagnoses for which it lacks specific
evaluates the rule breaker. Others, although not guidelines, the medical community may respond
explicitly adopting an interactionist or labeling by depending on cultural expectations, stereo-
perspective, posit that when the clinician and the types, and previous experiences. The guidelines
patient do not share similar cultural back- provided in the past were not specific enough,
grounds, the clinician may not be able to according to advocates of DSM-III. With the
establish a rapport with the client, to resolve development and usage of DSM-III, however,
problems in communication and disclosure, or some authors have speculated that the clear-cut
to reconcile divergent attitudes and beliefs criteria laid out in the manual will, in effect,
(Adebimpe 1981; Bell, Bland, Houston, and prevent misinterpretations resulting from cul-
Jones 1983). Furthermore, the uncertainty that tural differences and/or from the observer's
psychiatrists express in their ability to under- inability to understand the actor's behavior
stand their clients may prompt the clinicians to (Adebimpe 1981). Regrettably, this prediction
base their diagnoses on previous experiences, was not tested by Spitzer and his associates
cultural stereotypes, and/or statistical reports ondespite the ample opportunity to do so in the
racial differences in mental disorders. NIMH-sponsored field trials of the reliability
The above discussion is based on the and validity of DSM-III. Even so, enough
implications of white psychiatrists evaluating fragmentary evidence to make this position at
black clients. A less common event, but one that least tenable was provided by Craig, Goodman,
justifies more empirical attention than it has and Haugland (1982), who reexamined the
received, is that of the black psychiatrist records of 1023 patients diagnosed by a previous
evaluating white (and black) clients. Although nosological system (DSM-II) and reclassified on
we have much less information about the black the basis of the more stringent criteria of
clinicians, several competing possibilities arise. DSM-III. These authors discovered that if they
On one hand, if the interactionist argument is simply adhered to the new nosological system,
true, blacks might not be able to empathize with the diagnoses of over one-third of the blacks
those who do not share a similar racial or would be shifted (as compared to 17% of the
cultural heritage; as a result, they might make whites). Even more striking is the direction of
different and conceivably more severe evalua- the rediagnoses. Over 64 percent of the blacks
tions of their white clients. In contrast, one diagnosed previously as having a schizophrenic
could argue that the black clinician already has disorder failed to meet the DSM-III criteria for
distanced himself or herself from most other this diagnosis (in contrast to 21% of the white
blacks and consequently will not differentiate patients), thereby reducing significantly the
between blacks and whites in his or her racial difference in the incidence of schizo-
diagnosis. Finally, one can hypothesize that phrenia in the hospital. The authors, however,
because most training of black clinicians has also noted less consensus about nonwhites than
been conducted by white physicians, the diffi-about whites and less agreement about females
culties in diagnosing whites may have been than about males. Craig, Goodman, and
attenuated. The last two possibilities may work Haugland concluded, "DSM-III can be expected
in tandem and may even result in blacks to make a major contribution toward ensuring
diagnosing whites less severely than blacks. more effective and appropriate treatment of
Unfortunately, these explanations have been minorities" (1982, p. 925).
Given the narrow scope of their study, we attributed with a schizophrenic disorder more
question the optimism of Craig et al.'s predic- frequently through adolescence (2:1 ratio); the
tions.4' 5 Does the establishment of a new, ratio shifts to 1:1 in early adulthood and to 2:3
formalized taxonomy for diagnosis-DSM-III- in later adulthood (APA 1980). There is some
eliminate the effect of the psychiatrist's and the indication, however, that paranoid schizo-
client's race on diagnosis? This question re- phrenic disorders are assigned to males more
mains meaningful and deserves resolution. commonly than to females. A large body of
literature has attempted to seek the etiology for
these differences, although the divergent perspec-
GENDER AND PSYCHOPATHOLOGY tives have not been reconciled (Brodsky and
Hare-Mustin 1980; Dohrenwend and Dohr-
Heated dialogues among sociologists, psychol- enwend 1976; Gove and Tudor 1973; Kessler
ogists, and other social scientists in the field of and McLeod 1984; Phillips and Segal 1969;
psychopathology have surfaced with respect to Thoits 1986; Weissman and Klerman 1977).
sex differences. Moreover, the types of ques- While the aforementioned issues continue to
tions about gender and mental illness parallel command center stage in the sociology of
closely those mentioned in the previous section mental health, interest in a topic that was
on race. viewed as extremely important in the late 1960s
One area of contention is whether the true and the 1970s has abated: namely, the presence
prevalence of mental illness among females of sex differences not in clients' actual behavior
exceeds that among males. This debate is but in the diagnosis and treatment of mental
typified by the exchange between the Dohren- illness. Broverman, Broverman, Clarkson, Ros-
wends (1976, 1977, 1980) and Gove and Tudor encrantz, and Vogel (1970) conducted a study
(1973, 1977). A related discussion assesses not that has had a marked influence on our view of
the sex differences in the overall rates of mental the potential sex bias (or gender-based assump-
illness but the types of psychopathology over- tions) in the mental health system. In this
represented by males or by females. A consid- seminal study, mental health professionals
erable amount of epidemiological evidence ascribed the characteristics of the mentally
suggests that women are more likely than men healthy adult to the mentally healthy male while
to be treated for cases of what can be labeled as concurrently establishing a dissimilar standard
intropunitive problems (Allport 1958), namely, for the mentally healthy female. This study has
disorders resulting from the internalization of been criticized on methodological grounds and
conflict. Disorders such as depression would because the findings of replications have not
belong to this set of problems (Weissman 1980; agreed consistently with the initial results
Weissman and Klerman 1977). In contrast, (Stricker 1977), but the significance of Brover-
males are more likely to be treated for man et al.'s inquiry was not unnoticed. A
extropunitive difficulties, in which they "act differential set of expectations for men and for
out" the conflict (for example, antisocial and women may result in 1) differential diagnoses of
paranoid personality disorders). Recent data men and of women even when they exhibit the
from studies using the DSM-III typologies same problems and behavior; 2) variation in
provide corroborating evidence for these sugges- treatment of males and of females by those in
tions. Depression, simple phobia, and histrionic the mental health profession; and 3) codification
personality disorders are diagnosed more com- of these expectations in the publicized reports on
monly for women (American Psychiatric Asso- the mental health of men and of women.
ciation 1980; Kass, Spitzer, and Williams 1983; For the next decade, a proliferation of reports
Pearlin 1975), whereas paranoid personality based on anecdotal evidence, epidemiological
disorders and antisocial personality disorders are reports, surveys of mental health workers, and
more likely to be assigned to men (American experiments either from natural settings or from
Psychiatric Association 1980). The data do not analogues were disseminated to the academic
confirm the popular belief that schizophrenia is community. Unfortunately, the innovative and
more prevalent among males than among rigorous projects were outnumbered by many
females. Rather, the sex ratio for schizophrenic studies tainted by faulty design, weak samples,
disorders changes over time, resulting in an and/or blind adherence to certain ideological
aggregate ratio of approximately 1:1. Males are assumptions. The reviews and commentaries on
this research thwarted consensus further. For effects of gender on mental health assessments,
example, two summaries of the analogue studies did not find significant differences between the
testing for differential attribution by client's ratings of male and of female therapists.
sex-generally acknowledged as the technique Because female practitioners are under the
least likely to yield evidence of bias or guidance of male psychiatrists during their
attributional error (Hare-Mustin 1983; Sherman training, they may internalize the values and
1980)-reflected the inability to reach a consen- beliefs of their mentors. Nevertheless, a sizable
sus. Abramowitz and Dokecki (1977) con- number of studies replicating the Broverman
cluded, "Clinical analogues that have afforded a study report significant effects of the clinician's
more direct test of the notion of evaluative sex on assessments of clients (Sherman 1980).
prejudice against women have for the most part In contrast, some evidence suggests that female
refuted it," while Sherman (1980 p. 51) mental health professionals may make more
characterized the bulk of the studies as "consis- negative judgments of female clients in certain
tent with bias and sex role stereotyping." The conditions than do male psychiatrists (Young
state of affairs was summarized well by Zeldow: and Powell 1985). Yet, as with the studies on
"the results of the . . . studies are sufficiently black psychiatrists' evaluations of white clients,
diverse and ambiguous as to be interpretable the research on female psychiatrists' diagnoses
both as strong and weak evidence for sexism in of males is limited at best.
the mental health field, depending on the point In the past five years we have witnessed a
of view of the interpreter" (1978, p. 93). general moratorium on studies addressing these
Complicating this issue is the effect of the concerns. Perhaps it results from dissatisfaction
psychiatrist's gender on the diagnostic process. with the lack of any coherent pattern found in
Using the interactionist perspective mentioned the literature, from the belief that these
earlier, we predict that when the observer differences may have moderated in the past
(psychiatrist) and the actor (patient) do not decade, or from the changing political climate of
share the same status (gender), the distance the 1980s. Other authors have suggested that the
between them will make the observer less development of DSM-III lessens the possibility
competent in understanding the actor's behav- of dissimilar diagnosis of the same case and
ior. If one accepts this orientation, the key issue consequently reduces the chance that gender
in psychiatric diagnosis is not necessarily the will contaminate the diagnostic process.6 If this
client's sex, as many previous studies imply, but argument is true, in effect it nullifies all the
