Daniel L. Segal Editor Diagnostic Interviewing Fifth Edition Diagnostic Interviewing Daniel L

Daniel L. Segal Editor Diagnostic Interviewing Fifth Edition Diagnostic Interviewing Daniel L. Segal Editor

Diagnostic Interviewing

Fifth Edition Editor Daniel L. Segal Department of Psychology University of Colorado Colorado Springs, CO, USA

ISBN 978-1-4939-9126-6 ISBN 978-1-4939-9127-3 (eBook) https://doi.org/10.1007/978-1-4939-9127-3

Library of Congress Control Number: 2019932992

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This Springer imprint is published by the registered company Springer Science+Business Media, LLC part of Springer Nature. The registered company address is: 233 Spring Street, New York, NY 10013, U.S.A. Daniel L. Segal: To Cindy, Shaynie, Mom, and my oldest brother Phil, and to the memory of my Dad and my middle brother Eddie. Preface

The first three editions of this book had Michel Hersen and Samuel M. Turner as its editors. After Sam’s untimely death, Michel invited me to join the team and we co- edited the fourth edition together, which was published in 2010. Now that Michel has retired, I remain as the sole editor for this new fifth edition. That being said, I owe a debt of gratitude to both Sam and Michel for conceiving of the vision for this book and affording me the opportunity to play a role in its continuing evolution. Michel has been a great mentor and friend to me since we met in 1992, and I remain greatly appreciative of all that he has taught me about writing, publishing, supervis- ing, mentoring, and teaching. As stated in the first edition of this book, one of the most difficult milestones in a new clinician’s career is the completion of the first interview with a real live client (as opposed to role playing with other students). Generally, such endeavor is fraught with much apprehension. However, if the interview goes well, there is much rejoic- ing. On the other hand, if the interview falls flat, there will be considerable conster- nation on the part of the clinician and usually heavy doses of constructive feedback from the supervisor. Regardless of the amount of preparation that has taken place before the interview, the beginning clinician will justifiably remain apprehensive about this endeavor. Thus, this new edition of Diagnostic Interviewing, like the prior editions, remains devoted to providing clear guidance and structure for new and seasoned clinicians in successfully engaging with a large variety of clients and presenting problems in diverse interviewing settings. I sincerely hope that readers of this book find many pearls of wisdom in these pages and that this book helps them become better clinicians. In consideration of the positive response to the first four editions of this book, our editor at Springer, Sharon Panulla, and I decided that it was time to update the material. However, the basic premise that a book of this nature needs to encompass theoretical rationale, clinical description, and the pragmatics of “how to” once again has been dutifully followed. Thus, the reader will find consistencies between this new fifth edition and the prior ones that have been published. We still believe that students definitely need to read the material covered herein with consummate care. We are particularly concerned that in the clinical education of our graduate students,

vii viii Preface interviewing unfortunately continues to be given insufficient attention. Considering that good interviewing leads to appropriate clinical and research targets, we continue to underscore the critical importance of this area of training. Many years have elapsed since publication of the first edition, and many developments in the field have occurred, including repeated revisions of the DSM system of classification and diagnosis. However, the basic structure of this new edition remains identical to those of the prior ones, in that Part I deals with General Issues, Part II with Specific Disorders, and Part III with Special Populations. Chapters in Parts II and III generally follow the outline below: 1. Description of the Disorder, Problem, or Special Population 2. Procedures for Gathering Information 3. Recommendations for Formal Assessment 4. Case Illustrations 5. Impact of Gender, Race, Culture, Age, and Other Aspects of Diversity 6. Information Critical to Making a Diagnosis 7. Dos and Don’ts 8. Summary 9. References Many individuals have contributed to the development and production of this new edition. First, I wish to thank our eminent contributors for sharing with us their clinical and research experience and expertise. Second, I would like to thank Sylvana Ruggirello and Chitra Gopalraj for their technical assistance and for their excellent work in shepherding the book through production. Third, I wish to thank my departmental colleagues and friends at the University of Colorado at Colorado Springs (UCCS) for their support, and likewise I am grateful to my students at UCCS from whom I have learned so much. Finally, I once again thank my friend and editor at Springer, Sharon Panulla, for her appreciation of the need for this new edition of our text and for her ongoing enthusiasm and support for this endeavor.

Colorado Springs, CO, USA Daniel L. Segal Contents

Part I General Issues 1 Basics and Beyond in Clinical and Diagnostic Interviewing �� 3 Daniel L. Segal, Andrea June, and Marissa Pifer 2 Interviewing Strategies, Rapport, and Empathy �� 29 Catherine Miller 3 Presenting Problem, History of Presenting Problem, and Social History �� 55 Thomas B. Virden III and Melissa Flint 4 Mental Status Examination �� 77 Brenna N. Renn and Samantha E. John 5 Consideration of Neuropsychological Factors in Interviewing �� 103 Brian P. Yochim and Stephanie Potts

Part II Specific Disorders 6 Anxiety Disorders �� 129 Cierra B. Edwards, Amber L. Billingsley, and Shari A. Steinman 7 Obsessive-Compulsive and Related Disorders �� 155 Michelle L. Davis, Elizabeth McIngvale, Sophie C. Schneider, Wayne K. Goodman, and Eric A. Storch 8 Trauma and Stressor-Related Disorders �� 179 Osnat Lupesko-Persky and Lisa M. Brown 9 Depressive Disorders �� 213 Leilani Feliciano, Amber M. Gum, and Katherine A. Johanson 10 Bipolar Disorders �� 239 Samantha L. Connolly and Christopher J. Miller

ix x Contents

11 Schizophrenia �� 261 Jason E. Peer and Zachary B. Millman 12 Personality Disorders �� 293 Neil Bockian 13 Substance Use Disorders �� 325 Catherine E. Paquette, Jessica F. Magidson, Surabhi Swaminath, and Stacey B. Daughters 14 Sexual Dysfunctions, Gender Dysphoria, and Paraphilic Disorders �� 349 Caroline F. Pukall, Tony Eccles, and Stéphanie Gauvin 15 Eating Disorders �� 375 Brittany K. Bohrer, Danielle A. N. Chapa, Alexis Exum, Brianne Richson, Michaela M. Voss, and Kelsie T. Forbush 16 Dissociative Disorders �� 401 Tyson D. Bailey, Stacey M. Boyer, and Bethany L. Brand

Part III Special Populations 17 Children �� 427 Rebecca A. Grossman, Niza A. Tonarely, and Jill Ehrenreich-May 18 Older Adults �� 455 Rachael Spalding, Emma Katz, and Barry Edelstein 19 Interviewing in Health Psychology and Medical Settings �� 481 Jay M. Behel and Bruce Rybarczyk

Index �� 505 Contributors

Tyson D. Bailey Private Practice, Lynnwood, WA, USA Jay M. Behel Department of Behavioral Sciences, Rush Medical College of Rush University, Chicago, IL, USA Amber L. Billingsley West Virginia University, Morgantown, WV, USA Neil Bockian Department of Psychology, Adler University, Chicago, IL, USA Brittany K. Bohrer University of Kansas, Department of Psychology, Lawrence, KS, USA Stacey M. Boyer Christiana Care Health System, Newark, DE, USA Bethany L. Brand Towson University, Towson, MD, USA Lisa M. Brown Palo Alto University, Palo Alto, CA, USA Danielle A. N. Chapa University of Kansas, Department of Psychology, Lawrence, KS, USA Samantha L. Connolly VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), Boston, MA, USA Harvard Medical School, Department of Psychiatry, Boston, MA, USA Stacey B. Daughters University of North Carolina at Chapel Hill, Chapel Hill, NC, USA Michelle L. Davis Baylor College of Medicine, Menninger Department of Psychiatry and Behavioral Sciences, Houston, TX, USA Tony Eccles Forensic Behavior Services, Kingston, ON, Canada Barry Edelstein West Virginia University, Morgantown, WV, USA Cierra B. Edwards West Virginia University, Morgantown, WV, USA

xi xii Contributors

Jill Ehrenreich-May Department of Psychology, University of Miami, Coral Gables, FL, USA Alexis Exum University of Kansas, Department of Psychology, Lawrence, KS, USA Leilani Feliciano University of Colorado, Colorado Springs, CO, USA Melissa Flint Midwestern University, Glendale, AZ, USA Kelsie T. Forbush University of Kansas, Department of Psychology, Lawrence, KS, USA Stéphanie Gauvin Sexual Health Research Laboratory, Department of Psychology, Queen’s University, Kingston, ON, Canada Wayne K. Goodman Baylor College of Medicine, Menninger Department of Psychiatry and Behavioral Sciences, Houston, TX, USA Rebecca A. Grossman University of Miami, Coral Gables, FL, USA Amber M. Gum Louis de la Parte Florida Mental Health Institute University of South Florida, Tampa, FL, USA Katherine A. Johanson University of Colorado, Colorado Springs, CO, USA Samantha E. John Department of Neurology and Goizueta Alzheimer’s Disease Research Center, Emory University School of Medicine, Atlanta, GA, USA Andrea June Department of Psychology, Central Connecticut State University, New Britain, CT, USA Emma Katz West Virginia University, Morgantown, WV, USA Osnat Lupesko-Persky Palo Alto University, Palo Alto, CA, USA Jessica F. Magidson University of Maryland, College Park, College Park, MD, USA Elizabeth McIngvale Baylor College of Medicine, Menninger Department of Psychiatry and Behavioral Sciences, Houston, TX, USA Catherine Miller Pacific University, School of Graduate Psychology, Hillsboro, OR, USA Christopher J. Miller VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), Boston, MA, USA Harvard Medical School, Department of Psychiatry, Boston, MA, USA Zachary B. Millman Department of Psychology, University of Maryland Baltimore County, Baltimore, MD, USA Catherine E. Paquette University of North Carolina at Chapel Hill, Chapel Hill, NC, USA Jason E. Peer VA Maryland Health Care System, Baltimore, MD, USA Contributors xiii

Marissa Pifer Department of Psychology, University of Colorado, Colorado Springs, CO, USA Stephanie Potts VA Saint Louis Health Care System, St. Louis, MO, USA Caroline F. Pukall Department of Psychology, Queen’s University, Kingston, ON, Canada Brenna N. Renn Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA Brianne Richson University of Kansas, Department of Psychology, Lawrence, KS, USA Bruce Rybarczyk Department of Psychology, Virginia Commonwealth University, Richmond, VA, USA Sophie C. Schneider Baylor College of Medicine, Menninger Department of Psychiatry and Behavioral Sciences, Houston, TX, USA Daniel L. Segal Department of Psychology, University of Colorado, Colorado Springs, CO, USA Rachael Spalding West Virginia University, Morgantown, WV, USA Shari A. Steinman West Virginia University, Morgantown, WV, USA Eric A. Storch Baylor College of Medicine, Menninger Department of Psychiatry and Behavioral Sciences, Houston, TX, USA Surabhi Swaminath University of North Carolina at Chapel Hill, Chapel Hill, NC, USA Niza A. Tonarely University of Miami, Coral Gables, FL, USA Thomas B. Virden III Midwestern University, Glendale, AZ, USA Michaela M. Voss Children’s Mercy – Kansas City, Department of Adolescent Medicine, Kansas City, MO, USA Brian P. Yochim VA Saint Louis Health Care System, St. Louis, MO, USA Part I General Issues Chapter 1 Basics and Beyond in Clinical and Diagnostic Interviewing

