Differences in DSM-III-R and DSM-IV Diagnoses in EatingDisorder Patients

Suzanne R. Sunday, Carol B. Peterson, Karen Andreyka, Scott J. Crow, James E. Mitchell,and Katherine A. Halmi

Two hundred eighty-eight eating disorder patientswere administered the DSM-III-R Structured ClinicalInterview (SCID) and the DSM-IV SCID for axis I and II.Concordance between DSM-III-R and DSM-IV was ex-cellent for the axis I affective and anxiety disorders,bulimia nervosa, and substance abuse/dependence. Itwas also excellent for axis II paranoid, schizoid, bor-derline, and antisocial personality disorders. Agree-ment between the two nosological systems waslower for alcohol abuse/dependence with a kappa of.63. Kappas were also poor for the following person-ality disorders: schizotypal (.44), histrionic (.29), de-pendent (.54), obsessive-compulsive (.62) and not oth-

erwise specified (.63). There was a substantialdifference in the diagnosis of anorexia nervosa be-tween DSM-III-R and DSM-IV. Fourteen patients werediagnosed with anorexia nervosa, binge/purge type,using DSM-IV criteria, while only six received the di-agnoses of anorexia nervosa and bulimia nervosa us-ing DSM-III-R criteria. Kappa was .49 and the percentagreement was 79%. While there are considerableareas of overlap in DSM-IV and DSM-III-R, there arealso areas of substantial differences. Clinicians andresearchers must be very cautious when attemptingto compare data from the different nosologies.Copyright 2001 by W.B. Saunders Company

THE DIAGNOSTIC and Statistical Manuals ofMental Disorders (DSM), published by theAmerican Psychiatric Association, have reflectedconsensus among experts in the field and thechanging knowledge base of psychiatry and psy-chology. As such, these manuals have changed andmust continue to be modified over time. The pri-mary goal of the DSM has been to provide descrip-tions of diagnostic categories so that clinicians andresearchers are better able to diagnose, assess, andtreat people with psychiatric disorders. The evolv-ing nature of the DSM has presented problemsbecause the diagnoses and their criteria have oftenchanged substantially from one nosological systemto the next.

The earliest versions of the DSM1,2 did not in-clude specific diagnostic criteria and were not em-pirically based. This changed with the develop-

ment of DSM-III in 1980.3 Diagnostic criteria wereexplicitly stated and were based, in part, on empir-ical data. Axis II was also added to diagnose per-sonality disorders. Further, criteria were descrip-tive and not specifically linked to etiologicaltheories. These changes led to the development ofinstruments to assess the specific criteria. One suchinstrument was the Diagnostic Interview Schedule(DIS),4 a structured interview that could be admin-istered by laypeople with little training. Using thisinterview, researchers were able to assess psychi-atric diagnoses, and many studies were publishedusing this measure.5

The revision of DSM-III6 further clarified andrefined the diagnostic criteria. However, thechanges in definitions and diagnostic criteria alsopresented problems. Recently, Regier et al.7 dis-cussed the impact of these changes on psychiatricdiagnoses of community-based samples in epide-miological studies. In comparing the Epidemio-logic Catchment Area (ECA) DSM-III studies withthe National Comorbidity Survey (NCS) DSM-III-R study, they reported substantial increases inthe diagnosis of alcohol dependence, panic disor-der, and social phobia based on the changes in thecriteria between the two nosological systems.These changes reflected inconsistencies in diag-noses between the two systems rather than in-creases in base rates.

Morey8 compared axis II diagnoses betweenDSM-III and DSM-III-R in 291 case reports fromclinicians. In general, the author found quite pooragreement between the two systems; only border-line personality disorder had a kappa value above

From the New York Presbyterian HospitalWeill MedicalCollege of Cornell University, White Plains, NY; Department ofPsychiatry, University of Minnesota, Minneapolis, MN; Neuro-psychiatric Research Institute and University of North Dakota,Fargo, ND.

