Please see the attached 

Week 1

Respond to the following in a minimum of 175 words each question, post must be substantive responses: 

What are the similarities and differences between structured and semi-structured clinical interviews?

What role does the setting of the interview play in deciding which style of interview is most appropriate?

Respond to classmates in a minimum of 175 words each person, post must be substantive responses: 

T.W.

What are the similarities and differences between structured and semi-structured clinical interviews? The similarities between a structured and semi-structured clinical interviews is that they are both designed to gather information in order to diagnosis and treat the client. The difference between the two are that the structured interview is a standardized interview that is used with each client. A semi-structured interview is not so standard. There is an order or a process however each client may not be asked the same questions in the same exact way. Sometimes in an unstructured interview the questions are not already set.

What role does the setting of the interview play in deciding which style of interview is most appropriate? I have experience with interviewing clients in a professional setting and also in a home setting. Based on my experience, the setting plays a crucial role in the behavior of both the client and counselor. When I have met with clients in a more professional or structured setting the interview seemed to be more structured and professional. However, when I was in the client’s home, the behavior was more relaxed and more casual. The interview was dictated by the client’s behavior. If they are more relaxed and more comfortable in their home you unconsciously or at least I did tried to be as light as possible. I could still ask the necessary questions to gather the information it just because in a different approach or manner. It was more in a conversation form. For me, that was harder because I had to pay more close attention and then pulling out the information I needed.  But in that approach, I learned more than I would have if I were in a more professional (office) setting. This sounds contrary to the job of the interviewer and the purpose of the interview, however, according to the clinical interviewing text the interview does not always have to be direct. Indirect interviews are also effective in any setting and at the appropriate situation.

H.G.

The similarities of structured and semi-structured clinical interviews are that both are used to gather information from an individual. Structured interviews are standardized and gather specific information. Whereas a semi-structured interview may have different questions or questions may be asked differently depending on the individual that is being assisted.

The setting of where an interview is to be taken place is extremely important. It is important that a counselor is aware of how their setting must match their interviewing. Counselors must allow individuals to feel comfortable. If a counselor is assisting a child, they may have a setting that has things that may be interesting to children, including books, puzzles, and toys. If a counselor is assisting individuals who may be destructive or who may be affected by different things, they may have an office with little to no distractions or objects. Counselors must have a professional, private setting where individuals may feel comfortable. Depending on what population a counselor is assisting may depend on the setting of the interview or the session. There may also be times that professional have to assist an individual in a setting other than their office setting. Professionals must still maintain professionalism and provide services to individuals.

Chapter 1
Mental Disorders as Discrete Clinical Conditions: Dimensional Versus Categorical Classification

Thomas A. Widiger and Cristina Crego

In DSM-IV, there [was] “no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or from no mental disorder” (American Psychiatric Association [APA], APA, 2000, p. xxxi). This carefully worded disclaimer, however, was somewhat hollow, as it was the case that “DSM-IV [was] a categorical classification that divides mental disorders into types based on criterion sets with defining features” (APA, 2000, p. xxxi). The categorical model of classification is consistent with a medical tradition in which it is believed (and often confirmed in other areas of medicine) that disorders have specific etiologies, pathologies, and treatments (Guze, 1978; Guze & Helzer, 1987; Zachar & Kendler, 2007).

Clinicians, following this lead, diagnosed and conceptualized the conditions presented in DSM-IV-TR as disorders that are qualitatively distinct from normal functioning and from one another. DSM-IV-TR provided diagnostic criterion sets to help guide clinicians toward a purportedly correct diagnosis and an additional supplementary section devoted to differential diagnosis that indicated “how to differentiate [the] disorder from other disorders that have similar presenting characteristics” (APA, 2000, p. 10). The intention of the manual was to help the clinician determine which particular mental disorder provides the best explanation for the symptoms and problems facing the patient. Clinicians devote initial time with a new patient to identify, through differential diagnosis, which specific disorder best explains a patient’s presenting complaints. The assumption is that the person is suffering from a single, distinct clinical condition, caused by a specific pathology for which there will be a specific treatment (Frances, First, & Pincus, 1995).

Authors of the diagnostic manual devote a considerable amount of time writing, revising, and researching diagnostic criteria to improve differential diagnosis. They buttress each disorder’s criterion set, trying to shore up discriminant validity and distinctiveness, following the rubric of Robins and Guze (1970) that the validity of a diagnosis rests in large part on its “delimitation from other disorders” (p. 108). “These criteria should…permit exclusion of borderline cases and doubtful cases (an undiagnosed group) so that the index group may be as homogeneous as possible” (Robins & Guze, 1970, p. 108).

Scientists may devote their careers to attempting to identify the specific etiology, pathology, or treatment for a respective diagnostic category. Under the assumption that the diagnoses do in fact refer to qualitatively distinct conditions, it follows that there should be a specific etiology, pathology, and perhaps even a specific treatment for each respective disorder. The theories, hypotheses, findings, and disputes regarding the specific etiology, pathology, and/or treatment of a respective mental disorder largely inform the respective chapters of professional, graduate, and undergraduate texts on psychopathology, such as this current edition of Adult Psychopathology and Diagnosis.

However, the question of whether mental disorders are, in fact, discrete clinical conditions or arbitrary distinctions along continuous dimensions of functioning has been a long-standing issue (Kendell, 1975) and its significance is escalating with the growing recognition of the limitations of the categorical model (Goldberg, 2015; Hyman, 2010; Stephan et al., 2016; Widiger & Clark, 2000; Widiger & Samuel, 2005). The principal model for the validation of mental disorder diagnostic categories was provided by Robins and Guze (1970), who articulated five fundamental phases: clinical description, laboratory study, delimitation from other disorders, follow-up, and family studies. However, the research that has accumulated to date has not supported the validity of the delimitation of the disorders from one another. “Indeed, in the last 20 years, the categorical approach has been increasingly questioned as evidence has accumulated that the so-called categorical disorders like major depressive disorder and anxiety disorders, and schizophrenia and bipolar disorder seem to merge imperceptibly both into one another and into normality…with no demonstrable natural boundaries” (First, 2003, p. 661). As expressed by the vice chair of DSM-5, “the failure of DSM-III criteria to specifically define individuals with only one disorder served as an alert that the strict neo-Kraepelinian categorical approach to mental disorder diagnoses advocated by Robins and Guze (1970), Spitzer, Endicott, and Robins (1978), and others could have some serious problems” (Regier, 2008, p. xxi). As acknowledged by Kendell and Jablensky (2003), “it is likely that, sooner or later, our existing typology will be abandoned and replaced by a dimensional classification” (p. 8).

In 1999, a DSM-5

Research

Planning Conference was held under joint sponsorship of the APA and the National Institute of Mental Health (NIMH), the purpose of which was to set research priorities that would optimally inform future classifications. One impetus for this effort was the frustration with the existing nomenclature.

In the more than 30 years since the introduction of the Feighner criteria by Robins and Guze, which eventually led to DSM-III, the goal of validating these syndromes and discovering common etiologies has remained elusive. Despite many proposed candidates, not one laboratory marker has been found to be specific in identifying any of the DSM-defined syndromes. Epidemiologic and clinical studies have shown extremely high rates of comorbidities among the disorders, undermining the hypothesis that the syndromes represent distinct etiologies. Furthermore, epidemiologic studies have shown a high degree of short-term diagnostic instability for many disorders. With regard to treatment, lack of treatment specificity is the rule rather than the exception (Kupfer, First, & Regier, 2002, p. xviii).

DSM-5 Research Planning Work Groups were formed to develop white papers that would set an effective research agenda for the next edition of the diagnostic manual. The Nomenclature Work Group, charged with addressing fundamental assumptions of the diagnostic system, concluded that it will be “important that consideration be given to advantages and disadvantages of basing part or all of DSM-V on dimensions rather than categories” (Rounsaville et al., 2002, p. 12).

The white papers developed by the DSM-5 Research Planning Work Groups were followed by a series of international conferences whose purpose was to further enrich the empirical database in preparation for the eventual development of DSM-5 (a description of this conference series can be found at 

www.dsm5.org

). The first conference was devoted to shifting personality disorders to a dimensional model of classification (Widiger, Simonsen, Krueger, Livesley, & Verheul, 2005). The final conference was devoted to dimensional approaches across the diagnostic manual, including substance use disorders, major depressive disorder, psychoses, anxiety disorders, and developmental psychopathology, as well as the personality disorders (Helzer et al., 2008a).

Nevertheless, despite all this preparatory work toward a shift to a dimensional classification, DSM-5 retained the categorical model for all its diagnoses. The apparent failure of the categorical model of classification was at least duly noted within the introduction to DSM-5. “The historical aspiration of achieving diagnostic homogeneity by progressively subtyping within disorder categories is no longer sensible; like most common human ills, mental disorders are heterogeneous at many levels, ranging from genetic risk factors to symptoms” (APA, 2013, p. 12). The authors of DSM-5 further suggested that “dimensional approaches to diagnosis…will likely supplement or supersede current categorical approaches in the coming years” (APA, 2013, 13).

The purpose of this chapter is to review the DSM-IV-TR and DSM-5 categorical diagnostic approach. The chapter begins with a discussion of the problematic boundaries among the DSM-IV-TR and DSM-5 categorical diagnoses. We then focus in particular on depression, alcohol abuse and dependence, personality disorders, and intellectual disability. We conclude with a discussion of the shifts within DSM-5 toward a dimensional classification.

Diagnostic Boundaries

In an effort to force differential diagnosis, a majority of diagnoses in DSM-III (APA, 1980) contained exclusionary criteria specifying that a respective disorder could not be diagnosed if it occurred in the presence of another disorder. These exclusions by fiat did not prove to be effective (Boyd et al., 1984) and many were deleted in DSM-III-R (APA, 1987). As expressed at the time by Maser and Cloninger (1990), “it is clear that the classic Kraepelinian model in which all psychopathology is comprised of discrete and mutually exclusive diseases must be modified or rejected” (p. 12).

Many DSM-5 diagnostic criterion sets, however, continue to include exclusionary criteria that attempt to force clinicians to make largely arbitrary choices among alternative diagnoses (APA, 2013), and it is also evident that there will likely continue to be a highly problematic rate of diagnostic co-occurrence (Krueger & Markon, 2006; Maser & Patterson, 2002; Widiger & Clark, 2000). The term comorbidity refers to the co-occurrence of distinct disorders, apparently interacting with one another, each presumably with its own independent etiology, pathology, and treatment implications (Feinstein, 1970). If one considers the entire diagnostic manual (which has not yet been done by any epidemiological study), it would likely be exceedingly rare for any patient to meet the criteria for just one disorder, and the comorbidity rises even further if one considers lifetime co-occurrence. Brown, Campbell, Lehman, Grisham, and Mancill (2001), for instance, reported that 95% of individuals in a clinical setting who meet criteria for lifetime major depression or dysthymia also meet criteria for a current or past anxiety disorder. Comorbidity is the norm rather than the exception (Brown & Barlow, 2009; Friborg, Martinussen, Kaiser, Øvergård, & Rosenvinge, 2013; Friborg et al., 2014; Kessler, Chiu, Demler, & Walters, 2005; Kotov, Perlman, Gámez, & Watson, 2015). The excessive comorbidity across the APA diagnostic manual may be saying more about the invalidity of existing diagnostic distinctions than the presence of multiple coexisting conditions (Krueger, 2002; Widiger & Edmundson, 2011).

Diagnostic comorbidity has become so prevalent that some researchers have argued for an abandonment of the term comorbidity in favor of a term (e.g., co-occurrence) that does not imply the presence of distinct clinical entities (Lilienfeld, Waldman, & Israel, 1994). There are instances in which the presence of multiple diagnoses suggests the presence of distinct yet comorbid psychopathologies, but in most instances the presence of co-occurring diagnoses does appear to suggest a common, shared pathology and, therefore, a failing of the current diagnostic system (Krueger & Markon, 2006; Widiger & Clark, 2000). “Comorbidity may be trying to show us that many current treatments are not so much treatments for transient ‘state’ mental disorders of affect and anxiety as they are treatments for core processes, such as negative affectivity, that span normal and abnormal variation as well as undergird multiple mental disorders” (Krueger, 2002, p. 44).

Diagnostic criteria have traditionally been developed and subsequently modified in order to construct a disorder that is as homogeneous as possible, thereby facilitating the likelihood of identifying a specific etiology, pathology, and treatment (Robins & Guze, 1970). However, the typical result of this effort is to leave a large number of cases unaccounted for, given that many, if not most patients, have a complex, hetergenous array of symptoms. (Smith & Combs, 2010). New diagnostic categories are added to the nomenclature in large part to decrease clinicians’ reliance on the nonspecific, wastebasket label of “not otherwise specified” (NOS). NOS has been among the most frequent diagnoses within clinical populations (Widiger & Edmundson, 2011). The function of many of the new disorders that have been added to recent editions of the manual have not involved the identification of uniquely new forms of psychopathology. Their purpose was generally instead to fill problematic gaps. Notable examples for DSM-IV included bipolar II (filling a gap between DSM-III-R bipolar and cyclothymic mood disorders), mixed anxiety-depressive disorder (a gap between anxiety and mood disorders), depressive personality disorder (personality and mood disorders), and postpsychotic depressive disorder of schizophrenia (schizophrenia and major depression) (Frances et al., 1995).

When new diagnoses are added to fill gaps, they have the ironic effect of creating additional boundary problems (i.e., more gaps), thereby making differential diagnosis even more problematic (Phillips, Price, Greenburg, & Rasmussen, 2003; Pincus, Frances, Davis, First, & Widiger, 1992; Pincus, McQueen, & Elinson, 2003). One must ask, for instance, whether it is really meaningful or useful to determine whether mixed anxiety-depressive disorder is a mood or an anxiety disorder, whether schizoaffective disorder is a mood disorder or a form of schizophrenia (Craddock & Owen, 2010), whether postpsychotic depressive disorder of schizophrenia is a form of depression or schizophrenia, whether early-onset dysthymia is a mood or a personality disorder (Widiger, 2003), whether acute stress disorder is an anxiety or a dissociative disorder (Cardena, Butler, & Spiegel, 2003), whether hypochondriasis is an anxiety disorder or a somatoform disorder, whether body dysmorphic disorder is an anxiety, eating, or somatoform disorder, and whether generalized social phobia is an anxiety or a personality disorder (Widiger, 2001a). In all these cases the most accurate answer is likely to be that each respective disorder includes features of different sections of the diagnostic manual. Yet the arbitrary and procrustean decision of which single section of the manual in which to place each diagnosis must be made by the authors of a categorical diagnostic manual, and a considerable amount of effort and research are conducted to guide this decision, followed by further discussion and research to refute and debate whatever particular categorical decision was made.

There are comparable examples of what might be arbitrary splitting of categories in DSM-5 (APA, 2013). DSM-5 split out from reactive attachment disorder a new diagnosis of disinhibited social engagement disorder. Binge eating disorder (which was originally included within the diagnosis of bulimia nervosa) obtained official recognition. However, for the most part, changes that occurred in DSM-5 were consistent with the intention to shift the manual more closely toward a dimensional model. For example, there are cases in which previously “distinct” diagnoses were lumped together rather than split apart. For example, DSM-5 autism spectrum disorder subsumes within one diagnosis DSM-IV-TR autistic disorder, Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified (Lord & Bishop, 2015). The archaic subtypes of schizophrenia were deleted. “Instead a dimensional approach to rating severity of core symptoms of schizophrenia is included in DSM-5 Section III” (APA, 2013, p. 810). The problematic categorical distinction of substance abuse versus dependence was replaced by a level of severity, from mild, moderate, to severe, based simply on the number of diagnostic criteria. Included in Section III of DSM-5 is a proposed dimensional trait model that would subsume all of the existing personality disorder categories.

Depression

Mood disorders is a section of the APA diagnostic manual for which the presence of qualitatively distinct conditions is particularly difficult to defend, especially for the primary diagnoses of dysthymia and major depressive disorder (Brown & Barlow, 2009). Discussed here will be early-onset dysthymia, the continuum of depression, and subthreshold major depression, along with more general points concerning the boundary between mood and personality disorder.