Daniel L. Segal, Andrea June, and Marissa Pifer

The ability to conduct an efficient and effective clinical and diagnostic interview is arguably one of the most valued skills among mental health professionals. It is during the interview that the clinician learns about the difficulties and challenges experienced by the client and begins to form the foundations of a healing professional therapeutic relationship. Although the metaphor is not a novel one, the job of the interviewer may be likened to that of a detective trying to collect enough data and organize the clues to “solve the mystery,” in this example, the presenting problem and diagnosis of the client. The most important aspect of this detective metaphor is that effective interviewers (detectives) are served well by their natural curiosity (truly wanting to understand all aspects of the client’s experiences, no matter how painful or uncomfortable) and the thoughtfulness of their approach (being guided by strategies and principles for gathering data while also forming an emotional connection with the client). Broadly construed, the clinical interview is the foundation of all clinical activity in counseling and psychotherapy (Hook, Hodges, Segal, & Coolidge, 2010; Segal, Maxfield, & Coolidge, 2008). Indeed, one cannot be a good clinician without well- developed interviewing skills. Although specific attention is often paid to the initial clinical interview (or first contact between clinician and client), it is ill-advised to think that clinicians first complete an interview and then start treatment. Rather, it is more accurate to view the clinical interview as an ongoing part of the psychotherapeutic process (Hook et al., 2010). For the beginning clinician, trying to manage the content and process of the interview can seem like a daunting task, one that often evokes considerable anxiety. However, with guidance, feedback-informed practice, and a good deal of self-reflection on one’s clinical strengths and still-developing

D. L. Segal (*) · M. Pifer Department of Psychology, University of Colorado, Colorado Springs, CO, USA e-mail: [email protected] A. June Department of Psychology, Central Connecticut State University, New Britain, CT, USA

© Springer International Publishing AG 2019 3 D. L. Segal (ed.), Diagnostic Interviewing, https://doi.org/10.1007/978-1-4939-9127-3_1 4 D. L. Segal et al. skills, many beginning clinicians find that they are able to refine their interviewing skills over time and become much more comfortable with the process. Indeed, when successfully mastered, clinical and diagnostic interviewing skills become an important part of the clinicians’ repertoire. The purpose of this chapter is to discuss and elucidate some of the key factors that can facilitate the interview process. The overview presented in this chapter of the basic issues regarding clinical interviewing will also set the stage for the following chapters in this volume that provide considerable depth in the major areas of clinical and diagnostic interviewing, including many disorder-specific approaches. We begin with discussions of the different settings in which interviews occur, confidentiality, and the basic skills used in interviews. Next, we describe the importance of understanding the impact of client diversity on the interview process and pay targeted attention to the issues faced by mental health professionals who are in the beginning stages of professional development as a clinician and interviewer. We conclude this chapter with a discussion of some dos and don’ts of clinical and diagnostic interviewing.

The Impact of the Interview Setting

Perhaps the first critical factor that influences the nature of the interview is the setting in which the interview takes place. There are a variety of settings in which interviews may occur and the type of setting often determines how the client is approached. Specifically, the setting will help determine the depth and length of the interview, the domains of functioning that are assessed, the types of questions that should be asked, and the degree of cooperation that can be expected. For example, the level of cooperation that can be expected from a juvenile delinquent forced to participate in court-ordered psychotherapy will be substantially different than that from an adult or older adult who is burdened with responsibilities of caring for a frail family member and who is eagerly seeking psychotherapy at a community mental health clinic. As such, each interview will require a different approach because of the circumstances of how each client comes to be interviewed and the expectations established for client behavior. To address the issues of the setting on the interviewing process, we discuss emergency and crisis settings, outpatient mental health settings, medical settings, and jail, prison, and courthouse settings.

Emergency and Crisis Settings

Emergency and crisis settings are diverse and include general hospital emergency rooms, inpatient psychiatric hospitals, and crisis centers. Clients who may be encountered in these settings include individuals with acute medical problems that are compounded by psychiatric factors (including those in acute pain), people who are brought for psychiatric evaluation by law enforcement or emergency medical 1 Basics and Beyond in Clinical and Diagnostic Interviewing 5 personnel, individuals involved in voluntary or involuntary psychiatric commitment proceedings, and people who are experiencing an acute, often volatile crisis situation. Individuals requiring emergency care may exhibit psychotic disturbances, including active hallucinations (false sensory experiences, such as hearing voices when none are objectively present), delusions (false beliefs, not supported by one’s culture, such as paranoid ideation), and disorganized thinking and speech (incoherent, confused, rambling, or tangential thinking and speech, along with decreased problem-solving ability); drug and alcohol problems, including acute intoxication and disorientation; organic brain syndromes, such as a traumatic brain injury, delirium, or other types of neurological disorders; depressive disorders (e.g., severe depression with psychotic features and/or active suicidal thoughts); and personality disorders, especially those characterized by volatile and impulsive behaviors (e.g., borderline personality disorder). Because the interview occurs under emergency conditions, clinicians should be prepared to alter the style and format of the traditional interview. Clients in emergency settings are often frightened by their perceptions and feelings, as well as by the surroundings in which they find themselves, and they often exhibit extremes in emotions. They may be too agitated, frightened, or paranoid to provide detailed histories. Thus, the goal in such settings is to gain enough information to make a tentative diagnosis and offer emergency treatment planning, including whether to hospitalize the person or not. One primary focus should be a thorough assessment of dangerous- ness, including suicidal or homicidal ideation or plans. Some emergency depart- ments in the USA have enacted a universal screening approach to suicidality, which has resulted in greater screenings and greater detection of those at risk for suicide (Betz et al., 2015). Nevertheless, challenges remain even in these settings, including barriers to lethal-means assessment (Betz et al., 2018) and some disparities in screening and treatment for older adults (Arias et al., 2017; Betz et al., 2016). In emergency settings, a careful examination of the client’s current mental status is more important than a detailed social history or formal psychological testing. It is helpful to strive to try and pinpoint how and why the client is in the current state of crisis and what the immediate precipitating events were (Dattilio & Freeman, 2010), although the full story may not always be easy to discern. Keep in mind that a calm and understanding attitude on the part of the clinician can increase the client’s comfort level enough to allow the interviewer to obtain a reasonable sense of the nature of the problem. Collateral interviews with concerned others are usually important in emergency settings, especially if the client is unwilling or unable to participate in the interview.

Outpatient Mental Health Settings

Compared to clients seen in emergency settings, clients served by outpatient community mental health centers and private outpatient practices will have a more varied range of psychopathology. Whereas psychotic disturbances and suicidal ideation 6 D. L. Segal et al. may be encountered within this setting, typically clients are more stable and not in severe enough crisis to warrant hospitalization. Therefore, the nature of the interview will be considerably different from that in emergency and crisis settings. The objective of the interview in this setting is to learn as much about the client’s current psychological and emotional functioning as possible, including the client’s reasons for seeking psychotherapy, and to fully explore the client’s personal history (often called the social history) to put the client’s current problems in a proper context. The interview is typically guided by the problems and fortitude of the client, and because there is generally little or no mystery for the client as to the purpose of the interview, there is generally less resistance during the interview. Thus, the interviewer will typically have more time and less trouble in conducting a comprehensive interview, which typically occurs during a 60–90-minute session. A thorough understanding of the client’s current and past difficulties and the contexts in which the struggles occur is necessary for the clinician to develop an initial conceptualization of the problem and to develop an appropriate initial treatment plan. Compared to the pressure of emergency settings, interviewers in outpatient settings are usually afforded the luxury of time to establish rapport with the client and lay the groundwork for a productive therapeutic relationship. In outpatient settings, clients may be inquisitive about the nature of their problems or disorders (sometimes requesting a formal diagnosis), the causes of their problems or disorders, and the pragmatics of treatment (e.g., fees, length of treatment, and the theoretical orientation or general approach of the clinician). These questions should be addressed can- didly and sensitively to promote transparency and to foster trust in the relationship (Faust, 1998). Of course, there is no crystal ball to precisely determine how long treatment will last for a particular client, but it is often helpful to establish a general time frame with the client and to secure an initial agreement to treatment with a plan to review progress in a short period of time: “How would you feel about making an initial commitment to weekly psychotherapy for the next 8 weeks? At the end of that time (if not sooner), let’s evaluate how we are doing together and decide how we should proceed, to determine if we need to contract for another series of sessions.” The manner in which questions about diagnosis and treatment are answered will help the client develop an informed perspective on his or her treatment, specifically, what can and cannot be done and what the long-term prognosis entails. Even if the client does not request such information, it may be helpful for the clinician to address these types of issues with the client at the end of the initial interview.

Medical Settings

Medical settings (e.g., medical school hospitals, rehabilitation hospitals, Veterans Affairs medical centers, integrated care settings) present a unique challenge for clinical work. Often, medical patients do not request to consult with a mental health professional, but rather the referral is the decision of the treating physician. The reason for the referral may or may not have been explained to the patient, and 1 Basics and Beyond in Clinical and Diagnostic Interviewing 7 therefore the patient may be initially hesitant or reluctant to communicate to the clinician and, in some cases, may even refuse to be interviewed (Faust, 1998). Individuals in this setting frequently have various medical illnesses and therefore have defined their “problem” as solely a medical one. As such, they may not understand why a mental health professional has been called to see them. It behooves the mental health clinician in medical settings to be prepared for varying levels of knowledge about and active participation in the referral process among patients, and thus at the beginning of the interview should introduce him or herself, explain the purpose of the consultation, and state who requested it. In medical settings, the clinician is likely to garner cooperation with the medical patient when the clinician presents himself or herself as an information gatherer and acknowledges the client’s physical condition without immediately suggesting that there is a psychological disturbance, even if one is suspected. If the clinician is for- tunate enough to work within an interdisciplinary team within an integrated care setting, the interview can be framed as “comprehensive care” which may decrease some of the stigma associated with mental health treatment. In these settings, clinicians also should be prepared to adjust the format and length of the interview according to the needs of the medical patient. Depending upon the medical conditions experienced by the patient, he or she may be in considerable discomfort which impacts one’s ability to engage in a dialogue and answer questions. Some medical patients may need a period of cultivation (e.g., having a few informal visits to get to know the patient) before they are willing to delve into emotional concerns or psychological topics, requiring the clinician to be flexible on the number of visits needed to complete the interviewing task. Clinicians in medical settings also need to be mindful of the other professionals working within the facility and the schedules to which these other professionals must adhere. Some flexibility and coordination with the other care providers help to ensure the interview sessions and treatment sessions have as few interruptions as possible. If the clinician is a consultant in a medical setting, it is particularly important to avoid being manipulated into siding with the client against the physician. It is critical to maintain the stance of an investigator with no specific position. Consultant clinicians must remember they are invited by the treating physician to render their expert advice on a particular problem. A major difficulty can arise in this setting if negative statements and judgments about other aspects of the patient’s care are rendered by the clinician. This type of behavior will most certainly have a negative impact on the doctor-patient relationship and the doctor-clinician relationship to work in the best interest of the medical patient.

