Unstructured Clinical Interview Research Articles

How do eating disorder specialist clinicians apply DSM-IV diagnostic criteria in routine clinical practice? Implications for enhancing clinical utility in DSM-5

The clinical utility of the DSM-IV eating disorder (ED) diagnostic criteria among practicing clinicians has not been formally evaluated, despite the considerable diagnostic challenges these disorders present. This study evaluated inter-rater reliability between research and clinical diagnoses, identified discrepantly rated diagnostic criteria, and evaluated ED subtype use in a naturalistic treatment setting. Seventy-six adolescent and young adult female patients consecutively admitted to a residential ED program were evaluated independently by clinicians (unstructured clinical interview) and research assessors (Structured Clinical Interview for DSM-IV). Clinicians and research assessors conferred concordant ED diagnoses in 80.3% of cases ( κ = 0.70), thus highlighting the clinical utility of the extant DSM-IV diagnostic scheme in this specialty ED treatment setting. All but two discordant cases included a diagnosis of ED not otherwise specified (EDNOS). Clinicians applied ED subtypes in just 20.4% of eligible cases, and were significantly more likely to apply subtypes to major depressive disorder. Although clinical and research interviews yielded substantial reliability, EDNOS had the lowest reliability among the ED diagnoses. Moreover, infrequent subtype application on this specialty unit raises questions about the clinical utility of DSM-IV anorexia nervosa and bulimia nervosa subtypes, even in the context of clinically useful overarching categories.

The Unstructured Clinical Interview

In mental health, family, and community counseling settings, master's‐level counselors engage in unstructured clinical interviewing to develop diagnoses based on the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM‐IV‐TR; American Psychiatric Association, 2000). Although counselors receive education about diagnosis and the DSM classification system, the majority of them are not specifically trained in clinical interviewing. This article provides information about using the unstructured clinical interview to make a DSM‐IV‐TR diagnosis for adult clients with Axis I and Axis II disorders.

Improving the Reliability of the Diagnosis of Post-Traumatic Stress Disorder in Civil Litigation

Post-traumatic stress disorder (PTSD) has become one of the most frequently diagnosed psychiatric disorders, although there is little evidence that PTSD can be reliably diagnosed using an unstructured clinical interview. There are reports, however, of reasonable agreement in the diagnosis of the disorder between clinicians using structured interviews. PTSD is unusual in the inclusion of a necessary cause for the disorder in the A, or stressor criteria, which can lead expert witnesses in civil cases to pre-empt the court by deciding the cause of the patients' condition. Removing the A criterion in the diagnostic criteria for PTSD in DSM-V, or at least excluding opinion about the A criterion from expert evidence, would separate the diagnosis of PTSD from judgements about its aetiology.

Evidence-based assessment of personality disorders.

The purpose of this article is to provide a foundation for the development of evidence-based guidelines for the assessment of personality disorders, focusing in particular on integrated assessment strategies. The general strategy recommended herein is to first administer a self-report inventory to alert oneself to the potential presence of particular maladaptive personality traits followed by a semistructured interview to verify their presence. This strategy is guided by the existing research that suggests particular strengths of self-report inventories and semistructured interviews relative to unstructured clinical interviews. However, the authors also consider research that suggests that further improvements to the existing instruments can be made. The authors emphasize, in particular, a consideration of age of onset, distortions in self-perception and presentation, gender bias, culture and ethnicity, and personality change.

Reduced Brain GABA in Primary Insomnia: Preliminary Data from 4T Proton Magnetic Resonance Spectroscopy (1H-MRS)

