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.

Using SCIDs

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.

Catch-22

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.

Editor’s note: Jon G. Allen, PhD, and Heather Kranz, MEd, CRC, also contributed to this blog post.

As a research/diagnostic interviewer, it’s my job to determine if a patient’s symptoms are severe enough to be labeled “clinically significant” and thus to warrant a psychiatric diagnosis. This is much easier said than done. 

Diagnosing clinical syndromes, such as depression or anxiety, is much more straightforward than diagnosing personality disorders. To meet criteria for a personality disorder diagnosis, the patient must have several traits characteristic of that particular disorder – a whole pattern of traits. Thus, diagnosing personality disorders is a two-step process. The first step is to determine if the patient meets the threshold for various individual traits. The second step is to determine if the patient has a sufficient number of traits within each category to qualify for the diagnosis.

Common personality disorder traits    

Recently, I have been entering information about personality disorder traits that patients have met into a database, and I have noticed several personality disorder traits that are the most common among patients at The Menninger Clinic. One is “rigidity or stubbornness,” which is one of the traits considered in the diagnosis of obsessive-compulsive personality disorder. According to the current data, more than a third of patients meet the criteria for the “stubbornness” trait. The Diagnostic and Statistical Manual for Mental Disorders-IV (DSM-IV) gives no guidelines regarding the prevalence of this trait. Based on our findings, a substantial minority of patients either believe they are stubborn or have been told by others that they are stubborn. This begs the question: Exactly how stubborn does someone have to be to meet the criteria for the stubbornness trait? 

The Merriam-Webster Dictionary defines stubborn as “unreasonably and perversely unyielding.” The DSM-IV description is a tad more in-depth. Persons who are stubborn are so concerned about having things done the one “correct” way that they have trouble going along with anyone else’s ideas. These individuals meticulously plan ahead and are unwilling to consider changes in plans. Such persons are wrapped up in their own perspective and have difficulty acknowledging the viewpoints of others. Their rigidity frustrates friends and colleagues. Furthermore, persons with this trait might recognize that it is in their best interest to compromise, but they stubbornly (for lack of a better term) refuse, arguing that it is “the principle of the thing.” The diagnostic trait of stubbornness or rigidity means more than simply being “unreasonably and perversely unyielding.”

Borderline personality disorder

Another common trait I observe is “chronic feelings of emptiness,” one of the traits of borderline personality disorder. In fact, one third of patients have this trait. Merriam-Webster defines empty as “having no purpose or result” or “marked by the absence of human life, activity or comfort.” The DSM-IV adds little to this definition beyond the point that people who suffer from chronic feelings of emptiness get easily bored and are continually seeking something to do. “Emptiness” is left to the eye of the beholder.

The DSM-IV offers some explication of stubbornness and emptiness, but the decision is left to the interviewer as to whether a patient indeed has the trait at a clinically significant level. There is no clear line distinguishing normal from clinically significant levels of a trait. This is a judgment call for the interviewer, taking into account the degree of functional impairment that the trait causes. For example, a person’s stubbornness may be so extreme that it inhibits him or her from maintaining mutually satisfying relationships. Similarly, persons may feel so empty inside that nothing provides them with joy. For a trait to be functionally impairing, there must be an enduring and pervasive influence on the person’s behavior or attitude. It is important to note that traits are only a part of the constellation of the associated personality disorder.

Traits vs. clusters

Moreover, the distress or impairment is not based on any simple trait but rather several traits that make up the disorder. For example, other traits of obsessive-compulsive personality disorder include preoccupation with details, perfectionism, excessive devotion to work, unwillingness to delegate tasks and so forth. We must also keep in mind that individual traits (stubbornness) and clusters (obsessive-compulsive personality disorder) can be beneficial in moderation. Having too little stubbornness might lead to being too easily swayed or influenced.

Other obsessive-compulsive characteristics such as a need for order, structure and organization can certainly be helpful. Think of Steve Jobs: He was notorious for his need to have things exactly right, and he was tremendously successful because of it. Once again, it all comes down to the level of clinical functional impairment that a trait or cluster causes. In personality disorders, this occurs mainly in the context of relationships. As I have illustrated, the diagnostic manual goes beyond the textbook definition found in the dictionary.

More generally, there is an inherent difficulty in drawing a bright line when all traits come in degrees. It is important to avoid overdiagnosing. When we overdiagnose we risk stigmatizing the patient. When given the diagnosis of a personality disorder, patients are liable to misinterpret it, thinking they are being told they have a “bad personality.” Not true: The diagnosis refers to a specific problematic aspect of personality functioning, not the entire personality. A person might have a personality disorder coupled with many positive personality traits. In my work as a diagnostic interviewer, I aspire to pinpoint problems to help guide treatment. Yet treatment must be based on a full understanding of the whole person.