rather the congruence (or lack of congruence) research conducted before 1980, when DSM-III
between the client's and the psychiatrist's sex. was adopted. This assumption is taken for
When the client and the psychiatrist are not of granted; research has not yet been conducted to
the same gender, more error (or at least more test whether the establishment of an explicit
differential evaluations) might occur than when diagnostic system prevents the sex of the client
the client and the psychiatrist are of the same and the psychiatrists from influencing diagnostic
sex. Using primarily anecdotal reports, Chesler determination. This argument has not been
(1972) maintains that the combination of men's subject to experimental scrutiny, but we attempt
inability to comprehend the actions of their here to begin filling this void.
female clients and men predominating in
psychiatry may explain in part the overrepresenta-
tion of women diagnosed as having an affective RESEARCH DESIGN
disorder (in particular, depression). Other au-
thors, using similar logic, suggest that female Because the object of this research project is
mental health professionals maintain a liberal to examine the effects of the psychiatrist's and
stance on what is "acceptable" behavior (or the client's sex and race on DSM-III-guided
behavior within the boundary of "normalcy") diagnoses, we employ an analogue approach in
for their female clients (Brown and Hellinger which psychiatrists are asked to assess written
1975). case studies. While keeping all other informa-
These suggestions are not incontestable, tion about the client constant, we alter the
however. Indeed, the Broverman et al. study, client's sex and race so that an approximately
which prompted the other investigations of the equal proportion (one-fifth) of the psychiatrists
evaluates a white male, a black male, a white itself, which was not especially long or
female, or a black female.7 Furthermore, to labor-intensive. Response rates by sex, race,
examine whether the absence of information and type of professional affiliation (APA or state
influences clinical judgments directly, we in- membership) varied only minimally.
clude an additional category in which one-fifth
of the psychiatrists assess a client whose sex and
race are not disclosed. Because we are interested Questionnaire
in the joint effects of the characteristics of the
client and the psychiatrist, the research scheme The questionnaire opened with a cover letter
requires a large number of white male, black which explained that the intent of the study was
male, white female, and black female psychia- to evaluate the reliability and validity of
trists for our sample. The goal is to see whether DSM-III. This letter did not mention sex or
ostensibly objective diagnostic tools prevent race. Each questionnaire included two case
psychiatrists from being swayed by status studies; the client's sex and race were the same
characteristics; thus psychiatrists are asked to in each of the two studies. After reading the first
use the classification from the Diagnostic and case study, the subject was to answer several
Statistical Manual (DSM-III) in making clinical questions. The first question asked the subject to
judgments. "select from the choices below the diagnosis
that applies to the client in the attached case
study." To facilitate the completion of the
Sample study, we restricted responses to several Axis 1
categories: 1) paranoid schizophrenic disorder;
Our stratified random sample of psychiatrists 2) brief reactive psychosis; 3) undifferentiated
was chosen from membership lists of the schizophrenic disorder; 4) recurrent manic
American Psychiatric Association, which noted disorder; 5) unspecified substance dependence;
the sex and race of each member. After we 6) recurrent depressive disorder; and 7) none of
decided that the number of psychiatrists avail- the above. (The distinctions among these
able through the APA might be insufficient to diagnoses will be discussed in a later section.)
yield a sufficiently large sample size, we also Subjects then were asked a similar question
obtained membership lists of two state psychiat- geared to Axis 2 of DSM-III (personality
ric associations.8 In combination, these member- disorders). Again we restricted the responses to
ship lists netted a total of 488 psychiatrists, the following categories: 1) histrionic personal-
distributed approximately evenly by sex and ity disorder; 2) paranoid personality disorder; 3)
race. The five case variations were distributed antisocial personality disorder; 4) dependent
randomly among the psychiatrists in the target personality disorder; 5) asocial (schizoid) per-
sample. sonality disorder; 6) compulsive personality
Two hundred ninety psychiatrists returned disorder; and 7) none of the above. The
completed questionnaires, resulting in a re- subsequent questions (which will not be dis-
sponse rate of 59.4 percent. Previous studies cussed in this paper) referred to the less
reveal that psychiatrists are reluctant to volun- frequently used axes. Respondents then were
teer for research of this type and thus yield low asked to read the second case study and to
response rates -for example, a 10 percent return answer the same questions. After evaluating
of a study of racial attitudes (Wilkinson 1980) both cases, subjects were asked how familiar
and a 21 percent response rate on a study of the they were with DSM-III. Over four-fifths of the
effects of political orientation on psychiatric psychiatrists responded that DSM-III is "used in
assessment (Schwartz and Abramowitz 1975). my professional work and I am familiar with
In this context our response rate should be it." The remainder checked the response that
viewed as respectable, although the generaliz- they were "familiar with it and have used or am
ability of our findings must be viewed with able to use it although I do not use it in my
caution. We suspect that the relatively high professional work." No one responded that he
response rate was the result of 1) the letter of or she was "somewhat familiar" or "unfamil-
support provided by the APA; 2) the controver- iar" with DSM-III. This high degree of
sial nature of DSM-III; 3) the questionnaire familiarity was expected because many insur-
ance companies accept the nomenclature from and dishwasher). The client's attributions for the
DSM-III as the sole basis for reimbursement. failure in employment were both external
We did not ask psychiatrists to provide ("people always treat me mean") and internal
information about their age, type of practice, ("I get so nervous I have to quit"). The client
years of experience, or theoretical orientation, explained that the sleeping problems stemmed
though admittedly such characteristics may help from the fear that when asleep, "someone else is
to explain their diagnostic behavior. It is in the room." The vignette also revealed that the
conceivable, for example, that younger psychi- client had experienced "visions" and "voices"
atrists may follow DSM-III-based criteria more in the past and had spent some time in a
rigidly in their diagnoses because of the recency psychiatric ward over a year ago.
of DSM-III and of their training. In deciding The second case documented a slightly
whether to include such questions on our younger (30-year-old) client with an unstable
inventory, we had to weigh the possible costs of employment history and an equally unsuccessful
a low, even unacceptable, response rate result- marital history. The client revealed that he (or
ing from asking too many (and, to some she) was so disturbed by the spouse's alleged
respondents, too personal) questions against the promiscuity (has had "many other lovers") that
benefits of extra information. Because initially he (she) was unable to go to work. There were
we had anticipated a far lower response rate than insufficient funds to support the family, and "no
we finally received, we concluded that the costs one will help me." As a result, the client took
outweighed the benefits. the children to a relative's home. The client
Subjects were invited to make any additional compulsively described a "figure standing over
comments and were asked to return the me at night," "a black figure with horns and
questionnaire in the enclosed stamped, self- breasts," "a kind of black devil person insignia
addressed envelope. on its chest." After going to a mental health
clinic but leaving because the nurses and
clinicians acted "as if I was crazy" and "wanted
Case Studies me to take some pills," the client discounted the
vision as merely something he (she) thought he
Two different case studies were provided to (she) saw upon awakening. Nevertheless, the
each psychiatrist to evaluate.9 The vignettes client asked later to be "locked up" in a hospital
followed the format recommended by the because of an urge to kill the spouse, an
American Psychiatric Association in its DSM-III inability to concentrate any more, and a level of
Case Book (Spitzer, Skodol, Gibbon, and nervousness so high that the client could not
Williams 1981). Both case studies reflect actual function even minimally at work or at home.
cases of individuals receiving psychiatric treat-
ment at the time. They were diagnosed by their
psychiatrist as having a undifferentiated schizo- Diagnostic Categories
phrenic disorder (Axis 1) with a dependent
personality disorder (Axis II). Both cases As mentioned previously, we have restricted
presented individuals who had experienced our analysis to some categories from Axis 1 and
some type of perceptual disturbances (for 2 for DSM-III. Although we limit the choice of
example, "visions") or "voices"), who had responses to six specific Axis 1 diagnoses (plus
difficulty in remaining employed, and whose "none of the above"), they represent the major
personal life had deteriorated. diagnoses. In the much-heralded field trials for
One vignette presented a 43-year-old indi- DSM-III, these alternatives cover approximately
vidual who was "very nervous, irritable, tense 90 percent of all diagnoses. Nevertheless, we
all the time, and unable to sleep at night." The should note that our constriction of categories
client was described as having problems in may well lead to an underestimation of variation
maintaining a satisfactory family relationship in response. A brief summary of each diagnosis
(separated from spouse, rarely having any is provided in Chart 1.
meaningful contact with three teenage children)
and keeping a job (having been fired from Personality disorders (Axis 2) are defined as
various entry-level jobs such as laundry worker lifelong personality traits which are "inflexible
CHART 1. BRIEF SUMMARIES OF AXIS 1 DIAGNOSTIC CATEGORIES
Paranoid Schizophrenic and Undifferentiated Schizophrenic Disorders
Schizophrenic disorders are the most commonly diagnosed disorders leading to institutionalization in the United
States (APA 1980). DSM-Ill describes schizophrenic disorders as consisting of a "disturbance in mood, thinking, and
behavior, manifested by distortions and reality which include delusions and hallucinations." Generally, reliability
studies of DSM-Ill have not distinguished among the types of schizophrenic disorder. In this study we differentiated