Both basic and clinical data suggest a potential significant role for GABA in the etiology and maintenance of primary insomnia (PI). Proton magnetic resonance spectroscopy (1H-MRS) can non-invasively determine GABA levels in human brain. Our objective was to assess GABA levels in unmedicated individuals with PI, using 1H-MRS. Matched-groups, cross-sectional study conducted at two university-based hospitals. Sixteen non-medicated individuals (8 women) with PI (mean age = 37.3 +/- 8.1) and 16 (7 women) well-screened normal sleepers (mean age = 37.6 +/- 4.5). PI was established with an unstructured clinical interview, a Structured Clinical Interview for DSM-IV (SCID), sleep diary, actigraphy and polysomnography (PSG). 1H-MRS data were collected on a Varian 4 Tesla magnetic resonance imagingl spectroscopy scanner. Global brain GABA levels were averaged from samples in the basal ganglia, thalamus, and temporal, parietal, and occipital white-matter and cortex. Average brain GABA levels were nearly 30% lower in patients with PI (.18 +/- .06) compared to controls (.25 +/- .11). GABA levels were negatively correlated with wake after sleep onset (WASO) on two independent PSGs (r = -0.71, p = 0.0024 and -0.70, p = 0.0048). Our preliminary finding of a global reduction in GABA in non-medicated individuals with PI is the first demonstration of a neurochemical difference in the brains of those with PI compared to normal sleeping controls. 1H-MRS is a valuable tool to assess GABA in vivo, and may provide a means to shed further light on the neurobiology of insomnia.

Elevated Peripheral Visfatin Levels in Narcoleptic Patients

ObjectiveNarcolepsy is a severe sleep disorder that is characterized by excessive daytime sleepiness, cataplexies and a tendency towards obesity. Recent discoveries indicate that the major pathophysiology is a loss of hypocretin (orexin) producing neurons due to immunologically mediated degeneration. Visfatin is a recently described proinflammatory adipokine. It is identical to the immune modulating pre-B-cell colony enhancing factor (PBEF). Our study examines the hypothesis that visfatin levels are altered in narcoleptic patients.MethodsFor the analysis, a total of n = 54 patients (n = 18 males and n = 36 females) with the diagnosis of narcolepsy according to DSM-IV and the International Classification of Sleep Disorders were examined (BMI mean 30.3±5.5, age mean 52.5±16.1 years). As a control group 39 unrelated (n = 12 males and n = 27 females) healthy volunteers with no sleep disorder according to DSM-IV were included (BMI mean 28.5±4.6, age mean 51.1±13.6 years). Peripheral visfatin levels were measured using a commercial enzyme immunoassay kit with a measurement range from 0.1–1000 ng/ml. Narcolepsy symptoms, severity and frequency of symptoms as well as the total duration of various aspects of the symptomatology were assessed by unstructured and structured clinical interviews in including the Stanford Center for Narcolepsy Sleep Inventory.ResultsCirculating visfatin was found to be significantly increased in HLA DR2 positive narcoleptic patients compared to controls.ConclusionTaken together, our results add to the evidence of disturbed immunological regulation in patients with narcolepsy.

Combination of antidepressants and cognitive behaviour therapy

This study examined the association of various clinical features of obsessive-compulsive disorder (OCD) with quality of life (QoL) in 102 adults with a principal diagnosis of OCD. Participants were assessed by trained clinicians using the Anxiety Disorders Interview Schedule 4th edition, the Yale-Brown Obsessive-Compulsive Scale, and an unstructured clinical interview. Subjects completed the MOS-36 Item Short Form Health Survey, and Beck Depression Inventory-II. Obsessive-compulsive symptom severity was negatively correlated with emotional health, social functioning and general health QoL. Depressive symptoms mediated the relationship between obsessive-compulsive symptom severity and emotional health, social functioning and general health QoL. Additionally, interference of obsessive-compulsive symptoms mediated the relationship between obsessive-compulsive symptom severity and emotional health, social functioning and general health QoL. Resistance against obsessive-compulsive symptoms mediated the relationship between obsessive-compulsive symptom severity and social functioning QoL. Diminished QoL is present in persons with OCD and is essential in understanding the complete clinical picture of OCD.