There is no meaningful distinction between early-onset dysthymia, an officially recognized mood disorder diagnosis, and depressive personality disorder, a diagnosis proposed for DSM-IV but included within its appendix (APA, 2000). In fact, much of the empirical and conceptual basis for adding dysthymia to the DSM-III (i.e., Keller, 1989) came from research and clinical literature concerning depressive personality. As acknowledged by the principal architects of DSM-III, dysthymia is “roughly equivalent to the concept of depressive personality” (Spitzer, Williams, & Skodol, 1980, p. 159). Depressive personality disorder was included within the mood disorders section of DSM-III despite the recommendations to recognize its existence as a disorder of personality (Klerman, Endicott, Spitzer, & Hirschfeld, 1979), because it resembled the symptomatology of other mood disorders (i.e., depressed mood) more than it resembled the symptoms of other personality disorders (e.g., schizoid). However, whereas mood disorders are defined largely by similarity in content (i.e., mood being the predominant feature; APA, 2013), the personality disorders are defined largely by form (i.e., early onset, pervasive, and chronic) often with quite different content (e.g., schizoid personality disorder has little resemblance to histrionic personality disorder).

After DSM-III was published, it became evident that many of the persons who were consistently and characteristically pessimistic, gloomy, cheerless, glum, and sullen (i.e., dysthymic) had been that way since childhood and that in many cases no apparent or distinct age of onset could be established. In other words, its conceptualization as a personality disorder became apparent. DSM-III-R, therefore, added an early-onset subtype (APA, 1987) and acknowledged that “this disorder usually begins in childhood, adolescence, or early adult life, and for this reason has often been referred to as a Depressive Personality” (APA, 1987, p. 231).

Personality disorder researchers proposed again for DSM-IV to include a depressive personality disorder diagnosis. They were told that in order for it to be included, it would need to be distinguished from the already established diagnosis of early-onset dysthymia, a task that might be considered rather difficult, if not unfair, given that the construction of dysthymia had been based in large part on the research and literature concerning depressive personality (Keller, 1989). Nevertheless, the DSM-IV

Personality Disorders

Work Group developed a proposed diagnostic criterion set that placed relatively more emphasis on cognitive features not currently included within the criterion set for dysthymia (including early-onset), as well as excluding somatic features (Task Force on DSM-IV, 1991). This criterion set was provided to the DSM-IV Mood Disorders Work Group to include within their DSM-IV field trial to determine empirically whether it was indeed possible to demarcate an area of functioning not yet covered by early-onset dysthymia, or at least identify persons not yet meeting diagnostic criteria for early-onset dysthymia.

The proposed criterion set was successful in reaching this goal (Phillips et al., 1998), which, perhaps, should not be surprising because no criterion set for a categorical diagnosis appears to be entirely successful in covering all cases. However, the Mood Disorders Work Group was equally impressed with the potential utility of the depressive personality diagnostic criteria for further describing and expanding the coverage of dysthymia (Keller et al., 1995) and, therefore, incorporated much of the proposed criteria for depressive personality into their proposed revisions for dysthymia, including early-onset dysthymia (Task Force on DSM-IV, 1993). The DSM-IV Task Force recognized that it might be problematic to now require the personality disorder researchers to further redefine depressive personality to distinguish it from this new version of dysthymia. Therefore, the DSM-IV Task Force decided instead to include both criterion sets in the appendix to DSM-IV (along with the original criterion set for dysthymia within the mood disorders section), with the acknowledgment that there may not be any meaningful distinction between them (APA, 1994; Frances et al., 1995). However, depressive personality disorder was not even included within the appendix for DSM-5, in large part because the DSM-5 Personality and Personality Disorders Work Group was not interested in adding any new categorical diagnoses to the manual (Skodol, 2012). Nevertheless, included within DSM-5 Section III, for emerging measures and models, is a five-domain, 25-trait, dimensional model of personality disorder, which includes the personality trait of “depressivity” that would likely be very difficult to distinguish from an early onset dysthymia.

The Continuum of Depression

The common view is that many instances of sadness (or even depression) do not constitute a mental disorder. Persons can be very sad without having a mental disorder (Horwitz & Wakefield, 2007). However, a simple inspection of the diagnostic criteria for major depressive disorder would not lend confidence to a conceptualization of this condition as being qualitatively distinct from “normal” depression or sadness (Andrews et al., 2008). Persons who are just very sad will have the same symptoms of a major depressive disorder but just at a lesser degree of severity. Persons who are very sad will have a depressed mood, decreased interest in pleasurable activities, appetite change, decreased energy, and lower self-esteem. Each of the diagnostic criteria for a major depressive disorder is readily placed along a continuum of severity that would shade imperceptibly into what would be considered a “normal” sadness. DSM-5, therefore, includes specific thresholds for each of them, but they are clearly arbitrary thresholds that simply demarcate a relatively higher level of severity from a lower level of severity (e.g., “nearly every day” or “markedly diminished,” and at least a “2-week” period; APA, 2013, p. 188). The diagnosis requires five of these nine criteria, with no apparent rationale for this threshold other than it would appear to be severe enough to be defensible to be titled as a “major” depressive episode, as distinguished from a “minor” depressive episode, which is then distinguished from “normal” sadness (APA, 2013).

Depression does appear to shade imperceptibly into “normal” sadness (Andrews et al., 2008). Üstün and Sartorius (1995) conducted a study of 5,000 primary-care patients in 14 countries and reported a linear relationship between disability and number of depressive symptoms. Kessler, Zhao, Blazer, and Swartz (1997) examined the distribution of minor and major symptoms of depression using data from the National Comorbidity Survey. They considered the relationship of these symptoms with parental history of mental disorder, number and duration of depressive episodes, and comorbidity with other forms of psychopathology. Respective relationships increased with increasing number of symptoms, with no clear, distinct break. Sakashita, Slade, and Andrews (2007) examined the relationship between the number of symptoms of depression and four measures of impairment using data from the Australian National Survey of Mental Health and Well-Being, and found that the relationship was again simply linear, with no clear or natural discontinuity to support the selection of any particular cutoff point.

Taxometrics refers to a series of related statistical techniques to detect whether a set of items is optimally understood as describing (assessing) a dimensional or a categorical construct (Beauchaine, 2007; Ruscio & Ruscio, 2004). Other statistical techniques, such as cluster or factor analyses, presume that the construct is either categorical or dimensional (respectively) and then determines how best to characterize the variables or items in either a categorical or dimensional format, respectively. Taxometric analyses are uniquely intriguing in providing a direct test of which structural model is most valid in characterizing the set of items or variables.

A number of taxometric studies have been conducted on various symptoms and measures of depression. The first was provided by Ruscio and Ruscio (2000) in their taxometric analyses of items from the Beck Depression Inventory and, independently, items from the Zung Self-Rating Depression Scale in a sample of 996 male veterans who had received a diagnosis of post-traumatic stress disorder but who also had a high prevalence rate of major depressive disorder, as well as a sample of 8,045 individuals from the general population (60% female) who completed the items from the Depression scale of the Minnesota Multiphasic Personality Inventory. They indicated that “results of both studies, drawing on three widely used measures of depression, corroborated the dimensionality of depression” (Ruscio & Ruscio, 2000, p. 473).

The taxometric findings of Ruscio and Ruscio (2000) have been subsequently replicated, including taxometric analyses of: (a) structured interview assessments of DSM-IV-TR major depressive disorder symptoms and, independently, items from the Beck Depression Inventory in a sample of 960 psychiatric outpatients (Slade, 2007); (b) major depressive disorder diagnostic criteria assessed in the 1,933 persons who endorsed at least one criterion in the Australian National Survey of Mental Health and Well-Being (Slade & Andrews, 2005); (c) self- and parent-reported depressive symptoms in 845 children and adolescents drawn from the population-based Georgia Health and Behavior Study (Hankin, Fraley, Lahey, & Waldman, 2005); (d) responses to MMPI-2 depression scales completed by 2,000 psychiatric inpatients and outpatients (Franklin, Strong, & Greene, 2002); (e) epidemiologic survey of depressive symptoms within 392 college students (Baldwin & Shean, 2006); (f) Beck Depression Inventory items reported by 2,260 college students (Ruscio & Ruscio, 2002); and (g) depression items in the Composite International Diagnostic Interview as administered in the National Comorbidity Survey to 4,577 participants who endorsed the item concerning a lifetime occurrence of sad mood or loss of interest (Prisciandoro & Roberts, 2005). However, in contrast to the findings from these eight taxometric studies, three taxometric studies have supported a latent class taxon, including semistructured interview assessments of DSM-IV-TR major depressive disorder symptoms in 1,800 psychiatric outpatients (Ruscio, Zimmerman, McGlinchey, Chelminski, & Young, 2007), interview and self-report assessments of depression in 1,400 high school students (Solomon, Ruscio, Seeley, & Lewinsohn, 2006), and self-report and interview data on depression in 378 adolescents receiving treatment for depression (Ambrosini, Bennett, Cleland, & Haslam, 2002). In sum, the bulk of the evidence does appear to support a dimensional understanding of depression, but there is some ambiguity and inconsistency in the taxometric findings (Beach & Amir, 2003; Beauchaine, 2007; Widiger, 2001b).

Subthreshold Major Depression

Depression is a section of the diagnostic manual that does have considerable difficulty identifying or defining a clear boundary with “normal” sadness. Subthreshold cases of depression (i.e., persons with depressive symptoms below the threshold for a DSM-5 mental disorder diagnosis) are clearly responsive to pharmacologic interventions, do seek treatment for their sadness, and are often being treated within primary care settings (Judd, Schettler, & Akiskal, 2002; Pincus et al., 2003). These facts contributed to the proposal to include within an appendix to DSM-IV a diagnosis of “minor depressive disorder,” which it is acknowledged “can be difficult to distinguish from periods of sadness that are an inherent part of everyday life” (APA, 2000, p. 776).

Wakefield (2016) has been critical of the criteria for major depressive disorder for including an inconsistently applied exclusion criterion. The DSM-IV-TR excluded most instances of depressive reactions to the loss of a loved one (i.e., uncomplicated bereavement). Depression after the loss of a loved one could be considered a mental disorder if “the symptoms persist for longer than 2 months” (APA, 2000, p. 356). Allowing persons just 2 months to grieve before one is diagnosed with a mental disorder does appear to be rather arbitrary. More importantly, it is also unclear if depression in response to other losses should not also then be comparably excluded, such as depression secondary to the loss of a job or physical health (Wakefield, Schimtz, First, & Horwitz, 2007). Why the loss of a person is treated so differently from the loss of health or a job is not clear.

On the other hand, one could argue alternatively that all exclusion criteria should be removed. Perhaps the problem is not that depression in response to a loss of a job or physical disorder should not be a disorder, analogous to bereavement (Wakefield, 2007), but that bereavement should be a mental disorder (Bonanno et al., 2007; Forstmeier & Maercker, 2007; Widiger & Miller, 2008). What is currently considered to be a normal depression in response to the loss of a loved one does often, if not always, include pain and suffering, meaningful impairment to functioning, and is outside of the ability of the bereaved person to fully control, the essential hallmarks of a mental disorder (Widiger & Sankis, 2000). The depression is a reasonable response to the loss of a loved one, a psychological trauma, but many physical disorders and injuries are reasonable and understandable responses to a physical trauma. The loss is perhaps best understood as part of the etiology for the disorder, not a reason for which a disorder is not considered to be present (Widiger, 2012a).

One of the major revisions for DSM-5 was indeed to weaken the distinction between normal bereavement and a mental disorder of depression. DSM-5 no longer excludes the diagnosis of a major depressive disorder if the depression is secondary to the loss of a loved one. “Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability)” (APA, 2013, p. 161) can now all be diagnosed as a mental disorder.

Alcohol Abuse and Dependence

One of the sections of the diagnostic manual for which a categorical model of classification and conceptualization has had a firmly entrenched tradition has been the substance use disorders. Alcoholism, in particular, has long been conceptualized as a qualitatively distinct disease (Garbutt, 2008; Goodwin & Guze, 1996; Nathan, Conrad, & Skinstad, 2016). A significant change to its diagnosis and conceptualization occurred with DSM-III-R (APA, 1987) when it shifted from being understood as a purely physiological dependence to a broader and less specific behavioral dependence (Carroll, Rounsaville, & Bryant, 1994; Edwards & Gross, 1976). “Dependence is seen as a complex process that reflects the central importance of substances in an individual’s life, along with a feeling of compulsion to continue taking the substance and subsequent problems controlling use” (Schuckit et al., 1999, p. 41). To many, though, the diagnosis does still refer to a disease, but one that is developed through a normal social-learning history (Kandel, 1998).

However, the diagnosis has been broadened considerably in DSM-5 wherein it is referred to as a behavioral addiction, and would, therefore, be listed along with pathological gambling (Martin, 2005; Petry, 2006; Potenza, 2006). Pathological gambling has been considered by many substance use and pathological gambling researchers and clinicians to be an addiction, but it could not be included within the substance-related disorders section because it does not involve the ingestion of a substance (Bradford, Geller, Lesieur, Rosenthal, & Wise, 1996). This requirement has been deleted in DSM-5, with the section renamed “substance-related and addictive disorders” (APA, 2013).

This new class of disorders could eventually contain a wide variety of possible behavioral addictions, including an excessive participation in shopping, sex, or the Internet. As stated at one point on the DSM-5 website, along with pathological gambling, “other addiction-like behavioral disorders such as ‘Internet addiction’…will be considered as potential additions to this category as research data accumulate” (APA, 2010, “Substance Related Disorders,” para. 1). The preface to this section of the diagnostic manual explicitly states that Internet, sex, and shopping addictions are not included because there is currently insufficient evidence to support their validity. However, it is apparent that the broadening of the concept of substance dependence to include behavioral forms of addiction will encourage clinicians to diagnose these additional variants. “This ‘slippery slope’ makes it difficult to know where to draw the line demarcating any excessive behavior as an addiction” (Petry, 2005a, p. 7). Provided within an appendix to DSM-5 for conditions needing further study is Internet gaming disorder (i.e., behavioral addiction to Internet games), including its diagnostic criteria, risk factors, prevalence, and differential diagnosis. Proposed for inclusion in the sex disorders section of DSM-5 was hypersexual disorder, which can indeed be identified as a sex addiction (Kafka, 2010; Ragan & Martin, 2000; Winters, 2010).

The distinction between harmful substance use and a substance use disorder is itself unclear and indistinct. Presumably, persons can choose to consume alcohol without being compelled to do so by the presence of a mental disorder. The DSM-5 diagnostic criteria for a substance use disorder are fallible indicators for harmful and dyscontrolled usage (e.g., use more than originally intended, continue to use despite social consequences, and reduction of other activities in preference for the substance; APA, 2013). The more of these indicators of dyscontrol that are present, the more likely it is that there is, in fact, dyscontrol, but none can be considered infallible in the identification of dyscontrol and no particular number of them clearly demarcates a boundary between the presence and absence of dyscontrolled usage. It is not even clear how much purportedly volitional or regulatory control a normal, healthy person has over adaptive, healthy behaviors (Bargh & Ferguson, 2000; Howard & Conway, 1986; Kirsch & Lynn, 2000; Wegner & Wheatley, 2000), let alone the boundary between controlled and dyscontrolled harmful behaviors. Both normal and abnormal human functioning are, at best, the result of a complex interaction of apparent volitional choice with an array of biogenetic and environmental determinants.

The distinction between DSM-IV-TR alcohol abuse and dependence was equally fuzzy. Abuse has generally been considered to be simply a residual category and/or a less severe form of dependence (Saunders, 2006). Some of the diagnostic criteria for abuse were contained with the criterion set for dependence (e.g., interference with social, occupational, or recreational activities), which is always a problem for disorders that would be considered to be qualitatively distinct. It is largely for this reason that the formal distinction between abuse and dependence was abandoned in DSM-5 (APA, 2013).

The diagnostic criteria for alcohol dependence were written largely in an effort to describe a prototypic case of the disorder, a practice that is still followed for all but a few of the disorders throughout DSM-5. However, prototypic cases are typically understood to be the most severe cases and/or the cases that involve all possible features or symptoms of the disorder (First & Westen, 2007). The construction of diagnostic criterion sets in terms of prototypic cases does work to an extent, but it also fails to adequately describe many of the actual cases, including the subthreshold cases, and perhaps even the typical cases, depending upon the distribution of features and symptomatology within the population. Constructing criterion sets in terms of prototypic cases can be comparable to confining the description and diagnosis of (for instance) intellectual disability to the most severe variant, and then attempting to apply this description to mild and moderate variants; a method of diagnosis that would obviously be sorely limited in the description, assessment, and diagnosis of intellectual disability. The limitations of the prototypic case approach are now becoming more closely appreciated in the diagnosis of dyscontrolled substance use and, more specifically, alcohol use disorders, where the existing criterion sets are failing to adequately describe (for instance) dyscontrolled and impairing alcohol usage in adolescents (Crowley, 2006) and other “diagnostic orphans” (Saunders, 2006).