Jail, Prison, Corrections, and Courthouse Settings

There are certain aspects of correctional facilities which present unique challenges to the clinical interviewer including population factors, limits to confidentiality, and environmental factors. Depending upon the reason for referral, these settings can 8 D. L. Segal et al. have a distinctly unpleasant adversarial tone. Clients may range from being very resistant and defiant of the entire process to being overly attentive and concerned. Some clients, in fact, may honestly want psychological assistance. A client’s motivation to be truthful, forthright, and forthcoming with information will also depend upon the perceived referral question and the circumstances of the interview (Faust, 1998). Jail and prison settings have higher rates of mental disorders compared to the general population. As such, mental health screens are particularly important in these settings (Abram, Teplin, & McClelland, 2003; Fazel & Seewald, 2012). Without adequate assessment for potential mental disorders and subsequent treatment, inmates may be at risk of harming themselves or other inmates, may become a target for violence, or may become disruptive to prison operations (Lee, 2015). In these settings, privacy is likely to be limited when conducting interviews as other people (e.g., fellow inmates, guards, attorneys) may be within listening proximity to the interview. Additionally, because many of these evaluations are court mandated, confidentiality of records does not apply (Faust, 1998). In these cases, clinicians should be clear and honest with the client about these limits and the role of the clinician. The clinician may also be restricted by time in this setting. In an emergency hearing, for example, the clinician may have limited time to interview the client and make recommendations. Prisons tend to have rigid schedules, and clinical interviewers often have little-to-no control over the schedule or time allotted for the interview. At other times, the clinician will need to coordinate his or her schedule with others at the jail or prison, limiting flexibility as compared to some other settings. Safety is another important concern in these settings. It is important for clinicians to be aware of their surroundings and to avoid exposure to vulnerable positions as much as possible (Lee, 2015). Although most inmates are not aggressive or violent toward clinicians, certain inmates may need to be left in restraints throughout the interview, and often a prison guard will remain present or just outside the door throughout the interview process (Lee, 2015). During interviews in this setting, the clinician may want to look for inconsistencies in the client’s behavior and self-report because there may be perceived benefits to the client to either minimize reports of psychopathology or conversely to exaggerate mental health concerns. When possible, interviewing and observing the significant people in the client’s life (e.g., spouses, parents, children) may also be informative (Faust, 1998). For example, referrals concerning adult guardianship often require the court-appointed clinician to interview both parties vying for guardianship as well as other people involved in the adult’s life (e.g., guardian ad litem, the adult protective agency worker, the adult’s children, other kin). These additional interviews can help to verify information, uncover inconsistencies, and ultimately help the clinician determine the most optimal course of action. It is especially important for clinicians to evaluate their personal biases and reduce judgment which may occur when working in prison settings. Clinicians may naturally have more negative views about inmates than the general population, especially those inmates who have committed especially heinous crimes such as child sexual abuse or mur- der. Negative reactions to the interviewee may cause the clinician to lose objectiv- ity; this may lead to difficulty exploring all relevant areas or missing diagnoses. 1 Basics and Beyond in Clinical and Diagnostic Interviewing 9

Inmates are also often expecting judgment and therefore may be more sensitive to changes in the clinician’s demeanor which may suggest negative feelings toward the inmate. This will damage rapport and make diagnostic interviewing more difficult and less effective (Lee, 2015). Clinicians should be careful to assess their biases and maintain a nonjudgmental attitude, no matter the population.

Confidentiality

A hallmark feature of a professional therapeutic relationship is confidentiality, which is the requirement that mental health clinicians protect their client’s privacy by not revealing the contents of psychotherapy or counseling. Indeed, confidentiality is a critical aspect to address in an initial interview. Guidelines for psychologists regarding confidentiality are established by the American Psychological Association (APA) in the Ethical Principles of Psychologists and Code of Conduct (APA, 2017). Specifically, the APA ethical principle (standard 4.01) states that “Psychologists have a primary obligation and take reasonable precautions to protect confidential information obtained through or stored in any medium, recognizing that the extent and limits of confidentiality may be regulated by law or established by institutional rules or professional or scientific relationship.” Because a breach in confidentiality is such a serious action, clients must be fully and dutifully informed of the limits of confidentiality at the onset of a clinical interview, prior to any other information discussed (see Table 1.1 for common limitations to confidentiality). Such disclosure is almost always done verbally with the client and provided in written form, as part of an informed consent document. We advise taking a straightforward approach when discussing and educating clients about the limitations of confidentiality. Although there is no clear answer about whether the conversation should take place at first contact over the phone or at first contact in the session, it is probably best to wait until meeting the client for the first time to fully explain the concept so that the clinician can see the client’s response and gauge the client’s understanding. However, there may also be times where it is appropriate to discuss such limitations over the phone. For example, if a new client

Table 1.1 Common limitations to confidentiality in counseling and psychotherapy Clinicians may disclose private information without consent in order to protect the client or the public from serious harm, for example, when a client discusses serious plans to attempt suicide or to harm another specific person Clinicians are commonly required to report child abuse or neglect, elder abuse or neglect, and abuse or neglect of persons with intellectual and developmental disabilities Clinicians may release confidential information if they receive a court order from a judge. This event may occur when a client’s mental health comes into question during legal proceedings Note: The client’s right to confidentiality has legal as well as clinical implications. Laws pertaining to confidentiality vary from state to state, so mental health clinicians should refer to their state’s specific laws as well as their discipline-specific code of ethics 10 D. L. Segal et al. became overly detailed about his or her struggles over the phone, it would behoove the clinician to make attempts to respectfully curtail such disclosures until confidentiality has been addressed sufficiently. Confidentiality is such an important topic that state laws regulating the practice of psychologists typically have provisions about confidentiality and guidelines pertaining to the clinician-client relationship. In short, clinicians must maintain the privacy of their client’s communications and records in order for effective evaluation and treatment to be possible. Caution must be exercised in releasing information to anyone but the client, and it is always best to err on the conservative side (Faust, 1998). If in doubt, do not release information without written consent from the client or court order. Several important factors that may impinge on confidentiality are discussed next.

Age

The age of consent to psychological evaluation or treatment varies among the states. Therefore, a 15-year-old adolescent seeking mental health services without parental or legal guardian consent may be able to do so legally in one state but not the other. In a state where it is legal to provide services to a 15-year-old without parental or guardian consent, all confidentiality laws of that state and professional ethical guidelines would apply. In other states, persons under the age of 18 would be considered minors, and no services may be rendered without parental or guardian consent. In such cases, the minor client should be informed of this requirement prior to the interview, and the client should also be made aware that his or her parents or guardians have a legal right to all records of evaluation and treatment.

Confidentiality of Written Records

Written records of psychological assessment and treatment are confidential documents. These records may not be released to any third party (including other professionals) without written consent from the client. For unlicensed professionals or students in training, the supervisor or clinical supervision team will be privy to the information, and the client should be duly informed of this, usually in writing in the informed consent document. It is the responsibility of each professional to maintain up-to-date, detailed, and accurate records of treatment and to provide safeguards for such material. Given the number of people who could potentially access records (i.e., whomever the client releases the information to, third-party payers, legal guardians, etc.), it is prudent to take care when documenting in the record. It would be wise for clinicians to imagine that judges, attorneys, insurance company personnel, physicians, and the client himself or herself are looking over their shoulder while documenting treatment (Faust, 1998). Alternatively, whereas one must be 1 Basics and Beyond in Clinical and Diagnostic Interviewing 11 careful and prudent when documenting in charts, records should have enough detail to facilitate treatment planning and meet the requirements for reimbursement from third-party payers. Certain aspects of the clinical record (e.g., dates of sessions, diagnoses) may be released to a third-party payer for reimbursement. Maintaining adequate records is particularly important should the client transfer to another agency or clinician in the future. Although malpractice claims or lawsuits arising from interviews or treatments are relatively uncommon, an appropriately detailed record may also be an important part of the clinician’s defense. The security of client records is the responsibility of the treating clinician. Written or printed information should never be left unattended and should be filed promptly and properly when not being used. Written or printed records should be kept in locked files with limited access. As most records are now created and stored digitally or electronically, this has resulted in new challenges, for example, ensuring that computers and servers are physically secure and that no data breaches occur. Indeed, the safety of electronic records is an increasingly important issue. At a minimum, electronic records must be stored on a password-protected computer in a locked office. However, more secure methods of storing records electronically are preferred. Often, this includes use of encryption software or a secure medical record system. Electronic medical record systems make it easier and more convenient for mental health providers to document and access client medical and mental health records. They also can add more security to client information than was previously offered with written records. Confidentiality concerns may arise with electronic medical records though, especially in settings where interprofessional collaboration is common or where access is not heavily restricted (Richards, 2009). Clinicians may need to be particularly mindful of information they include in a client’s chart, especially if that information may be available to other providers. However, as technology advances, developers are adding new ways to control who can access client information, as well as where, when, and how they are able to access the information (Nielsen, 2015). As with all record keeping, clinicians should be mindful of the information they include in the chart as well as mindful of who may potentially have access to those records.

