With each revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM), now in its fourth iteration (DSM-IV), criteria for the diagnoses of psychiatric disorders are refined in a bootstrapping process: increasingly objective criteria facilitate research; in turn, research findings contribute to the knowledge base for developing better understanding of disorders and for refining the diagnostic criteria.
Yet research on psychiatric disorders requires not only that the same diagnostic criteria be used from study to study but also that the same procedure for assessing the criteria be employed. Accordingly, Structured Clinical Interviews for DSM Disorders (SCIDs) have been developed to standardize the diagnostic process for research. Interviewers guide patients systematically through a comprehensive review of symptoms and problems and make decisions about the criteria met for various disorders. Owing to their objectivity, repeatability, standardization and comprehensiveness, SCID interviews have become the gold standard for research diagnoses in psychiatry.
For the past year and a half, we have been administering SCID interviews to all adult patients at The Menninger Clinic. The purpose is twofold. First, although the interviews are designed for research, we put clinical practice first and thus provide the results to treating psychiatrists and treatment teams to provide additional information that they might incorporate into their understanding of the patient and their clinical diagnoses. In this endeavor, we take a no-stone-unturned approach, covering diagnoses that are not necessarily encompassed in the patients’ presenting problems. Second, we employ the research diagnoses in our studies of treatment outcomes, and these standardized diagnoses also will be essential in planned research in neuroscience that will include genetic studies and functional brain imaging.
Although they are designed to maximize objectivity, the SCIDs nonetheless also rely on subjective judgments on the part of the patient and interviewer. In our language, these judgments depend on mentalizing: awareness and understanding of mental states in self and others. Answering interviewers’ questions about their perceptions, thoughts, beliefs, emotions, moods and personality characteristics requires that patients be self-aware and able to remember and articulate their internal experience. Some questions about symptoms are relatively objective and do not require extensive mentalizing, for example, questions about weight changes, self-injurious behavior, drug use or behavioral rituals.
Other questions relate to symptoms and problems that are more subjective and require an exceptional level of self-awareness. Many diagnoses, for example, depend on the duration or timing of symptoms. The diagnosis of major depression requires a two-week period during which mood is depressed most of the day, nearly every day. Dysthymic disorder requires depressed mood most of the day more days than not for at least two years. Schizoaffective disorder requires that a person with a mood disorder have a period of at least two weeks during which hallucinations or delusions were present in the absence of prominent mood symptoms. These judgments require detailed memory for highly subjective experience.
There are some paradoxes in expecting patients to mentalize and report symptoms of which they might be unaware. For example, exceptional mentalizing is required of persons with delusions who are asked if they have unusual or unrealistic beliefs—those with delusions consider their unrealistic beliefs to be reasonable. Patients with obsessive-compulsive disorder may rationalize their excessive checking, hand washing, organizing or perfectionistic standards as being necessary for safety or as being required for a high level of performance. Patients who abuse substances may not remember how much they consume and may not be attuned to the extent of impairment in their functioning or relationships.
Thus the Achilles’ heel of the SCID is its dependence on self-report. The catch-22: patients’ current psychiatric symptoms (e.g., depression, anxiety, psychosis) as well as their defensiveness and shame may interfere with their capacity to mentalize, yet they must mentalize to give an accurate account of their symptoms. Ironically, the shame associated with stigma affects patients in psychiatric interviews as well as in other social settings.
The interviewer’s mentalizing capacity comes into play in two senses. First, the interviewer must understand and empathize with the patient’s experience and then map this understanding onto diagnostic criteria (e.g., to determine if reports of sadness or discouragement count as depressed mood). Diagnoses require that the patient’s symptoms are of sufficient severity as to cause impaired functioning or marked distress; this judgment requires comparison of the patient’s experience with some normative yardstick on the part of the interviewer as well as the patient. How much impairment or distress is beyond the norm?
Second, more fundamentally, the interviewer must establish rapport with the patient and provide a climate of respect and safety. Thus the interviewer will be most effective when maintaining what we call the mentalizing stance of open-minded, nonjudgmental and compassionate curiosity about patients’ inner worlds. This stance is essential to help patients feel comfortable being forthcoming about symptoms and problems about which they might feel anxious or ashamed.
Achieving diagnostic understanding is a therapeutic process. With the DSM and SCIDs, we employ science and technology. But art and craft also come into play in an endeavor that—at bottom—is entirely dependent on mentalizing capacity.