The limitation is perhaps most clearly demonstrated in studies using item response theory (IRT) methodology. IRT allows the researcher to investigate the fidelity with which items are measuring a latent trait along the length of its continuum, contrasting, for instance, the amount of information that different diagnostic criteria provide at different levels of the latent trait (Muthen, 2006). Some diagnostic criteria, for instance, might be most useful in distinguishing among mild cases of the disorder, whereas other diagnostic criteria are most useful in distinguishing among the more severe cases of the disorder. A number of IRT analyses have now been conducted for the diagnosis of substance dependence (and other disorders) and the findings are remarkably consistent (Reise & Waller, 2009). The existing diagnostic criterion sets (and/or symptoms currently assessed in existing instruments) cluster around the high end of the disorder, as opposed to being spread out across the entire range of the continuum (e.g., Kahler & Strong, 2006; Langenbucher et al., 2004; Muthen, 2006; Proudfoot, Baillie, & Teesson, 2006; Saha, Chou, & Grant, 2006). This consistent pattern of results is in stark contrast to what is traditionally found in cognitive ability testing, where IRT analyses have been largely developed and previously applied (Reise & Waller, 2009).

It is evident from the IRT analyses that the existing diagnostic criterion sets are sorely inadequate in characterizing the lower and even middle range of substance use dysfunction, consistent with the DSM-IV-TR and DSM-5 descriptions being confined to a prototypic (most severe) case. If alcohol usage was conceptualized along a continuum, the job of the authors of the diagnostic manual would be to construct a description and measurement of the disorder that adequately represent each of the levels or degrees to which the disorder appears along this continuum, rather than attempting to describe the prototypic case. The DSM-IV-TR criterion set was confined to the most severe cases and was not describing well a large proportion of persons with clinically significant alcohol use dysfunction. As a result, clinicians had to rely on the nondescriptive, wastebasket diagnosis of NOS to describe the lower range of the continuum (Saunders, 2006).

A step in the direction of recognizing the continuous nature of substance use disorder was incorporated in DSM-5. Along with the abandonment of the distinction between abuse and dependence, DSM-5 also includes a rating of severity for a substance use disorder, depending upon the number of diagnostic criteria that are met. For example, a “mild” substance use disorder is suggested by the presence of just two to three features (APA, 2013). However, the features for the mildest and the most severe cases are still the same. What would be more informative would be to have the different levels defined by the features that are relatively specific to that level, analogous to how the comparable distinctions are made between the levels of severity for an intellectual disability.

Personality Disorders

There are three major problematic boundaries for the personality disorders: the boundaries between personality disorders and other mental disorders; the boundaries between personality disorders and normal personality; and the boundaries among the personality disorders. The boundaries with other mental disorders will be discussed first, followed by the other two boundaries.

Boundaries with Other Mental Disorders

Among the proposals considered for the personality disorders at the DSM-5 Research Planning Conference (Kupfer et al., 2002) was the suggestion to replace the diagnosis of personality disorder with early-onset and chronic variants of existing Axis I mental disorders (First et al., 2002). This might appear at first blush to be a radical proposal, and perhaps it is. However, it does have support from a variety of sources.

There is no clear or consistent boundary between the personality disorders and many other mental disorders, particularly the mood, anxiety, impulse dyscontrol, and psychotic disorders (Krueger, 2005). In fact, DSM-5 schizotypal personality disorder has long been classified as a form of schizophrenia rather than as a personality disorder in the World Health Organization’s International Classification of Diseases (ICD-10; WHO, 1992), the parent classification for the APA’s DSM-5. Schizotypal personality disorder is genetically related to schizophrenia, most of its neurobiological risk factors and psychophysiological correlates are shared with schizophrenia (e.g., eye tracking, orienting, startle blink, and neurodevelopmental abnormalities), and the treatments that are effective in ameliorating schizotypal symptoms overlap with treatments used for persons with Axis I schizophrenia (Kwapil & Barrantes-Vidal, 2012).

On the other hand, there are also compelling reasons for continuing to consider schizotypal as a personality disorder (Kwapil & Barrantes-Vidal, 2012; Raine, 2006). Simply because a personality disorder shares a genetic foundation with another disorder does not then indicate that it is a form of that other disorder. Running counter to viewing schizotypal personality disorder as a variant of schizophrenia are the following: the disorder is far more comorbid with other personality disorders than it is with any other schizophrenia-related disorder; persons with schizotypal personality disorder rarely go on to develop schizophrenia; and schizotypal symptomatology is seen in quite a number of persons within the general population who lack any genetic association with schizophrenia and who would not be appropriately described as having some form of schizophrenia (Raine, 2006).

However, a fate similar to that of schizotypal personality disorder in ICD-10 (WHO, 1992) and depressive personality disorder in DSM-IV (APA, 1994) could await the other personality disorder diagnostic categories in a future edition of the diagnostic manual (First et al., 2002). For example, social phobia was a new addition to DSM-III (Spitzer et al., 1980; Turner & Beidel, 1989). It was considered then to be a distinct, circumscribed condition, consistent with the definition of a phobia as a “persistent, irrational fear of a specific object, activity, or situation” (APA, 1994, p. 336, our emphasis). However, it became apparent to anxiety disorder researchers and clinicians that the fears of many of their patients were rarely so discrete and circumscribed (Spitzer & Williams, 1985). Therefore, the authors of DSM-III-R developed a generalized subtype for when “the phobic situation includes most social situations” (APA, 1987, p. 243). DSM-III-R generalized social phobia, however, overlapped substantially with the DSM-III diagnosis of avoidant personality disorder. Both were concerned with a pervasive, generalized social insecurity, discomfort, and timidity. Efforts to distinguish them have indicated only that avoidant personality disorder tends to be, on average, relatively more dysfunctional than generalized social phobia (Sanislow, da Cruz, Gianoli, & Reagan, 2012; Turner, Beidel, & Townsley, 1992).

DSM-IV provided no solution. In fact, it was acknowledged that generalized social phobia emerged “out of a childhood history of social inhibition or shyness” (APA, 1994, p. 414), consistent with the fundamental definition of a personality disorder. An argument raised for classifying this condition as an anxiety disorder rather than a personality disorder was that many persons with the disorder benefit from pharmacologic interventions (Liebowitz, 1992). “One may have to rethink what the personality disorder concept means in an instance where 6 weeks of phenelzine therapy begins to reverse long-standing interpersonal hypersensitivity as well as discomfort in socializing” (Liebowitz, 1992, p. 251). Of course, one might also have to rethink what the anxiety disorder concept means when an antidepressant is an effective form of treating an anxiety disorder. In addition, it is unclear why a maladaptive personality trait should not be responsive to a pharmacologic intervention (Knorr & Kessing, 2010; Knutson et al., 1998; Tang et al., 2009). In any case, the authors of DSM-IV-TR concluded that these two conditions “may be alternative conceptualizations of the same or similar conditions” (APA, 2000, p. 720).

There does not currently appear to be a meaningful distinction between avoidant personality disorder and generalized social phobia (APA, 2000; Sanislow et al., 2012; Tyrer, 2005; Widiger, 2003). Some suggest that the best solution is to simply abandon the personality disorder diagnosis in favor of the generalized anxiety disorder (First et al., 2002; Schneider, Blanco, Anita, & Liebowitz, 2002). “We believe that the more extensive evidence for syndromal validity of social phobia, including pharmacological and cognitive-behavioral treatment efficacy, make it the more useful designation in cases of overlap with avoidant personality” (Liebowitz et al., 1998, p. 1060). The reference to treatment efficacy by Liebowitz et al. (1998) falls on receptive ears for many clinicians who struggle to obtain insurance coverage for the treatment of maladaptive personality functioning. It is often reported that a personality disorder diagnosis is stigmatizing, due in large part to its placement on a distinct axis that carries the implication of being an untreatable, lifetime disorder (Frances et al., 1991; Kendell, 1983). For reasons such as these, the Assembly of the APA (which has authoritative governance over the approval of revisions to the diagnostic manual) has repeatedly passed resolutions to explore proposals to move one or more personality disorders to Axis I, in large part to address the stigma and lack of reimbursement for their treatment. This proposal is now moot, given the abandonment of the multiaxial system in DSM-5 (APA, 2013).

Future proposals of the Assembly, though, might now take the form of shifting individual personality disorders into a respective mood, anxiety, or impulse dyscontrol disorder as an early-onset, chronic variant. Just as the depressive, schizotypal, and avoidant personality disorders could be subsumed within an existing section of Axis I, borderline personality disorder could be reclassified as a mood dysregulation and/or impulse dyscontrol disorder; obsessive-compulsive personality disorder could be reclassified as a generalized and chronic variant of obsessive-compulsive anxiety disorder (although there is, in fact, only weak evidence to support a close relationship between the obsessive-compulsive anxiety and personality disorders; Samuels & Costa, 2012); and antisocial personality disorder could be reclassified as an adult variant of conduct (disruptive behavior) disorder. In DSM-5, schizotypal personality disorder is cross-listed within the schizophrenia spectrum section, and antisocial is cross-listed within the disruptive behavior disorders section (APA, 2013).

In sum, the future for many of the personality disorder diagnostic categories might be reformulations as early-onset chronic variants of existing Axis I disorders, as explicitly proposed at the initial DSM-5 Research Planning Conference (First et al., 2002). A difficulty for any such proposal, beyond the fundamental concern that the diagnostic manual would no longer recognize the existence of maladaptive personality functioning, is that it might just create more problems than it solves (Widiger, 2003). It is well established that persons have constellations of maladaptive personality traits that have significant consequential life outcomes (Ozer & Benet-Martinez, 2006; Roberts & DelVecchio, 2000). These personality traits are not currently well described by just one or even multiple personality disorder diagnoses (Clark, 2007; Trull & Durrett, 2005; Widiger, 2012b) and will be described even less well by multiple diagnoses across the broad classes of mood, anxiety, impulse dyscontrol, psychotic, and disruptive behavior disorders.

Boundaries with Other Personality Disorders and Normal Personality

Rounsaville et al. (2002) suggested that the first section of the diagnostic manual to shift to a dimensional classification should be the personality disorders. The personality disorders have been among the most problematic of disorders to be diagnosed categorically (First et al., 2002; Kendell, 1989). It is the norm for patients to meet diagnostic criteria for more than one personality disorder (Clark, 2007; Lilienfeld et al., 1994; Livesley, 2003; Trull & Durrett, 2005). Excessive diagnostic co-occurrence was, in fact, the primary reason that five of the 10 personality disorder diagnoses were proposed for deletion in DSM-5 (Skodol, 2012). The excessive co-occurrence may be the result of the nature of the construct of personality. For instance, it is perhaps self-evident that persons are not well described by just one trait term (e.g., introverted). Each person has instead a constellation of personality traits, many of which are adaptive, and some of which may also be maladaptive. There is little reason to think that it would be different when a person is said to have a personality disorder (Widiger & Trull, 2007).

There also appears to be no clear or distinct boundary between normal and abnormal personality functioning. The DSM-IV-TR diagnostic thresholds were not set at a point that has any theoretical or clinical significance. They were arbitrarily set at half or one more than half of the diagnostic criteria (APA, 2000). In fact, all the personality disorders are readily understood as extreme and/or maladaptive variants of normal personality traits distributed within the general population; more specifically, the domains and facets of the five-factor dimensional model (FFM) of general personality structure (Widiger, Samuel, Mullins-Sweatt, Gore, & Crego, 2012; Widiger & Trull, 2007).

The FFM consists of five broad domains of general personality functioning: neuroticism (or emotional instability), extraversion versus introversion, openness versus closedness, agreeableness versus antagonism, and conscientiousness versus undependability. Studies have now well documented that all of the DSM-IV-TR personality disorder symptomatology is readily understood as maladaptive variants of the domains and facets of the FFM (O’Connor, 2002, 2005; Samuel & Widiger, 2008; Saulsman & Page, 2004; Widiger & Costa, 2002; Widiger et al., 2012). Saulsman and Page (2004) concluded on the basis of their meta-analytic review of the FFM-personality disorder research that “each of the personality disorders shows associations with the five-factor model that are meaningful and predictable given their diagnostic criteria” (p. 1075). As acknowledged by Livesley (2001b), “all categorical diagnoses of DSM can be accommodated within the five-factor framework” (p. 24). As expressed by Clark (2007), “the five-factor model of personality is widely accepted as representing the higher-order structure of both normal and abnormal personality traits” (p. 246). The problematic diagnostic co-occurrence among the DSM-IV-TR personality disorders is well explained by the extent to which each of the personality disorders shares traits of the FFM (Lynam & Widiger, 2001; O’Connor, 2005).

A team of researchers are now working together to develop a Hiearchical Taxonomy of Psychopathology (HiTOP) as an alternative to the existing categorical nomenclature (Kotov et al., 2017). The HiTOP model includes two broad domains of externalizing dysfunction and emotional dysregulation that cut across the mood, anxiety, substance use, psychotic, and personality disorders. At the five-domain level are maladaptive personality traits (i.e., internalizing, thought disorder, misconduct, antagonism, and detachment) which are said to align with the FFM of general personality structure (Kotov et al., 2017).

Proposed for DSM-5 was another five-domain, 25-trait dimensional model that represented “maladaptive variants of the five domains of the extensively validated and replicated personality model known as the ‘Big Five,’ or the Five Factor Model of personality” (APA, 2013, p. 773). These five domains are negative affectivity (FFM neuroticism), detachment (FFM introversion), psychoticism (FFM openness), antagonism (FFM antagonism), and disinhibition (low FFM conscientiousness) (Krueger, Derringer, Markon, Watson, & Skodol, 2012). The DSM-5 dimensional trait model does differ in important ways from the FFM; more specifically, it is confined to maladaptive personality functioning and it is unipolar in structure (e.g., it does not recognize any maladaptive variants of extraversion that is opposite to detachment, or agreeableness that is opposite to antagonism). Nevertheless, there is strong conceptual and empirical support for its alignment with the five domains of the FFM (APA, 2013; De Fruyt, De Clerq, De Bolle, Markon, & Krueger, 2013; Gore & Widiger, 2013; Krueger & Markon, 2014; Thomas et al., 2013).

The FFM of personality disorder has a number of advantages over the existing categorical approach (Widiger et al., 2012). It would help with the stigmatization of a personality disorder diagnosis because no longer would a personality disorder be conceptualized as something that is qualitatively distinct from general personality traits. All persons vary in the extent of their neuroticism, the extent to which they are agreeable versus antagonistic, and the extent to which they are conscientious, impulsive, and/or undependable (McCrae & Costa, 2003). The FFM of personality disorder provides not only a more precise description of each person’s individual personality structure but also a more complete picture through the inclusion of normal, adaptive traits, recognizing thereby that a person is more than just the personality disorder and that there are aspects to the self that can be adaptive, even commendable, despite the presence of the maladaptive personality traits. Some of the personality strengths may also be quite relevant to treatment, such as openness to experience, indicating an interest in exploratory psychotherapy; agreeableness, indicating an engagement in group therapy; and conscientiousness, indicating a willingness and ability to adhere to the demands and rigor of dialectical behavior therapy (Sanderson & Clarkin, 2002). The FFM of personality disorder would also bring to the psychiatric nomenclature a wealth of knowledge concerning the origins, childhood antecedents, stability, and universality of the dispositions that are known with respect to the FFM (Widiger et al., 2012; Widiger & Trull, 2007).