Duty to Warn and Protect

As noted above, one noteworthy limitation of confidentiality is the legal and ethical responsibility of mental health professionals to protect their clients and members of society from imminent danger. Although clinicians are legally and ethically required to maintain confidentiality between themselves and their clients, clinicians also have an obligation to protect dangerous clients from themselves (i.e., suicide) and to protect potential victims from dangerous clients (i.e., homicide, child or elder neglect, or abuse). This blurring of the responsibility of confidentiality occurred because of the landmark Tarasoff v. Regents of University of California case in 1976. In this landmark case, the California Supreme Court required clinicians to 12 D. L. Segal et al. take steps to protect individuals who are potential victims of their clients. This law held that psychotherapists in the state of California have a duty to protect intended victims of their patients if their intended conduct “presents a serious danger of violence to another.” Since this ruling in 1976, 33 other states have formally established similar laws (Bersoff, 2014). Therefore, should a client inform a clinician that he or she has a specific and imminent homicidal plan with an identified potential victim, the following actions may need to be taken: the clinician has a duty to warn an intended victim, the clinician may need to commit the client to a psychiatric facility, and the clinician may need to notify the police about the client’s plan (Faust, 1998). Consultation with supervisors or professional colleagues is clearly advised during these types of situations to think through the necessary steps one must take to protect clients and members of society. A full assessment of suicidal and homicidal ideation or thoughts should be a part of most, if not all, clinical interviews with a new client. New clinicians may avoid asking about suicidal or homicidal ideation for fear of the response and added responsibility. However, failing to assess for either suicidal or homicidal ideation is dangerous, and a clinician could be held liable if someone is hurt and the clinician had failed to reasonably assess the client. Before addressing thoughts of suicidal or homicidal ideation, it is important to discuss the limits of confidentiality. Limits to confidentiality must be discussed thoroughly at the start of treatment to ensure clients are aware of them and choose what information to disclose accordingly (APA, 2017). In some cases, clients who have been told these confidentiality limits may choose not to disclose information concerning suicidal or homicidal thoughts. If thoughts of harm are suspected the most a clinician can do is communicate concern and emphasize the importance of client safety. Further guidance about the duty to warn and protect is provided by Werth (2017).

Managing the Temptation to Discuss Cases

Information gathered from clinical interviews should not be the topic of casual conversation under any circumstances. Even anecdotal de-identified information can be highly identifiable if the situation is distinct. Describing a client during the course of a conversation with professional colleagues in what may seem to be a private setting may actually include unintended listeners who can identify the client’s information due to the distinguishing features of the story. Novice clinicians may be more prone to discussing aspects of therapeutic experiences with peers in inappropriate settings (e.g., restaurants, bars, etc.). They may also be compelled to discuss clients in areas of the treatment setting where other listeners may be present (e.g., at the front desk, elevators, hallways). Remember that confidentiality is the rule for information gathered in a clinical interview, not the exception, and that respect for confidentiality is one of the most important elements in forging an open and honest dialogue. Violation of the client’s confidentiality without just cause is a serious offense, both legally and ethically, so great caution is always advised. 1 Basics and Beyond in Clinical and Diagnostic Interviewing 13

The issue of confidentiality is serious and complex with many potential ramifications. It can be tricky to navigate and must be handled with care. One simple rule of thumb is to avoid saying anything to anyone about the client that the clinician would be uncomfortable saying to them in front of the client, the client’s attorney, and the clinician’s supervisor. Whereas the intent of this section was to alert the clinician to the primary issues, for more in-depth coverage of confidentiality, the interested reader is referred to Knapp, VandeCreek, and Fingerhut (2017), Koocher and Keith- Spiegel (2016), and the Ethical Principles of Psychologists and Code of Conduct (APA, 2017).

Interviewing Basics

In this section, we provide a broad overview of some of the foundational concepts and skills that impact the clinical interview.

Establishing Rapport

Establishing rapport refers to creating an open, trusting, warm, and safe relationship with the client. Of course, this is easier said than done, but establishing rapport with the client is an important requisite for effective interviewing and ongoing psychotherapy. Indeed, research has consistently identified that a positive therapeutic relationship is essential to the success experienced by most clients (see through review by Norcross, 2011). The therapeutic relationship is one of the so-called “common factors” of psychotherapy that robustly contributes to the benefits of treatment (Wampold, 2015). At the most basic level, for clients to participate in psychotherapy, it is vital that they feel at ease with the clinician, which facilitates the clients in disclosing and discussing intimate and personal details of their lives. Remember that, initially, many clients do not know what to expect from psychotherapy or from the clinician. Clients are faced with the task of being expected to reveal private and emotionally sensitive information to a veritable stranger! As such, they may be apprehensive, embarrassed, or downright terrified at the beginning of the first interview. Some clients find it difficult to ask for help because of the stigma associated with mental disorders and their treatment. Others may have been in psychotherapy before but did not find it useful and therefore are cautious and skeptical of what the clinician can offer. Faced with these challenges, the role of the clinician is to convey to the client an appreciation of their feelings and a willingness to listen without judgment to whatever the client may present. If the clinician keeps in mind that the client must be permitted time and patience for the establishment of trust, favorable results are likely to follow. Indeed, trust must be earned and should not be automatically 14 D. L. Segal et al. expected. Critically important to the establishment of trust is the client’s belief that the psychotherapy will provide new perspectives, change, and the possibility for growth. If the clinician can demonstrate this hope, clients will likely experience the freedom and security to more fully disclose and explore their problems. The course of establishing an effective client-clinician relationship will be varied, but two overarching goals of the clinician are to establish and maintain a trusting and respectful therapeutic relationship with the client.

Being Empathic

A fundamental skill for any clinician is the ability to empathize with another person’s experiences and convey such empathy through validation and understanding. Empathy is the ability to perceive and understand a client’s feelings “as if” the clinician was experiencing them and to communicate that accurate understanding to the client (Faust, 1998). Always keep in mind that no two clients are the same and the clinician should be attuned to the subtleties of the client’s thoughts, feelings, behaviors, and lived experiences. A distinction to be made is that empathy is understanding, not sympathy. By responding empathically, the client knows that the clinician is accepting, understanding, and joining his or her “world” without judgment, rather than just “feeling bad” for the client (Johnston, Van Hasselt, & Hersen, 1998). This empathic understanding enhances trust and increases the likelihood that the client will reveal intimate details of his or her life, possibly details that the client has never previously revealed to anyone. Empathy can be conveyed in many ways (e.g., nonverbal behaviors, such as listening attentively, nodding, showing a concerned facial expression, verbal communication of understanding, and support), allowing the clinician to choose a style that is most comfortable for him or her. It is hard to do any of these things while taking notes, so keep note-taking to a minimum. Other important strategies for conveying empathy and validation include tone of voice, time and rate of comments and questions, and the area of questioning. When used correctly, these latter, seemingly trivial, strategies can be critical in conveying warmth and understanding.

Using Reflection

Reflection statements address what the client has communicated (verbally or non- verbally) and are typically used to highlight a specific point. A reflection statement, however brief, usually marks a specific feeling or point of information and thus can be divided into reflection of feelings or reflection of content. Liberal use of both throughout clinical interviews is advised. Indeed, reflection is an important tool for any interviewer. When a clinician reflects a client’s feelings or the content of what 1 Basics and Beyond in Clinical and Diagnostic Interviewing 15 a client is saying, or both simultaneously, this accomplishes two important tasks. First, it conveys a sense of empathy to the client by sending a message that the client is accurately understood, which strengthens the therapeutic bond. Second, it provides a mirror image for the client of what they are feeling and saying. This “clinician mirror” is an invaluable method for the client to learn about himself or herself (Johnston et al., 1998). Reflection is a skill that assists clients to monitor and identify different feeling states and also to express those states in a healthy way. Mastery of this skill does not mean that the clinician mimes or mimics the responses of the client. Reflection of feeling can be delivered in a simple phrase, such as “Sounds like you are feeling …,” “You must be feeling …,” or “I hear that you are feeling …” Reflection of content means that the clinician accurately para- phrases or summarizes the client’s statements, reflecting the “essence” of what the client communicated but not using the exact words or phrases. Think of this skill as helping the client in “getting to the heart of the matter” (Johnston et al., 1998) but not parroting back to the client exactly what he or she said. In summary, reflective statements can aid in the development of rapport as clients perceive that they are being truly and deeply understood. In turn, the client may relay more information that further strengthens the bond and ultimately assists the clinician in determining appropriate interventions.

Paying Attention to Language and Avoiding Jargon

An integral part of a successful interview is the communication between clinician and client. To arrive at an accurate diagnostic picture, the clinician must communicate to the client what is being asked of him or her. The clarity and comprehensibil- ity of the questions will facilitate identification of pertinent information while enhancing rapport and trust in the client-clinician relationship (Faust, 1998). A common mistake that new clinicians sometimes make is their use of jargon or non- familiar vocabulary. The clinician’s use of vocabulary heavy in psychological terminology often hinders effective communication. For example, a graduate student asked her new client, “What kind of boundaries do you have with your mother?” The term boundaries may mean something completely different to the client than it does to the clinician. In this example, the student clinician risks her client answering without a clear understanding of what is being asked and possibly hindering development of an accurate case formulation. Similar risks are possible with respect to unfamiliar language. Clinicians should consider the client’s level of education, intelligence, age, background, and geographical location (Faust, 1998). This does not mean that the clinician should “talk down to” the client in any way. It does mean that words should be chosen with consideration. 16 D. L. Segal et al.

Using Humor

The image of the stoic, impersonal, unflappable, and humorless clinician who is devoid of feelings is an outdated one. Certainly, being able to see the humorous elements even in the most challenging situations in one’s life can be an adaptive coping strategy for clinicians and clients alike. In the interview setting, humor has the potential to “take the edge” off a discussion of particularly painful material and can serve to release physical tension. Smiling or even laughing together can be a source of bonding between clinician and client. These positive aspects of humor notwithstanding, some judicious caution in the use of humor is advised. For the clinician, the use of jokes or humor should be done sparingly and with caution before a therapeutic relationship is solidly formed. Although the intention of the clinician may be to lighten the mood, a humorous remark is typically not appropriate during the course of an initial clinical evaluation. When clients show the pattern of habitually using humor, sarcasm, or jokes as a way to distance themselves from feelings that are too painful or scary, the clinicians’ reaction should be dependent on the context of the situation. At times, the clinician may choose to offer a gentle interpretative statement, such as “I have noticed that when you start to experience or discuss very painful feelings, you sometimes seem to make a joke to get away from those feelings. Have you noticed this in yourself?” Like all interventions and tactics, humor has its place in the clinical interview, especially if it is timed correctly and not over- used. Regardless of when humor is used, it is most imperative that clinicians laugh with clients and not at them or their predicaments.

