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A Study of Co-occurrence of Hierarchy-Free Syndromes

Jeffrey H. Boyd, MD, MPH; Jack D. Burke, Jr, MD, MPH; Ernest Gruenberg, MD, DrPH; Charles E. Holzer III, PhD; Donald S. Rae, MA; Linda K. George, PhD; Marvin Karno, MD; Roger Stoltzman, MD; Larry McEvoy, MA; Gerald Nestadt, MD, MPH

Arch Gen Psychiatry. 1984;41(10):983-989.

Abstract
• The diagnostic criteria of the third edition of the DSM-III often state that one diagnosis cannot be made If It is "due to" another disorder. Using data from the National Institute of Mental Health Diagnostic Interview Schedule, with a sample of 11,519 subjects from a community population, we found that if two disorders were related to each other according to the DSM-III exclusion criteria, then the presence of a dominant disorder greatly increased the odds of having the excluded disorder. We also found that disorders, which DSM-III says are related to each other, were more strongly associated than disorders, which DSM-III says are unrelated. However, we also found there was a general tendency toward co-occurrence, so that the presence of any disorder increased the odds of having almost any other disorder, even if DSM-III does not list it as a related disorder. We concluded that empirical studies are needed to study the assumptions underlying the use of a diagnostic hierarchy.

Author Affiliations
From the Division of Biometry and Epidemiology, National Institute of Mental Health (NIMH), Rockville, Md (Drs Boyd and Burke and Mr Rae); the Eastern Baltimore Health Survey, School of Hygiene and Public Health and the Department of Psychiatry, The Johns Hopkins University Medical School, Baltimore (Drs Gruenberg and Nestadt); the Yale Greater New Haven (Conn) Health Survey, Department of Psychiatry, Yale University Medical School and Department of Sociology, Yale University (Dr Holzer); the Piedmont Health Survey, Department of Psychiatry, Duke University Medical Center, Durham, NC (Dr George); the Los Angeles ECA Survey, UCLA (Dr Karno); and the St Louis Health Study, Department of Psychiatry, Washington University Medical School (Dr Stoltzman and Mr McEvoy).

Footnotes
Accepted for publication April 2, 1984.

Reprint requests to NIMH, Room 18-105, Parklawn Building, 5600 Fishers Lane, Rockville, MD 20857 (Dr Boyd).

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