The Nomenclature Work Group at the initial DSM-5 Research Planning Conference called for the replacement of the DSM-IV-TR diagnostic categories by a dimensional model (Rounsaville et al., 2002). “If a dimensional system of personality performs well and is acceptable to clinicians, it might then be appropriate to explore dimensional approaches in other domains” (Rounsaville et al., 2002, p. 13). A subsequent APA DSM-5 preparatory conference was devoted to making this shift, providing its extensive empirical support (Widiger et al., 2005). The proposal of the DSM-5 Personality and Personality Disorders Work Group, however, was more conservative. The initial proposal was not to replace the diagnostic categories with a dimensional trait model. It was only to provide a dimensional trait model as a supplement for the existing diagnostic categories to be used when the patient failed to meet the diagnostic criteria for a respective personality disorder category (Skodol, 2012). In the final version of the proposal, six diagnostic categories remained. The only time in which a clinician would describe a patient in terms of the five trait domains would be when the patient failed to meet the criteria for one of the six traditional syndromes. Traits from the dimensional model were now included with the diagnostic criterion sets of these categories, but they were not even considered to be sufficient for the diagnosis. Also included were deficits in the sense of self and interpersonal relatedness obtained from psychodynamic literature that were considered to be independent of maladaptive personality traits (Skodol, 2012).

The proposal was ultimately rejected, largely because of inadequate empirical support (Skodol, Morey, Bender, & Oldham, 2013). The initial dimensional trait proposal had been created de novo by work group members, thereby lacking a strong empirical foundation. In addition, rather than closely tying the proposal to the well-validated FFM, the authors explicitly distanced the proposal from the FFM (i.e., Clark & Krueger, 2010). In the last year of the proposal it was more closely tied to the FFM (APA, 2012) but the DSM-5 Scientific Review Committee was not provided with the FFM-personality disorder research (Widiger, 2013). By then strong opposition to the proposal had also accumulated (e.g., Clarkin & Huprich, 2011; Gunderson, 2010; Shedler et al., 2010). Further, the dimensional trait model was structurally embedded within a much more extensive and complex proposal that included the additional features of self pathology derived from psychodynamic theory and research (Skodol, 2012). Nevertheless, the proposal was at least included in Section III of DSM-5 for emerging measures and models as an alternative to the DSM-5 diagnostic categories that were equivalent to the DSM-IV-TR syndromes, carried over without any revision.

A more radical proposal has been made for the 11th edition of the WHO International Classification of Diseases, in which all of the current ICD-10 personality syndromes (comparable to the DSM-IV and DSM-5 syndromes) would be replaced with five broad domains of maladaptive personality traits: negative affective, detachment, dissocial, disinhibition, and anankastic. These traits are also said to be aligned with the FFM: “Negative Affective with neuroticism, Detachment with low extraversion, Dissocial with low agreeableness, Disinhibited with low conscientiousness and Anankastic with high conscientiousness” (Mulder, Horwood, Tyrer, Carter, & Joyce, 2016, p. 85). Most importantly, “the proposed ICD-11 classification abolishes all type-specific categories of personality disorder” (Tyrer et al., 2015, p. 721). In this regard, the ICD-11 proposal may indeed represent a paradigm shift in how personality disorders are conceptualized and diagnosed within the next edition of the ICD (Tyrer, 2014). This ICD-11 proposal may, of course, meet the same fate as the DSM-5 proposal.

Intellectual Disability

Rounsaville et al. (2002) and others suggested that the personality disorders section should be the first to shift toward a dimensional classification, apparently not fully appreciating that one section has long been dimensional: intellectual disability (previously called mental retardation). Many persons write as if a shift to a dimensional classification represents a new, fundamental change to the diagnostic manual (e.g., Regier, 2008). For much of the manual such a shift would certainly represent a fundamental change in how mental disorders are conceptualized and classified (Guze, 1978; Guze & Helzer, 1987; Robins & Guze, 1970). Nevertheless, there is a clear precedent for a dimensional classification of psychopathology already included within DSM-5: the diagnosis of intellectual disability (APA, 2013).

Intellectual disability in DSM-5 is diagnosed along a continuum of cognitive and social functioning—more precisely, deficits in adaptive functioning and intellectual functions confirmed by standardized intelligence testing. This typically translates to an intelligence quotient (IQ) score of 70 ± 5 (APA, 2013). An IQ of 70 does not carve nature at a discrete joint or identify the presence of a qualitatively distinct condition, disease, or disorder. On the contrary, it is a quantitative cutoff point along the dimension of intelligence. An IQ of 70 is simply two standard deviations below the mean (American Association of Mental Retardation [AAMR], AAMR, 2002).

Intelligence involves the ability to reason, plan, solve problems, think abstractly, comprehend complex ideas, learn quickly, and learn from experience (AAMR, 2002). Intelligence, like personality, is distributed as a hierarchical, multifactorial continuous variable. Most persons’ levels of intelligence, including most of those with an intellectual disability, are the result of a complex interaction of multiple genetic, fetal, and infant development, and environmental influences (Deary, Spinath, & Bates, 2006). There are no discrete breaks in its distribution that would provide an absolute distinction between normal and abnormal intelligence. The point of demarcation for the diagnosis of an intellectual disability is an arbitrary, quantitative distinction along the normally distributed levels of hierarchically and multifactorially defined intelligence. This point of demarcation is arbitrary in the sense that it does not carve nature at a discrete joint, but it was not, of course, randomly or mindlessly chosen. It is a defensible selection that was informed by the impairments in adaptive functioning commonly associated with an IQ of 70 or below (AAMR, 2002). For example, a previous cutoff point of an IQ of 79 identified too many persons who were in fact able to function independently.

In addition, the disorder of intellectual disability is not diagnosed simply on the basis of an IQ of 70 or below (an IQ score is not even necessarily required in DSM-5; APA, 2013). It must be accompanied by a documented impairment to functioning. “Mental retardation is a disability characterized by significant limitation in both intellectual functioning and in adaptive behavior as expressed in conceptual, social and practical adaptive skills” (AAMR, 2002, p. 23). Persons with IQ scores lower than 70 who can function effectively would not be diagnosed with the disorder (APA, 2013). The diagnosis is understood in the context of the social and practical requirements of everyday functioning that must be met by the person (Luckasson & Reeve, 2001). The purpose of the diagnosis is not to suggest that a specific pathology is present, but to identify persons who, on the basis of their intellectual disability, would be eligible for public health care services and benefits to help them overcome or compensate for their relatively lower levels of intelligence.

Many instances of intellectual disability are due in large part to specific etiologies, such as tuberous sclerosis, microcephaly, von Recklinghausen’s disease, trisomy 21, mosaicism, Prader–Willi syndrome, and many, many more (Kendell & Jablensky, 2003). Nevertheless, the disorders that result from these specific etiologies are generally understood as medical conditions, an associated feature of which is also the intellectual disability that would be diagnosed concurrently and independently. The intellectual disability that is diagnosed as a mental disorder within DSM-5 is itself a multifactorially determined and heterogeneous dimensional construct falling along the broad continuum of intellectual functioning. “The causes of intellectual disabilities are typically complex interactions of biological, behavioral/psychological, and sociocultural factors” (Naglieri, Salter, & Rojahn, 2008, p. 409). An important postnatal cause for intellectual disability is “simply” psychosocial deprivation, resulting from poverty, chaotic living environment, and/or child abuse or neglect. No clear etiology will be evident in up to 40% of cases. In sum, intellectual disability may serve as an effective model for the classification of the rest of the diagnostic manual, including mood, psychotic, personality, anxiety, and other mental disorders.

DSM-5 and Dimensional Classification

The modern effort to demarcate a taxonomy of distinct clinical conditions is often traced to Kraepelin (1917). Kraepelin (1917), however, had himself acknowledged that “wherever we try to mark out the frontier between mental health and disease, we find a neutral territory, in which the imperceptible change from the realm of normal life to that of obvious derangement takes place” (p. 295). The Robins and Guze (1970) paradigm for the validation of categorical diagnosis has also been widely influential within psychiatry (Klerman, 1983; Kupfer et al., 2002). In 1989, L. Robins and Barrett (1989) edited a text in honor of this classic paper. Kendell (1989) provided the final word in his closing chapter. His conclusions, however, were curiously negative. “Ninety years have now elapsed since Kraepelin first provided the framework of a plausible classification of mental disorders. Why then, with so many potential validators available, have we made so little progress since that time?” (Kendell, 1989, p. 313). He answered his rhetorical question in the next paragraph: “One important possibility is that the discrete clusters of psychiatric symptoms we are trying to delineate do not actually exist but are as much a mirage as discrete personality types” (Kendell, 1989, p. 313).

It is stated in the preface to DSM-5 that “this edition of DSM was designed first and foremost to be a useful guide to clinical practice” (APA, 2013, p. xii). First (2005) argued, in his rejoinder to a proposal to shift the diagnostic manual into a dimension model, that “the most important obstacle standing in the way of its implementation in DSM-5 (and beyond) is questions about clinical utility” (p. 561). However, one should question whether the existing diagnostic manual in fact has appreciable clinical utility (Mullins-Sweatt & Widiger, 2009). “Apologists for categorical diagnoses argue that the system has clinical utility being easy to use and valuable in formulating cases and planning treatment [but] there is little evidence for these assertions” (Livesley, 2001a, p. 278). First (2005) suggested that “the current categorical system of DSM has clinical utility with regard to the treatment of individuals” (p. 562), yet elsewhere has stated that “with regard to treatment, lack of treatment specificity is the rule rather than the exception” (Kupfer et al., 2002, p. xviii). The heterogeneity of diagnostic membership, the lack of precision in description, the excessive diagnostic co-occurrence, the failure to lead to a specific diagnosis, the reliance on the “not otherwise specified” wastebasket diagnosis, and the unstable and arbitrary diagnostic boundaries of the DSM-IV-TR and DSM-5 categories, are matters of clinical utility that are a source of considerable frustration for clinicians and public health care agencies (Mullins-Sweatt & Widiger, 2009).

The primary goal of the authors of the DSM-5 was to shift the manual toward a dimensional classification (Helzer, Wittchen, Krueger, & Kraemer, 2008b; Regier, Narrow, Kuhl, & Kupfer, 2010). This intention represented an explicit recognition of the failure of the categorical system (Goldberg, 2010, 2015). And the DSM-5 does indeed include a number of clear and potentially significant shifts toward a dimensional classification. The introduction to the manual explicitly acknowledges the failure of the categorical model: “The once plausible goal of identifying homogeneous populations for treatment and research resulted in narrow diagnostic categories that did not capture clinical reality, symptom heterogeneity within disorders, and significant sharing of symptoms across multiple disorders” (APA, 2013, p. 12). Many of the changes that were made to the nomenclature reflected a preference for a more dimensional conceptualization (e.g., the autism spectrum disorder, the conceptualization of a schizophrenia spectrum, the level of severity for substance use disorder, and the reference within the introduction of the manual to the broad dimensions of internalizing and externalizing dysfunction that cut across existing categories). Included in Section III of DSM-5 for emerging models and measures is a five-domain, 25-trait dimensional model of maladaptive personality functioning (Krueger et al., 2011) that is aligned conceptually and empirically with the FFM dimensional model of general personality structure (APA, 2013; De Fruyt et al., 2013; Gore & Widiger, 2013; Thomas et al., 2013). This model is presented as an alternative to the traditional diagnostic categories “to address numerous shortcomings of the current approach” (APA, 2013, p. 761) and its presence within the diagnostic manual will help to stimulate further research as well as increase the familiarity and interest of clinicians with respect to this alternative approach (Widiger, 2013).

Nevertheless, it is also acknowledged that “DSM-5 remains a categorical classification of separate disorders” (APA, 2013, p. xii). The shifts that did occur were frankly tentative, if not timid. “What is being proposed for DSM-V is not to substitute dimensional scales for categorical diagnoses, but to add a dimensional option to the usual categorical diagnoses for DSM-V” (Kraemer, 2008, p. 9). None of the mental disorders, including even the personality disorders, converted to a dimensional classification. There was a shift toward the conceptualization of some disorders as existing along a spectrum (e.g., autism and schizophrenia), and substance use disorder collapsed the problematic distinction between abuse and dependence into one disorder that includes four levels of severity. However, with respect to the latter, there remains no acknowledgement of the continuum into normal substance usage. There will continue to be a reliance on the NOS category to identify subthreshold conditions (the threshold for a substance use diagnosis was, in fact, raised from one criterion to two).

DSM-III is often said to have provided a significant paradigm shift in how psychopathology is diagnosed (Kendell & Jablensky, 2003; Klerman, 1983; Regier, 2008). Much of the credit for the innovative nature and success of DSM-III is due to the foresight, resolve, and perhaps even courage of its Chair, Dr. Robert Spitzer. The primary authors of DSM-5 fully recognized the failure of the categorical model of classification (Kupfer et al., 2002; Regier, 2008; Regier et al., 2010). They had the empirical support and the opportunity to lead the field of psychiatry to a comparably bold new future in diagnosis and classification, but no true paradigm shift in the classification of psychopathology has occurred.

There was never an intention to actually shift the diagnostic manual into a dimensional system. As acknowledged by Helzer, Kraemer, and Krueger (2006), “our proposal [for DSM-5] not only preserves categorical definitions but also does not alter the process by which these definitions would be developed. Those charged with developing criteria for specific mental disorders would operate just as their predecessors have” (p. 1675). In other words, work groups, for the most part, continued to develop diagnostic criteria to describe prototypic cases in a manner that would maximize homogeneity and differential diagnosis (Robins & Guze, 1970; Spitzer et al., 1980), thereby continuing to fail to adequately describe typical cases and again leaving many patients to receive the diagnosis of NOS. Dimensional proposals for DSM-5 were only to develop “supplementary dimensional approaches to the categorical definitions that would also relate back to the categorical definitions” (Helzer et al., 2008b, p. 116). It was the intention for these dimensions to serve only as ancillary descriptions that lacked any official representation within a patient’s medical record. They have no official alphanumerical code and may then not even be communicated to any public health care agency.

Kraemer, Noda, and O’Hara (2004) argued that in psychiatry “a categorical diagnosis is necessary” (p. 21). “Clinicians who must decide whether to treat or not treat a patient, to hospitalize or not, to treat a patient with a drug or with psychotherapy, or what type, must inevitably use a categorical approach to diagnosis” (Kraemer et al., 2004, p. 12). This is a not uncommon perception, but it is not an accurate characterization of actual clinical practice (Mullins-Sweatt & Widiger, 2009). In many common clinical situations, the decision is not, in fact, black and white. Clinicians and social agencies make decisions with respect to a frequency of therapy sessions, an extent of insurance coverage, a degree of medication dosage, and even degrees of hospitalization (e.g., day hospital, partial hospitalization, residential program, or traditional hospitalization).

It is evident that these different clinical decisions are not well informed by a single, uniform diagnostic threshold. The current diagnostic thresholds are not set at a point that is optimal for any one particular social or clinical decision, and the single diagnostic threshold is used to inform a wide variety of different decisions. A dimensional system has the flexibility to provide different thresholds for different social and clinical decisions and would then be considerably more useful for clinicians and more credible for social agencies than the current system. A flexible (dimensional) classification would be preferable to governmental, social, and professional agencies because it would provide a more reliable, valid, explicitly defined, and tailored means for making each respective social and clinical concern. It is for this reason that the authors of DSM-5 included the supplementary dimensional scales to facilitate particular clinical decisions (e.g., Shear, Bjelland, Beesdo, Gloster, & Wittchen, 2008).

The NIMH has largely rejected DSM-5, indicating that they are no longer interested in funding studies that rely upon this nomenclature. As expressed by the director of the NIMH, “it is critical to realize that we cannot succeed if we use DSM categories” (Insel, 2013). NIMH has developed its own nomenclature, referred to as the Research Domain Criteria (RdoC; Insel, 2009; Sanislow et al., 2010), consisting of five broad areas of research (i.e., negative valence systems, positive valence systems, cognitive systems, systems for social processes, and arousal/modulatory systems) that cut across the existing DSM-5 diagnoses. The RDoC nomenclature is described as dimensional, because it is concerned with underlying mechanisms that are best described in terms of levels or degrees of functioning rather than distinct categories (Cuthbert, 2014). “Each level of analysis needs to be understood across a dimension of function” (Insel, 2013). However, the primary distinction with DSM-5 is that the RDoC system emphasizes a neurobiological model of psychopathology. “Mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior” (Insel, 2013). NIMH is primarily critical of the DSM-5 for deriving its diagnoses on the basis of overt symptoms (Craddock & Owen, 2010; Kapur, Phillips, & Insel, 2012). “Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure” (Insel, 2013). However, it is also unclear if a biological reductionism will be any more successful (Kendler, 2005).