Responding to Questions from Clients and Managing Self-Disclosure

How one responds to questions from clients depends on the clinician’s level of training and the types of questions being asked. In the early stages of training, beginning clinicians should generally be cautious about offering diagnostic or disposition information without first discussing the topic in supervision. For example, if during an interview a client asks, “Do you think I have schizophrenia?,” the clinician should address the client’s feelings that are associated with the label but delay answering the question directly until after a consultation with the supervisor has occurred. In contrast to emotionally laden or complicated questions, simple questions of a pragmatic nature, for example, about agency policies, should be answered directly (e.g., questions about billing, payment, or times the clinic is open). Some clients ask clinicians to reveal personal information which can be a difficult situation to navigate. Should clinicians self-disclose and if so, what kind of details and how much should they reveal? Whereas clinicians have highly divergent opinions on the potential costs and benefits of self-disclosure, an occasional sharing of personal information can facilitate the interview and enhance rapport (Knox & 1 Basics and Beyond in Clinical and Diagnostic Interviewing 17

Hill, 2003). However, like the use of humor, self-disclosure must be timed appropriately and used limitedly, and perhaps most important, the “shadow side” of self-disclosure must be carefully considered. One negative impact of revealing personal details is that it frequently switches the focus of the interview from the client (where it rightfully should be) to the clinician. In some cases, clients prod clinicians for self-disclosures to test the limits of the psychotherapy relationship. Therefore, clinicians must always ask themselves about the intent and impact the disclosure could have on the client’s progress toward his or her identified goals. An inappropriate disclosure can also burden the client. As such, beginning clinicians should generally keep self-disclosure to a minimum. One guiding principle is to freely disclose details one would not mind seeing printed in the local newspaper, such as one’s age, level of training and education, and the name of one’s supervisor. Clinicians should be cautious about disclosing details of a more personal nature. When a personal disclosure is made, the clinician should be able to articulate to the supervisor the reason why the disclosure was made including the goal the clinician was trying to accomplish specifically by the disclosure. Clinicians should also ask themselves “Could the goal have been accomplished in another fashion that does not carry the risks associated with self-disclosure?” If not, another general guiding principle is to disclose feelings rather than facts: “I know what it feels like to be hurt by somebody I trusted” rather than “I also felt hurt when my ex-spouse cheated on me.” Should clients press for a self-disclosure (e.g., “Have you ever been raped?”), it is advisable to reflect the client’s curiosity and try to understand what is behind the question, to illuminate the client’s assumptions or concerns about the clinician. It also helps to refocus the discussion back to the client. Under no circumstances is it appropriate for the clinician to self-disclose about any ongoing personal problems or problems with other clients.

Diversity and the Interview Process

Culture refers to a common sense of beliefs, norms, and values among a group of people. Culture impacts whether individuals seek help, what type of help they seek, what types of coping styles and social supports are available, and how much stigma is attached to having a mental disorder (US Department of Health and Human Services [DHHS], 2001). The main purposes of a diagnostic interview are to establish a therapeutic relationship with the client and to begin to formulate a clinical diagnosis. Failing to consider issues of diversity can negatively impact both the relationship and the diagnosis, which can ultimately reduce the effectiveness of psychotherapy. Diversity, as it is discussed here, includes all aspects of cultural identity such as age, gender, geographic location, physical ability, race and ethnicity, religious preference, sexual orientation, and socioeconomic status. Consideration of multicultural issues is particularly important given the increasing diversity of the USA and the likelihood of clinicians encountering clients from cultural backgrounds different from their own, sometimes markedly so. Three major domains of 18 D. L. Segal et al. multicultural competence are (1) awareness of one’s own assumptions, values, and biases, (2) understanding the worldview of culturally diverse clients, and (3) knowledge of culturally appropriate intervention strategies and techniques (Sue & Sue, 2016). Culturally sensitive and competent clinicians intentionally work to understand the worldview of others without negative judgments (Fawcett & Evans, 2012). Moreover, as Chung and Bemak (2012) state, “social justice is at the very core of multicultural counseling competencies” such that clinicians must understand eco- logical factors that influence clients and pose the skills to challenge any systemic barriers that impede growth to enhance well-being. Next, we briefly touch upon each of these domains with the caveat that this section provides a general overview of the issues and therefore is not intended to provide the necessary background material for clinicians to adequately assess clients from different cultural groups. Recommendations for additional reading are provided at the end.

Impact of Diversity on the Therapeutic Relationship

As we have highlighted earlier, a good working alliance is crucial for psychotherapy to be effective. Particularly during the first few sessions, clinicians must create good rapport and establish their credibility in a way that is sensitive. Among refugee populations and other minority groups who have experienced significant oppres- sion, trust may not be as easily established as with White American clients (Chung & Bemak, 2012; Ward, 2005). For example, Dana (2002) describes a process by which African American clients may “size up” a mental health clinician and suggests that African Americans look for signs of genuineness, authenticity, and approachability in mental health clinicians. It is often necessary to spend time during the clinical and diagnostic interview to discuss, define, and clarify roles of the client and psychologist and to explore the client’s expectations regarding psychotherapy; this may be especially true for clients from non-Western cultures, where personal problems are not usually shared with people outside the family network (Chung & Bemak, 2012). For instance, different meanings for the term clinician can be found across different cultural groups, ranging from physician, to medicine man/ woman, to folk healer (Paniagua, 2014). Moreover, in some cultures, confidentiality may mean that family members or close friends may have access to the client’s personal information, so it is important for the clinician to ensure a workable definition that the client feels comfortable with and agrees upon (Chung & Bemak, 2012). Individuals from more collectivistic cultures may also experience confusion about the “distance” or “coolness” of the Western counselor who defines the social and professional relationship more narrowly and refuses social invitations to family events (Chung & Bemak, 2012). Traditional psychological intervention strategies are often bound by the Western cultural norms and practices with which they were created. The culturally competent counselor is able to adapt, alter, and modify these techniques to meet the needs 1 Basics and Beyond in Clinical and Diagnostic Interviewing 19 of the diverse client. Sue and Sue (2016) describe several culture-bound values of psychology including focus on the individual; preference for verbal, emotional, behavioral expressiveness; insight; self-disclosure; scientific empiricism; distinctions between mental and physical functioning; ambiguity; and patterns of communication. Nonverbal communication, such as bodily movements (e.g., eye contact, facial expression, posture), the use and perception of personal and interpersonal space, and vocal cues (e.g., loudness of voice, pauses, rate, inflection), can vary depending on cultural factors (Sue & Sue, 2016). Clinicians should be aware of their own communication style and anticipate how it may affect clients with a different communication style. To facilitate rapport with clients of a different culture, it may be helpful for clinicians to match the client’s rhythm and pace of speech, maximize awareness of their comfort level with eye contact and physical distance, show respect for hierarchy in the family and extended family, and use appropriate metaphors and symbols (Ingram, 2006). Adjustments can be made to the interview that may help to increase the comfort level of the client and serve to strengthen the therapeutic relationship. For example, clients with a visual impairment may require large print questionnaires and informed consent forms. Alternatively, the clinician could offer to read printed materials aloud. Hearing amplifiers can be offered to those clients with a hearing impairment. Translators or interpreters may be used when the clinician and client do not share the same language, although such practice is not without notable complications. Paniagua (2014) cautions that the use of translators introduces a third person into the psychotherapeutic process, which can lead to miscommunications or misunderstandings, and that the use of a translator may be perceived negatively by some clients, who would prefer to speak to a clinician who understands their language. If translators must be used, and no better options exist, then professional translators should have formal training in mental health and culture-related syndromes and also share a similar level of acculturation as the client. Due to possible privacy and confidentiality concerns, use of a client’s relative or friend as a translator for psychotherapy is cautioned and should be considered and discussed within the client’s definitions of these concepts (Paniagua, 2014). Modifications in the diagnostic interview may also include clinicians being more flexible in their role and shifting the traditional boundaries of “clinician.” For example, for a client who has difficulty getting to the mental health clinic because of lack of transportation, the clinician may conduct the interview outside of the office, such as in the client’s home or another convenient location. Having a more active style by offering concrete advice and assistance may be necessary, such as providing information on obtaining social services if they are needed by the client. Consulting family members and paraprofessionals or folk healers may be appropriate in some cases in order to better understand the struggles and sources of resilience of culturally diverse clients (Paniagua, 2014). Where traditional talk therapy may not be the natural means of resolving problems, culturally competent clinicians will be open to incorporating alternative techniques (Chung & Bemak, 2012). 20 D. L. Segal et al.

Impact of Diversity on Clinical Diagnosis

Clinicians must be sensitive to cultural issues not only to more effectively establish a therapeutic relationship, but also because of the impact of diversity on clinical diagnosis. An accurate diagnosis is essential, as it facilitates communication, dic- tates the nature of treatment, and provides an indication of the likely prognosis and course of the disorder (Segal & Coolidge, 2001). During the clinical interview, clinicians use the client’s description of the frequency, intensity, and duration of the symptoms; signs from a mental status examination; and the clinician’s own observations and judgment of the client’s behavior to determine a formal diagnosis of a mental disorder. The final diagnosis depends on the clinician’s belief about whether the client’s signs, symptom patterns, and impairment of functioning meet criteria for a given diagnosis, as set forth by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5; American Psychiatric Association, 2013). Although the symptoms of mental disorders are found worldwide, diagnosis can be challenging because the manifestations of mental disorders vary with age, gender, race, ethnicity, and culture (DHHS, 2001). Culture can account for variation in the ways in which clients communicate their symptoms, which symptoms they report, and the meanings they attach to the mental disorder. Clinicians who are unfamiliar with a client’s frame of reference may incorrectly diagnose as psychopathology variations in behavior, belief, or experience that are particular to and normative within the client’s culture. For example, speaking in tongues, hearing the voice of God, or witnessing spiritual beings should probably not be considered pathological for individuals from certain religious communities, whereas it may be considered a problem from someone who is nonreligious (Johnson & Friedman, 2008). Aklin and Turner (2006) suggested that the use of structured and semi- structured interviews can reduce clinician bias with regard to diagnosis, and we agree since structured and semi-structured interviews provide a standardized way to assess thoroughly all the diagnostic criteria for all of the major mental disorders in the DSM system (Segal & Williams, 2014). The DSM-5 (American Psychiatric Association, 2013) provides an outline designed to assist clinicians with developing a culturally appropriate clinical formulation. Clinicians are encouraged to explore and provide a narrative summary for each of five categories (see Table 1.2). The DSM-5 also includes the Cultural Formation Interview (CFI), a 16-item assessment tool that may be used to gain information about the impact of culture on an individual’s presentation and care plan. Developed as a brief semi-structured interview, it emphasizes four domains of assessment: cultural definition of the problem; cultural perceptions of cause, context, and support; cultural factors affecting self-coping and past help seeking; and cultural factors affecting current help seeking. Finally, clinicians should become familiar with the Glossary of Cultural Concepts of Distress in the DSM-5, which provides information on nine culture-specific conditions that may or may not be linked to a specific diagnostic category. 1 Basics and Beyond in Clinical and Diagnostic Interviewing 21