between paranoid schizophrenic disorders and undifferentiated schizophrenic disorders; this distinction is more a
matter of degree than of kind. Paranoid schizophrenic disorders tend to be characterized by "prominent persecutory or
grandiose delusions, or hallucinations with a persecutory or grandiose content. Associated features include unfocused
anxiety, anger, argumentativeness, and violence" (APA 1980, p. 191). This category represents the most severe
diagnosis in our inventory because it offers the least opportunity for a favorable prognosis and indicates that the
individual is dangerous not only to himself or herself but to others.
In contrast, undifferentiated schizophrenic disorders suggest that the client manifests certain behavior linked with
schizophrenic disorders but cannot be diagnosed as neatly as any of the other subtypes. Generally, undifferentiated
schizophrenia is not considered to be as serious or as dangerous as paranoid schizophrenia.
Brief Reactive Psychosis
Most clinicians would consider a brief reactive psychosis the least serious diagnostic category in our inventory.
According to the DSM-llI manual this is the "sudden onset of a psychotic disorder" that lasts for a short term, with
"eventual return to the premorbid level of functioning." The symptoms "appear immediately following a recognizable
psychosocial stressor that would evoke significant symptoms in almost anyone" (APA 1980, p. 200). Thus the major
distinction between this disorder and schizophrenic disorders is that it is a short-term event preceded by a stressful
situation. In contrast to schizophrenic disorder, a brief reactive psychosis offers the possibility of a complete recovery
and involves minimal chance of violent behavior.
Recurrent Manic Disorder and Recurrent Depressive Disorder
Both disorders are subsets of the category "affective disorder," which is "a disturbance of mood that is not due to
any other physical or mental disorder" (APA 1980, p. 205). A recurrent manic disorder is a subclassification of bipolar
disorder, whose "essential feature is a distinct period when the predominant mood is either elevated, expansive, or
irritable and where there are associated symptoms of the manic syndrome" (p. 208), whereas the salient characteristic
of a recurrent depressive disorder is "either dysphoric mood, usually depression, or loss of interest or pleasure in all
or almost all usual activities and pastimes" (p. 206).
Unspecified Substance Dependence
The classification is self-explanatory: "an initial diagnosis in cases in which the specific substance is not yet
known." The case studies in our project provide no reference to any dependence on or abuse of drugs or alcohol.
and maladaptive and cause either significant of the effects of sex and race on clinical judg-
impairment in social or occupational functioning ment. Several authors, however, have ques-
or subjective distress" (APA1980, p.305). Chart tioned the appropriateness of using an analogue
2 offers a short description of each personality approach in the study of systematic variation in
disorder used in our inventory. diagnosis. Hare-Mustin (1983), for example, ar-
gues against the usage of analogue studies be-
cause the "transparencies" of the study and the
Advantages and Disadvantages of the subjects' proclivities to respond in a socially de-
Analogue Approach sirable manner may result in what she calls "less
impressive evidence than that provided in a nat-
Before examining the results, we need to weigh uralistic setting." We respond that the purpose of
the merits and the limitations of the analogue the study was not obvious: no respondent indi-
approach. We contend that this approach is the cated that he or she thought the study was about
most appropriate way to conduct an investigation race and sex. In fact, several subjects volun-
CHART 2. BRIEF SUMMARIES OF AXIS II DIAGNOSTIC CATEGORIES
Dependent Personality Disorder
Individuals with dependent personality disorders are characterized as extremely passive, lacking in self-confidence,
dependent upon others, and unable to function independently (APA 1980). The two clients who were the basis of the
two case studies in this research project were diagnosed originally by their psychiatrist with dependent personality
disorders.
Paranoid Personality Disorder
The paranoid personality disorder represents the only "severe" personality disorder (Millon 1981) used in the
inventory. According to the DSM-III description, the salient components of this disorder are "a pervasive and
unwarranted suspiciousness and mistrust of people, hypersensitivity and restricted affectivity" (APA 1980, p. 307).
Among the characteristics associated with this disorder are "hypervigilance," "guardedness or secretiveness,"
"questioning the loyalty of others," "pathological jealousy," "exaggeration of difficulties," "readiness to
counterattack when any threat is perceived," and "absence of passive, soft, tender, and sentimental feelings" (APA
1980, p. 309).
Histrionic Personality Disorder
The histrionic personality disorder was labeled in DSM-III as the "hysterical personality." The primary
characteristics of the histrionic personality disorder are "overly dramatic, reactive, and intensely expressed behavio
and characteristic disturbances in interpersonal relationships" (APA 1980, p. 315). DSM-lII describes individuals wi
personality disorders as "dramatic," "always drawing attention to themselves," "prone to exaggeration," often acting
"out a role, such as the 'victim' or the 'princess,' without being aware of it" (APA 1980, p. 313).
Antisocial Personality Disorder
The antisocial personality disorder is denoted by a "history of continuous and chronic antisocial behavior in which
the rights of others are violated" (APA 1980, p. 318). Among the behaviors associated with this personality disorder
are truancy, delinquency, lying, drunkenness or substance abuse, vandalism, fights, "inability to sustain consistent
work behavior," and "failure to accept social norms with respect to lawful behavior" (APA 1980, pp. 320-21).
Schizoid (Asocial) Personality Disorder
The key characteristics associated with schizoid (asocial) personality disorders are "emotional coldness and
aloofness," "indifference to praise or criticism or to the feelings of others," and "close friendships with no more than
one or two persons" (APA 1980, p. 311).
Compulsive Personality Disorder
The major features linked to a compulsive personality disorder are "restricted ability to express warm and tender
emotions, perfectionism that interferes with the ability to grasp 'the big picture,' insistence that others submit to his
her way of doing things, excessive devotion to work and productivity . . . and indecisiveness" (APA 1980, p. 326)
teered that they thought the study was about con- would expect these differences to be magnified
sistency of evaluation (because they were asked in a naturalistic setting.
to examine two case studies). Moreover, if Hare- Others, such as Hyler, Williams, and Spitzer
Mustin is correct, her criticism merely implies (1982), express a preference for experiments
that the analogue approach provides the most employing live interviews rather than the
conservative test of the effects of sex and race. analogue approach. They argue that the live
That is, if we should find that differences by sex interview provides "more complete informa-
and race are present in the diagnostic process, we tion" and allows clinicians to make use of
"subtle cues that would not appear in a case atrists as having an undifferentiated schizo-
summary," thereby leading to higher reliability phrenic disorder. Although we cannot confirm
and validity in diagnosis. that this is the "correct" diagnosis, Table 1
Although we see merit in the use of the live indicates that it is the modal response; nearly
interview, we still believe that the analogue ap- two-fifths (.38) of the sample psychiatrists
proach is warranted for the following six rea- attributed this diagnosis to the case studies.
sons: Nevertheless, the responses show sufficient
1. Whereas the live interview allows two heterogeneity that it becomes necessary to seek
people in the same hospital (quite likely sharing the source of this variation. Table 1, which
the same practice and/or theoretical orientation) pools the diagnoses from both cases,'0 shows
to examine the same case, it does not allow a the proportion choosing "undifferentiated schizo-
large number of people throughout the nation to phrenic disorder" by characteristics of the
evaluate the same case. psychiatrist and of the case study. Examining
2. It is experimentally impossible to assess the the marginals, we find that approximately the
effects of sex and race and to control completely same proportion of white male (.36), black male
for other factors in studies using live interviews. (.37), white female (.39), and black female
Although we could initiate an experiment in which (.39) psychiatrists chose undifferentiated schizo-
a black man and a white man discuss similar phrenic disorders. The marginals by characteris-
symptoms, we could never determine whether tics of the case reveal that 1) when no
the differences in diagnosis, if any, were the information about the sex and race of the case is
result of race or of slightly different styles in presented, a majority (.56) of the clinicians
presentation. Moreover, just as Hyler et al. sug- choose undifferentiated schizophrenic disorder;
gest that the saying "a picture is worth a thou- and 2) when characteristics of the case studies
sand words" applies to diagnosis, others, such as are known, the rate of concurrence is less,
Young and Powell (1985), have demonstrated especially when the case is a white female."I
that appearance (for example, level of over- Several other interesting patterns emerge. White
weight) might confound these evaluations. male psychiatrists agree that the undifferentiated
3. Even if it were possible to assess the effects schizophrenic disorder is the most appropriate
of sex and race in a live interview, such an diagnosis when the case study describes a white
interview precludes testing whether an absence male (.57), but there is much less agreement
of information on sex and race influences when the case is not male and/or not white (.23
diagnostic judgment. for black male, .23 for white female, and .21 for
4. The "subtle cues" that Hyler et al. use to black female). Similarly, black male and black
justify live interviews are exactly the types of
information intended not to influence DSM-III TABLE 1. Proportion Diagnosing Undifferentiated
Schizophrenic Disorder by Sex and Race
typology. The argument that subjectively deter-
of Psychiatrist and Client
mined phenomena are necessary for accurate
diagnostic assessment runs counter to the
Psychiatrist
orientation of DSM-III.
5. The American Psychiatric Association rec- Client WM BM WF BF Total
ognizes the utility of the written case study, as WM 57 .14 .47 .23 .35
demonstrated by the training it recommends based (28)* (28) (30) (30) (116)
on the DSM-III Casebook (Spitzer et al. 1981). BM .23 .65 .17 .38 .35
6. Because case studies are less labor- (30) (26) (30) (26) (112)
intensive than interviews, studies employing
WF .23 .23 .20 .18 .21
case studies result in a higher response rate. (30) (30) (30) (28) (118)
BF .21 .33 .50 .57 .40

