Diagnostic Interviewing

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Diagnostic Interviewing

• Source Page, A. C., Stritzke, W. G. K. (2006).
  Clinical psychology for trainees Foundations of
  science-informed practice. Cambridge Cambridge
  University Press.

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Picture yourself

• A 32 year old married woman presents due to
  difficulty getting to sleep and so you have
  prepared for the first interview by reading about
  insomnia.
• You open the interview by asking the client to
  elaborate on her problem and she tells you about
  a variety of issues.
• She describes lying in bed being unable to sleep
  because she finds that she has concerns about the
  previous day. Worries about the future spin
  around her mind making sleep an impossibility.
• However, in addition to the symptoms you expect a
  person with insomnia to describe, the client
  tells you that she is overly irritable during the
  day, has extreme difficulty concentrating, is
  chronically indecisive, and feels immense
  fatigue.
• What issues face you?

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Possible Issues

• Are the problems related in any way? If so,
  which problem do you treat first to assist the
  client as quickly as possible?
• Are the problems are all manifestation of the
  same underlying cause or multiple causes? Thus,
  is there an underlying cause(s) to be treated?
• What treatment is best for which problem or
  constellation of problems?

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Do Taxonomies Help?

• Diagnostic manuals and systems represent the
  collation of many years of clinical experience
  and research determining which problems tend to
  group into meaningful clusters.
• These clusters can be used to organize the
  literature and assist clients and therapists to
  identify treatments that are going to be
  potentially effective for a given client with a
  particular set of problems.

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Videos

• DID
• Ere

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What is a mental disorder?

• The World Health Organization (WHO) in the
  section on classification of mental and
  behavioral disorders in its Tenth Revision of the
  International Classification of Diseases and
  Related Health Problems (ICD-10 WHO, 1992) does
  not define a mental disorder.
• The authors note that although they use the term
  disorder (in preference to disease and
  illness), it is not an exact term, but is used
  here to imply the existing of a clinically
  recognizable set of symptoms or behavior
  associated in most cases with distress and
  interference with personal functions (WHO, 1992
  p. 5).

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DSM IV Definition of Mental Disorder

• Clinically significant behavioral or
  psychological syndrome or pattern that occurs in
  an individual and that is associated with present
  distress or disability or with a significantly
  increased risk of suffering death, pain,
  disability, or important loss of freedom.
• Must not be an expectable culturally sanctioned
  response to event.
• Must currently be a manifestation of a
  behavioral, psychological, or biological
  dysfunction in the individual.
• Neither deviant behavior nor conflicts that are
  primarily between the individual and society are
  mental disorders unless symptom of a dysfunction.

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Why Diagnose at All?

• necessary to have an agreed nomenclature so that
  mental health professionals can share a common
  language.
• common language is needed so that information
  about particular psychopathologies can be
  retrieved.
• classification is a fundamental human activity
  that is necessary to organise the world within
  which we live, and therefore diagnostic systems
  aim to identify
• American Psychiatric Associations DSM-IV-TR
  (APA, 2000)
• World Health Organization ICD-10 (1992, 1993)

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DSM-IV Multiaxial Assessment

• Axis I Clinical Disorders
• gt1 Axis I disorder, all reported principal
  diagnosis or reason for visit indicated by
  listing it first.
• Principal diagnosis or reason for visit assumed
  to be Axis I unless Axis II diagnosis is followed
  by "(Principal Diagnosis)" or "(Reason for
  Visit)."
• No Axis I disorder, code V71.09.
• Axis I diagnosis deferred, pending additional
  information, code 799.9.

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DSM-IV Multiaxial Assessment

• Disorders 1st Diagnosed in Infancy, Childhood, or
  Adolescence (not MR)
• Delirium, Dementia, Amnestic Other Cognitive
  Disorders
• Mental Disorders Due to a General Medical
  Condition
• Substance-Related Disorders
• Schiz. Other Psychotic Disorders
• Mood Disorders

• Anxiety Disorders
• Somatoform Disorders
• Factitious Disorders
• Dissociative Disorders
• Sexual Gender Identity Disorders
• Eating Disorders
• Sleep Disorders
• Impulse-Control Disorders NEC
• Adjustment Disorders
• Other Conditions