Cocaine rapid evaluation screening trials: Design, results, and lessons learned

This study examined the association of various clinical features of obsessive-compulsive disorder (OCD) with quality of life (QoL) in 102 adults with a principal diagnosis of OCD. Participants were assessed by trained clinicians using the Anxiety Disorders Interview Schedule 4th edition, the Yale-Brown Obsessive-Compulsive Scale, and an unstructured clinical interview. Subjects completed the MOS-36 Item Short Form Health Survey, and Beck Depression Inventory-II. Obsessive-compulsive symptom severity was negatively correlated with emotional health, social functioning and general health QoL. Depressive symptoms mediated the relationship between obsessive-compulsive symptom severity and emotional health, social functioning and general health QoL. Additionally, interference of obsessive-compulsive symptoms mediated the relationship between obsessive-compulsive symptom severity and emotional health, social functioning and general health QoL. Resistance against obsessive-compulsive symptoms mediated the relationship between obsessive-compulsive symptom severity and social functioning QoL. Diminished QoL is present in persons with OCD and is essential in understanding the complete clinical picture of OCD.

Teaching ethics and medical conduct in developing countries under unstable political conditions

This study examined the association of various clinical features of obsessive-compulsive disorder (OCD) with quality of life (QoL) in 102 adults with a principal diagnosis of OCD. Participants were assessed by trained clinicians using the Anxiety Disorders Interview Schedule 4th edition, the Yale-Brown Obsessive-Compulsive Scale, and an unstructured clinical interview. Subjects completed the MOS-36 Item Short Form Health Survey, and Beck Depression Inventory-II. Obsessive-compulsive symptom severity was negatively correlated with emotional health, social functioning and general health QoL. Depressive symptoms mediated the relationship between obsessive-compulsive symptom severity and emotional health, social functioning and general health QoL. Additionally, interference of obsessive-compulsive symptoms mediated the relationship between obsessive-compulsive symptom severity and emotional health, social functioning and general health QoL. Resistance against obsessive-compulsive symptoms mediated the relationship between obsessive-compulsive symptom severity and social functioning QoL. Diminished QoL is present in persons with OCD and is essential in understanding the complete clinical picture of OCD.

Integrated treatment of male and female desire disorders

This study examined the association of various clinical features of obsessive-compulsive disorder (OCD) with quality of life (QoL) in 102 adults with a principal diagnosis of OCD. Participants were assessed by trained clinicians using the Anxiety Disorders Interview Schedule 4th edition, the Yale-Brown Obsessive-Compulsive Scale, and an unstructured clinical interview. Subjects completed the MOS-36 Item Short Form Health Survey, and Beck Depression Inventory-II. Obsessive-compulsive symptom severity was negatively correlated with emotional health, social functioning and general health QoL. Depressive symptoms mediated the relationship between obsessive-compulsive symptom severity and emotional health, social functioning and general health QoL. Additionally, interference of obsessive-compulsive symptoms mediated the relationship between obsessive-compulsive symptom severity and emotional health, social functioning and general health QoL. Resistance against obsessive-compulsive symptoms mediated the relationship between obsessive-compulsive symptom severity and social functioning QoL. Diminished QoL is present in persons with OCD and is essential in understanding the complete clinical picture of OCD.

Neurobiology and treatment of cocaine dependence

This study examined the association of various clinical features of obsessive-compulsive disorder (OCD) with quality of life (QoL) in 102 adults with a principal diagnosis of OCD. Participants were assessed by trained clinicians using the Anxiety Disorders Interview Schedule 4th edition, the Yale-Brown Obsessive-Compulsive Scale, and an unstructured clinical interview. Subjects completed the MOS-36 Item Short Form Health Survey, and Beck Depression Inventory-II. Obsessive-compulsive symptom severity was negatively correlated with emotional health, social functioning and general health QoL. Depressive symptoms mediated the relationship between obsessive-compulsive symptom severity and emotional health, social functioning and general health QoL. Additionally, interference of obsessive-compulsive symptoms mediated the relationship between obsessive-compulsive symptom severity and emotional health, social functioning and general health QoL. Resistance against obsessive-compulsive symptoms mediated the relationship between obsessive-compulsive symptom severity and social functioning QoL. Diminished QoL is present in persons with OCD and is essential in understanding the complete clinical picture of OCD.