Supported by The McKnight Foundation, The New YorkCommunity Trust established by DeWitt-Wallace, and the Min-nesota Obesity Center Grant No. P30DK50456 from the Na-tional Institute of Health.

Presented in part at the annual meeting of the Eating Dis-order Research Society, November 21, 1997, Albuquerque, NM.

Address reprint requests to Suzanne R. Sunday, PhD, WeillMedical College at Cornell University, 21 Bloomingdale Rd,White Plains, NY 10605.

Copyright 2001 by W.B. Saunders Company0010-440X/01/4206-0005$35.00/0doi:10.1053/comp.2001.27896

448 Comprehensive Psychiatry, Vol. 42, No. 6 (November/December), 2001: pp 448-455

.75. Further, there were marked increases in somedisorders (e.g., an 800% increase for schizoid per-sonality disorder) and an overall increase in over-lap of axis II disorders using DSM-III-R. Blash-field et al.9 compared the DSM-III and DSM-III-Rdiagnoses of personality disorders among 72 pa-tients using the Structured Interview for DSM-III(SIDP) and for DSM-III-R (SIDP-R). Kappas forall of the personality disorders were below .6.Rates of paranoid, avoidant and, to a lesser degree,obsessive-compulsive personality disorders all in-creased with DSM-III-R; rates of schizotypal andborderline personality disorders decreased.

After the introduction of DSM-III-R, many in-vestigators and clinicians questioned whether ac-curate psychiatric diagnoses could be assigned us-ing a structured interview administered bynonclinicians. In response to such criticisms, theStructured Clinical Interview for DSM (SCID) wasdeveloped.10,11 This instrument has been shown tobe both reliable and valid.11,12 The widespread useof this semistructured, clinician-administered inter-view in research studies led to an increase in thedescription of comorbid psychiatric disordersamong numerous groups of psychiatric patients.For example, Braun et al.13 described comorbiddisorders among subgroups of eating disorder pa-tients. Hundreds of articles have been publisheddescribing typical axis I and axis II comorbiditypatterns for each of the axis I disorders, and re-searchers and clinicians alike have incorporatedthe findings into their work. For example, thosewho work with eating disorder patients expect tofind comorbid major depression, obsessive-com-pulsive disorder, and cluster C personality disor-ders in anorectic and bulimic patients and comor-bid alcohol and substance dependency, socialphobia and cluster B personality disorders (partic-ularly borderline personality disorder) in bulimicpatients.13

The publication of DSM-IV14 represents furthermodifications of the diagnostic criteria. For the firsttime, the literature was closely reviewed, data werereanalyzed, and extensive field trials were con-ducted so that changes in diagnostic criteria weredriven primarily by empirical data. For some diag-noses (most notably axis II diagnoses), the newcriteria have led to major changes, such that aperson who was given a diagnosis in DSM-III-Rmight not receive that diagnosis in DSM-IV. Con-

versely, patients might receive a diagnosis inDSM-IV but not in DSM-III-R.

In axis I, two areas that did change substantiallywere eating disorders and alcohol/substance abuseand dependence. While the criteria for anorexianervosa did not change in DSM-IV, the subclassi-fication into restricting and binge-eating/purgingtypes has been added. Previously in DSM-III-R ananorexia nervosa patient who binged and purged atleast twice per month was given the additionaldiagnosis of bulimia nervosa. However, researchfindings indicated that anorexia nervosa patientswho binge ate and/or purge regularly appeared tobe different from those who only restricted.15,16 InDSM-IV, individuals who meet criteria for an-orexia nervosa and binge and purge are classifiedin the binge-eating/purge subtype rather than givenan additional diagnosis of bulimia nervosa.