Most (if not all) mental disorders appear to be the result of a complex interaction of an array of interacting biological vulnerabilities and dispositions with a number of significant environmental, psychosocial events that often exert their effects over a progressively developing period of time (Rutter, 2003). The most complete and compelling explanation will not likely be achieved through a biological reductionism because much will be lost by a failure to appreciate that explanation and understanding at the level of behavior and cognition remains fundamentally valid, and necessary (Kendler, 2005). The symptoms and pathologies of mental disorders appear to be highly responsive to a wide variety of neurobiological, interpersonal, cognitive, and other mediating and moderating variables that help to develop, shape, and form a particular individual’s psychopathology profile. This complex etiological history and individual psychopathology profile are unlikely to be well described by single diagnostic categories that attempt to make distinctions at nonexistent discrete joints along the continuous distributions (Widiger & Samuel, 2005). The publication of DSM-III was said to have provided a significant, major advance in the diagnosis and classification of psychopathology (Klerman, 1983). The APA diagnostic nomenclature, however, is now beset by substantial criticism (Frances, 2013; Greenberg, 2013; Widiger & Crego, 2015), with NIMH openly rejecting it (Insel, 2013). Perhaps it is time for a paradigm shift.

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Chapter 4

Structured and Semistructured Interviews for Differential Diagnosis

: Fundamental Issues, Applications, and Features

Vicie Hurst, Deborah C. Beidel, and Daniel L. Segal

Structured and semistructured interviews were developed to address the difficulties that clinicians and researchers historically have had in making accurate diagnoses of mental disorders with traditional unstructured clinical interviews. A major contributing factor to diagnostic imprecision was the lack of uniformity or standardization of questions asked of respondents in evaluating the nature and extent of their psychiatric symptoms and arriving at a formal diagnosis. Structured and semistructured interviews solve this problem by their very nature, leading to vastly improved diagnostic clarity and precision. This chapter provides a basic introduction to the structured and semistructured interviews used to diagnose psychopathology among adults. We begin by discussing the basic types of structured and semistructured interviews, and this is followed by an exploration of their major features, advantages, and drawbacks. We conclude with a discussion of the most popular multidisorder structured and semistructured interviews that are used to diagnose clinical disorders and personality disorders.

The publication of the fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association [APA], 2013) introduced many changes, especially regarding the classification and organization of many clinical disorders. One major change was the removal of the multiaxial system, which previously denoted an important distinction between clinical disorders and personality disorders on separate diagnostic axes. Notably, no changes were made to the classification and diagnostic criteria for the personality disorders. In this chapter, we describe the changes made to some of the major structured and semistructured interviews, as these measures have been updated to reflect the changes in DSM-5 (APA, 2013).

Basic Issues Regarding Structured and Semistructured Interviews

The most common method used by mental health professionals to evaluate and diagnose their clients is the direct clinical interview (Segal & Hersen, 2010). Such interviews, however, can vary tremendously, especially with regard to the amount of structure that is imposed. Indeed, there are some important differences between less structured interviews and more structured ones. Unstructured clinical interviews are dependent on the clinician’s unique background, knowledge base, theoretical model, and interpersonal style, and thus are highly flexible. Within this unstructured approach, clinicians are entirely responsible for asking whatever questions they decide are necessary to reach a diagnostic conclusion. In fact, any type of question or topic (relevant or not) can be pursued in any way that fits the mood, preferences, training, specific interests, or philosophy of the clinician. One can easily imagine the resulting variability across interviews from one clinician to another. On the other hand, structured interviews conform to a standardized list of questions (including follow-up questions), a uniform sequence of questioning, and systematized ratings of the client’s responses. These questions are designed to measure the specific criteria for many mental disorders as presented in the DSM. These essential elements of structured interviews serve several important purposes, most notably that their use:

· increases coverage of many mental disorders that otherwise might be overlooked;

· enhances the diagnostician’s ability to accurately determine whether particular symptoms are present or absent;

· reduces variability among interviewers, which improves reliability.

These features of structured interviews add much in terms of developing clinical psychology into a true science. For example, structured interviews are subject to evaluation and statistical analysis, and they can be modified and improved, based on the published literature regarding their psychometric properties.

Not all structured interviews are the same. In fact, the term structured interview is broad, and the actual extent of structure provided by an interview varies considerably. Structured interviews can be divided into one of two types: fully structured or semistructured. In a fully structured interview, questions are asked of the respondent verbatim, the wording of probes used to follow up on initial questions is specified, and interviewers are trained not to deviate from this rigid format. In a semistructured interview, although initial questions regarding each symptom are specified and are typically asked verbatim, the interviewer has substantial latitude to follow up on responses. The interviewer can modify or augment the standard inquiries with individualized and contextualized probes to more accurately rate specific symptoms. The extent of structure provided in an interview clearly impacts the amount of clinical experience and judgment that are required to administer the interview appropriately: semistructured interviews require clinically experienced examiners to administer the interview and to make diagnoses, whereas fully structured interviews can be administered by nonclinicians who receive training on the specific instrument. This latter difference makes fully structured interviews popular and economical, especially in large-scale research studies in which accurate diagnoses are essential.

Structured and semistructured interviews assist with the differential diagnosis of all major clinical disorders and personality disorders. Interviews used for psychiatric diagnosis are typically aligned with the DSM system and, therefore, assess the formal diagnostic criteria specified in the manual. However, structured interviews exist beyond those designed for DSM differential diagnosis. Other structured interviews are narrower in focus; for example, to assess a specific problem or form of psychopathology in great depth (e.g., eating disorders, substance abuse, borderline personality disorder features). An excellent resource for information on a host of specialized interviews is provided by Rogers (2001). Our focus now turns to a discussion of some common functions of structured and semistructured interviews.

Applications of Structured and Semistructured Interviews

Whereas structured and semistructured interviews are used in many different venues and for many different purposes, their application falls into three broad areas: research, clinical practice, and clinical training.

Research

The research domain is the most common application, whereby structured or semistructured interviews are used to formally diagnose participants for inclusion into a study so that etiology, comorbidity, and treatment approaches (among other topics) can be explored for a diagnosis or group of diagnoses. Sound empirical research on mental disorders certainly requires that individuals assigned a diagnosis truly meet full criteria for that diagnosis. Another research application for structured interviews is to provide a standardized method for assessing change in one’s clinical status over time. As noted by Rogers (2003), these types of longitudinal comparison are essential for establishing outcome criteria, which is vital to diagnostic validity.

Clinical Practice

In clinical settings, administration of a structured or semistructured interview may be used as part of a comprehensive and standardized intake evaluation. Routine and complete administration of a structured interview is increasingly common in psychology training clinics, but doing so requires considerable training for clinicians and time for full administration. A variation on this theme is that sections of a structured interview may be administered subsequent to a traditional unstructured interview to clarify and confirm the diagnostic impressions. Widiger and Samuel (2005) provide another thoughtful alternative, especially regarding the assessment of personality disorders in clinical practice. They recommend the strategy of administering an objective self-report inventory, which is followed by a semistructured interview that focuses on the personality disorders that received elevated scores from the testing. This strategy is responsive to time constraints in clinical practice but also allows for collection of standardized, systematic, and objective data from the structured interview. Finally, we wish to emphasize that in clinical settings, structured interviews should not take the place of traditional clinical interviews. Both can be performed, although at various times and for different purposes. The combination of the two approaches, integrated flexibly to meet the needs of individual clinicians and their clients, reflects the best of the scientist–practitioner model, in which the science and art of assessment are both valued and valuable (Rogers, 2003).

Clinical Training

Use of structured or semistructured interviews for training mental health professionals is an increasingly popular and ideal application, because interviewers can learn (through repeated administrations) specific questions and follow-up probes used to elicit information and evaluate specific diagnostic criteria provided by the DSM. Modeling the questions, sequence, and flow from a structured interview can be an invaluable source of training for beginning clinicians.

Advantages and Disadvantages of Structured and Semistructured Interviews

No assessment device in the mental health field is perfect, and structured and semistructured interviews are no exception. In this section, the strengths and weaknesses of structured interviews are discussed. Our intention is to give readers an appreciation of the key issues to be considered when deciding whether to use the structured interview approach to assessment. A summary of the advantages and disadvantages is presented in 

Table 4.1

.

Table 4.1

 Advantages and Disadvantages of Structured and Semistructured Interviews

Advantages

Disadvantages

Increased reliability Because questions are standardized, structured interviews decrease variability among interviewers, which enhances interrater reliability. Structured interviews also increase the reliability of assessment for a client’s symptoms across time, as well as the reliability between client report and collateral information. Increased validity Structured interviews assure that diagnostic criteria are covered systematically and completely. This is important because it serves to increase the validity of diagnosis. Utility as training tools Structured interviews are excellent training tools for clinicians in training because they promote the learning of specific diagnostic questions and probes used by experienced clinical interviewers. In addition, nonclinicians can easily be trained to administer fully structured interviews, which can be cost-effective in both research and clinical settings.

May hinder rapport Use of structured interviews may damage rapport because they are problem-centered, not person-centered, and poorly trained interviewers may neglect to use their basic clinical skills during the assessment. Limited by the validity of the classification system itself Structured interviews used for diagnosis are inherently tied to diagnostic systems. Thus, they are only as valid as the systems upon which they are based. Furthermore, it is difficult to establish the validity of particular structured interviews because there is no gold standard in psychiatric diagnosis. The trade-off of breadth versus depth Structured interviews are limited because they cannot cover all disorders or topic areas. When choosing a structured interview, one must evaluate carefully the trade-offs of breadth versus depth of assessment.

Advantage: Increased Reliability

Perhaps the most important advantage of structured interviews centers on their ability to increase diagnostic reliability (reliability defined in this context refers to consistency or agreement about diagnoses assigned by different raters; Coolidge & Segal, 2010a). By systemizing and standardizing the questions interviewers ask, and the way answers to those questions are recorded and interpreted, structured interviews decrease the amount of information variance in diagnostic evaluations (e.g., Rogers, 2001). That is, structured interviews decrease the chances that two different interviewers will elicit different information from the same client, which may result in different diagnoses. Thus, interrater reliability, or the likelihood that two different interviewers examining the same individual will arrive at the same diagnosis, is greatly increased.

Increased interrater reliability has broad implications in clinical and research settings. Because many psychological and psychopharmacological treatments are intimately tied to specific diagnoses, it is imperative that those diagnoses are accurate (Segal & Coolidge, 2001). Thus, if different clinicians interviewing the same client arrive at different diagnostic conclusions, it would be challenging to make a definitive decision about treatment. Similarly, accurate diagnosis is also essential for many types of clinical research, for example, studies that address causes and treatments of specific forms of psychopathology (Segal & Coolidge). Imagine a study examining different treatments for bipolar disorder. In such a study, it would be imperative to be certain that those individuals in the treatment groups have accurate diagnoses of bipolar disorder. Researchers must be able to accurately and definitively diagnose participants with the disorder being studied before researchers can even begin to examine theories of etiology or the effectiveness of treatment for that mental disorder.

In addition to increasing interrater reliability, structured interviews increase the likelihood that the diagnosis is reliable across time and across various sources of information (Rogers, 2001). In many clinical and research settings, individuals are, in fact, assessed on different occasions. Making multiple assessments could be dangerous if an interviewer evaluates a client in a different manner with different questions on different occasions. The client’s presentation may be substantially altered because the way he or she is asked about those symptoms has changed, rather than the client’s symptoms or diagnosis being different. Using a standardized interview for multiple assessments helps to ensure that if a client’s presentation has changed, it is because his or her symptoms are actually different, not because of variance in interviews (Rogers, 2001). This type of reliability is particularly important for pre- and post-assessments for both clinical and research outcomes. Likewise, in many settings, clinicians conduct collateral interviews with significant people in the client’s life to glean a broader picture of the client’s symptoms, problems, and experiences. Using a structured interview for both a client and a collateral source will likely increase the chances that discrepancies between the client and collateral informant are real, rather than a consequence of different interviewing styles (Rogers, 2001).

Advantage: Increased Validity

Validity of psychiatric diagnosis refers to the meaningfulness or usefulness of the diagnosis (Coolidge & Segal, 2010b). A required prerequisite for validity is reliability. Thus, because structured interviews greatly increase the reliability of diagnosis, they also increase the likelihood that the diagnosis is valid. Structured interviews also improve the validity of diagnoses in other ways. The systematic construction of structured interviews lends a methodological validity to these types of assessment compared with unstructured approaches. Because structured interviews are designed to thoroughly and accurately assess well-defined diagnostic criteria, they are often better assessments of those criteria than are unstructured interviews (Rogers, 2001). According to Rogers, clinicians who use unstructured interviews sometimes diagnose too quickly, narrow their diagnostic options too early, and miss comorbid diagnoses. Because structured interviews essentially force clinicians to assess all specified criteria for a broad range of diagnoses, they offer a more thorough and valid assessment of many disorders than do unstructured interviews.

In our experience, it is common for beginning clinicians who are conducting an unstructured clinical interview to gather information about the presence or absence of only a few common mental disorders. Coverage of other disorders may be neglected during an unstructured interview if the interviewer is unfamiliar with the specific criteria of some disorders. Some unstructured interviews may also provide limited information about whether comorbid psychopathology exists or about the severity of the psychopathology. Because they incorporate systematic ratings, structured and semistructured interviews easily provide information that allows for the determination of the level of severity and the level of impairment associated with a diagnosis. Structured interviews provide the same information about comorbid disorders as well.

Advantage: Utility as Training Tools

Structured interviews can be invaluable training tools for beginning mental health professionals as well as experienced clinicians who want to enhance their diagnostic skills. Use of structured interviews in the training context can help clinicians to develop or enhance their understanding of the flow, format, and questions inherent in a comprehensive diagnostic interview. With repeated administrations, much of a structured interview can be internalized by the clinician. In addition, use of structured interviews for training can reduce anxiety, especially among inexperienced clinicians, because the format and flow are clearly outlined for the interviewer. This type of structure can be helpful and calming for beginning clinicians, who may be initially overwhelmed by the diagnostic process and its inherent complexity.

Structured interviews can also be useful in training those who make preliminary mental health assessments, for example, intake staff at hospitals, so that clients are thoroughly and accurately evaluated in preparation for treatment planning. In the case of nonclinician interviewers, fully structured interviews are advisable, because they minimize the amount of clinical judgment needed for accurate administration. Use of these trained paraprofessionals can make large-scale research studies cost-effective.

Disadvantage: May Hinder Rapport

Despite the advantages of structured interviews, their application is not without controversy. The most common criticism of structured interviews is that their use may damage rapport or the therapeutic alliance (Segal, Maxfield, & Coolidge, 2008), which is widely viewed as an essential component of effective psychotherapy. Attaining a reliable and accurate diagnosis for a client is a hollow victory if the process prevents the therapeutic alliance from forming, or, in a more dramatic example of clinical failure, the client does not return to continue treatment. The well-known joke poking fun at medicine, “the operation was a success but the patient died,” might be recast in terms of structured interviews as “the diagnosis was impeccable but the client never came back for another session.”

How exactly might structured interviews damage rapport? Perhaps most importantly, structured interviews may impede the connection between client and clinician because interviews are problem-centered rather than person-centered. There is a danger that interviewers become so concerned with the protocol of their interview that they fail to demonstrate the warmth, empathy, and genuine regard necessary to form a therapeutic alliance. Indeed, the standardization of the interview may play out as “routinization” (Rogers, 2003). In addition, interviewers who are overly focused on the questions that they must “get through” in an interview may, consequently, miss important behavioral cues or other information that could prove essential to the case.

Proponents of structured interviews note that the problem of rapport-building during a structured interview can be overcome with training, experience, and flexibility (Rogers, 2003). We concur, and emphasize the observation that “rapid inquiries or monotonous questioning represents clear misuses of structured interviews” (Rogers, 2003, p. 22). If interviewers use their basic clinical skills, structured interviews can and should be conducted in such a way that establishes rapport and enhances understanding of the client. To ensure that this is the case, however, interviewers must be aware of the potential negative effects of structured interviews on rapport-building and make the nurturance of the therapeutic alliance a prominent goal during an interview, even while they are focused on following the protocol. It behoves those who use structured interviews to engage their respondents in a meaningful way during the interview and to avoid a rote-like interviewing style that may alienate. On the other hand, not all clients have a negative perception of a structured interview that must be intentionally overcome. Some clients like the structured approach to assessment because it is perceived as thorough and detailed, and in these cases rapport is easily attained.