(28) (30) (28) (28) (114)
RESULTS
NI .53 .50 .63 .57 .56
(30) (30) (30) (30) (120)
Axis I
Total .36 .37 .39 .39 .38
As mentioned earlier, the two cases were (146) (144) (148) (142) (580)
diagnosed originally by their practicing psychi- * Total number of responses per cell.
effects
female psychiatrists tend to of sex and race
diagnose of the psychiatrist and of
undifferenti-
theto
ated schizophrenic disorders casecase
on the likelihood
studies of whose
choosing undif-
sex and race are congruent ferentiated
with their schizophrenic
own disorder. The coeffi-
(black
males, .65; black females, .57), whereas they cients confirm what was suggested in Table 1:
the inclusion of any information on the client's
assign this diagnosis less frequently to their white
counterparts and to cases of the opposite sex (.14 sex or race decreases the probability that the
for white males, .23 for white females, and .33 psychiatrist will diagnose the client as having
for black females as evaluated by black males; undifferentiated schizophrenia. Column 2 of
.23 for white males, .38 for black males, and .18 Table 2 includes parameter estimates testing
for white females as diagnosed by black fe- whether the similarity of the client and the
males). The one exception is that of white fe- psychiatrist (in race and sex) increases the
males, who attribute undifferentiated schizo- chance of assigning this diagnosis. Again this
phrenic disorders to both white males and black pattern is corroborated. Column 3 adds one
females (.47 and .50 respectively), but not to more interaction terms to the model, and
black males (.17) or white females (.18). Thus it indicates that the exception we noted in Table 1
appears that the diagnostic process is confounded (white females) is statistically meaningful.
by the sex and race of the case study and of the If undifferentiated schizophrenic disorder is
psychiatrist. not assigned to the cases, in what direction are
We tested several logistic response models to the alternative diagnoses? When viewing Table
fit the data from Table 1. Table 2 presents the 3, one should bear in mind that a diagnosis of
parameter estimates based on three log-linear paranoid schizophrenia connotes an evaluation
models. The first model tests for the main of greater severity, whereas a diagnosis of brief
TABLE 2. Parameter Estimates of Logistic Response Models of Axis I Diagnosis (Undifferentiated Schizo-
phrenic Disorder vs. Other) on Sex and Race of Case Study and Psychiatrist
1 2 3
Independent Main Effects Similarity of Case Similarity with
Variables Only Model and Psychiatrist Model Exception Model
Sex of case study'
(male= 1) -.639* - 1.304** - 1.542**
(.250) (.295) (.316)
(female= 1) -.843** - 1.552** -2.313**
(.251) (.303) (.448)
Race of case study' -.431* -.471* -.007
(black= 1) (.200) (.208) (.286)
Sex of psychiatrist .124 .138 .144
(female= 1) (.176) (.180) (.181)
Race of psychiatrist .017 - .021 - .039
(black= 1) (.176) (.181) (.182)
Similarity of case's and .453* .466*
psychiatrist's sex (similar= 1) (.206) (.207)
Similarity of case's and .890** .893**
psychiatrist's race (similar= 1) (.208) (.210)
Sex of case by .980*
race of case (.417)
Constant .165 .176 .182
(.222) (.224) (.225)
*p<.05 **p<.Ol
L2 75.48 24.83 19.24
df 14 12 11
1 There are three
no information).
neither is informa
TABLE 3. Proportions of Alternative Axis I Diagnoses",2 by Sex and Race of Psychiatrist and Client (Stan-
dardized Scores in Parentheses3)
Psychiatrist
Client WM BM WF BF Total
A=.57 (.1) A=.14 (-3.0)* A=.47 (-.7) A=.23 (-2.4)* A=.35