Two weeks' quetiapine treatment for schizophrenia, drug-induced psychosis and borderline personality disorder: a naturalistic study with drug plasma levels

Objective: To evaluate clinical outcomes and the tolerability of 2 weeks' quetiapine (QTP) treatment for hospitalised patients in a naturalistic setting. Methods: Patients with schizophrenia (n = 18), drug-induced psychosis (n = 10; 3 cocaine, 4 hashish and marijuana, and 3 all three substances) or borderline personality disorder (n = 13), were diagnosed by two expert clinicians on the basis of an unstructured clinical interview, and were treated with QTP (250 – 1000 mg/day). The subjects were then clinically assessed at baseline, and after 7 and 15 days, using the Brief Psychiatric Rating Scale, the Positive and Negative Symptoms Scale (PANSS) and the Hamilton Rating Scale for Depression. At the end of the study, plasma QTP levels were determined and examined in relation to clinical outcome and tolerability. Results: The mean scores of each rating scale were significantly lower at the end of the study in the population as a whole, and within each diagnostic group. The percentage improvement was significantly greater in the patients with drug-induced psychosis than in those with schizophrenia (42.4 ± 9.1% versus 23.6 ± 13.5%). QTP was well tolerated, and the incidence of extrapyramidal side effects was low. There was a linear correlation between plasma levels and dose/kg of QTP (r = 0.31; p < 0.05). The improvement in PANSS significantly correlated with plasma levels and dose/kg in each diagnostic category (Spearman's coefficient was 0.75 [p < 0.01] for schizophrenia and borderline personality disorder, and was 0.68 [p < 0.05] for drug-induced psychosis). Conclusion: The results suggest that 2 weeks' QTP treatment may improve the clinical outcome of psychotic re-exacerbation phases in different diagnostic categories and indicate that QTP improves clinical outcome in drug-induced psychosis, as QTP levels correlated with the clinical improvement measured by PANSS.

Bipolar and nonbipolar obsessive-compulsive disorder: a clinical exploration

Comorbidity of obsessive-compulsive disorder (OCD) in bipolar disorder is well documented. However, clinical characteristics of bipolar OCD are not well studied. The objective of the present study was to compare the clinical characteristics of bipolar and nonbipolar OCD. We chose 28 subjects with bipolar-OCD comorbidity from a sample of 80 remitted bipolar subjects (bipolar OCD) attending the outpatient services of the National Institute of Mental Health and Neurosciences, Bangalore, India, over a period of 11 months. We also recruited 78 nonbipolar OCD subjects consecutively during the same period from the OCD clinic of the institute. They underwent systematic assessment using both structured and unstructured clinical interviews and corroborative information obtained from the immediate family members and the hospital clinical charts. Bipolar OCD subjects were characterized by episodic course of OCD, high family loading for mood disorders, and comorbidity with depression, social phobia, and generalized anxiety disorder. They had less severe OCD and had somewhat different symptom profile compared with nonbipolar OCD. The OCD predated bipolar disorder in 54% of the bipolar OCD subjects; and in the remaining subjects, it had an onset during the course of bipolar disorder. Most bipolar OCD subjects reported worsening of OCD in depression (n = 22, 78%) and improvement in manic/hypomanic episodes (n = 18, 64%). Our findings suggest that OCD in those with a primary diagnosis of bipolar disorder is perhaps pathophysiologically related to bipolar disorder than to OCD. This is strongly supported by the episodic course of OCD, high familial loading for mood disorders, and worsening of OCD in depression with improvement in hypomania/mania phases. There is a need for systematic exploration of the OCD-bipolar comorbidity in both OCD and bipolar samples. Family-genetic and other neurobiological research and the prospective follow-up of bipolar and nonbipolar OCD subjects would further enhance our understanding of this complex comorbidity. The cross-sectional nature of the study based on retrospective assessment of course, the small sample size and the inclusion of only remitted bipolar subjects are the limitations of this study.

Evidence-based assessment of personality disorders.