Disadvantage: Limited by the Validity of the Classification System Itself

Earlier, we noted that proponents of structured interviews claim that they render more valid diagnoses in general. The assumption inherent in this argument is that the DSM diagnostic criteria are inherently valid, which is a debatable point. One should recognize that DSM diagnostic criteria were developed to operationalize theoretical constructs (e.g., depression, panic disorder, schizophrenia) so there is no absolute basis on which criteria were created. Furthermore, mental disorders are social constructions, which implies that they evolve over time as societies evolve.

Although successive editions of the DSM have been better grounded in empirical research, and the criteria for some disorders (e.g., major depression) have solid research support, other disorders (e.g., most of the personality disorders) and their criteria have not been examined as consistently or as completely, therefore leaving questions about their validity (Widiger & Trull, 2007). This point is also bolstered by the fact that the criteria for some disorders have changed significantly from one edition to another in the evolution of the DSM (Coolidge & Segal, 1998; Segal, 2010).

Furthermore, criteria for many disorders in the DSM are impacted by cultural and subcultural variations in the respondent, as well as by the age of the respondent. Indeed, the diagnostic criteria for many mental disorders do not fit the context of later life and, therefore, some criteria do not adequately capture the presentation of the disorders among many older adults (e.g., Segal, Coolidge, & Rosowsky, 2006; Segal, Qualls, & Smyer, 2011). Thus, certain criteria may be valid only for certain individuals, at a particular point in time, at a particular age. The primary method clinicians currently use to conceptualize diagnoses (the DSM), while improving, is far from perfect. Because the DSM generally does poorly in attending to these issues of age and diversity, interviews based on poorly fitting diagnostic criteria are similarly limited.

In addition to potential problems with DSM diagnostic criteria, another issue regarding structured interviews is that it is difficult to establish their validity firmly. The quandary is that our best means of establishing the validity of a structured interview is to compare diagnoses obtained from such interviews with diagnoses obtained by expert clinicians or by other structured interviews. This is inherently problematic because we cannot be certain that diagnoses by experts or other structured interviews are in fact valid in the first place (Segal et al., 2008).

Disadvantage: The Trade-Off of Breadth Versus Depth

A final criticism of structured interviews centers on the fact that no one structured interview can be all things in all situations, covering all disorders and eventualities. For example, if a structured interview has been designed to cover an entire diagnostic system (like the DSM, which identifies several hundred specific mental disorders), then inquiries about each disorder must be limited to a few inclusion criteria. In this case, the fidelity of the official diagnostic criteria has been compromised for the sake of a comprehensive interview. If the fidelity of the criteria is not compromised, then the structured interview becomes unwieldy in terms of time and effort required for its full administration. Most structured interviews attempt some kind of compromise between these two points of tension.

Thus, in terms of breadth versus depth of approach, users of structured interviews are forced to make a choice regarding what is most useful in each situation. Both choices have their limitations. If clinicians or researchers decide to use an interview that provides great breadth of information, they ensure that a wide range of disorders and a great many different areas of a respondent’s life are assessed. However, one may not have the depth of information needed to fully conceptualize a case. On the other hand, deciding to use an interview focused on a few specific areas will provide clinicians and researchers with a wealth of information about those specific areas, but it may result in missing information that could lead to additional diagnoses or a different case conceptualization. Thus, it is essential to understand that when choosing a particular structured or semistructured interview, there are often trade-offs regarding breadth and depth of information.

Weighing Advantages and Disadvantages

Our examination of the strengths and limitations of structured interviews highlights the importance of carefully contemplating what is needed for the clinical or research situation before choosing a structured interview. Structured interviews can be invaluable tools in both clinical and research work; however, it is essential that one does not use such tools without accounting for the problems inherent in their use. Rogers (2001) voiced the helpful perspective that it would be unwise to view the interviewing process as an either/or proposition (i.e., unstructured vs. structured interview). In certain situations, unstructured interviews may meet the objectives more efficiently than a structured interview. For example, in a crisis, flexibility on the part of the clinician is required to meet the pressing demands of this fluid and potentially volatile interaction. However, in other cases, greater assurances that the diagnostic conclusions are valid and meaningful would take priority, for example, in clinical research or in the delivery of clearly defined psychotherapeutic intervention protocols. As noted earlier, the integration of a nonstandardized or clinical interview with a structured or semistructured interview may also be an excellent option for clinicians and researchers.

Finally, despite some potential limitations of structured and semistructured interviews, their use has clearly revolutionized the diagnostic process, vastly improving diagnostic reliability and validity. Such interviews have greatly improved clinical and research endeavors by providing a more standardized, scientific, and quantitative approach to the evaluation of specific symptoms and mental disorders. As such, it is likely that the use of structured and semistructured interviews will increase in the coming decades.

Structured and Semistructured Interviews for Differential Diagnosis

In this section, we examine several popular structured and semistructured interviews. These interviews can be divided into those that focus on clinical disorders and those that focus on personality disorders. As noted earlier, although the DSM-5 no longer makes a distinction between clinical disorders and personality disorders (with the replacement of the multiaxial coding system by a nonaxial coding system), the distinction is still relevant to the current crop of structured and semistructured interviews which were developed with this difference in mind. In addition, the names and content of many of the instruments for personality disorders remain unchanged, which reflects the absence of changes from DSM-IV to DSM-5. Instruments that focus on clinical disorders include the Anxiety Disorders Interview Schedule for DSM-5, the Diagnostic Interview Schedule for DSM-5, the

Schedule for Affective Disorders and Schizophrenia

, and the Structured Clinical Interview for DSM-5. Instruments that measure personality disorders include the Diagnostic Interview for DSM Personality Disorders, the

International Personality Disorder Examination

, the Structured Clinical Interview for DSM-5 Personality Disorders, and the Structured Interview for DSM-IV Personality.

Where possible, we describe updates made to some of these instruments as they were revised to conform to the current DSM-5 system. However, not all instruments have been updated to reflect DSM-5 criteria; this lack of changes, and any instruments that are still awaiting changes, will also be noted in the descriptions of each. A general overview of each instrument is provided in 

Table 4.2

. Each instrument assesses a variety of mental disorders and, therefore, can assist in the important task of differential diagnosis (i.e., a systematic means of discriminating among numerous possible disorders to identify specific ones for which the client meets the diagnostic threshold). Each interview also allows for an assessment of many comorbid mental disorders. The instruments presented in this chapter do not represent an exhaustive list of structured and semistructured interviews, but they are among the most common and well-validated ones. Interested readers are referred to Rogers (2001), Segal and Hersen (2010), and Summerfeldt, Kloosterman, and Antony (2010) for information on instruments not reviewed in this chapter.

Table 4.2

 Comparison of Major Diagnostic Interviews

90–150 minutes

Semistructured, interviewer administered

Semistructured, interviewer administered

Semistructured, interviewer administered

Name	Time Required	Format	Comment
Anxiety Disorders Interview Schedule for DSM-5 (Brown & Barlow, 2014a)	45–60 minutes				Semistructured, interviewer administered	Provides in-depth assessment of anxiety disorders and other frequently comorbid conditions (e.g., mood disorders, substance abuse). Designed to be administered by trained mental health professionals with training in administration. Available in separate current and lifetime versions.
Diagnostic Interview Schedule (Robins et al., 2000)		90–150 minutes	Fully structured, computerized, closed-ended questions	Designed for epidemiological research. Includes most diagnoses in DSM-5. Can be administered by nonclinicians, although interviewers must receive specialized training.
Schedule for Affective Disorders and Schizophrenia (Endicott & Spitzer, 1978)	Provides in-depth coverage on clinical disorders, namely mood and psychotic disorders. Designed for administration by trained mental health professionals, and additional training in administration is required.
Structured Clinical Interview for DSM-5 (First, Williams, Karg, & Spitzer, 2016b)	45– 90 minutes	Covers DSM-5 clinical disorders most commonly seen in clinical settings. Designed for use by professionals with knowledge of psychopathology, DSM-5 diagnostic criteria, and basic interviewing skills. Research Version, Clinical Version and Clinical Trials Version available.
Diagnostic Interview for DSM-IV Personality Disorders (Zanarini, Frankenburg, Sickel, & Yong, 1996)	90 minutes	Designed to assess the 10 standard DSM-IV personality disorders. Requirements for administration include, at a minimum, a bachelor’s degree, at least 1 year of clinical experience with personality-disordered clients, and several training interviews.
International Personality Disorder Examination (Loranger, 1999)	15 minutes (self- administered screen), 90 minutes (interview)	Contains self- administered pencil-and-paper questionnaire and semistructured interview	Evaluates personality disorders for both the DSM-IV and the International Classification of Diseases, 10th ed. (ICD-10). Intended for use by experienced clinicians with specialized training in administration.
Structured Clinical Interview for DSM-5 Personality Disorders (First, Williams, Benjamin, & Spitzer, 2016)	20 minutes (self- administered screen), 60 minutes (interview)	Contains self-report screening questionnaire and semistructured interview	Assesses the 10 standard DSM-5 personality disorders. Designed for administration by professionals with knowledge of psychopathology, DSM-5 diagnostic criteria, and basic interviewing skills.
Structured Interview for DSM-IV Personality (Pfohl, Blum, & Zimmerman, 1997)	60–90 minutes	Semistructured interview	Comprehensive interview for DSM-IV personality disorders. Collateral sources encouraged. Requirements for administration include an undergraduate degree in the social sciences and 6 months’ experience with diagnostic interviewing in addition to specialized training.

Anxiety Disorders Interview Schedule for DSM-5

The Anxiety Disorders Interview Schedule for DSM-5 (ADIS-5; Brown & Barlow, 2014a) is a semistructured clinician-administered interview designed to assess anxiety disorders as defined by the DSM-5. It provides differential diagnosis among anxiety disorders and includes sections on mood, somatoform, and substance use disorders, as anxiety disorders are frequently comorbid with such conditions. There are two versions of the adult ADIS-5: the Standard Version, which provides only current diagnostic information, and the Lifetime Version (ADIS-5L; Brown & Barlow, 2014b), which offers both past and current diagnostic information. The ADIS-5L is similar in structure to the ADIS-5, but contains separate sections that assess the prior occurrence of disorders. The ADIS-5 can be used in both clinical and research settings.

At the beginning of the ADIS-5, basic demographic information is collected, as well as a short description of the presenting problem. This information gives the examiner an idea of which topics should be pursued in more detail throughout the interview. Following the presenting problem, the examiner asks the respondent, “What would you say is the main reason that brought you here today?” and the response is recorded verbatim. Next, the respondent is asked to describe any recent struggles in functioning within the past year (e.g., school, work, relationships). Notably, medical/treatment history has been moved to the front of the ADIS-5, before the diagnostic portion of the instrument, for several reasons, one of which is to consider the influence of current medications and medical problems on current symptomatology.

The interview then continues with the assessment of anxiety disorders. This section begins with the more prevalent anxiety disorders (e.g., panic disorder, agoraphobia, social anxiety disorder) and is organized logically to reflect the shared symptoms among many anxiety disorders. Next are sections assessing mood disorders, somatoform disorders, post-traumatic stress disorder, depressive disorders, mood disorders, somatic disorders, alcohol and substance use/dependence, and screening for other disorders (e.g., hoarding). A segment assessing the individual’s family history of psychological disorders is also included. Prior to the DSM-5 revisions to the ADIS, Brown, DiNardo, and Barlow (1994b) recommended administering the Hamilton Rating Scale for Depression and the Hamilton Anxiety Rating scale for additional information regarding anxiety and depression; however, the authors of the ADIS-5 (Brown & Barlow, 2014a) no longer recommend administration of the Hamilton scales following the administration of the ADIS, and the two measures have been separated.

Each section on the ADIS-5 includes items assessing diagnostic criteria for the given disorder. The examiner begins with several dichotomous yes/no initial inquiry questions, and affirmative answers warrant further questioning to gauge the presence or absence of the disorder. In some sections, these dichotomous items are considered skip-out points in which, pending negative ratings, continuation is not necessary. Dimensional ratings are also obtained regarding both current and past experiences of major symptoms of the given disorder. As noted previously, the ADIS-5L contains separate sections for current and past occurrences of disorders, whereas the ADIS-5 assesses only current disorders. However, the ADIS-5 contains screening questions for past episodes in the initial inquiry items. If the respondent denotes a positive response to these screening questions, the clinician’s manual recommends that the interviewer adapt other items in that section to obtain information about previous disorders. The manual notes that this information may be useful in differential diagnosis.

After the initial inquiry section, the clinician continues with the current episode segment of the interview, which provides items that collectively assess all diagnostic criteria for a specific disorder. The questions in the current episode section are arranged so that they begin as open-ended and are followed by more specific inquiries. The need for the more specific inquiries is contingent upon the response to the initial open-ended question. For instance, if the respondent provides a specific response to a question regarding the timeline of a given symptom (e.g., “The symptom began around 1 month ago”), then follow-up questions may not be needed. The current episode section also contains questions that assess the onset of the disorder and etiological factors. After the current episode section, the administrator again asks about past episodes of the disorder. The purpose of this repeated item is that the interviewer can reassess the previous occurrence of the disorder given the wealth of diagnostic information collected in that section. In the ADIS-5L, the current episode portion of the interview is followed by the past episode section, which is similar in structure to the current episode segment.

The ADIS-5 contains a score sheet in which the interviewer records diagnoses (including dates of onset) in addition to a diagnostic confidence rating (0–100, with 100 indicating complete certainty). If the diagnostic confidence rating is less than 100, the interviewer must indicate why. Each disorder listed is given a rating of clinical severity ranging from 0 to 8, with higher numbers indicating more distress. Ratings of 0 indicate that there are no features of a given disorder present. These ratings are used to identify clinical versus subclinical disorders, such that ratings of 3 or below indicate subsyndromal symptomatology, and ratings of 4 and above indicate the presence of a disorder (as per the DSM-5 criteria). The ADIS-5L also contains a “diagnostic timeline” page that synthesizes information regarding the temporal sequence of disorders as well as etiology.

The ADIS-5 is designed for use by experienced clinicians who are familiar with the DSM-5 as well as the ADIS-5. Examiners are encouraged to use clinical judgment to determine whether an item should be read verbatim or reworded as needed (e.g., shortening length and complexity of questions for those with lower levels of education). Examiners are also encouraged to use their clinical judgment to gather further clarifying information from respondents, and to decide when to skip certain sections of the interview.

Overall, both the ADIS-5 and ADIS-5L are popular and valuable tools in diagnosing anxiety disorders as well as frequently comorbid conditions. Studies of the previous versions of the ADIS (e.g., ADIS-IV; see Grisham, Brown, and Campbell, 2004 for a summary) indicated empirical support regarding the reliability and validity of the instrument); however, due to the recent publication of the ADIS-5, psychometric properties of the newest version are yet to be established and will likely be the focus of future studies. Previous versions of the ADIS have been translated into at least five other languages (the ADIS-5 is likely to follow this trend). There is an adapted version for use with children. The ADIS-5 interview and manual are available from Oxford University Press (

global.oup.com

).

Diagnostic Interview Schedule for DSM-5

The Diagnostic Interview Schedule (DIS; Robins et al., 2000) is designed to ascertain the presence or absence of major mental disorders of the DSM-5 (APA, 2013). It is unique among the multidisorder diagnostic interviews in that it is a fully structured interview specifically designed for use by nonclinician interviewers, whereas the other interviews are semistructured. By definition, a fully structured interview clearly specifies all questions and probes, and does not permit deviations.

The original DIS was developed in 1978 at the request of the National Institute of Mental Health Division of Biometry and Epidemiology, which was commencing a series of large-scale, multicenter epidemiological investigations of mental disorders in the general adult population in the United States. The development of a structured interview that could be administered by nonclinicians was imperative because of the prohibitive cost of using professional clinicians as interviewers. As a result, the DIS was designed as a fully structured diagnostic interview explicitly crafted so that it could be administered and scored by nonclinician interviewers.

The most recent DIS (DIS-5; “History and Scope”, n.d.) has been revised to map onto the DSM-5 diagnostic criteria and includes revisions prompted by field experience and associated feedback. The DIS-5 comprises changes in the assessment of current syndrome, assessing for whether a disorder has been present in the last 12 months and having interviewees indicate when in the last 12 months the symptoms were present. The DIS-5 also covers substance use disorders as coded by the DSM-5 and the International Classification of Diseases, 10th ed. (ICD-10). Separation anxiety and somatization disorders are omitted from the DIS-5; however, the DIS-IV modules for these disorders can still be obtained for use. In addition, the DIS-5 no longer includes screening for cognitive concerns (e.g., dementia).