B=.00 (-1.6) B=.00 (-1.6) B=.20 (2.0)* B=.03 (-1.0) B=.06
WM C =.21 (1.9) C =.54 (7.3)* C =.17 (1.2) C =.23 (2.4)* C =.28
D= .21 (1.9) D= .32 (3.1)* D= .10 (0.0) D= .40 (5.2)* D= .26
E=.00 (-2.1)* E=.00 (-2.1)* E=.07 (-1.2) E=.10 (-.7) E=.05
A=.23 (-2.4)* A=.65 (.6) A=.17 (-2.9)* A=.38 (-1.2) A=.35

B =.47 (6.9)* B =.27 (3.1)* B =.53 (8.1)* B =.42 (5.7)* B=.43
BM C=.03 (-1.2) C=.00 (-1.0) C=.07 (.6) C=.12 (.3) C=.05
D=.10 (.0) D=.04 (-1.0) D=.17 (1.2) D=.00 (-1.6) D=.08
E=.17 (.2) E=.04 (-1.5) E=.07 (-1.2) E=.08 (-1.0) E=.09
A=.23 (-2.4)* A=.23 (-2.4)* A=.20 (-2.6)* A=.18 (-2.7)* A=.21

B =.10 (.2) B =.10 (.2) B=.10 (.8) B=.11 (.3) B =.10
WF C=.00 (-1.7) C=.00 (1.7) C=.50 (7.1)* C=.50 (6.7)* C=.25
D= .53 (7.6)* D= .50 (7.1)* D= .10 (0.0) D= .14 (-.7) D= .32
E =.13 (-.2) E =.17 (.2) E=.10 (-.7) E =.07 (-1.1) E =.12
A=.21 (-2.4)* A=.33 (-1.7) A=.50 (-.1) A=.57 (.1) A=.40

B=.07 (-.3) B=.17 (1.4) B=.14 (.9) B=.11 (.3) B=.12
BF C=.14 (.7) C=.00 (-1.7) C=.11 (.1) C=.07 (-.5) C=.08
D =.43 (5.5)* D =.40 (5.3)* D =.07 (-.5) D=.11 (.1) D=.25
E=.14 (-.1) E=.10 (-.7) E=.18 (.6) E=.14 (-.1) E=.14
A=.53 (.2) A=.50 (-.4) A=.63 (.5) A=.57 (.1) A=.56

B =.13 (.8) B =.07 (-.4) B =.03 (-1.0) B =.13 (.8) B =.09
NI C=.13 (.6) C=.13 (.6) C=.10 (.0) C=.03 (-1.2) C=.10
D =.07 (-.6) D=.10 (.0) D =.13 (.6) D=.10 (.0) D=.10
E =.13 (-.2) E =.20 (.7) E=.10 (-.7) E =.17 (.2) E =.15
A=.36 A=.37 A=.39 A=.39 A=.38

B =.16 B =.12 B =.20 B=.15 B =.16
Total C=.10 C=.13 C=.19 C=.19 C=.14
D =.27 D=.28 D=.11 D =.15 D=.20
E=.11 E=.10 E=.11 E=.13 E=.12
A= Undifferentiated Schizophrenic Disorder.

B = Paranoid Schizophrenic Disorder.
C = Brief Reactive Psychosis.
D = Recurrent Depressive Disorder.
E = Other.
2 Because of rounding errors, sums within each cell may not equal 1.00.
Standardized score is where x is actual frequency and y is expected frequency based on pooled NI fre-
quencies.
* p<.05.
reactive psychosis indicates that the therapist abuse, which shows a response of less than one
considers the disorder as short-term and as the percent). Thus, using the combined distribution
"natural" result of a psychosocial stressor. from the NI row, we can estimate the expected
Table 3 presents the proportions and the frequencies for all other cells in the table.
standardized scores of the alternative Axis I Accordingly, we can calculate a standardized
diagnoses by sex and race of psychiatrist and score for each cell, showing how it departs from
client. An inspection of the "no information" the expectation.'3 A standardized score above
(NI) category reveals no systematic pattern 2.0 implies the presence of an effect.
among those who did not choose undifferenti- We find that black male and black female
ated schizophrenic disorders. 12 An approxi- psychiatrists tend to give white males the least
mately equal proportion chose each alternative serious diagnoses; black males lean toward brief
(with the exception of unspecified substance reactive psychosis (.54 and a standardized score
of 7.3) and black females favor a recurrent (as compared to Table 2, in which diagnoses are
depressive disorder (.40 and a standardized dichotomized into undifferentiated schizo-
score of 5.2). On the other hand, white females, phrenic disorders and others). The table corrob-
when not assigning undifferentiated schizo- orates that neither a simple main effects model
phrenia to white males, generally choose (Model 2), a "similarity of case and psychiatrist
paranoid schizophrenic disorder. Not a single model" (Model 3), nor a model including all
white male psychiatrist diagnosed the white two-way interactions with the dependent vari-
male client as having a paranoid schizophrenic ables (Model 4) is adequate to explain the
disorder (nor did any black male psychiatrist)! distribution of diagnostic assessments. The
In contrast, black males are most likely to be best-fitting model for this set of data (Model 6)
diagnosed by each type of psychiatrist as having takes into account the interaction of the case's
a paranoid schizophrenic disorder. Black male sex and race with the psychiatrist's sex and the
psychiatrists, however, are the least likely of theinteraction of the case study's sex and race with
four types of psychiatrists to assign black males the psychiatrist's race.'4 As in Table 2, these
to this category. Depressive disorder and brief higher-order interactions, which differentiate
reactive psychosis rarely are attributed to the Model 5 and Model 3, can be traced primarily to
black male case studies. the seeming inconsistency of white female
Males' diagnoses of the female case studies psychiatrists not choosing undifferentiated schizo-
diverge considerably from the evaluations by phrenia for white female case studies.
their female peers. Male psychiatrists are
inclined to diagnose females with a depressive
disorder, but female psychiatrists are reluctant Axis II
to use this category. Female psychiatrists do not
reveal any decided preference beyond undif- The modal personality disorder diagnosed to
ferentiated schizophrenic disorder when examin-
the case study was dependent personality
ing the black female case study, but both black disorder (.45). Again, in Table 5 (standardized
and white female clinicians tend to diagnose scores in parentheses), the "no information"
brief reactive psychosis to the white female case study is the type most likely to be
client. diagnosed with this personality disorder (.62).
Table 4 compares the fit of several log-linear Similarly, psychiatrists tend to ascribe this
models of the overall distribution of diagnoses personality disorder to case studies whose sex
TABLE 4. Selected Log-linear Models Fitted to Cross-Classifications of Case's Race* (R), Case's Sex* (S),
Psychiatrist's Race (A), Psychiatrist's Sex (B), and Axis I Diagnosis (D)**
Model Fitted Marginals L2 df Lp2 p value
(Null model) (D)(ABRS)*** 307.1 76 0 <.001