While the number of criteria required byDSM-IV for substance dependence and abuse isnot different from DSM-III-R (three and one, re-spectively), the items that can be considered for thediagnoses are different. DSM-IV has differentquestions that comprise the dependence and abusesections, generally resulting in lower rates of bothdiagnoses than DSM-III-R. The agreement be-tween DSM-III-R and IV concerning substanceabuse and dependence has been discussed recentlyin the literature. Rounsaville et al.17 reported highlevels of agreement and high kappa values ($.85)between the two systems for alcohol and substancedependence; however, the kappa values for abuseranged from .56 for alcohol to .78 for sedatives.Similar findings were reported by others for alco-hol and other substances.18-22

Many of the personality disorders have under-gone substantial changes from DSM-III-R toDSM-IV. Some of the changes were minor, such asrequiring three rather than four criteria for antiso-cial personality disorder and adding one additionalitem to the criteria for borderline personality dis-order. Other axis II disorders underwent majorchanges. The definition of schizotypal personalitydisorder was modified. In DSM-III-R, it includedexcessive social anxiety, especially with unfamiliarpeople; for DSM-IV it requires excessive socialanxiety that does not diminish with familiarity. Forhistrionic personality disorder, the number of cri-teria required for a diagnosis was changed fromfour to five and several criteria were changed. Both

DSM-III R/DSM-IV DIAGNOSES IN EATING DISORDERS 449

definitions and criteria were changed for narcissis-tic, avoidant, and dependent personality disorders.DSM-IV obsessive-compulsive personality disor-der requires four rather than five criteria, has adifferent definition, and includes different criteriathan DSM-III-R. Thus, it should be expected thatthe agreement between DSM-III-R and DSM-IVshould be lower for schizotypal, histrionic, narcis-sistic, avoidant, dependent, and obsessive-compul-sive personality disorders because of the degree ofchange for those disorders.

Blais et al.23,24 recently evaluated DSM-IV per-sonality disorder criteria psychometrically. Whencluster B (narcissistic, histrionic, borderline, andantisocial) personality disorders were examinedin 94 patients, improvements in divergence andreliability were found. Diagnoses in DSM-IVand DSM-III-R were also compared. Agreement(kappa) was high for borderline and antisocial per-sonality disorders but low for the other two. Over-all, there was a decrease in axis II diagnoses usingDSM-IV. Poling et al.25 also compared SCID IIDSM-III-R and DSM-IV personality disorder di-agnoses by interviewing 370 substance abusingor dependent patients. They reported very pooragreement between the two systems for histrionic(kappa 5 .42) and dependent (kappa 5 .34) per-sonality disorders and only moderate kappas foravoidant and obsessive-compulsive personalitydisorders.

Despite the fact that reliability, validity, diver-gence, and consistency are better with DSM-IVthan with DSM-III-R, discriminant validity re-mains a problem. This problem leads to very highlevels of comorbidity between different personalitydisorders. This issue was discussed in detail byClark et al.26 Their review of the DSM-III-R liter-ature revealed percentages of multiple axis II di-agnoses between 76% and 100%; in other words,greater than three quarters of the personality dis-order patients had two or more personality disor-ders. Personality disorder not otherwise specified(PD-NOS) was generally the most common axis IIdiagnosis. Such overlap between different person-ality disorders reflects a problem both with theconceptualization of the disorders and in the oper-ational definitions of the criteria.

The SCID has been revised to reflect thechanges in DSM-IV for both axis I and axis II.27,28It was the purpose of the present study to examine

the differences in axis I and axis II diagnoses usingthe SCID for DSM-III-R and the SCID forDSM-IV in a sample of eating disorder patients.

METHOD

Two hundred eighty-eight female inpatients and outpatientsserved as participants; 167 were patients in the Eating DisorderProgram at New York Presbyterian Hospital-Weill CornellMedical Center, White Plains, NY, and 121 were participants inthe Eating Disorder Research Program at the University ofMinnesota. The mean age of the patients was 29.2 years (SD8.7). The racial groups of the patients were: Caucasian 91.7%(n 5 264), Hispanic 3.1% (n 5 9), African-American 2.8%(n 5 8), Asian 1.7% (n 5 5), and Native American 0.7% (n 52). Written informed consent was obtained from all subjects(and from their parents if subjects were under 18 years of age)at the time the study was explained. Subjects could withdrawtheir consent at any time during the study.