Table 1.2 Aspects of a cultural formulation Cultural identity of the individual: Describe the individual’s racial, ethnic, or cultural reference groups that may influence his or her relationship with others, access to resources, and developmental and current challenges, conflicts, or predicaments. For immigrants and racial or ethnic minorities, the degree and kinds of involvement with both the culture of origin and the host culture or majority culture should be noted separately. Language abilities, preferences, and patterns of use are relevant for identifying difficulties with access to care, social integration, and the need for an interpreter. Other clinically relevant aspects of identity may include religious affiliation, socioeconomic background, personal and family places of birth and growing up, migrant status, and sexual orientation Cultural conceptualizations of distress: Describe the cultural constructs that influence how the individual experiences, understands, and communicates his or her symptoms or problems to others. These constructs may include cultural syndromes, idioms of distress, and explanatory models or perceived causes. The level of severity and meaning of the distressing experiences should be assessed in relation to the norms of the individual’s cultural reference groups. Assessment of coping and help-seeking patterns should consider the use of professional as well as traditional, alternative, or complementary sources of care Psychosocial stressors and cultural features of vulnerability and resilience: Identify key stressors and supports in the individual’s social environment (which may include both local and distant events) and the role of religion, family, and other social networks in providing emotional, instrumental, and informational support. Social stressors and social supports vary with cultural interpretation of events, family structure, developmental tasks, and social context. Levels of functioning, disability, and resilience should be assessed in light of the individual’s cultural reference groups Cultural features of the relationship between the individual and the clinician: Identify differences in culture, language, and social status between an individual and the clinician that may cause difficulties in communication and may influence diagnosis and treatment. Experiences of racism and discrimination in the larger society may impede establishing trust and safety in the clinical diagnostic encounter. Effects may include problems eliciting symptoms, misunderstanding of the cultural and clinical significance of symptoms and behaviors, and difficulty establishing or maintaining the rapport needed for an effective clinical alliance Overall cultural assessment: Summarize the implications of the components of the cultural formulation identified in earlier sections of the outline for diagnosis and other clinically relevant issues or problems as well as appropriate management and treatment intervention Note: Adapted from the DSM-5 (APA, 2013)

Appraisal of the client’s cultural background should be a standard part of any clinical or diagnostic interview. However, a word of caution with regard to issues of diversity: “Although it is critical for clinicians to have a basic understanding of the generic characteristics of counseling and psychotherapy and the culture-specific life values of different groups, overgeneralizing and stereotyping are ever-present dangers” (Sue & Sue, 2016, p. 154). In addition, because each person has multiple identity dimensions, clinicians should be cognizant of the many within-group differences that can exist between members of a cultural group, which can sometimes outnumber the between-group differences. For example, differences between individuals considered to be in the same racial or ethnic group can be due to any number of factors, such as varying national origin, socioeconomic class, level of acculturation, age, or gender, to name a few. Moreover, clinicians should not automatically assume that the problems of culturally diverse clients are necessarily 22 D. L. Segal et al. related to cultural experiences or background. For example, it would be erroneous to assume that an 85-year-old client is depressed because of age alone. Readers are encouraged to consult a number of sources that cover issues of diversity more comprehensively: Chung and Bemak (2012); Paniagua (2014); Pedersen, Lonner, Draguns, Trimble, and Scharron-del Rio (2016); and Sue and Sue (2016).

Issues Specific to Emerging Professionals

The process of learning how to conduct an effective and thorough clinical interview can be exciting but also anxiety provoking. Many emerging professionals feel overwhelmed by the task and lack confidence in their knowledge and skills. Conducting an effective interview is a skill that can only be developed over time and, in the beginning, errors are likely to be made. In fact, struggling with one’s first several interviews is to be expected and therefore should not be a source of undue anxiety for the emerging professional. Common issues specific to emerging professionals in the context of clinical interviewing include managing anxiety, obtaining the appropriate breadth and depth of information, overlooking the process (i.e., the interaction between client and clinician) of the interview, premature advice-giving, interacting with clients with diverse characteristics, and handling personal questions. Clients can often sense a clinician’s anxiety or discomfort; therefore, it is essential for emerging professionals to learn to manage their nervousness during interviews. Frequently, clients are anxious at the interview as well and might not know what to expect, depending on whether or not they have had previous experience with psychotherapy. It can be helpful to ease into the initial interview by engaging the client in brief discussions of “lighter” topics (e.g., “Tell me a little bit about where you are from or where you grew up”) before delving into the client’s significant concerns. Emerging professionals can reduce their own anxiety regarding interviews by activities such as observing more experienced clinicians conduct diagnostic interviews, practicing mock diagnostic interviews with peers, and reviewing ahead of time any information gathered about the client and the client’s pressing concerns. In addition, the beginning of one’s career is a good time to learn to engage in adequate self-care. Regular exercise, a sufficient amount of sleep, and use of relaxation exercises and meditation are all ways of maintaining an overall sense of well-being and control, which will likely have a positive impact on one’s level of professional confidence. Emerging professionals tend to worry about getting “all” of the necessary information in the initial interview and struggle with asking too many superfluous questions (Faust, 1998). This can make the interview feel like an interrogation rather than a conversation between the clinician and client. However, in a sense, the entire course of psychotherapy with a client can be thought of as an ongoing “information- gathering” process. Indeed, clinicians continue to learn more about the client as psychotherapy progresses. As such, although it is important to obtain as much relevant information as possible, getting all of the information in one or two interviews 1 Basics and Beyond in Clinical and Diagnostic Interviewing 23 is not necessarily a requirement. On the other hand, emerging professionals may struggle with not exploring sensitive areas out of the belief that it is impolite to explore certain aspects of clients’ lives (Faust, 1998). Avoidance of socially sensitive topics has the potential for communicating to the client that certain areas are “off-limits” and should not be explored in psychotherapy. For example, young clinicians may be hesitant to discuss sexuality with an older client, even when it is central to the presenting problem. In addition, avoiding sensitive topics in an interview could be life-threatening if a client has suicidal or homicidal ideation or is dealing with domestic violence or substance abuse. Clinicians who are anxious or hesitant to explore certain topics with their clients should certainly discuss their fears with a trusted supervisor or colleague. Some emerging professionals focus so much on the content of the interview that they end up overlooking the process of the interview. Many clinics use interview outlines or checklists to assist emerging professionals with obtaining relevant information. However, this can lead to an excessive amount of note-taking in an attempt to make sure every blank on the intake form is filled in. This may give the impression to clients that the clinician is more interested in filling out paperwork than getting to know them as individuals, which can negatively impact the development of rapport. If diagnostic interviews are recorded for the purpose of supervision, clinicians can use those recordings to ensure no vital information was overlooked. Emerging professionals may become frustrated if there are significant gaps in the information obtained during an initial interview, in spite of repeated attempts to get pertinent answers. Difficulty with obtaining information from a client is often important diagnostically. For example, it could reflect the client’s ambivalence about psychotherapy, personality style, cognitive impairment, or a poor therapeutic alliance. It is often useful to address this difficulty directly by checking in with the client about how he or she is feeling about the interview, about the clinician, and about disclosing personal information. Many emerging professionals struggle with the impulse to “fix” the client (Ingram, 2006). At times it may be necessary to take action during an interview, for example, to ensure the safety of a suicidal client or assist a low-income client with obtaining financial assistance for basic needs such as food or electricity. However, advice-giving often evolves from the interviewer’s experiences and perspective, rather than the client’s (Faust, 1998). Some clinicians feel a sense of pressure to “do something” to demonstrate their competence to a client early in the interview or treatment process and may be tempted to offer simple advice. We encourage clinicians to resist this temptation and discuss it in supervision. Often clients enter psychotherapy only when they have tried every other solution to address their problems and none of those solutions have been effective. It is likely that the clinician who gives advice without adequate exploration will make suggestions that have already been tried, adding to a sense of hopelessness and frustration on the part of the client and undermining the client’s confidence in the clinician’s abilities. Simple solutions for complex problems simply do not work! Emerging clinicians can assure themselves that providing empathic listening and emotional support for the client are active strategies that are known to be beneficial. 24 D. L. Segal et al.

Some emerging professionals are uncomfortable interacting with clients from diverse backgrounds, and one’s level of comfort with diverse characteristics will determine how issues of diversity are handled (Faust, 1998). Consultations with supervisors and peers who are more knowledgeable about issues of diversity as well as attending workshops and continuing education programs can better equip clinicians to work with diverse populations (DHHS, 2001). In addition, clinicians should constantly strive to be aware of their own biases and stereotypes to ensure they are not impacting the interview process or impairing the therapeutic relationship. Clinical supervision and the clinician’s personal psychotherapy are appropriate environments in which to explore one’s own biases, stereotypes, and areas of discomfort. Clinicians should be willing to do extra research after meeting with a new client if there is a knowledge deficit in a particular area. If a clinician determines that he or she is not competent to work with a specific client, that client should be referred to another clinician with greater expertise. Dealing with personal questions such as the clinician’s age, ethnic background, marital status, or whether or not the clinician has children can be especially difficult for emerging professionals. There are several reasons for why a client might ask a clinician a personal question. Sometimes clients who ask personal questions are looking for a way to “bond” or become more comfortable with the clinician by seeking common ground, for instance, by asking where the clinician grew up. Alternatively, clients may be unaware of the unique nature of clinician-client relationships and how this professional relationship is different from social relationships with family or friends. Other times, clients are unsure whether the clinician has the expertise or life experience to adequately understand their struggles and assist them with finding solutions to those struggles. For example, an older client might ask about the clinician’s age because the clinician seems “too young” to be helpful. As we noted earlier, answering these types of factual questions in a non- defensive way that reassures the client of one’s professional competence can lessen the client’s concerns. It may also be useful to discuss with the client the reason behind the question. Exploring the client’s concerns can facilitate the therapeutic alliance as well as provide further diagnostic information.