The purpose of this article is to provide a foundation for the development of evidence-based guidelines for the assessment of personality disorders, focusing in particular on integrated assessment strategies. The general strategy recommended herein is to first administer a self-report inventory to alert oneself to the potential presence of particular maladaptive personality traits followed by a semistructured interview to verify their presence. This strategy is guided by the existing research that suggests particular strengths of self-report inventories and semistructured interviews relative to unstructured clinical interviews. However, the authors also consider research that suggests that further improvements to the existing instruments can be made. The authors emphasize, in particular, a consideration of age of onset, distortions in self-perception and presentation, gender bias, culture and ethnicity, and personality change.

Evaluating Competencies: Forensic Assessments and Instruments, Second Edition

Evaluating Competencies: Forensic Assessments and Instruments, Second Edition

An illustration of how a self-report diagnostic screening scale could improve the internal validity of antidepressant efficacy trials

Background: During the past 20 years semi-structured diagnostic interviews have been the standard for diagnostic evaluations in research relying on reliable and valid psychiatric assessment and diagnosis; however, only a minority of antidepressant efficacy trials (AETs) employ these interviews. This might be important insofar as several studies have found that clinicians conducting unstructured clinical interviews underrecognize diagnostic comorbidity. Because of the financial incentives to recruit patients into AETs quickly, there is little incentive to vigorously determine the presence of comorbid conditions that should result in exclusion from the trial. In the present report we demonstrate how a self-report diagnostic screening scale could be used to identify systematic differences in diagnostic practice across settings, and how such a scale could be used to compare samples of patients who pass screening evaluations and are accepted into an AET. Methods: Depressed patients completed the Psychiatric Diagnostic Screening Questionnaire (PDSQ), and were evaluated with either an unstructured clinical interview or with the Structured Clinical Interview for DSM-IV (SCID). Results: The two samples were clinically comparable based on their scores on the self-administered PDSQ. Consistent with the greater thoroughness of the SCID, compared to unstructured diagnostic evaluations, more patients administered the SCID were diagnosed with comorbid conditions. After excluding patients with disorders that might be the basis for exclusion from an AET, the two samples then differed in their scores on the PDSQ. That is, more patients in the sample evaluated by an unstructured interview had ‘occult’ pathology than patients evaluated with the SCID. Conclusion: These findings demonstrate how systematic differences in diagnostic practice might be detected across sites when conducting AETs. Limitations: The study was conducted with patients in a single outpatient clinical practice rather than participants of a multi-site trial.

Is posttraumatic stress disorder underdiagnosed in routine clinical settings?

The goal of the present study was to examine whether posttraumatic stress disorder (PTSD) is underrecognized in routine clinical practice. One thousand patients were evaluated at the Rhode Island Hospital Department of Psychiatry outpatient practice. The first 500 patients completed a psychiatric diagnostic screening questionnaire that included a PTSD subscale. The next 500 individuals were interviewed with the Structured Clinical Interview for DSM-IV (SCID). In the first 500 patients, 36 (7.2%) patients were diagnosed by their clinicians with PTSD and an additional 18.6% of the sample screened positive on the questionnaire but were not diagnosed with PTSD. The patients who were diagnosed with PTSD and the patients who screened positive but were not given the diagnosis were significantly younger, had lower GAF scores, and less frequently graduated from college than the non-PTSD group. The frequency of suicidal thoughts was identical in the two PTSD groups and twice as high as the frequency in the non-PTSD group. Scores on 9 of the other 12 psychopathology dimensions assessed by the screening questionnaire were significantly higher in the two PTSD groups than the non-PTSD group. In the 500 patients interviewed with the SCID the prevalence of PTSD was two times higher than in the 500 patients diagnosed with an unstructured clinical interview (14.4% vs. 7.2%). The difference in prevalence rates of PTSD between the SCID and clinical samples was significant when considering PTSD as an additional diagnosis; there was no difference in prevalence rates when restricting the analysis to principal diagnoses. The results of this study suggest that PTSD is frequently overlooked in routine clinical practice when symptoms of PTSD are not the presenting complaint.

Psychiatric diagnosis in clinical practice: Is comorbidity being missed?