All patients were interviewed at, or shortly after, entry to theprogram. To establish axis I diagnoses, SCID I for DSM-IV27and the H module (eating disorders) from SCID I for DSM-III-R10 were used. SCID I for DSM-IV interviews were recoded forDSM-III-R criteria after each interview by the interviewer. Inorder to minimize differences between DSM-III-R and DSM-IVratings due to interviewer biases, the same clinician conductedboth interviews. SCID II for DSM-IV28 was conducted on thesame day as SCID II for DSM-III-R,11 because test-retest reli-ability for the DSM-III-R SCID II between 1 day and 2 weeksapart is moderate to poor (kappas ranged from .24 to .7412).SCID II questionnaires (for both DSM-IV and DSM-III-R)were completed prior to the interviews for all participants. Formost subjects, SCID I and II interviews were conducted ondifferent days; however, all interviews were completed within a2-week period. All interviews were conducted by either the firstor the second author; both were experienced clinical and re-search interviewers who had been extensively trained to admin-ister the SCID I and II. The interviewers had initially receivedtraining using the SCID for DSM-III-R; the first author wastrained by one of the SCID coauthors (M. Gibbon) and thesecond author was trained by an expert at her site and viewedthe DSM-III-R SCID tapes. Both interviewers conducted manyof these interviews before the inception of the current project.When the DSM-IV SCID was released, the interviewers re-ceived further training and taped all interviews. A subset ofthese tapes were reviewed for both interviewing and scoringprocedures.

Percent agreement and kappas between DSM-III-R andDSM-IV were computed for all axis II diagnoses and thefollowing axis I diagnoses: alcohol and substance abuse anddependence, anorexia nervosarestricting type (AN-R), and an-orexia nervosabinge-eating/purge type (AN-BP). For alcoholand substances, data were analyzed separately for each sub-stance but with abuse and dependence within a single analysis.

RESULTS

Axis IOnly 85 patients (29.5%) had no axis I disorders

other than the eating disorder. There was complete

450 SUNDAY ET AL

agreement between DSM-III-R and DSM-IV diag-noses for all axis I disorders except anorexia ner-vosa, alcohol abuse/dependence, and substanceabuse/dependence. Of the 14 patients who werediagnosed as AN-BP using DSM-IV, only six werediagnosed as meeting criteria for anorexia nervosaand bulimia nervosa using DSM-III-R. Thirty-twopatients were diagnosed as only meeting criteriafor anorexia nervosa using the DSM-III-R criteriawhile 24 received the diagnosis using DSM-IV.Thus, there was a 79% agreement between DSM-III-R and IV for anorexia nervosa but the kappavalue was only .485. One hundred seventy-twopatients were classified with bulimia nervosa and78 with eating disorder not otherwise specified(ED-NOS) using both systems.

Table 1 presents the occurrence of alcohol andsubstance disorders. Percent agreement was highthroughout with greater variation among the kap-pas. With the exception of alcohol abuse and de-pendence (.63), all kappas were quite high (..75).

Axis IIPersonality DisordersThe majority of this sample (n 5 156 or 54%)

had no axis II pathology. The agreement betweenDSM-III-R and DSM-IV varied by personality dis-order; the data appear in Table 2. Again, percentagreement was high for all disorders but kappasvaried widely with all but paranoid, schizoid, bor-derline, and antisocial below .75. The prevalenceof the diagnoses was not dramatically differentbetween DSM III-R and IV except for substantialdecreases in schizotypal, histrionic, and dependentpersonality disorders and a twofold increase inobsessive-compulsive personality disorder. Thetwo most prevalent axis II disorders in both noso-logical systems were borderline and avoidant.