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DSM-IV Multiaxial Assessment

• Axis II Personality Disorders Mental
  Retardation
• Paranoid Personality Disorder
• Schizoid Personality Disorder
• Schizotypal Personality Disorder
• Antisocial Personality Disorder
• Borderline Personality Disorder
• Histrionic Personality Disorder
• Narcissistic Personality Disorder
• Avoidant Personality Disorder
• Dependent Personality Disorder
• Obsessive-Compulsive Personality Disorder
• Personality Disorder Not Otherwise Specified
• Mental Retardation

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DSM-IV Multiaxial Assessment

• Axis III Medical Conditions
• Axis IV Psychosocial and Environmental Problems
• Problems with primary support group
• Problems related to the social environment
• Educational problems
• Occupational problems
• Housing problems
• Economic problems
• Problems with access to health care
• Problems related to interaction with the legal
  system/crime
• Other PE problems
• Axis V Global Assessment of Functioning

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GAF

• 90-81 Absent or minimal symptoms (e.g., mild
  anxiety before an exam), good functioning in all
  areas, interested and involved in a wide range of
  activities, socially effective, generally
  satisfied with life, no more than everyday
  problems or concerns (e.g., an occasional
  argument with family members).
• .
• 60-51 Moderate symptoms (e.g., flat affect and
  circumstantial speech, occasional panic attacks)
  OR moderate difficulty in social, occupational,
  or school functioning (e.g., few friends,
  conflicts with peers or co-workers).
• 50-41 Serious symptoms (e.g., suicidal ideation,
  severe obsessional rituals, frequent shoplifting)
  OR any serious impairment in social,
  occupational, or school functioning (e.g., no
  friends, unable to keep a job).
• .
• 20-11 Some danger of hurting self or others
  (e.g., suicide attempts without clear expectation
  of death frequently violent manic excitement)
  OR occasionally fails to maintain minimal
  personal hygiene (e.g., smears feces) OR gross
  impairment in communication (e.g., largely
  incoherent or mute).
• 10-1 Persistent danger of severely hurting self
  or others (e.g., recurrent violence) OR
  persistent inability to maintain minimal personal
  hygiene OR serious suicidal act with clear
  expectation of death.

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Multiaxial Assessment

• Example 1
• Axis I 296.23 Major DepressiveDisorder, Single
  Episode, Severe without Psychotic Features
• 305.00 Alcohol Abuse
• Axis II 301.6 Dependent PD Frequent use of
  denial
• Axis III None
• Axis IV Threat job loss
• Axis V GAF35 (current)

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Multiaxial Assessment

• Axis I 300.4 Dysthymic Disorder
• 315.00 Reading Disorder
• Axis II V71.09 No diagnosis
• Axis III 382.9 Otitis media, recurrent
• Axis IV Victim of child neglect
• Axis V GAF53 (current)

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ICD-10

• The official coding system is the International
  Classification of Diseases, Tenth Revision,
  (ICD-10 WHO, 1992)
• Most DSM-IV-TR disorders have a numerical ICD-10
  code
• ICD-10 does not use a multiaxial system of
  diagnosis, although there is discussion of a
  triaxial system in which there are the clinical
  diagnoses on Axis I, Disabilities on Axis II, and
  contextual factors on Axis III.
• The first volume includes the clinical
  descriptions and the diagnostic guidelines

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ICD Structure

• (i) Organic, including symptomatic, mental
  disorders (e.g., dementia in Alzheimer's disease)
• (ii) Mental and behavioral disorders due to
  psychoactive substance use (e.g., harmful use of
  alcohol)
• (iii) Schizophrenia, schizotypal and delusional
  disorders
• (iv) Mood (affective) disorders
• (v) Neurotic, stress-related and somatoform
  disorders (e.g., generalized anxiety disorder)
• (vi) Behavioral syndromes associated with
  physiological disturbances and physical factors
  (e.g., eating disorders)
• (vii) Disorders of adult personality and behavior
  (e.g., transsexualism)
• (viii) Mental retardation
• (ix) Disorders of psychological development
  (e.g., childhood autism)
• (x) Behavioral and emotional disorders with onset
  usually occurring in childhood and adolescence
  (e.g., conduct disorders).