2
(Main effects model) (DA)(DB)(DR)(DS) 160.5 56 .477 <.001
3
(Similarity of case (DAR)(DBS) 92.2 40 .700 <.001
and psychiatrist model)
4 (DAR)(DBS)(DAB)(DRS) 61.8 24 .799 <.001

(DAS)(DRB)
5 (DBRS)(DAR) 36.0 28 .883 >.05

6 (DBRS)(DARS) 15.6 20 .949 >.05
* There are three categories for case's r
information). If the case's race is unkno
will reflect that there are five race-sex c
** The five Axis I diagnosis are undiff
reactive psychosis, major depressive disor
*** Models 2-6 also include the fitted
TABLE 5. Proportion of Alternative Axis I Personality Disorder Diagnoses" 2 by Sex and Race of Psychia-
trist and Client (Standardized Scores in Parentheses3)
Psychiatrist
Client WM BM WF BF Total
A=.57 (-.3) A=.54 (-.6) A=.47 (-1.1) A=.50 (-.8) A=.52
WM B=.08 (-.6) B=.25 (2.2)* B=.27 (2.6)* B=.27 (2.6)* B=.22
C=.12 (.1) C=.00 (-1.8) C=.10 (-.2) C=.13 (4) C=.09
D= .36 (1.0) D= .21 (.6) D= .17 (-.0) D= .10 (-.9) D= .18
A=.33 (-1.8) A=.50 (-.8) A=.30 (-2.2)* A=.46 (-1.0) A=.39

BM BB=.50 (6.4)* B=.46 (5.4)* B=.57 (7 5)* B=.46 (5.4)* B =.50
C=.13 (.4) C=.04 (-1.1) C=.07 (-.7) C=.00 (-1.7) C=.06
D=.03 (-1.6) D=.00 (-2.1)* D=.07 (-.5) D=.08 (-1.1) D=.04
A=.33 (-2.0)* A=.13 (-3.4)* A=.63 (.1) A=.46 (-1.1) A=.39

WF BB=.07 (-.7) B=.27 (2.6)* B=.10 (-.2) B=.18 (1.2) B=.15
C=.47 (5.9)* C=.43 (5-3)* C=.07 (-.7) C=.18 (1.2) C=.29
D=.13 (-.5) D=.17 (-.0) D=.20 (.5) D=.18 (-.1) D=.17
A=.04 (-3.9)* A=.20 (-2.9)* A=.57 (-3.4)* A=.54 (-.6) A=.33

BF B ==.61 (7.9)* B =.47 (5.9)* B =.14 (.7) B =.07 (-.6) B =.32
C=.21 (1.7) C=.27 (2.6)* C=.07 (-.6) C=.29 (2.8)* C=.21
D=.14 (.4) D=.07 (-1.3) D=.21 (.6) D=.11 (-.8) D=.13
A=.60 (-.1) A=.67 (.3) A=.60 (-.1) A=.60 (-.1) A=.62

NI B =.03 (-1.3) B =.17 (.9) B=.10 (-.2) B =.13 (.4) B=.11
C ==.17 (.9) C =.07 (-.7) C =.13 (.4) C =.07 (-.7) C=.11
D=.20 (.4) D=.10 (-.9) D =.17 (-.0) D=.20 (.4) D=.17
A=.38 A =.40 A =.51 A =.51 A =.45

B=.26 B=.32 B=.24 B=.22 B=.26
Total C=.22 C=.17 C=.09 C=.13 C=.15
D=.15 D=.11 D=.16 D=.13 D=.14
A = Dependent Personality Disorder.

B = Paranoid Personality Disorder.
C = Histrionic Personality Disorder.
D = Other.
2 Because of rounding errors, sums may not equal 1.00.
3 Standardized score is where x is actual frequency and y is expected frequency based on pooled NI fre-
quencies.
* p<.05.
and race coincide with those of the psychiatrist are more likely to diagnose the case with a
(.58 for white males, .50 for black males, .63 dependent personality disorder when the sex and
for white females, and .54 for black females). race of the case study and of the psychiatrist are
Notice that white female psychiatrists do not the same. In contrast to the logistic response
defy this pattern for Axis 2, perhaps because model for Axis I (Table 2), there is no need to
dependent personality disorders are not consid- include any additional interaction terms.
ered to be as severe as undifferentiated schizo- The source of variation in response is worth
phrenic disorders. noting. For white male case studies, when
Table 6 presents the parameter estimates for dependent personality disorder is not assigned,
two logistic response models in which the psychiatrists tend to attribute paranoid personal-
dependent variable is a dichotomy of Axis II ity disorders. The only exception, perhaps not
diagnoses (dependent personality disorder vs. too surprisingly, is found among white male
other). Column 1, the main effects model, psychiatrists.'5 For black male cases, paranoid
documents that the added knowledge about the personality disorder is assigned when dependent
client's sex and race decreases the likelihood of personality is not. Furthermore, it is the modal
an assignment of dependent personality disor- response; 50 percent chose this category.
der. Column 2, the "similarity of case and The pattern for white and black female case
psychiatrist" model, indicates that psychiatrists studies also reflects the importance of sex and
TABLE 6. Parameter Estimates of Logistic Response Models of Axis H Diagnosis (Dependent Personality Dis-
order vs. Other) on Sex and Race of Case Study and Psychiatrist
1 2
Independent Main Effects Similarity of Case Study
Variables Only Model and Psychiatrist Model
Sex of case study
(male= 1) -.862** - 1.585**
(.253) (.296)
(female= 1) - 1.251** -2.071**

(.256) (.315)
Race of case study .376 .408*

(black= 1) (.194) (.200)
Sex of psychiatrist .521** .569**
(female = 1) (.172) (.179)
Race of psychiatrist .056 .077
(black= 1) (.172) (.177)
Similarity of case's .978**
and psychiatrist's (.203)
sex (similar= 1)
Similarity of case's .476*

and psychiatrist's (.200)
race (similar= 1)
Constant .195 .162

(.223) (.225)
*p<.05 **p<.ol.
L 2 77.17 13.63
df 14 12
race. Male psychiatrists, when diagnosing white DISCUSSION