The number of personality disorders present ap-pears in Table 3. The majority of patients who werediagnosed with a personality disorder had one ortwo diagnoses. There were few differences be-tween DSM-IV and DSM-III-R. Table 4 presents

Table 1. Substance Abuse and Dependence Diagnoses in DSM-III-R and DSM-IV

Substance % Agreement KappaAbsentBoth

AbuseBoth

DependenceBoth

Abuse III-ROnly

Abuse IVDependence III-R*

Alcohol 80% .63 177 36 48 10 17Sedatives 99% .92 261 7 16 0 4Cannabis 97% .89 242 18 12 1 7Stimulants 99% .91 262 5 17 2 2Opioids 99% .93 271 7 7 0 3Cocaine 99% .95 256 6 23 2 1Hallucinogens 98% .77 275 7 1 0 5Other 97% .87 265 2 12 7 2Poly-drug 99% .90 277 0 9 1 0

*The changes from DSM-III-R to DSM-IV in criteria for abuse and dependence were such that subjects were more likely to meetdependence criteria using DSM-III-R than in DSM-IV. This column reflects cases where subjects met dependence criteria forDSM-III-R but only abuse criteria using DSM-IV.

Table 2. Axis II Diagnoses in DSM-III-R and DSM-IV

Personality Disorder % Agreement KappaAbsentBoth

PresentBoth

IVOnly

III-ROnly

% inIV

% inIII-R

Paranoid 100% 1.00 261 27 0 0 9.4 9.4Schizotypal 99% .44 284 1 0 3 .3 1.4Schizoid 100% 1.00 285 3 0 0 1.0 1.0Histrionic 95% .29 271 2 0 15 .7 5.9Narcissistic 98% .71 274 8 3 3 3.8 3.8Borderline 96% .88 235 52 10 1 21.5 18.4Antisocial 100% .91 281 6 1 0 2.4 2.1Avoidant 92% .72 227 39 12 10 17.7 17.0Dependent 95% .54 261 11 1 15 4.2 9.0Obsessive-compulsive 94% .62 252 20 20 0 13.8 6.9PD-NOS 97% .63 271 8 5 4 4.5 4.2

DSM-III R/DSM-IV DIAGNOSES IN EATING DISORDERS 451

the co-occurrence of the personality disorders; thatis, for each personality disorder, the number ofsubjects who had at least one other personalitydisorder diagnosis. For all of the disorders, a ma-jority of subjects had additional axis II comorbidityand there were few differences between the twodiagnostic systems. Only obsessive-compulsivepersonality disorder showed a substantial decreasein axis II comorbidity from DSM-III-R to DSM-IV.Several specific pairings of personality disorderswere found to occur. Borderline and avoidant co-occurred (with or without additional personalitydisorders) most frequently (for 28 subjects usingDSM-IV and for 23 using DSM-III-R), followedby paranoid and borderline (21 and 17, respec-tively), borderline and obsessive-compulsive (17and 9), avoidant and obsessive-compulsive (12 and9), borderline and dependent (7 and 17), andavoidant and dependent (7 and 15).A Comparison Between Subgroups of EatingDisorders

DSM-IV axis I and II diagnoses were examinedfor each of the eating disorder subgroups. OnlyDSM-IV diagnoses are presented since this is thecurrent nosological system. Due to the small num-bers in the two anorexia groups (24 for AN-R and12 for AN-BP), detailed breakdowns of the diag-noses will be presented only for the bulimics. Ap-proximately one third of patients in each of thegroups had had no other axis I disorder than aneating disorder (BN, n 5 63% to 37%; AN-R, n 58% to 33%; AN-BP, n 5 4% to 33%). A substantialnumber of patients in each of the groups had hadsome form of affective disorder (almost alwaysmajor depression)38% of BN (n 5 65), 29% ofAN-R (n 5 7), and 50% of AN-BP (n 5 7). Any

history of alcohol or drug dependence or abuse wastwice as prevalent in BN and AN-BP as in ANR(42% and 43% as compared with 21%). The pres-ence of any anxiety disorder was seen more in theanorectic patients than in BN (50% for AN-R, 42%for AN-BP as compared to 25% for BN). For BN,obsessive-compulsive disorder was most prevalent(n 5 22), followed by post-traumatic stress disor-der (n 5 17), and social phobia (n 5 13). All otheranxiety disorders were found in fewer than 10 BNpatients.