To assure standardization of the DIS-5, computerized administration is required, which may be either administered by the interviewer or self-administered. In both formats, the exact wording of all questions and probes is presented to the respondent in a fixed order on a computer screen. Rephrasing of questions is discouraged, although DIS-5 interviewers can repeat questions as necessary to ensure that the respondent understands them. All questions are closed-ended, and replies are coded with a forced-choice yes/no response format. The DIS-5 gathers all necessary information about the person from his or her self-report. Collateral sources of information are not used. The DIS-5 is self-contained and covers all necessary symptoms to make most DSM-5 diagnoses. To this end, the DSM-5 diagnostic criteria for the disorders have been faithfully turned into specific questions in the DIS-5. The coded responses are directly entered into a database during the interview, and the diagnosis is made according to the explicit rules of the DSM-5 diagnostic system.

Because the DIS was designed for epidemiological research with normative samples, interviewers do not elicit a presenting problem from the respondent, as would be typical in unstructured clinical interviews. Rather, interviewers begin by asking questions about symptoms in a standardized order. Like most of the other structured interviews examined here, the DIS-5 has sections that cover different disorders. Each diagnostic section is independent, except where one diagnosis pre-empts another. Once a symptom is reported to be present, further closed-ended questions are asked about diagnostically relevant information, such as severity, frequency, time frame, and possibility of organic etiology of the symptom. The DIS-5 includes a set of core questions that are asked of each respondent. Core questions are followed by contingent questions which are administered only if the preceding core question is endorsed. Interviewers use a probe flowchart that indicates which probes to select in which circumstances.

For each symptom, the respondent is asked to state whether it has ever been present and how recently. All data about the presence or absence of symptoms and time frames of occurrence are coded and entered into the computer. Consistent with its use of nonclinician interviewers who may not be overly familiar with the DSM-5 or psychiatric diagnosis, the diagnostic output of the DIS-5 is generated by a computer program that analyzes data from the completed interview. The output provides estimates of prevalence for two time periods: current and lifetime.

Due to its highly structured format, full administration of the DIS-5 typically requires between 90 and 150 minutes. To shorten administration time, the modular format makes it possible to drop evaluation of disorders that are not of interest in a study. Another option is to drop further questioning for a disorder once it is clear that the threshold number of symptoms needed for diagnosis will not be met. Although designed for use by nonclinician administrators, training for competent administration of the DIS-5 is necessary. Trainees typically attend a 3-day training program at University of Florida (Gainesville, Florida) or at their own location. The training entails review of the DIS-5 manual, didactic presentations about the structure and conventions of the DIS-5, homework exercises, and practice interviews followed by feedback and review. Additional supervised practice is also recommended.

The psychometric properties of the original DIS and its revisions are excellent, and such data have been documented in an impressive array of studies; however, due to the newness of the DIS-5, psychometric properties for the newest version have not yet been established. Interested readers are referred to Compton and Cottler (2004) for an excellent summary of the psychometric characteristics of the DIS-IV. Overall, the DIS has proven to be a popular and useful diagnostic assessment tool, especially for large-scale epidemiological research.

The DIS has been translated into more than a dozen languages, is used in countries across the globe for epidemiological research, and served as the basis for the Composite International Diagnostic Interview used by the World Health Organization. For further information on DIS-5 materials, training, and developments, refer to the DIS website (

http://epidemiology.phhp.ufl.edu/assessments/c-dis-5-and-c-sam-5/

).

Schedule for Affective Disorders and Schizophrenia

The Schedule for Affective Disorders and Schizophrenia (SADS; Endicott & Spitzer, 1978) is a semistructured diagnostic interview designed to evaluate a range of clinical disorders, with a focus on mood and psychotic disorders. Ancillary coverage is provided for anxiety symptoms, substance abuse, psychosocial treatment history, and antisocial personality features. The SADS provides in-depth but focused coverage of the mood and psychotic disorders and supplies meaningful distinctions of impairment in the clinical range for these disorders. The SADS can be used to make many DSM-IV diagnoses, but it is not completely aligned with the DSM system, representing a significant point of concern. With substantive changes made in DSM-5, the SADS is at risk of becoming more outdated if it is not revised substantially.

The SADS is intended to be administered to adult respondents by trained mental health professionals. It focuses heavily on the differential diagnosis of mood and psychotic disorders, with great depth of assessment in these areas. In the beginning of the interview, a brief overview of the respondent’s background and psychiatric problems is elicited via an open-ended inquiry. The SADS is then divided into two parts, each focusing on a different time period. Part I provides for a thorough evaluation of current psychiatric problems and concomitant functional impairment. A unique feature of the SADS is that, for the current episode, symptoms are rated when they were at their worst levels to increase diagnostic sensitivity and validity. In contrast, Part II provides a broad overview of past episodes of psychopathology and treatment. Overall, the SADS covers more than 20 diagnoses in a systematic and comprehensive fashion and provides for diagnosis of both current and lifetime psychiatric disorders. Some examples include schizophrenia (with six subtypes), schizoaffective disorder, manic disorder, hypomanic disorder, major depressive disorder (with 11 subtypes), minor depressive disorder, panic disorder, obsessive- compulsive disorder, phobic disorder, alcoholism, and antisocial personality disorder (Endicott & Spitzer, 1978). In DSM-5, the subtypes of schizophrenia have been deleted (due to poor validity and clinical utility), so the distinction made by the SADS in this area may not be of much use in the future.

In the SADS, questions are clustered according to specific diagnoses. For each disorder, standard questions are specified to evaluate specific symptoms of that disorder. Questions are either dichotomous or rated on a Likert-type scale, which allows for uniform documentation of levels of severity, persistence, and functional impairment associated with each symptom. To supplement client self-report and obtain the most accurate symptom picture, the SADS allows for consideration of all available sources of information (i.e., chart records, input from relatives). In addition to the standard questions asked of each respondent, optional probes may be selectively used to clarify responses, and unstructured questions may be generated by the interviewer to augment answers to the optional probes. Thus, considerable clinical experience and judgment are needed to administer the SADS. To reduce length of administration and evaluation of symptoms that are not diagnostically significant, many diagnostic sections begin with screening questions that provide for skip-outs to the next section if the respondent shows no evidence of having the disorder. Administration of the SADS typically takes between 90 and 150 minutes. The interviewer makes formal diagnostic appraisals after the interview is completed. No computer scoring applications have been designed for the SADS because of the complex nature of the diagnostic process and the strong reliance on clinical judgment.

As noted earlier, the SADS was designed for use by trained clinicians. Considerable clinical judgment, interviewing skills, and familiarity with diagnostic criteria and psychiatric symptoms are requisite for competent administration. As such, it is recommended that the SADS only be administered by professionals with graduate degrees and clinical experience, such as clinical psychologists, psychiatrists, and psychiatric social workers (Endicott & Spitzer, 1978). Training in the SADS is intensive and can encompass several weeks. The process includes reviewing the most recent SADS manual and practice in rating written case vignettes and videotaped SADS interviews. Additionally, trainees typically watch and score live interviews as if participating in a reliability study with a simultaneous-rating design. Throughout, discussion and clarification with expert interviewers regarding diagnostic disagreements or difficulties add to the experience. Finally, trainees conduct their own SADS interviews, which are observed and critiqued by the expert trainers.

Numerous additional versions of the SADS have been devised, each with a distinct focus and purpose. Perhaps the most common is the SADS-L (Lifetime version), which can be used to make both current and lifetime diagnoses but has significantly fewer details about current psychopathology than the full SADS and results in a quicker administration time. The SADS-L generally is used with nonpsychiatric samples in which there is no assumption of a significant current psychiatric problem. The SADS-Change Version is also popular and consists of 45 key symptoms from the SADS Part 1. Extensive study of the SADS suggests that it possesses excellent psychometric characteristics. See Rogers, Jackson, and Cashel (2004) for a comprehensive review of these data.

The SADS has been translated into several languages, but its primary use has been in North America. The SADS has been widely used in clinical research over the past three decades, and consequently has a large body of empirical data associated with it. As such, it is often the instrument of choice for clinical researchers desiring in-depth assessment of depression and schizophrenia. The extensive subtyping of disorders provided by the SADS is also highly valued by clinical researchers. However, owing to its length and complexity, the SADS is infrequently chosen for use in many traditional, purely clinical settings (e.g., community mental health centers). Because the SADS is most closely aligned with the Research Diagnostic Criteria (and not the DSM criteria), there are no plans to update the measure to fit the DSM-5 (J. Endicott, personal communication, January 6, 2017). The SADS can be obtained directly from the instrument’s developers.

Structured Clinical Interview for DSM-5 Disorders

The Structured Clinical Interview for DSM-5 5 Disorders (SCID-5) is a flexible, semistructured diagnostic interview designed for use by trained clinicians to diagnose many adult DSM-5 clinical disorders. The SCID has widespread popularity as an instrument to obtain reliable and valid psychiatric diagnoses for clinical, research, and training purposes, and the previous versions have been used in more than 1,000 studies.

The original SCID was designed for application in both research and clinical settings. Recently, the SCID has been split into three distinct versions: the Research Version, the Clinician Version, and the Clinical Trials Version. The Research Version covers more disorders, subtypes, and course specifiers than the Clinician Version and, therefore, takes longer to complete. The benefit, however, is that it provides for a wealth of diagnostic data that is particularly valued by clinical researchers. The coverage of the Clinical Trials Version is customizable and depends on the inclusion/exclusion criteria for specific clinical trials (First, Williams, Karg, & Spitzer, 2016b).

The most up-to-date version of the SCID has been modified to reflect changes in the DSM-5. The updated instrument contains several new disorders (e.g., hoarding, premenstrual dysphoric disorder, trichotillomania, gambling disorder, and attention-deficit/hyperactivity disorder), updated and new questions, and adjustments to the original SCID algorithm (First et al., 2016b).

The Clinician Version of the SCID (SCID-5-CV; First et al. 2016b) is designed for use in clinical settings. It has been trimmed to encompass only those DSM-5 disorders that are most typically seen in clinical practice and can further be abbreviated on a module-by-module basis. The SCID-5-CV contains 10 self-contained modules of major diagnostic categories (mood episodes, psychotic symptoms, psychotic disorders, mood disorders, substance use disorders, and anxiety disorders, obsessive-compulsive disorder and post-traumatic stress disorder, attention-deficit/hyperactivity disorder, screening for other disorders, and adjustment disorder).

The modular design of the SCID represents a major strength of the instrument, because administration can be customized easily to meet the unique needs of the user. For example, the SCID can be shortened or lengthened to include only those categories of interest, and the order of modules can be altered. The format and sequence of the SCID were designed to approximate the flowcharts and decision trees followed by experienced diagnostic interviewers. The SCID begins with an open-ended overview portion, during which the development and history of the present psychological disturbance are elicited, and tentative diagnostic hypotheses are generated. In addition, screening for substance abuse occurs prior to the diagnostic modules of the SCID so that the effects of the client’s substance use can be clarified from the beginning of the interview. Then, the SCID systematically presents modules that allow for assessment of specific disorders and symptoms. Most disorders are evaluated for two time periods: current (meets criteria for the past month) and lifetime (ever-met criteria).

Consistent with its linkage with DSM, formal diagnostic criteria are included in the SCID booklet, thus permitting interviewers to see the exact criteria to which the SCID questions pertain. This unique feature makes the SCID an outstanding training tool for clinicians, because it facilitates the learning of diagnostic criteria and presents excellent questions to assess the criteria. The SCID has many open-ended prompts that encourage respondents to elaborate freely about their symptoms. At times, open-ended prompts are followed by closed-ended questions to fully clarify a specific symptom. Although the SCID provides structure to cover criteria for each disorder, its semistructured format provides significant latitude for interviewers to re-state questions, ask for further clarification, probe, and challenge if the initial prompt was misunderstood by the interviewee or clarification is needed to rate a symptom. SCID interviewers are encouraged to use all sources of information about a respondent, and gentle challenging of the respondent is encouraged if discrepant information is suspected.

During administration, each symptom is rated as either absent (or below threshold) or present (and clinically significant). The SCID flowchart instructs interviewers to skip out of a diagnostic section when essential symptoms are judged to be below threshold or absent. These skip-outs result in decreased time of administration as well as the skipping of items with no diagnostic significance. Administration of the SCID is typically completed in one session and takes 45–90 minutes. Once administration is completed, all current and past disorders for which criteria are met are listed on a Diagnostic Summary sheet.

The SCID is optimally administered by trained clinicians. Because of the semistructured format of the SCID, proper administration often requires that interviewers re-state or clarify questions in ways that are sometimes not clearly outlined in the manual to judge accurately if a diagnostic criterion has been met. The task requires that SCID assessors have a working knowledge of psychopathology, DSM-5 diagnostic criteria, and basic interviewing skills. Standard procedures for training to use the SCID include carefully reading the Users Guide to the SCID (First et al., 2016b), reviewing the SCID administration booklet and score sheet, viewing SCID videotape training materials that are available from the SCID authors, and conducting role-played practice administrations with extensive feedback discussions. Next, trainees may administer the SCID to representative participants who are jointly rated so that a discussion about sources of disagreements can ensue. In research settings, a formal reliability study is advantageous. The reliability and validity of the previous versions of the SCID in adult populations with diverse disorders have been evaluated in several investigations, with generally excellent results among widely varied participant samples and experimental designs (see review by First & Gibbon, 2004; Segal, Hersen & Van Hasselt, 1994).

Overall, the SCID is a widely used and respected assessment instrument. Previous versions have been translated into 12 languages and it has been applied successfully in research studies and clinical practice in many countries. As clinicians and researchers shift to using the updated instrument, the SCID-5 is likely to gain similar utilization and support. For more information on the SCID, visit the SCID website (

www.scid5.org

).

Semistructured Interviews for Personality Disorders

Diagnostic Interview for Personality Disorders

The Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV; Zanarini, Frankenburg, Sickel, & Yong, 1996) is a semistructured interview designed to assess the presence or absence of the 10 standard DSM-IV personality disorders as well as depressive personality disorder and passive-aggressive personality disorder in the DSM-IV appendix. Prior to personality disorder assessment, a full screening for clinical disorders is recommended. Additionally, an assessment of the respondent’s general functioning (e.g., in the domains of work, school, and social life) is advised before administration of the DIPD-IV (Zanarini et al., 1996).

The interview is conducted on a disorder-by-disorder basis. The interview contains 108 sets of questions, each designed to assess a specific DSM-IV personality disorder diagnostic criterion. The DSM-IV criterion is provided in bold below each set of questions for easy cross-reference. The initial question for each criterion typically has a yes/no format which is followed by open-ended questions to explore clients’ experiences more fully. Clients are informed that the interview pertains to the past 2 years of their life and that the interviewer wants to learn about the thoughts, feelings, and behaviors that have been typical for them during the 2-year period. Whereas clients are the sole source of information for rating most of the diagnostic criteria, behavior exhibited during the interview is valued and may override client self-report if there are contradictions. The administrator is encouraged to probe further if responses appear incomplete or fallacious.

Each diagnostic criterion is rated on the following scale: 0, absent or clinically insignificant; 1, present but of uncertain clinical significance; 2, present and clinically significant; and NA, not applicable. After all 108 criteria are evaluated, final categorical diagnosis for each personality disorder is made based on the number of criteria met. The final output is recorded as 2, indicating yes or met full criteria, 1 indicating subthreshold (one less than required number of criteria), or 0 indicating no.

Information about administration and scoring of the DIPD-IV is relatively sparse, at least compared with the other interviews focusing on personality disorders. The training requirements include, at a minimum, a bachelor’s degree, at least 1 year of clinical experience with personality-disordered clients, and several training interviews in which the person observes skilled administrators and then administers the interview. Training tapes and workshops are available, as is a Spanish version. Administration time is typically about 90 minutes. Most notably, the DIPD-IV has been chosen as the primary diagnostic measure for personality disorders in the Collaborative Longitudinal Personality Disorders Study, which is a large, multisite, prospective naturalistic longitudinal study of personality disorders and comorbid mental health problems. Because personality disorder criteria have not changed in the DSM-5 there are no anticipated changes to the DIPD-IV at this time (M.C. Zanarini, personal communication, January 25, 2017). For further information on the DIPD-IV, contact Dr. Mary C. Zanarini (

zanarini@mclean.harvard.edu

).