females, are most likely to choose histrionic
personality disorders. When black females are We recognize that the results of this investi-
evaluated by males, however, they are most gation should be viewed with caution because
likely to be assigned to paranoid personality only two case studies were used. One can argue
disorders; histrionic personality disorders are the that diagnosis of other mental illnesses may be
next most frequent diagnosis. influenced less (or more) strongly by the sex and
Table 7, which contrasts several log-linear race of the client and of the clinician. Moreover,
models fitting the distribution of four Axis II other information on the case studies-age (30
diagnoses (dependent personality disorder, and 43 years old), occupation (marginal employ-
histrionic personality disorder, paranoid per- ment, as in low-level entry jobs), and marital
sonality disorder, and other), indicates a status (married or separated)-may well have
slightly less complex model for Axis II than figured into the diagnostic process.
for Axis I (Table 4). A main effects model In addition, other characteristics of the
(Model 2) is insufficient to describe the psychiatrist could influence diagnostic deci-
distribution of Axis II diagnoses. Model 3, sions. Psychiatrists working in private practice,
"similarity of case and psychiatrist" model for example, may have less exposure to clients
(which includes a sex-of-case by sex-of- with problems as serious as those of the two
psychiatrist interaction and a race-of-case by presented in the questionnaire, and consequently
race-of-psychiatrist interaction), improves sig- may be more prone to rely upon stereotypes in
nificantly on the main effects model. When the assignment of diagnosis. Furthermore, as
either a sex-of-case by race-of psychiatrist mentioned earlier, the psychiatrist's age and/or
interaction or a race-of-case by sex-of- years of experience might influence whether the
psychiatrist interaction is added to the model, psychiatrist is basing his or her diagnoses in part
the fit does not differ significantly from that of on
a the client's sex and race. Possibly psychia-
fully saturated model.'6 trists with more experience will be influenced
less strongly by irrelevant factors in diagnoses. viewed by an observer and if this set can be
Young and Powell (1985), for example, indicate viewed in a vacuum (i.e., if the actor's social
that older mental health workers are less likely location is unknown), a reasonable degree of
than their younger counterparts to use physical agreement and perhaps accuracy may result.
attractiveness (in particular, level of overweight) Psychiatrists do not operate in a vacuum,
when evaluating their clients. Alternatively, however; they are aware of their clients' sex and
psychiatrists with fewer years of total experi- race. Our study suggests that these characteris-
ence may have more specific training in the use tics, in tandem with the clinician's sex and race,
of DSM-III because of the recency of DSM-III. will result ultimately in subjective assessments
If this is so, younger psychiatrists should be despite attempts by DSM-III to minimize the
swayed less by gender and race when reaching human element in judgment. In general, when
diagnoses. Because our data do not provide the sex and race of the psychiatrist and of the
information on the psychiatrist's age and case study coincide, the psychiatrist tends to
experience, we cannot address this issue with choose the same diagnosis as he or she probably
confidence. We can deduce, however, that the would choose if there were no information about
sample of black and female psychiatrists is the client's sex and race. That is, if the modal
younger and less experienced than the corre- responses of undifferentiated schizophrenic
sponding sample of white male psychiatrists disorder with a dependent personality disorder
because the entry of females and blacks into the are the "accurate" responses (as suggested by
psychiatric profession is a relatively new the uniformity in response when the "no
phenomenon. And, as our results indicate, all information" case study is diagnosed), then
four groups of psychiatrists seem to be influ- clinicians are reasonably "accurate" about case
enced by the clients' sex and race, although in studies whose sex and race are identical to their
slightly different directions. This finding sug- own.
gests that neither overall experience nor specific The above pattern is found consistently
experience in DSM-III provides a greater buffer among all four types of psychiatrists when Axis
to "subjective" diagnoses. Nevertheless, repli- 2 of DSM-III is used, but white females
cations and/or extensions of this study are represent a notable exception in regard to Axis
required to test whether these results will 1. We can only speculate on the cause of this
generalize beyond the specific disorders exam- seeming discrepancy. It may be instructive to
ined and across the psychiatrists' different levels examine the direction of the "error" by white
of experience. female clinicians when diagnosing white female
Our study raises several questions about clients: over one-half of the diagnoses are "brief
views toward gender and race and about our reactive psychosis," the least severe of the
confidence in the attempts by professions to possible diagnoses. This diagnosis suggests that
objectify subjective assessments. The results the clinician considers the disorder as short-
suggest that allegedly objective evaluations, term, with a favorable prognosis, and as the
even when guided by an intricate set of result of psychosocial stressors. Thus, for white
seemingly clear-cut criteria, can be influenced female psychiatrists evaluating white female
by characteristics of the observer making the case studies, the level of severity has primacy
judgments and of the individual being evalu- over the degree of "accuracy." Perhaps the
ated. We find that when information about the reason why white female psychiatrists do not
case study's gender and race is absent, psychia- provide an "inaccurate" Axis 2 diagnosis (one
trists, regardless of their sex and race, tend to differing from the diagnosis for the "no
concur with the diagnosis of undifferentiated information" case study) is that none of the
schizophrenic disorder (Axis 1) with a depen- alternative responses are less severe. As a result,
dent personality disorder (Axis 2). This type of they can offer the least (or among the least)
consistency in diagnosis is precisely the goal of severe and the modal (some might claim
DSM-III and could be used by itself to "accurate") diagnosis. Yet the source of this
corroborate the findings of the previous studies pattern remains unresolved. Perhaps the large
of the reliability and validity of this nosological body of literature delineating the special mental
system. This finding provides support for the health problems faced by white women has led
argument that when a certain set of behaviors iswhite female psychiatrists to emphasize social
TABLE 7. Selected Log-linear Models Fitted to Cross-Class

Psychiatrist's Race (A), Psychiatrist's Sex (B), and Axi
Li2_Lm2
Model Fitted Marginals df Lp2 p value

I (P)(ABRS)*** 200.0 57 0 <.001
(Null Model)
2
(Main Effects Model) (PA)(PB)(PR)(PS) 93.1 42 .535 <.001
3
(Similarity of Case and (PAR)(PBS) 45.4 30 .773 <.05
Psychiatrist Model)
4 (PAR)(PBS)(PAS) 39.0 27 .805 >.05