The majority of patients in each group (92 or53% with BN, 17 or 71% with AN-R, and seven or50% with AN-BP) did not meet criteria for anypersonality disorder. Of the personality disordersseen in these patients, any cluster A diagnoses wereinfrequent (8% of BN, 0% of AN-R, and 8% ofAN-BP). Cluster B disorders were found onlyamong those who binged and/or purged (26% ofBN, 25% of AN-BP, 0% of AN-R). Cluster Cdisorders were most prevalent for all three groups;however, AN-R had the lowest levels (17% ascompared with 30% for BN and 33% for AN-BP).The most prevalent personality disorders for BNwere borderline (n 5 40), avoidant (n 5 33),obsessive-compulsive (n 5 23), and paranoid (n 511). All other personality disorders occurred infewer than 10 BN patients.

DISCUSSION

Agreement between DSM-III-R and DSM-IVdiagnoses depended strongly on the disordersthemselves. Concordance between the two noso-

Table 3. Number of Personality Disorder Diagnoses inDSM-III-R and DSM-IV

No. ofPersonalityDisorders

DSM-IV DSM-III-R

n % n %

0 178 48.2 191 66.31 53 18.4 44 15.32 31 10.8 26 9.03 16 5.5 17 5.94 6 2.1 3 1.05 2 .6 2 .66 2 .6 3 1.07 0 0 2 .6

NOTE. Excludes PD-NOS diagnoses.

Table 4. Co-occurrence of Axis II Diagnoses in DSM-III-Rand DSM-IV

PersonalityDisorder

DSM-IV DSM-III-R

No. Withat Least

One OtherAxis II

Diagnoses %

No. Withat Least

One OtherAxis II

Diagnoses %

Paranoid 24 88.9 19 70.3Schizoid 2 66.7 3 100.0Schizotypal 2 66.7 3 75.0Histrionic 2 100.0 14 82.3Narcissistic 8 72.7 10 90.9Borderline 45 72.5 38 71.7Antisocial 5 71.4 4 66.7Avoidant 37 72.5 37 75.5Dependent 10 83.3 23 88.5Obsessive-compulsive 21 52.5 15 75.0

452 SUNDAY ET AL

logical systems was excellent on axis I for theaffective and anxiety disorders and bulimia ner-vosa, very good for non-alcohol substance depen-dence/abuse, and excellent on axis II for paranoid,schizoid, borderline, and antisocial personality dis-orders. Substantial differences arose for the re-maining Personality Disorders, alcohol depen-dence/abuse, and anorexia nervosa. These findingsare consistent with previous research that hasfound significant differences between classificationsystems.7,8

The subtyping of anorexia nervosa in DSM-IVis substantially different from the diagnosis of an-orexia nervosa or the dual diagnosis of anorexianervosa and bulimia nervosa in DSM-III-R. Thus,clinical descriptions of DSM-III-R anorexia ner-vosa patients in the literature and other differencesbetween these groups (such as response to therapy)should not be assumed to adequately describe ei-ther DSM-IV restricting or binge-eating/purgingpatients. It will be important to replicate much ofthis previous work using DSM-IV anorectic sub-types.

The convergence of axis II diagnoses was notgood between the two systems, except for para-noid, schizoid, borderline, and antisocial personal-ity disorders. This is especially interesting sincethe completion of both the DSM-III-R andDSM-IV SCID II questionnaires at the same timemay have actually increased convergence of thetwo systems. The majority of personality disordersdid not yield consistent results between the twosystems. Our findings concerning cluster B person-ality disorders are similar to those of Blais et al.23and Poling et al.25; agreement was very good forborderline and antisocial but less good for narcis-sistic and poor for histrionic personality disorders.The especially low kappa for histrionic personalitydisorder may be the result of the increase in thenumber of criterion responses required and thechanges in the content of the criteria in DSM-IV.There were several dramatic decreases in the fre-quencies of some personality disorders, notablyschizotypal, histrionic, and dependent.