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ICD

• Each disorder is listed
• description of the main clinical and important
  associated features
• diagnostic guidelines verbal descriptions that
  indicate the quantity and balance of symptoms
  required before a diagnosis can be made
• Flexibility
• The companion volume within the ICD-10 (WHO,
  1993) lists the research diagnostic criteria, and
  the format is much more similar to the DSM in
  that particular criteria are specified for each
  disorder.

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Comparison Contrast

• ICD identifies three varieties of a depressive
  episode, ranging from mild to severe
• DSM, where a client with a mild diagnosis, must
  first meet diagnostic criteria for a Major
  Depressive Episode, a mild depressive episode in
  ICD would report or exhibit for a two week period
  two symptoms of a depressed mood, loss of
  pleasure, reduced energy and fatigue, and two
  symptoms from tiredness, reduced concentration
  and attention, reduced self-esteem and
  self-confidence, ideas of guilt and unworthiness,
  bleak views of the future, ideas or acts of
  self-harm or suicide, disturbed sleep, diminished
  appetite
• Diagnostic specifiers used in DSM-IV-TR are
  incorporated into the ICD by asking the clinician
  to code the particular category. Therefore, a
  client with repeated mild episodes of depression
  may receive a diagnosis of F33.0 Recurrent
  depressive disorder, current episode mild.
• Note that the diagnostic codes are equivalent,
  yet the quantity and type of diagnostic criteria
  are not identical (see Rounsaville, Alarcón,
  Andrews, Jackson, Kendell, Kendler, 2002).

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Cultural Sensitivity

• Both diagnostic systems acknowledge the need for
  cultural sensitivity when assigning diagnoses.
• This will be achieved by explicitly considering
  the clients ethnic or cultural reference groups
  and possible cultural explanations of a clients
  symptoms.
• the mode of expression may vary across cultures
  (e.g., greater somatic presentations of mood
  disorders in some cultures)
• the meaning the symptoms
• and perceived causal models that are used by the
  client to explain their symptoms

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Cultural Sensitivity

• Although there are disorders that appear
  culturally specific, more usual situation facing
  the clinician is the need to be sensitive to the
  ways in which cultural and other social factors
  influence the presentation and impact of a
  disorder, as well as the way this is communicated
  to (and understood by the clinician).

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Diagnostic Interviewing

• Since your aim will be to assist a client while
  discussing what could well be sensitive,
  distressing, private, and damaging issues, it is
  necessary that a good rapport is established

• Courteous
• Questioning open, and designed to help the client
  talk while the clinician listens
• Notetaking?

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Diagnostic Interviewing

• While there may be times when tact and
  sensitivity dictate a more gradual introduction,
  clients typically arrive at a consultation
  prepared to tell their story. Thus, it may be
  helpful to encourage the client to phrase the
  problem in their own words. For instance, you
  may ask, I wonder if you could tell me what
  brought you here today?
• As the client begins to respond to this question,
  ensure that you model good listening behavior.
  Respond with verbal and nonverbal indications
  that you have heard and understood both the
  content of the speech, but also the broader
  emotional and social context that the person
  finds themselves in.

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Example Interview

• Therapist Your referral suggests that you are
  having trouble with sleeping. Could you tell me
  a bit about the troubles youve been having?
• Client Well, I just cant get off to sleep at
  night because these worrying thoughts keep
  popping into my head. They just go around and
  around, so that I cant fall asleep. Im now so
  tired that I feel that if I could just get a good
  nights sleep everything will be OK again.
• Therapist These worries seem to be having a huge
  impact on you.
• Client They are. In fact, they seem to be the
  main problem.
• Therapist What sort of things do you worry
  about?
• Client About anything and everything. I worry
  about my childrens health, I worry about not
  having enough money, I worry about the house
  burning down, I worry about work I even worry
  that I worry about worrying.