5 (PAR)(PBS)(PBR) 39.9 27 .801 >.05
* There are three categories for case's race (
formation). If the case's race is unknown (i.e.
flect that there are five race-sex case combinat
** The four Axis II diagnoses are dependent
disorder, and other.
*** Models 2-5 also include the fitted marg
factors in seeking explanations for the behavior cians evaluate their same-sex white case studies
of other white women. they choose either undifferentiated schizo-
The remaining heterogeneity in diagnosis is phrenic disorder (the modal response) or a less
highly suggestive. Male clinicians as a group severe disorder (i.e., brief reactive disorder),
tend to evaluate females as having a depressive further corroborating the idea that black profes-
disorder. This finding suggests that male sionals may have internalized in part the white
clinicians may overestimate the prevalence of standards provided in their medical training.
depressive disorders in women. Similarly, male Are there alternative explanations for the
clinicians assign to white females the Axis 2 patterns found in this study? Some researchers
category of histrionic personality disorder even might argue that insufficient information was
though the case studies give little indication of provided in the case studies to make any
this disorder. It appears that male psychiatrists informed diagnostic judgment. If this argument
see the women in the case study as having has merit, the level of consensus (or "accu-
emotional problems, a view that certainly racy") should be unacceptably low for all types
represents a stereotype of women's behavior. of case studies and for each subgroup of
Evaluations of blacks, particularly black men, psychiatrist. Nevertheless, we find a great deal
also indicate that diagnoses are influenced by of agreement among all groups of clinicians
certain cultural stereotypes of psychopathology. when they evaluate the "no information"
Although violent behavior is not imputed to the category. Moreover, this argument cannot
white males or to the females, black males are explain why variation in response depends on
most likely to be diagnosed as having a paranoid the clinician's sex and race as well as the
schizophrenic disorder. Similarly, both black client's. Ironically, several psychiatrists who
males and black females are most likely to be returned the questionnaire volunteered that there
diagnosed by Axis 2 as having a paranoid was not enough information about the client to
personality disorder. Clinicians appear to as- reach a reasonable assessment of the client's
cribe violence, suspiciousness, and dangerous- status. Of the 19 respondents who intimated this
ness to black clients even though the case problem, 12 belonged to the "no information"
studies are the same as the case studies for the category. That is, the "incompleteness" of the
white clients. Interestingly, black clinicians case study became salient primarily if the
seem to have internalized this view because they respondent had no information about the client's
also assign paranoid schizophrenic disorders to sex and race!
black men (although less frequently than do Others might contend that the variation in
white clinicians). Moreover, when black clini- response by type of clinician does not indicate
an inconsistency but that different types of role in the sense of mental illness in the mental
clinicians evaluate different types of clients. health professions, the social and behavioral
Those who use this argument assert that perhaps sciences, and the lay public.
the women treated by males are more prone to Our results should not be seen as an
depressive disorders and those diagnosed by indictment of attempts to improve diagnostic
females to brief reactive psychoses. We think consistency and accuracy in the mental health
this explanation is interesting but unconvincing. profession. On the contrary, the explicit criteria
If it is to be persuasive, the clinical experiences set forth in DSM-III may have made diagnosis
and settings of male versus female and black less arbitrary and may have attenuated the
versus white psychiatrists must be extraordinar- effects of sex and race on diagnostic evaluation.
ily different. If this suggestion is to be The intent of this study is to demonstrate that
considered seriously, the burden of proof should even with carefully drawn standards, diagnosis
fall on those who offer it. will remain a subjective activity. Professions-
What are the consequences of the variation in not only the psychiatric profession but others as
clinical response as evidenced in this study? well, including the educational and the legal
Some might claim that differential evaluations professions-seek legitimacy by demonstrating
do not lead to differential treatment. This the objective nature of their field. This trend
suggestion is ironic. The mental health profes- toward seeking consistent operational defini-
sion has attempted to establish an objective tions is both understandable and admirable, but
categorical system of mental illness to guard a false sense of confidence in objective
against inconsistency in evaluation. DSM-III is measures can be dangerous when it ignores the
based on the assumption that heterogeneity in possibility of bias (or misperception) and when
diagnoses yields variant therapeutic interven- it helps to maintain that bias through both
tions. Those in the forefront of the movement to treatment and statistical reports. We hope we
create a standard nosological system have have shown that it is premature to close the issue
contended for years that the choices of therapy of the effects of social location on diagnosis
may well be random without an appropriate and, more broadly, on "objective" evaluations
diagnostic system. We know that certain by professions.
diagnoses are likely to imply more severe
action; for example, the likelihood of institution- NOTES
alization and/or drug therapy is greater for
patients with a paranoid schizophrenic disorder 1. Several flaws exist. First, the sample of psychiatrists
was limited to the authors. Second, the familiarity of
than for those with a brief reactive psychosis.
the authors with each other could have led to a
Drugs prescribed to clients with depressive higher degree of reliability than would be found
disorders differ from medication given to those among psychiatrists who did not know each other.
with undifferentiated schizophrenic disorders. If Third, after each case, the psychiatrists in the sample
discussed their diagnosis. Thus it is not surprising
therapeutic intervention has utility, different
that the level of consensus increased as the study
diagnoses should lead to different treatments. continued.
Equally (if not more) important, if diagnoses 2. The most serious criticism of this research project is
are influenced by such characteristics as sex and that the psychiatrists making the diagnoses were
race, these different standards will change our familiar with each other. Generally, each case was
diagnosed by one psychiatrist and then by another
perceptions of mental health. The "reality" of
from the same hospital, clinic, or practice. This
psychopathology is derived increasingly from method may well have led to an artificial inflation of
hospital and epidemiological reports on mental reliability in judgment. Although some authors have
disorders. If women and men (and blacks and questioned the utility of the field trials (Scheff
1986), the overall appraisal in the mental health
whites) are seen differently by their psychiatrists
community is that the reliability of DSM-llI-derived
and are diagnosed differentially even if they diagnoses is confirmed.
exhibit the same behavior, these differences will 3. For a more complete discussion of how Rosenberg's
be reflected and legitimized in official statistics interactionist approach and Scheff's labeling orienta-
on psychopathology. In addition, because white tion converge and diverge, see Rosenberg (1984).
4. Several limitations of Craig et al.'s study are
males represent the majority of clinicians
apparent: a) only two subjects were making the
making these judgments, we expect that their re-evaluations. Craig et al. cannot demonstrate that
perceptions in particular will play a prominent their findings generalize beyond these two subjects;
b) the two subjects were the authors of the study; c) chi-square statistic for that cell, or x - y divided by
no information is provided about the race of the two the square root of y where x is the actual frequency
evaluators; d) the reasonably large dissensus over and y is the expected frequency based on the pooled
nonwhites and females in the study should raise NI frequencies.
some doubt about Craig et al.'s conclusions 14. Parameter estimates for all general log-linear models
regarding the color- and gender-blind nature of are available for inspection.
DSM-III. 15. We find that white males are diagnosed more
5. The above discussion is not intended to imply that all frequently with antisocial (schizoid) personality
members of the mental health community agree that disorders than females and black males.
the use of DSM-Ill will eliminate racial/ethnic 16. Model 3 differs significantly (although nominally)
differences in diagnosis. Nor does the discussion from a fully saturated model, whereas Models 4 and
suggest that no research on ethnicity/race and 5 do not. Yet because Models 4 and 5 do not yield a
psychopathology is being conducted. On the con- significant improvement in fit over Model 3 and
trary, some intriguing research questions continue to because Model 3 makes more substantive sense, we
be posed (Sue 1983). Even so, psychiatrists, would opt for Model 3.
psychologists, and sociologists have been reluctant
to respond to the ostensibly powerful argument that
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Gender, Race, DSM III

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Gender, Race, and DSM-III: A Study of the Objectivity of Psychiatric Diagnostic Behavior

Author(s): Marti Loring and Brian Powell

Journal of Health and Social Behavior 1988, Vol. 29 (March):1-22

CHART 1. BRIEF SUMMARIES OF AXIS 1 DIAGNOSTIC CATEGORIES

Paranoid Schizophrenic and Undifferentiated Schizophrenic Disorders

Brief Reactive Psychosis

Recurrent Manic Disorder and Recurrent Depressive Disorder

Unspecified Substance Dependence

CHART 2. BRIEF SUMMARIES OF AXIS II DIAGNOSTIC CATEGORIES

Dependent Personality Disorder

Paranoid Personality Disorder

Histrionic Personality Disorder

Antisocial Personality Disorder

Schizoid (Asocial) Personality Disorder

Compulsive Personality Disorder

BF .21 .33 .50 .57 .40

A=.57 (.1) A=.14 (-3.0)* A=.47 (-.7) A=.23 (-2.4)* A=.35

A=.23 (-2.4)* A=.65 (.6) A=.17 (-2.9)* A=.38 (-1.2) A=.35

A=.23 (-2.4)* A=.23 (-2.4)* A=.20 (-2.6)* A=.18 (-2.7)* A=.21

A=.21 (-2.4)* A=.33 (-1.7) A=.50 (-.1) A=.57 (.1) A=.40

A=.53 (.2) A=.50 (-.4) A=.63 (.5) A=.57 (.1) A=.56

A=.36 A=.37 A=.39 A=.39 A=.38

A= Undifferentiated Schizophrenic Disorder.

Model Fitted Marginals L2 df Lp2 p value

(Null model) (D)(ABRS)*** 307.1 76 0 <.001

4 (DAR)(DBS)(DAB)(DRS) 61.8 24 .799 <.001

5 (DBRS)(DAR) 36.0 28 .883 >.05

A=.33 (-1.8) A=.50 (-.8) A=.30 (-2.2)* A=.46 (-1.0) A=.39

A=.33 (-2.0)* A=.13 (-3.4)* A=.63 (.1) A=.46 (-1.1) A=.39

A=.04 (-3.9)* A=.20 (-2.9)* A=.57 (-3.4)* A=.54 (-.6) A=.33

A=.60 (-.1) A=.67 (.3) A=.60 (-.1) A=.60 (-.1) A=.62

A=.38 A =.40 A =.51 A =.51 A =.45

A = Dependent Personality Disorder.

(female= 1) - 1.251** -2.071**

Race of case study .376 .408*

Similarity of case's .476*

Constant .195 .162

race. Male psychiatrists, when diagnosing white DISCUSSION

TABLE 7. Selected Log-linear Models Fitted to Cross-Class

Model Fitted Marginals df Lp2 p value

4 (PAR)(PBS)(PAS) 39.0 27 .805 >.05

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(female= 1) - 1.251 -2.071