Clinical Interviews: Dos and Don’ts

Although there is great flexibility in the manner in which clinicians conduct clinical and diagnostic interviews, we gently offer the following guidance regarding some positive strategies that clinicians may endorse and some tactics that they may wish to avoid. Beginning with the “dos” of the interview, do focus as much on developing rapport as on gathering data. Whereas the two primary goals of the clinical interview are to develop a working alliance with the client and to gather relevant data about the personal background of the client and the types of problems he or she is experiencing, the first goal of establishing rapport is arguably the more important of the two. Indeed, without the development and ongoing nurturance of a positive 1 Basics and Beyond in Clinical and Diagnostic Interviewing 25 therapeutic relationship, the act of gathering information about the client is pointless if he or she does not return for ongoing treatment (Hook et al., 2010). Do provide structure and direction in the interview as needed (Segal et al., 2008). Whereas advantages of a non-structured clinical interview include its flexibility, which allows for discussion and exploration of topics that may not necessarily be covered by a structured interview, and its provision of extensive opportunities for empathizing with the client and developing a strong therapeutic alliance, a potential hazard is that the interview may stray excessively. A general guiding principle is that if clients provide appropriate structure to the interview (moving appropriately from topic to topic), then no active structuring is required by the clinician. However, if clients struggle with providing their own structure (e.g., spending too much time on topics of little or questionable relevance to the problems at hand), then the clinician must provide more guidance. Regarding the diagnostic process, do have a solid knowledge of the symptoms and requirements for diagnosing a wide range of mental disorders from the DSM-5 to be able to assess for the full range of cardinal and associated symptoms as part of a comprehensive diagnostic process. This knowledge will also be of help when crafting case conceptualizations and initial treatment plans. Do pay special attention to the final moments of the initial interview (Segal et al., 2008). There is a lot to accomplish during the first interview, and this includes the last 5–10 minutes as well. Rather than end abruptly, the clinician should attend to the sensitive information that has been shared and may want to thank the client for sharing personal, potentially upsetting experiences. The ending of the interview is also an opportunity to review important themes addressed, and, as a means for offering a sense of hope, clinicians can suggest some of the ways that psychotherapy could be helpful in addressing the presenting complaints. Conversely, there are a number of things to avoid during the interviewing process. Don’t become overly committed to an initial diagnostic hypothesis; instead, maintain multiple hypotheses (Segal et al., 2008). Although knowledge of a previous diagnosis and initial impressions of the client are useful, it is important to keep an open mind. If clinicians are not flexible in diagnosing, they may be closed off or dismissing of information that does not align with that first hypothesis. One strategy is to always consider at least five diagnostic possibilities or hypotheses and systematically rule each one in or out as part of a full differential diagnostic process. This so-called Rule of 5 prevents clinicians from settling too quickly on the most obvious diagnosis, which is sometimes incorrect, and encourages a more thorough assessment. Maintaining multiple hypotheses is essential in making accurate diagnoses and subsequently providing an effective treatment. Don’t make assumptions (Segal et al., 2008). It is tempting to believe that we understand the client’s symptoms when they use labels. For example, when someone says that they have been experiencing “panic attacks,” it is easy to imagine increased heart rate, sweating, and the intense fear that he or she is going to die or have a heart attack. As another example, when someone says that they are “code- pendent,” it likely conjures an image of a person who exhibits overdependence on people, behaviors, or things, such as a spouse who supports addiction by excusing, 26 D. L. Segal et al. denying, or concealing evidence of the partner’s alcohol misuse. At first blush, these labels seem reasonable. However, without specific inquiry and the gathering ofspe- cific examples of behaviors, it is unclear whether the clinician and client define the problem or symptoms in the exact same way. It is possible in fact that the clinician and client are thinking of quite different experiences, which would hinder appropriate and effective treatment. Finally, it is important that clinicians do not let their opinions or values unduly factor into the interview (Segal et al., 2008). There will be instances in which the clinician feels at odds with the client’s decisions and behaviors; however, with the exception of illegal and harmful actions, it is important to provide an environment for the client that is free of the clinician’s biases and values. This is especially challenging if the client has done things the clinician feels are reprehensible or disgust- ing. In these cases, it can be helpful to try to understand and empathize with “a person who has done awful things” rather than with “an awful client,” so try to conceptualize the person as not equivalent to their behavior. Because we are not always immediately aware of our own biases and judgments, we suggest that clinicians pay special attention to their emotional reactions to the content of interviews and psychotherapy sessions. In the event that a clinician’s opposition to the client’s behaviors, values, or decisions is intense or distressing, the clinician should discuss the issue with a colleague or supervisor, and if the feelings continue to intrude into the treatment, the clinician should refer the client elsewhere if ongoing psychotherapy is needed.

References

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U.S. Department of Health and Human Services. (2001). Mental health: Culture, race, and ethnicity- A supplement to mental health: A report of the Surgeon General. Rockville, MD: Author. Wampold, B. E. (2015). How important are the common factors in psychotherapy? An update. World Psychiatry, 14, 270–277. Ward, E. C. (2005). Keeping it real: A grounded theory study of African American clients engaging in counseling at a community mental health agency. Journal of Counseling Psychology, 52, 471–481. Werth, J. L. (2017). The duty to protect. In P. M. Kleespies (Ed.), The Oxford handbook of behavioral emergencies and crises (pp. 522–530). New York, NY: Oxford University Press. Chapter 2 Interviewing Strategies, Rapport, and Empathy

Catherine Miller

In the 10 years since the publication of the 4th edition of this book, there have been some significant developments that affect how clinicians conduct a clinical interview. First, the American Psychiatric Association published the fifth edition of Diagnostic and Statistical Manual (DSM-5) in 2013. Some of the changes to DSM-5 include the elimination of the multiaxial system, changes to diagnostic criteria for Autism Spectrum Disorder, and the addition of several new diagnoses, including disruptive mood dysregulation disorder (DMDD), avoidant restrictive food intake disorder (ARFID), and binge eating disorder (BED). These modifications necessitated changes to structured and semi-structured interview schedules based on existing diagnostic categories (Leffler, Riebel, & Hughes,2015 ; Robins & Cottler, 2004; Segal & Williams, 2014). Second, Congress passed the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008, with the intent of ending long-standing insurance policies that discriminated against those with mental disorders. Although parity in reality has not yet been achieved (The Mental Health and Substance Use Disorder Parity Task Force, 2016), the law underscores the importance of clinicians accurately and efficiently diagnosing mental disorders. Third, changing societal conditions, including the rising opioid epidemic (National Institute on Drug Abuse, 2018) and a recent spike in suicide rates (Stone et al., 2018), make it imperative that clinicians know how to accurately diagnose and effectively treat mental health issues. What has not changed in the 10 years since this book was published is clinicians’ reliance on the clinical interview as the foundation of clinical assessment and treatment (Edelbrock & Bohnert, 2000; Groth-Marnat & Wright, 2016; Institute of Medicine, 2015; Loney & Frick, 2003). There are numerous self-report instruments, questionnaires, and other assessment devices which assist clinicians in diagnosing and monitoring treatment progress. However, the clinical interview remains the

C. Miller (*) Pacific University, School of Graduate Psychology, Hillsboro, OR, USA e-mail: [email protected]

© Springer International Publishing AG 2019 29 D. L. Segal (ed.), Diagnostic Interviewing, https://doi.org/10.1007/978-1-4939-9127-3_2 30 C. Miller foremost tool in the clinician’s tool belt. In a survey of 412 American Psychological Association (APA) members, the clinical interview was rated as the most frequently used assessment procedure, with 93% stating that they “always” or “frequently” utilize clinical interviews with clients (Watkins, Campbell, Nieberding, & Hallmark, 1995). Edelbrock and Bohnert (2000) described the clinical interview as the default assessment technique due to its ubiquitousness in clinical and research settings. The term clinical interview is a broad one, including interview formats that vary in terms of topics addressed, length of time to complete, and degree of interviewer structure imposed. Regardless of interview format, the main goals of clinical interviews are as follows: (a) To identify the current context of the client’s presenting issues, including any biological, social, psychological, and cultural factors that may be maintaining the issues (b) To obtain historical information about the client’s presenting issues, including any biological, social, psychological, and cultural factors that may have caused the presenting issues (c) To utilize observations of clients, including speech patterns, thought processes, eye contact, etc., that may aid in diagnostic formulation (Institute of Medicine, 2015; Sattler, 2014) To effectively utilize the clinical interview, clinicians must have both technical and interpersonal skills. Technical skills involve knowing current diagnostic criteria and therefore what questions to ask during interviews in order to elicit the most accurate information from clients. Interpersonal skills involve the ability to create rapport and respond empathically to clients so that clients feel heard. This chapter will address technical skills by reviewing the two main interviewing strategies utilized by clinicians and researchers (unstructured and structured interviews), with a focus on updated interview protocols developed for DSM-5. This chapter will also address interpersonal skills by reviewing the concepts of rapport and empathy and how the different types of interviews impact the development of rapport and the expression of empathy with clients during the interview process (Groth-Marnat & Wright, 2016).

Technical Skills

Clinical interviews can be broadly divided into two main categories: unstructured and structured interviews (Sattler, 2014). Unstructured interviews are those in which the clinician develops the questions to ask of each client and records the responses in his/her own idiosyncratic way. In other words, there is no standardization of the questioning or recording of client responses (Jones, 2010). Structured interviews are those in which clinical inquiries and response recording are provided by the developers of the interview (Rogers, 2003). Structured interviews include both fully or highly structured and semi-structured formats. Fully structured interviews do not 2 Interviewing Strategies, Rapport, and Empathy 31 permit clinician-initiated probes but instead require clinicians to read questions verbatim. Semi-structured interviews provide verbatim questions and probes but allow clinicians to augment the interview with their own individualized queries in order to obtain additional information from clients (Rogers & Wupperman, 2007). An unstructured approach is the most common method of interviewing in direct clinical settings (Aboraya, Rankin, France, El-Missiry, & John, 2006; Mash & Barkley, 2007), whereas fully structured interviews are more commonly utilized in research settings (Rogers, 1995, 2003). Semi-structured interviews have been used in both research and clinical settings (Summerfeldt, Kloosterman, & Antony, 2010). In addition, both semi-structured and fully structured interviews have been utilized as part of clinical training of mental health professionals (Segal & Williams, 2014). Learning to administer such interviews is believed to aid the practitioner in training in two main ways. First, structured interviews, with their thorough review of diagnostic criteria, may assist trainees in internalizing relevant diagnostic criteria (Segal & Williams, 2014). Second, the comprehensive template in structured interviews can assist trainees in developing their own style of unstructured interviewing (Loney & Frick, 2003).

