avoided the reality of no free lunch; at least one HMO has known it for years. I’m not any happier about it than anyone else, and to smear all HMOS as willfully deceitful and insensitive to the “heartache and heartbreak of patients and families” does not promote the development of better health care delivery. RJCHARDJ.
M.D.
MOLDAWSKY,
Dr. Moldawsky is chi ef of the department ofpsychiatrj at Kaiser Permanente Medical Center in Douy, California. References 1. Fink PJ, Dubin WR: No free lunch: limitations on psychiatric care in HMOs. Hospital and Community Psychiatry 42: 363-365, 1991 2. Moldawsky RJ, Severoni EB: Rational rationing (ltr). Western Journal of Medicine 151:85-86, 1989
in Reply: I apologize to Dr. Moldawsky for what appears to be an overgeneralization and all-inclusive blast at HMOs in general. He is conrect that ovengencralization can have a very serious deleterious effect. The account by Dr. Dubin and me of our experience was intended as a warning to other physicians and hospital administratons of the need for carefully evaluating their ability to provide what an HMO wants. In my discussions with psychiatnists all over the country, I have found very few HMOs that compare with the Kaiser Penmanente program on the Harvard Community Health Plan. However, there are a significant number of HMOs that, because they are for-profit entities, focus mainly on cost-cutting efforts. Dr. Moldawsky correctly pointed out that one of the contributions of our paper was indicating the need for contractors
to control
every
segment
of the service system so they will be trapped or dumped on. We wanted to alert HMOs around country that are driven by costs have very little regard for quality we are concerned about their onities.
I appreciate ten and hope too great.
Dr. Moldawsky’s that
our offense
PAuLJAY
82
not also the and that pni-
FINK,
letwas
not
M.D.
Schizotypal
Disorder
To the Editor: In the discussion of the multiaxialsystem in the DSM-1V column in November 1990, Wilhams and associates (1) mention that DSM-IV work groups have been considening the wisdom of moving schizotypal personality disorder from axis II to within the schizophrenia section of axis I. Such a change has already been made in the forthcoming iCD-1O. We would like to cornment on this issue. The most compelling evidence for the placement ofschizotypal personality disorder in the true schizophrenia spectrum arises from studies suggesting a familial association between schizophrenia and schizotypal personality disorders (2-4). Follow-up data suggest that patients with schizotypal personality disorder are stable in their diagnosis (that is, they usually do not develop schizophrenia) and that their outcome, though it may be fairly poor, is different from that of schizophrenic patients (5). Thus the two disordens, although probably sharing the same underlying liability, appear to represent separate entities at different points. At a research level, the status of schizotypal personality disorder can be treated flexibly; indeed, within the same study (for example, in genetic linkage studies), it can be both included in and excluded from the schizophrenia domain to observe the effects of such changes on the logarithm ofodd scores. However, a diagnostic manual does not allow for such flexibility, and placement ofschizotypal personality disorder in the schizophrenia domain may not be advisable. DSMaims to be not only a research tool but also a frame of reference for the clinician, with important educational implications. Schizotypal personality disorder is a milder and probably more common disorder than schizophrenia, but its inclusion in the schizophrenia spectrum might lead many clinicians to conceptualize it as a similar illness, with the result that it would be viewed more pessimistically by the doctor, the patient, and the family. In addition, patients might be subject to greaten stigmatization,
w
January
1992
Vol. 43
No. 1
and therapeutic choices might be affected. Some clinicians might choose to treat the disorder with drugs similar to those used for schizophrcnia in an attempt to avoid the dcvelopmcnt ofthe more severe symptoms of schizophrenia. Because patients with schizotypal personality disorder are usually stable over time in spite of the occasional brief appearance of psychotic symptoms, a continuous pharmacotherapy regimen might increase the risk of long-term side eff#{232}cts and disabilities without a real gain in prevention. In summary, connecting schizotypal personality disorder with schizophrenia may cause problems. Keeping the two categories separated might be a good strategy both for research and for clinical psychiatry. MARCO
BATrAGLIA,
LAURA
BELLODI,
M.D. M.D.
Dvi. Battaglia and Beiodi are associatedwith the department of neuropsychiatric sciences atSt. Raffaele Hospital-University of Milan School of Medicine in Milan, italy. References 1. Williams JBW, Goldman HH, Gruenberg A, et a!: The multiaxial system. Hospital and Community Psychiatry 41: 1181-1182, 1990 2. KendlerKS,GruenbergAM: An independentanalysisofthe Copenhagen sample of the Danish adoption study of schizophrenia, N: the pattern of psychiatric illness, as defined in DSM-Ill, in adoptees and relatives. Archives of General Psychiatry 41:555-564,
1984
3. Siever U, Silverman JM, Horvath TB, et al: Increased morbidity risk for schizophrenia-related disorders in relatives of schizotypal personality-disordered patients. Archives ofGeneral Psychiatry 47: 634-640, 1990 4. Battaglia M, Gaspenini M, SciutoG, et al: Psychiatric disorders in the fmilies of schizotypal subjects. Schizophrenia Bulletin, in press 5. McGlashan TH: Schizotypal personality disordec Qestnut Lodge follow-up study, VI: long-term follow-upperspectives. Archives ofGeneral Psychiatry 43:329-334, 1986
in Reply: Our DSM-iV axis II cornmittee has agreed with the recommendation by Drs. Battaglia and Bellodi that schizotypal personality disorder should stay on axis II. Apart from the reasons they give, we consider it very important to maintain a
Hospital
and
Community
Psychiatry
M.D.