Similar decreases in histrionic and dependentpersonality disorders were also reported by Polinget al.25 Blais et al.23 reported similar decreases inthe diagnosis of histrionic personality disorder inDSM-IV as compared with DSM-III-R and notedthat the correlations with borderline and narcissis-

tic personality disorders had decreased as well.Only obsessive-compulsive personality disorderrates increased in DSM-IV, perhaps because thethreshold for diagnosis was lowered from five tofour items; it will be important to examine thispersonality disorders overlap with other axis IIdisorders. Although Poling et al.25 did report sim-ilar kappas for obsessive-compulsive personalitydisorders, they found only slight increases in theprevalence in DSM-IV rather than the twofoldincrease that we found. This finding may be spe-cific to eating disorder patients and may not gen-eralize to substance abusers.

Co-occurrence of personality disorders was nodifferent with both nosological systems. For all butone personality disorder (obsessive-compulsive),axis II comorbidity was present for more than twothirds of the patients. Similarly, the number ofpatients with two or more personality disorderswas not very different between the two systems.Despite the expressed interested in decreasing thenumber of mixed or atypical categorizations (PD-NOS) in DSM-IV, we obtained very similar num-bers of patients who received this diagnosis usingboth systems. However, for both DSM-III-R andDSM-IV, the use of PD-NOS was not particularlyhigh (about 4%) for our sample. This is in contrastto the findings of Clark et al.26 and may reflectdifferences using an eating disorder sample or dif-ferences in interviewer usage of the PD-NOS cat-egory between the two studies.

The amount of psychopathology found in thecurrent study among subjects with BN, AN-R, andAN-BP using DSM-IV criteria was somewhat lessthan what has been previously reported usingDSM-III-R.13 For example, Braun et al.13 reportedthat 82% of the eating disorder patients had axis Icomorbidity, 69% had axis II comorbidity, and65% of their BN patients had had an affectivedisorder. In contrast, we found that less than twothirds of our subjects had axis I comorbidity, lessthan half had axis II comorbidity, and only 38% ofbulimics had had an affective disorder. The formerstudy examined inpatients, whereas our study ex-amined outpatients; this could account for the dif-ferences. There were also similarities between ourfindings and those of Braun et al.13 Levels ofsubstance/alcohol problems and anxiety disorderswere very similar, as were the levels of cluster C

DSM-III R/DSM-IV DIAGNOSES IN EATING DISORDERS 453

personality disorders for all groups and cluster Bpersonality disorders for BN.

One potential limitation of this study is that thesame interviewer conducted both the DSM-III-Rand DSM-IV interviews, which may have inflatedthe correlations between the two interviews. How-ever, the decision to have the same interviewerconduct both interviews was made in order tominimize differences due to examiner variance.Thus, the differences between the two nosologicalsystems found in this study may actually be anunderstatement of the differences as measured bythe SCID. Future studies should attempt to repli-cate the findings of this investigation using inde-pendent raters for diagnostic system.

In conclusion, the results of this study suggestthat while there is considerable overlap betweenDSM-III-R and DSM-IV diagnoses, there are alsosubstantial differences, especially on axis II. Be-

cause of these differences, researchers and clini-cians must use caution in generalizing from onesystem to another. For example, a patient whoreceived a DSM-III-R diagnosis may have thesame diagnosis, a different diagnosis, or no diag-nosis at all according to DSM-IV. The differencesbetween the two classification systems suggest thatprevious findings using DSM-III-R require repli-cation using DSM-IV criteria. The inconsistenciesbetween DSM-III-R and DSM-IV have significantimplications to investigations of treatment out-come and comorbidity, which also need to be con-sidered in future revisions of DSM criteria. Whileit is important to improve the clarity and accuracyof axis II criteria, the diminished ability to confirmor disconfirm classic studies and track changes inthe epidemiology of personality disorders acrosstime suggests that further substantive changes inDSM criteria need to be carefully considered.

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