International Personality Disorder Examination

The International Personality Disorder Examination (IPDE; Loranger, 1999) is an extensive, semistructured diagnostic interview administered by experienced clinicians to evaluate personality disorders for both the DSM-IV and ICD-10 classification systems. The IPDE was developed within the Joint Program for the Diagnosis and Classification of Mental Disorders of the World Health Organization and US National Institutes of Health aimed at producing a standardized assessment instrument to measure personality disorders on a worldwide basis. As such, the IPDE is the only personality disorder interview based on worldwide field trials. The IPDE manual contains the interview questions to assess either the 11 DSM-IV or the 10 ICD-10 personality disorders. The two IPDE modules (DSM-IV and ICD-10) contain both a self-administered screening questionnaire and a semistructured interview booklet with scoring materials.

The Screening Questionnaire is a self-administered form that contains 77 DSM-IV or 59 ICD-10 items written at a fourth-grade reading level. Items are answered either “true” or “false,” and the questionnaire is typically completed in about 15 minutes. The clinician can quickly score the questionnaire and identify those respondents whose scores suggest the presence of a personality disorder. Subsequently, the IPDE clinical interview is administered.

The IPDE Interview modules (for either the DSM-IV or ICD-10 systems) contain questions, each reflecting a personality disorder criterion, which are grouped into six thematic headings: work, self, interpersonal relationships, affects, reality testing, and impulse control (Loranger, 1999). Because disorders are not covered on a one-by-one basis, the intent of the evaluation is less transparent, similar to the SIDP-IV. At the beginning of each section, open-ended inquiries are provided to enable a smooth transition from the previous section and to encourage respondents to elaborate about themselves in a less structured fashion. Then, specific questions are asked to evaluate each personality disorder criterion. For each question, the corresponding personality disorder and the specific diagnostic criterion are identified with specific scoring guidelines.

Respondents are encouraged to report their typical or usual functioning, rather than their personality functioning during times of episodic psychiatric disturbance. The IPDE requires that a trait be prominent during the past 5 years to be considered a part of the respondent’s personality. Information about age of onset of particular behaviors is explored to determine if a late-onset diagnosis (after age 25 years) is appropriate. When a respondent acknowledges a particular trait, interviewers follow up by asking for examples and anecdotes to clarify the trait or behavior, gauge the impact of the trait on the person’s functioning, and fully substantiate the rating. Such probing requires significant clinical judgment and knowledge on the part of interviewers about each criterion. Items may also be rated based on observation of the respondent’s behavior during the session, and this too requires a certain level of clinical expertise. To supplement self-report, an interview of informants is encouraged. Clinical judgment is needed to ascertain which source is more reliable if inconsistencies arise.

Each criterion is rated on a scale with the following definitions: 0 indicates that the behavior or trait is absent or within normal limits, 1 refers to exaggerated or accentuated degree of the trait, 2 signifies criterion level or pathological, and ? indicates the respondent refuses or is unable to answer. Comprehensive item-by-item scoring guidelines are provided in the manual (Loranger, 1999). At the end of the interview, the clinician records the scores for each response on the appropriate IPDE Answer Sheet. Ratings are then collated by hand or computer. The ultimate output is extensive, including presence or absence of each criterion, number of criteria met for each personality disorder, a dimensional score (sum of individual scores for each criterion for each disorder), and a categorical diagnosis (definite, probable, or negative) for each personality disorder (Loranger, 1999). Such comprehensive output is often of value to clinical researchers.

The IPDE is intended to be administered by experienced clinicians who have also received specific training in its use. Such training typically involves a workshop with demonstration videotapes, discussions, and practice. The average administration time for the interview is 90 minutes, which can be reduced by using the screening questionnaire (omitting interview items associated with unlikely personality disorders). Because the IPDE has been selected by the WHO for international application, it has been translated into numerous languages to facilitate cross-cultural research. Ample evidence of reliability and validity of the IPDE has been documented (Loranger, 1999; Loranger et al., 1994). Because of the instrument’s ties to the DSM-IV and ICD-10 classification systems, and adoption by the WHO, the IPDE is widely used for international and cross-cultural investigations of personality disorders. No major updates to the IPDE are planned at present (S. Fox, representative of PAR Inc., personal communication, January 23, 2017). The instrument can be purchased through PAR Inc. at 

http://www4.parinc.com/

. The user manual is available through 

http://www.who.int/en/

.

Structured Clinical Interview for DSM-5 Personality Disorders

To complement the clinical disorder version of the SCID, a version focusing on personality disorders was developed: the Structured Clinical Interview for DSM-5 Personality Disorders (SCID-5-PD; First, Williams, Benjamin, & Spitzer, 2016a). The SCID-5-PD is the DSM-5-updated version of the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (First, Gibbon, Spitzer, Williams, & Benjamin, 1997). The SCID-5-PD has a similar semistructured format as the original SCID but it covers the 10 standard DSM-5 personality disorders, as well as other specified personality disorders. This version also provides cluster categorization (e.g., Cluster A includes paranoid, schizotypal, and schizoid personality disorders) of the personality disorders, as well as a dimensional scoring component.

For comprehensive assessment, the SCID-5-PD may be easily used in conjunction with the original SCID that would be administered prior to personality disorder assessment. This is encouraged so that the respondent’s present mental state can be considered when judging accuracy of self-reported personality traits. The basic structure and conventions of the SCID-5-PD closely resemble those of the SCID-5. An additional feature of the SCID-5-PD is that it includes a 106-item self-report screening component called the Screening Personality Questionnaire which may be administered prior to the interview portion and takes about 20 minutes. The purpose of the Screening Personality Questionnaire is to reduce overall administration time, because only those items that are scored in the pathological direction are further evaluated during the structured interview portion.

During the structured interview component, the pathologically endorsed screening responses are further pursued to determine whether the symptoms are experienced at clinically significant levels. Here, the respondent is asked to elaborate on each suspected personality disorder criterion, and specified prompts are provided. Like the original SCID, the DSM-5 diagnostic criteria are printed on the interview page for easy review, and responses are coded as follows: ?, inadequate information; 0, absent or false; 1, subthreshold; and 2, threshold or true. Each personality disorder is assessed completely, and diagnoses are completed before proceeding to the next disorder. The modular format permits researchers and clinicians to tailor the SCID-5-PD to their specific needs and reduce administration time. Clinicians who administer the SCID-5-PD are expected to use their clinical judgment to clarify responses, gently challenge inconsistencies, and ask for additional information as required to rate each criterion accurately. Collection of diagnostic information from ancillary sources is permitted. Complete administration of the SCID-5-PD typically takes less than 60 minutes.

Training requirements and interviewer qualifications are similar to those of the original SCID. There is no separate clinician version of the SCID-5-PD. The psychometric properties of the SCID-5-PD are expected to be comparable to the SCID-II as minimal changes were instituted and personality disorder diagnostic criteria remain the same; however, establishment of the psychometric properties of the updated instrument is needed. For a comprehensive review of the SCID-II (previous version) psychometric properties, see First and Gibbon (2004). Given the extensive coverage of the personality disorders, the modular approach, and strong operating characteristics, the SCID-5-PD should remain a popular and effective tool for personality disorder assessment. The SCID-5-PD website is the same as for the original SCID (
www.scid5.org
).

Structured Interview for DSM-IV Personality

The Structured Interview for DSM-IV Personality (SIDP-IV; Pfohl, Blum, & Zimmerman, 1997) is a comprehensive semistructured diagnostic interview for DSM-IV personality disorders. It covers 14 DSM-IV personality disorder diagnoses, including the 10 standard personality disorders, self-defeating personality disorder, depressive personality disorder, negativistic personality disorder, and mixed personality disorder. Prior to the SIDP-IV structured interview, a full evaluation of the respondent’s current mental state is required (Pfohl et al., 1997). This is not surprising given that self-report of enduring personality characteristics can be seriously compromised in a respondent who is experiencing acute psychopathology. Indeed, the aim of all personality assessment measures is to rate the respondent’s typical, habitual, and lifelong personal functioning rather than acute or temporary states.

Interestingly, the SIDP-IV does not cover DSM personality categories on a disorder-by-disorder basis. Rather, DSM-IV personality disorder criteria are reflected in items that are grouped according to 10 topical sections that reflect a different dimension of personality functioning. These sections include interests and activities, work style, close relationships, social relationships, emotions, observational criteria, self-perception, perception of others, stress and anger, and social conformity. These categories are not scored; rather, they reflect broad areas of personal functioning under which personality disorder items can logically be subsumed (Pfohl et al., 1997).

Each SIDP-IV question corresponds to a unique DSM-IV personality disorder criterion, except that one item addresses two criteria. An attractive feature is that the specific DSM-IV criterion associated with each question is provided for interviewers to easily view. All questions are administered, and there are no options to skip out. Most questions are conversational in tone and open-ended to encourage respondents to talk about their usual behaviors and long-term functioning. In fact, respondents are specifically instructed to focus on their typical or habitual behavior when addressing each item and are prompted to “remember what you are like when you are your usual self.” Based on client responses, each criterion is rated on a scale with four anchor points: a rating of 0 indicates that the criterion was not present; 1 corresponds to a subthreshold level where there is some evidence of the trait but it is not sufficiently prominent; 2 refers to the criterion being present for most of the past 5 years; and 3 signifies a strongly present and debilitating level. The SIDP-IV requires that a trait be prominent for most of the past 5 years to be considered a part of the respondent’s personality. This 5-year rule helps to ensure that the personality characteristic is stable and of long duration, as required by the General Diagnostic Criteria for Personality Disorders.

A strong point of the organizational format by personality dimensions (rather than by disorders) is that data for specific diagnoses are minimized until final ratings have been collated on the summary sheet. This feature can potentially reduce interviewer biases, such as the halo effect or changing thresholds, if it is obvious that a respondent needs to meet one additional criterion to make the diagnosis. This topical organization also makes the interview’s intent less transparent compared with the disorder-by-disorder approach of some other interviews.

Significant clinical judgment is required to properly administer the SIDP-IV, because interviewers are expected to ask additional questions to clarify client responses when necessary. Also, data are not limited to self-report; rather, chart records and significant others such as relatives and friends who know the client well should be consulted when available, and a standard informed consent is included for informant interviews. Such collateral information is particularly prized when evaluating personality-disordered individuals who may lack insight into their own maladaptive personality traits and distort facts about their strengths and limitations. Moreover, informants can also provide diagnostic data that can help resolve the state/trait distinction about specific criterion behaviors.

If discrepancies between sources of information are noted, interviewers must consider all data and use their own judgment to determine the veracity of each source. Making this distinction can be one of the challenges faced by SIDP-IV administrators. Given the multiple sources of diagnostic data, final ratings are made after all sources of information are considered. Such ratings are then transcribed onto a summary sheet that lists each criterion organized by personality disorder, and formal diagnoses are assigned. As required by the DSM, diagnoses are made only if the minimum number of criteria (or threshold) has been met for that disorder.

Minimum qualifications for competent administration consist of an interviewer with an undergraduate degree in the social sciences and 6 months’ experience with diagnostic interviewing. Moreover, an additional month of specialized training and practice with the SIDP is required to become a competent interviewer (Pfohl et al., 1997). Administrators are required to possess an understanding of manifest psychopathology and the typical presentation and course of clinical and personality disorders. Training tapes and workshop information are available from the instrument authors. The SIDP typically requires 60–90 minutes for the client interview, 20 minutes for interview of significant informants, and approximately 20 minutes to fill out the summary score sheet. Studies documenting the strong psychometric properties of the SIDP are plentiful, and they are summarized in the manual for the instrument (Pfohl et al., 1997). At the time of publication of this chapter, there were no intended changes to the SIDP-IV (N. Blum, personal communication, February 13, 2017). The SIDP-IV is available for purchase through 

https://www.appi.org/

.

The Cultural Formulation Interview (CFI) of DSM-5

New to DSM-5 is the Cultural Formulation Interview (CFI), which is a 16-question semistructured interview designed to assess the impact of cultural factors on an individual’s mental health. The CFI is based on the Outline for Cultural Formulation, a framework for assessing cultural factors as they relate to individuals’ mental health that was first introduced in the DSM-IV. Although the CFI is not used to diagnose mental disorders per se, we have included it in this chapter because the CFI can be used to understand important cultural issues that can impact the expression and diagnosis of mental disorders in diverse populations.

According to the DSM-5, cultural concepts are essential to effective diagnostic assessment and clinical management for several reasons, including:

· aiding in avoiding misdiagnosis;

· obtaining useful clinical information;

· improving clinical rapport and engagement as well as therapeutic efficacy;

· clarifying cultural epidemiology;

· guiding clinical research (APA, 2013, p. 759).

The purpose of the CFI is to provide a guide for cultural assessment that improves “cultural validity of diagnostic assessment,” aids in treatment planning, and fosters the individual’s commitment and satisfaction (APA, 2013). There are two versions of the CFI: the core CFI, which is used to interview the individual, and the CFI-Informant Version, which is used when individuals are unable to answer the question for themselves, as is the case with children, or persons who are cognitively impaired or psychotic. Information for the CFI-Informant version is collected from a person who knows the individual well, and is knowledgeable about the individual’s clinical problems and the person’s important life circumstances. The information gathered from the CFI-Informant version can be used as a supplement to, or a replacement for, the core CFI.

The CFI is rooted in a person-centered approach focusing on the individual’s perspective of their cultural experiences and social contexts. It is suggested that the CFI be used in conjunction with previously obtained demographic information in order to tailor the questions to the individual’s current cultural context (APA, 2013). The information collected from the CFI and or the CFI-Informant version along with all other clinical information should be integrated to create a comprehensive evaluation.

The CFI is composed of four main sections, each focusing on a different aspect of cultural factors encountered in diagnostic assessment. The first section (questions 1–3) focuses on the cultural definition of the problem; the second section (questions 4–10) concentrates on cultural perceptions of cause, contacts, and support; the third section (questions 11–13) focuses on cultural factors affecting self-coping and past help-seeking; and the fourth section (questions 14–16) focuses on cultural factors affecting current help-seeking. The CFI is formatted into two columns. The left-hand column provides information to the interviewer on both how to administer the CFI and the goals of the section. The right-hand column offers suggested questions that can be used in the interview. The CFI is a semistructured interview so the questions are flexible and may be rephrased. Clinicians are also encouraged to ask follow-up questions as needed to clarify individuals’ answers. The DSM-5 suggests that the CFI be used flexibly to maintain a natural flow during the interview and therapeutic rapport (APA, 2013). Additional modules have been created to guide clinicians who wish to expand on any of the sections and explore them further during the interview, and for specific populations such as older adults, children, and immigrants. The instrument and supplemental modules can be found online at 

www.psychiatry.org/dsm5

.

Summary and Conclusions

This chapter highlights the fact that structured and semistructured interviews have greatly facilitated psychiatric diagnosis, objective measurement of symptoms, and problem clarification in a diverse range of clinical and research settings. Reliability of diagnosis is much improved with the use of structured interviews compared with the nonstandardized approach that is common in clinical practice, and improved reliability provides the foundation for enhanced validity and utility of diagnosis. Given the field’s recent emphasis on empirically supported psychotherapeutic interventions and processes (e.g., Barlow, 2014; Castonguay & Beutler, 2006; McHugh & Barlow, 2010; Nathan & Gorman, 2007), we hope that a concomitant focus on clinically relevant, standardized, objective, and validated assessment procedures will be realized as well. Structured and semistructured interviews play a key role in the advancement of the science of clinical psychology.

This chapter provided a broad overview of the basic issues surrounding structured and semistructured interviews, and it described many interviews available to clinicians and researchers. We hope that this information enables clinicians and researchers to choose instruments that will most appropriately suit their needs. Finally, as noted earlier, with the publication of DSM-5, many of the structured and semistructured interviews described in this chapter have undergone significant revisions to match the classification changes that occurred for many diagnostic categories. The structured and semistructured interviews that are used to diagnose personality disorders have not required imminent revisions because the classification and criteria of the personality disorders did not change in the move from DSM-IV-TR to DSM-5. The areas of classification and clinical assessment will undoubtedly continue to evolve and change in the coming years. As such, this is an exciting time for researchers and clinicians who use structured and semistructured interviews and other empirically based assessment tools.

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