The recognition of comorbidity has important clinical significance. Comorbidity predicts a poorer outcome for patients with depressive and anxiety disorders, and the presence of multiple psychiatric disorders is associated with greater psychosocial impairment. In routine clinical settings, an unstructured interview is typically used to assess patients. However, unstructured interviews may result in missed diagnoses, with potential negative clinical consequences. The goal of the present study was to examine whether diagnostic comorbidity is less frequently identified during a routine clinical evaluation versus a semistructured diagnostic interview. Axis I diagnoses derived from structured and unstructured clinical interviews were compared in two groups of psychiatric outpatients in the same practice setting. Five hundred individuals presenting for an intake appointment to a general adult psychiatric practice underwent a routine unstructured clinical interview. Subsequent to completion of the first study, the method of conducting diagnostic evaluations was changed and 500 individuals were interviewed with the Structural Clinical Interview for DSM-IV Axis I Disorders (SCID). The two groups had similar demographic characteristics and scored similarly on symptom questionnaires. Individuals interviewed with the SCID were assigned significantly more axis I diagnoses than individuals assessed with an unstructured interview. More than one third of the patients interviewed with the SCID were diagnosed with three or more disorders, in contrast to fewer than 10% of the patients assessed with an unstructured interview. Fifteen disorders were more frequently diagnosed in the SCID sample, and these differences occurred across mood, anxiety, eating, somatoform, and impulse-control disorder categories. The results suggest that in routine clinical practice, clinicians underrecognize diagnostic comorbidity. Anxiety, somatoform, and not otherwise specified (NOS) disorders were the most frequently underdetected disorders. The implications of underdiagnosis for the treatment outcome are discussed.

Body dysmorphic disorder in psychiatric outpatients: Recognition, prevalence, comorbidity, demographic, and clinical correlates

The prevalence of Body Dysmorphic Disorder (BDD), based on structured and unstructured clinical interviews, was compared in two samples of psychiatric outpatients drawn from the same practice setting. In the first sample, 500 patients were diagnosed according to a routine, unstructured clinical interview. In the second sample, 500 subjects were diagnosed according to information obtained by the Structured Clinical Interview for DSM-IV (SCID). No patient was diagnosed with BDD in the clinical sample, whereas 16 (3.2%) patients were diagnosed with BDD in the SCID sample. Compared with patients without BDD, patients with BDD received significantly more current axis I diagnoses, and were more likely to be diagnosed with current obsessive-compulsive disorder (OCD) and social phobia. Both groups were diagnosed with major depression at similar rates. Patients with BDD, versus those without, tended to be sicker and more functionally impaired. It appears that BDD is an infrequent disorder in an outpatient setting, which is rarely recognized when clinicians conduct their routine diagnostic interview. Although it was not usually a patient's principal reason for seeking treatment, the majority of patients with BDD in this sample wanted their treatment to address these symptoms.

Prevalence of mood disorders according to dsm-iii-r criteria in the community elderly residents in Japan.

The prevalence rates of mood disorders according to the DSM- III -R criteria in the community elderly were investigated with structured interviews conducted by psychiatrists. The subjects were 1,965 randomly selected residents aged 65 years or more who lived in Nagai City, Japan. In the first phase, a questionnaire including the short form of the Geriatric Depression Scale (GDS) was distributed to all subjects. In the second phase, all persons scoring 6 points or more on the GDS and approximately half as many of these persons randomly selected from the remaining respondents scoring 5 points or less were examined by psychiatrists using the A and D modules of the Structured Clinical Interview for DSM-III-R. The 1-month prevalence rates of major depression and bipolar disorder were estimated to be 0.9% and 0.0%, and the current prevalence of dysthymia was estimated to be 0.5%. By using additional unstructured clinical interviews, we also found the prevalence rates of adjustment disorder with depressed mood and other types of depression to be 3.8% and 2.5%. For these categories of depression, prevalence rates did not differ significantly by sex or age group, except that the prevalence of adjustment disorder with depressed mood was significantly higher in women than in men.