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Example Interview

• Therapist Can you tell me about this worry
  about worrying?
• Client I feel I need to worry. If I dont, then
  I worry that something terrible will happen.
  Like when my children go out at night, Im never
  sure that theyll be safe, but if I worry then I
  feel that things are better because Ive done
  everything I can.
• Therapist Do these worries occur at times other
  than when you are trying to go to sleep?
• Client Yes, the happen all the time. Right now
  Im worrying that you might not be able to help
  me because Im not being clear enough. This has
  been going on for years now and I dont know if I
  have a problem or if its just the way I am.
• Therapist When people worry a lot for a long
  time, there can be effects in the rest of their
  life. Have you noticed any impact of the worry?
• Client As well as the sleep, I notice that I get
  really tense. The muscles around my neck tighten
  up so much that Im in pain.

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Example Interview

• Therapist That must be exhausting as well as
  painful.
• Client Youre right. I am so tired from all
  the worry and tension, but I still dont seem to
  be able to sleep it doesnt make sense.
• Therapist Well talk about trying to make sense
  of you experience a little later, but for the
  time being Id like to continue to get a clear
  idea in my head of the problems you are facing.
  When other people experience excessive worry and
  uncontrollable tension, they sometimes notice
  that they are more irritable or feel on edge and
  tense. Have you felt like this?
• Client Always on edge and erm what was the
  other thing?
• Therapist Irritable?
• Client Yes, often irritable at home, but never
  at work.
• Therapist How about difficulties with
  concentration?
• Client I dont seem to have trouble
  concentrating, just that I concentrate on my
  worries.
• Therapist When you are trying to concentrate on
  your work, do your worries break into that
  concentration?
• Client Yes, but its not that I cant
  concentrate. I concentrate on the wrong thing.

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Commentary

• First, if you consult the DSM-IV-TR criteria for
  Generalized Anxiety Disorder you can seen that
  the clinician is asking the client about symptoms
  relevant to the disorder.
• Second, you will see that the client becomes
  confused when multiple symptoms are included in a
  single question. Try to avoid questions that
  contain multiple issues and requests.
• Third, you will see that the client and clinician
  do not have a shared understanding of the word
  concentration.
• Finally, at the end of this section, the
  clinician would be in a position to speculate
  that the client may be suffering from GAD.
• excessive worry for more days than not for some
  years about a number of events (DSM-IV-TR
  Criterion A)
• difficulty controlling the worry (Criterion B)
• worry is associated with feeling keyed up or on
  edge, easily fatigued, irritability, muscle
  tension, and sleep disturbance (Criterion C)
• clinically significant distress and impairment
  (Criterion E)
• Criterion D requires the clinician to determine
  that the worries are not confined to the features
  of another Axis I disorder

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Adapted from Andrews, et al. Best practice
guideline for Panic Disorder Agoraphobia.

• An interview to diagnose panic disorder needs to
  clearly establish what it is that the individual
  is fearful of. The clinician needs to gather
  details of symptomatology including information
  to aid differential diagnosis.

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Directing an Interview

• Choice of direction remain with a discussion of
  the presenting problem and elicit general
  personal and historical information later
• Advantages interview continues to flow naturally
  and the client keeps relating the details of the
  presenting problem until they have said
  everything they wish to say
• Weakness clinician does not have a good picture
  of the client as a person, the social and
  historical background to the problems, a sense of
  other psychological problems, and so on.

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Directing an Interview

• Clinician could signal a change of direction by
  saying perhaps, Thank you. You have given me an
  idea of the difficulties that you are having. I
  would like to pursue them in more detail, but
  before we talk about these difficulties I was
  wondering if I could get some idea about you as a
  person?

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Continuing the Interview

• Assuming that the clinician has decided to pursue
  the former line, the interview will seek to
  extend the inquiry perhaps by signally such with
  the comment, I wonder if we could discuss the
  difficulty you have been mentioning in some
  detail. When did you first notice that something
  was not right?
• This will direct the client to discuss the
  evolution of the problem acknowledging the fact
  that psychological difficulties exist in a
  dynamically evolving system. However, within the
  complexity, the clinician will be focused on
  trying to highlight the key milestones in the
  problem development.