MOLDAWSKY,
Dr. Moldawsky is chi ef of the department ofpsychiatrj at Kaiser Permanente Medical Center in Douy, California. References 1. Fink PJ, Dubin WR: No free lunch: limitations on psychiatric care in HMOs. Hospital and Community Psychiatry 42: 363-365, 1991 2. Moldawsky RJ, Severoni EB: Rational rationing (ltr). Western Journal of Medicine 151:85-86, 1989
in Reply: I apologize to Dr. Moldawsky for what appears to be an overgeneralization and all-inclusive blast at HMOs in general. He is conrect that ovengencralization can have a very serious deleterious effect. The account by Dr. Dubin and me of our experience was intended as a warning to other physicians and hospital administratons of the need for carefully evaluating their ability to provide what an HMO wants. In my discussions with psychiatnists all over the country, I have found very few HMOs that compare with the Kaiser Penmanente program on the Harvard Community Health Plan. However, there are a significant number of HMOs that, because they are for-profit entities, focus mainly on cost-cutting efforts. Dr. Moldawsky correctly pointed out that one of the contributions of our paper was indicating the need for contractors
to control
every
segment
of the service system so they will be trapped or dumped on. We wanted to alert HMOs around country that are driven by costs have very little regard for quality we are concerned about their onities.
I appreciate ten and hope too great.
Dr. Moldawsky’s that
our offense
PAuLJAY
82
not also the and that pni-
FINK,
letwas
not
M.D.
Schizotypal
Disorder
To the Editor: In the discussion of the multiaxialsystem in the DSM-1V column in November 1990, Wilhams and associates (1) mention that DSM-IV work groups have been considening the wisdom of moving schizotypal personality disorder from axis II to within the schizophrenia section of axis I. Such a change has already been made in the forthcoming iCD-1O. We would like to cornment on this issue. The most compelling evidence for the placement ofschizotypal personality disorder in the true schizophrenia spectrum arises from studies suggesting a familial association between schizophrenia and schizotypal personality disorders (2-4). Follow-up data suggest that patients with schizotypal personality disorder are stable in their diagnosis (that is, they usually do not develop schizophrenia) and that their outcome, though it may be fairly poor, is different from that of schizophrenic patients (5). Thus the two disordens, although probably sharing the same underlying liability, appear to represent separate entities at different points. At a research level, the status of schizotypal personality disorder can be treated flexibly; indeed, within the same study (for example, in genetic linkage studies), it can be both included in and excluded from the schizophrenia domain to observe the effects of such changes on the logarithm ofodd scores. However, a diagnostic manual does not allow for such flexibility, and placement ofschizotypal personality disorder in the schizophrenia domain may not be advisable. DSMaims to be not only a research tool but also a frame of reference for the clinician, with important educational implications. Schizotypal personality disorder is a milder and probably more common disorder than schizophrenia, but its inclusion in the schizophrenia spectrum might lead many clinicians to conceptualize it as a similar illness, with the result that it would be viewed more pessimistically by the doctor, the patient, and the family. In addition, patients might be subject to greaten stigmatization,
w
January
1992
Vol. 43
No. 1
and therapeutic choices might be affected. Some clinicians might choose to treat the disorder with drugs similar to those used for schizophrcnia in an attempt to avoid the dcvelopmcnt ofthe more severe symptoms of schizophrenia. Because patients with schizotypal personality disorder are usually stable over time in spite of the occasional brief appearance of psychotic symptoms, a continuous pharmacotherapy regimen might increase the risk of long-term side eff#{232}cts and disabilities without a real gain in prevention. In summary, connecting schizotypal personality disorder with schizophrenia may cause problems. Keeping the two categories separated might be a good strategy both for research and for clinical psychiatry. MARCO
BATrAGLIA,
LAURA
BELLODI,
M.D. M.D.
Dvi. Battaglia and Beiodi are associatedwith the department of neuropsychiatric sciences atSt. Raffaele Hospital-University of Milan School of Medicine in Milan, italy. References 1. Williams JBW, Goldman HH, Gruenberg A, et a!: The multiaxial system. Hospital and Community Psychiatry 41: 1181-1182, 1990 2. KendlerKS,GruenbergAM: An independentanalysisofthe Copenhagen sample of the Danish adoption study of schizophrenia, N: the pattern of psychiatric illness, as defined in DSM-Ill, in adoptees and relatives. Archives of General Psychiatry 41:555-564,
1984
3. Siever U, Silverman JM, Horvath TB, et al: Increased morbidity risk for schizophrenia-related disorders in relatives of schizotypal personality-disordered patients. Archives ofGeneral Psychiatry 47: 634-640, 1990 4. Battaglia M, Gaspenini M, SciutoG, et al: Psychiatric disorders in the fmilies of schizotypal subjects. Schizophrenia Bulletin, in press 5. McGlashan TH: Schizotypal personality disordec Qestnut Lodge follow-up study, VI: long-term follow-upperspectives. Archives ofGeneral Psychiatry 43:329-334, 1986
in Reply: Our DSM-iV axis II cornmittee has agreed with the recommendation by Drs. Battaglia and Bellodi that schizotypal personality disorder should stay on axis II. Apart from the reasons they give, we consider it very important to maintain a
Hospital
and
Community
Psychiatry