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Continuing the Interview

• This history will lead the client towards the
  present, at which time it will be possible to get
  a clearer description of the difficulties and any
  associated behaviors
• As a mental checklist, the clinician will be
  aiming to identify
• (i) what the problem is
• (ii) when it occurs
• (iii) where it happens
• (iv) how frequently the problem takes place
• (v) with whom these difficulties arise
• (vi) how distressing
• (vii) impairing the problem is
• The interview will evolve from a historical
  discussion to consideration of the problem in its
  current form. The clinician might ask, Could
  you please tell me about a typical day or
  occurrence of the problem? and then explore some
  of the maintaining factors
• The clinician will also ask about the variability
  in the problem and factors associated with the
  fluctuations (i.e., moderating variables).

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Integrating Background Details

• After the clinician has a good sense of the
  presenting problem, its present manifestation,
  and its history, the interview can expand to
  provide a more complete picture of the person.
• You have given me a good idea of the problems
  you are struggling with, but I dont think I have
  got a good idea about you as a person. Could you
  tell me something about you, apart from these
  difficulties?
• The aim of this process is to be able to put
  yourself in the clients shoes and imagine what
  it must be like to experience the life that the
  client has had.
• may be relevant to ask about family history
  (details of parents, other significant figures,
  brothers and sisters, as well as the childhood
  environment of family, school, and peers), a
  personal history (birth date and any significant
  issues, general adjustment in childhood, lifelong
  traits or behavioral patterns and tendencies,
  significant life events), schooling (duration and
  significant events), work history and present
  duties, relationships (current status, history
  and problems), leisure activities, living
  arrangements, social relationships, prior
  significant accidents, diseases and mental health
  problems, and personality (and particularly any
  changes).

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Coping Resources

• Enquire about coping resources and any assets in
  terms of personal strengths the individual
  possesses
• Motivation for change is a critical dimension
• identify the motivations intrinsic to the person,
  but identify any extrinsic motivators that are
  present or have been successful in the past
• Identify the stage of change that the client is
  in
• Prochaska, Norcross, and DiClemente, (1995
  Prochaska Norcross, 1998) see also Miller and
  Rollnicks (2002) book.

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Finishing

• At the end of the interview, the clinician will
  need to summarize and synthesize the material
  covered.
• I will try to draw together many of the themes
  we have been discussing. If I miss something
  out, or show that I have got a point wrong,
  please let me know.
• It is also wise to ask the client if there are
  any problems or issues which you have not asked
  them about or which there has not been time to
  discuss.
• A pro forma?

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Pro Forma

• Interview Date ____/____/____
• Name ________________________. Sex M / F Date
  of Birth ____________
• What has brought you here today?
• Presenting Problem
• Relevant Background/Personal History
• Family history
• Personal history
• Birth.
• Childhood adjustment.
• Schooling.
• Work.
• Relationships.
• Leisure.
• Significant illnesses/disorders
• Accidents
• Physical illnesses
• Mental disorders/problems.
• Personality
• Problem History

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Pro Forma

• Current Problem Presentation
• Proximal Factors
• Typical presentation
• Variations in presentation
• Maintaining factors?
• 1. Antecedents
• 2. Behavior
• 3. Consequences
• Motivation for change
• Stages of change
• MSE
• Summary
• Test Results
• DSM Diagnosis
• Axis I Clinical Disorder
• Axis II Personality Dis./Mental Retard.
• Axis III Medical Condition
• Axis IV Psychosocial Environ. Problems
• Axis V Global Assessment of Function.

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Useful Resources

• Hersen, M., Turner, S. M. (2003). Diagnostic
  interviewing (Third Edition). New York Kluwer
  Academic/Plenum.
• Sattler, D. N., Shabatay, V., Kramer, G. P.
  (1998). Abnormal psychology in context Voices
  and perspectives. New York Houghton Mifflin.
• Meyer, R. G. (2003). Case studies in abnormal
  behavior (Sixth edition). Boston Allyn Bacon.
• Oltmans, T. F., Neale, J. M., Davison, G. C.
  (2003). Case studies in abnormal psychology
  (Sixth edition). New York Wiley.
• Rogers, R. (2001). Handbook of diagnostic and
  structured interviewing. New York Guilford.
• Spitzer, R. L., Gibbon, M., Skodol, A. E.,
  Williams, J. B.W., First M. B. (2001).
  DSM-IV-TR Casebook A Learning Companion to the
  Diagnostic and Statistical Manual of Mental
  Disorders, Fourth Edition, Text Revision.
  Washington APA Press.