Unstructured Approaches to Interviewing

Unstructured interviews are extremely versatile, allowing clinicians to formulate their own questions depending on a client’s issues and concerns. In addition, unstructured approaches allow clinicians to record client responses in idiosyncratic ways (Rogers, 2001). Use of unstructured interviews is recommended when the interviewer wants clients to tell their stories with minimal guidance (Sattler, 2014). Utilizing such formats, it is the clinician who is “entirely responsible for determining what questions to ask and how the resulting information is to be used in arriving at a diagnosis” (Summerfeldt & Antony, 2002, p. 3). This lack of uniformity or standardization allows for an interview in which “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” (Segal & Williams, 2014, p. 104). There are two main advantages of utilizing an unstructured approach, including the flexibility of the approach and the degree of rapport that can be developed between the client and clinician. The flexibility of unstructured interviews lies in the fact that each interview is “highly dependent on the specific interviewer, the specific interviewee, the type of interview, and the conditions under which the interview took place” (Sattler, 1992, p. 463). Unstructured approaches allow clinicians to have maximum latitude regarding what questions to ask, how to probe symptom patterns, and how much time to spend on different subject matters. Rapport may be enhanced by this flexibility, as clients may feel that the unstructured approach addresses their main concerns without wasting time on what they perceive as irrelevant or unnecessary queries (Sattler, 1992). 32 C. Miller

The flexibility that is the hallmark of unstructured approaches means that unstructured interviews are not essentially equivalent across different clinicians. Instead, unstructured interviews vary in four important ways. First, clinicians ask questions using idiosyncratic wording which may impact client responses. For example, clinicians may insert words that imply judgment or incredulity, either of which may greatly impact client responses. Second, clinicians utilize a non- systematic or idiosyncratic approach to coverage of diagnostic criteria, which likely results in clinicians’ missing important symptomatology. This idiosyncratic coverage may be due to the inability of clinicians to completely know all diagnostic categories, or to primacy bias, wherein clinicians overemphasize the importance of their first hypothesis and stop assessing when that hypothesis is supported. Third, clinicians order interview topics in different ways, and this idiosyncratic sequencing of questions may impact client responses. Finally, clinicians differ in terms of the amount of client information they record, as well as the way they record this information. For example, they rarely record the question that elicited specific client information, nor do they record whether information was obtained by observing the client or from client report. Also, clinicians tend to give unusual data disproportionate attention, so that their notes do not accurately reflect client presentations (Rogers, 2001). There are three major disadvantages to the unstructured approach, including poor reliability and questionable validity, inadequate coverage of diagnostic categories, and susceptibility to biases (Rogers, 2001; Rogers & Wupperman, 2007; Rosqvist, 2005), due to both criterion and information variance (Groth-Marnat & Wright, 2016). Rogers (2001) defined criterion variance as “variations among clinicians in applying standards for what is clinically relevant … and when the diagnostic criteria are met” and information variance as “variations among clinicians in what questions are asked, which observations are made, and how the resulting information is organized” (p. 5). Despite refinements in nosological systems, such as the current version of the DSM-5 (American Psychiatric Association, 2013), clinicians do not always systematically apply diagnostic criteria. For example, Blashfield (1992, as cited in Rogers, 2003) found that misdiagnoses occurred in 60% of cases due to idiosyncratic applications of diagnostic criteria. Information variance is manifested in multiple problematic ways, including stopping interviews prematurely and confirmatory bias. Some clinicians may stop the interview process after the first mental disorder is established, so that many diagnoses are missed (Rogers, 2001; Segal & Williams, 2014). For example, in reviewing 1000 interview protocols, Zimmerman and Mattia (1999) found that 33% of patients interviewed with a structured format were diagnosed with three or more disorders, whereas fewer than 10% of the patients interviewed with an unstructured format had similar results. Rogers and Shuman (2000) called this process premature closure and found that it prevented a comprehensive evaluation of client symptomatology. Finally, clinicians are subject to confirmatory bias, in that they tend to seek information selectively to confirm their initial hypothesis, ignoring any disconfirming evidence and missing important symptoms (Angold & Fisher, 1999; Rogers, 2001). For example, North et al. (1997) found that unstructured interviews tended to result in 2 Interviewing Strategies, Rapport, and Empathy 33 overdiagnosis of antisocial personality disorder and underdiagnosis of depression in a homeless population. Baker and Bell (1999) found that unstructured interviews resulted in overdiagnosis of schizophrenia and underdiagnosis of depression in African-American patients. In a classic study, Ward, Beck, Mendelson, Mock, and Erbaugh (1962) demonstrated the negative impact of information and criterion variance in unstructured interviews. These researchers reviewed disagreements on 40 clients interviewed within minutes by two different psychiatrists using unstructured interviews. Ward et al. reported that 62.5% of variability in clients’ responses resulted from criterion variance, 32.5% resulted from information variance, and only 5% resulted from true changes in clients’ clinical presentations. In other words, how the interview is conducted (information variance) and how the criteria are utilized to score responses (criterion variance) greatly affect the resulting information obtained during clinical interviews. The large discrepancies resulting from unstructured interviews led researchers to develop interviews with standardized questions and explicit ratings, in an attempt to reduce both information and criterion variance. The resulting interview formats are known as structured approaches to interviewing.

Structured Approaches to Interviewing

Structured interview approaches have been gaining ground over the past four decades (Rogers, 2001). These structured interviews were developed initially for use with adult clients in research settings, but their use has expanded to child/adolescent populations and to clinical settings (Loney & Frick, 2003). Structured interviews require clinicians to ask questions and follow-up probes in a standardized manner and sequence, and rate client responses using systematized ratings (Segal & Williams, 2014). Client responses are generally rated by clinicians in either a dichotomous yes/no format or by using a Likert-type scale that allows for symptom severity ratings. Interview questions typically start with a stem question and then follow-up with a series of questions designed to assess frequency, duration, and severity of the behavior of interest (Loney & Frick, 2003). Some of the structured interviews utilize a computer-assisted administration format, wherein the clinician reads each item and enters client responses. The computer scores responses along the way, allowing only appropriate follow-up questions to be presented (Loney & Frick, 2003). There are five main advantages of structured approaches over unstructured interview formats, including improved psychometrics, coverage of diagnostic categories, appropriate use of diagnostic categories, ratings of impairment, and use of non-pejorative questions (Rogers & Wupperman, 2007). First and foremost, structured interviews are able to demonstrate good-to-excellent psychometric properties (Rogers, 1995). Second, there is more comprehensive coverage of diagnostic categories with structured interviews, including diagnoses that are less prevalent 34 C. Miller

(Segal & Williams, 2014). Clients benefit from the more thorough diagnostic coverage by improved treatment planning, whereas clinicians benefit from decreased risk of negligence or malpractice allegations (Hodges & Cools, 1990). Third, structured interviews increase the appropriate use of diagnostic criteria by reducing variations in recording of clinical data. This uniform recording system allows clinicians to clearly document the course of the disorder as well as client response to specific treatments (Rogers & Wupperman, 2007). Fourth, structured interviews provide a way to reliably distinguish levels of impairment. They typically measure symptoms on a continuum (greater or lesser intensity, frequency, duration) rather than merely the presence or absence of a symptom. This increased specificity of impairment provides a great deal of information that can be utilized in treatment planning. Finally, the standardized questions on structured interviews are designed to promote respect and reduce pejorative, insensitive, or offensive inquiries (Rogers & Wupperman, 2007). An additional possible advantage of structured interviews is a reduction in the use of resources. The routine wording and ordering of questions of structured formats allow for lay interviewers or computers to administer some of the more highly structured interview formats. Not having to have highly trained doctoral-level clinicians administer interviews may allow thorough diagnostic interviews to be conducted in large settings where few clinicians traditionally are found, such as prisons, residential treatment centers, and homeless shelters (Shaffer, Fisher, & Lucas, 1999). However, it should be noted that structured interviews are time-consuming to learn to administer in the proscribed manner. Training in administration typically takes at least 1 week and often up to 4 weeks. Although their advantages are strong, structured interviews have several disadvantages. The most commonly cited disadvantage is that their use may hinder rapport between client and clinician (Sattler, 2014; Segal, Maxfield, & Coolidge, 2008). The rigid structure of the interview may interfere with relaxed communication. If clinicians become too tied to a rigid and inflexible protocol, there is a chance that clients may become disengaged from the diagnostic process (Rogers, 1995) and may not feel comfortable revealing personal information (Groth-Marnat & Wright, 2016). As stated by Segal and Williams (2014), “attaining a reliable and accurate diagnosis of a client achieves 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 for continued 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’” (pp. 108–109). Clinicians are advised to make rapport- building an explicit goal of the interview and avoid a mechanistic, rote-like approach that may alienate clients, or they will sacrifice accurate and helpful information (Segal & Williams, 2014). Second, there is some evidence that clients report more symptoms early in a structured interview, meaning that symptoms assessed later in the process may not be adequately evaluated (Loney & Frick, 2003). The reasons for this phenomenon are unclear, but two main hypotheses have been proposed. It may be that clients 2 Interviewing Strategies, Rapport, and Empathy 35 learn over time that endorsement of symptoms lengthens the interview process and so they begin to deny later symptoms. Alternatively, clients may become sensitized to the threshold for reporting issues by attending to the questions in the first part of the interview (Loney & Frick, 2003). Regardless of the reason, it is imperative that clinicians remain aware that clients may be endorsing more items in the beginning of the interview process and that this may be due to an artifact of the assessment method rather than a true picture of the client functioning. Third, because structured interviews do not allow for rephrasing of questions by clinicians, there is a risk that clients may misunderstand questions and then respond inappropriately (Shaffer et al., 1999). Fourth, some atypical symptoms may not be covered, as interviews cannot cover every diagnosis and symptom presentation or they risk being too long and cumbersome to be regularly employed (Shaffer et al., 1999). Even without complete coverage, administration of structured interviews typically takes at least 75 minutes but may take up to 4 hours with severely disturbed clients. Most structured interview formats share some common features (Hodges & Cools, 1990; Loney & Frick, 2003; Rogers, 2001). First, these interviews are typically organized by disorder or syndrome, a system called symptom clustering. Although this organization necessarily entails repeated questioning of symptoms contained in several diagnoses, it is advantageous, in that it allows clinicians to quickly rule out specific disorders and to allocate maximum time within the interview to those diagnoses that appear most likely (Summerfeldt & Antony, 2002). Second, structured interviews typically employ unidirectional scoring, meaning that endorsement of an item is a sign of psychopathology. Such a process allows for rapid scoring and diagnostic decision-making. Finally, questions included in many structured interviews directly correspond to diagnostic criteria contained in the DSM or some other classification system, such as the Research Diagnostic Criteria (RDC; Spitzer, Endicott, & Robins, 1978). This direct correspondence clearly aids clinicians when attempting to diagnose clients based on interview responses. This direct correspondence requires that structured interview formats be revised regularly to keep up with revisions to nosological systems (Angold & Fisher, 1999; Sattler, 2014), and there may be a delay of several years between the publication of the latest DSM and revisions to existing structured interviews. Despite common features, structured interviews vary considerably across three main dimensions, including diagnostic coverage, ease of use, and degree of structure (Rogers, 2001). First, structured interviews differ according to breadth and depth of focus. Due to time constraints, a single interview cannot simultaneously cover all diagnostic categories in considerable depth. Interviews with broad diagnostic coverage sacrifice depth in two ways: by screening out disorders and by minimizing the number of questions asked. In contrast, interviews with more questions on each symptom (greater depth) restrict coverage to common diagnoses. Second, structured interviews differ according to ease of use. Fully or highly structured interviews that prescribe specific questions simplify administration and require little clinical experience. Less structured or semi-structured interviews are more difficult to use and require considerably more clinical judgment (Rogers, 2001; Segal & Williams, 2014). 36 C. Miller

The main difference between the various structured interviews lies in the level of structure imposed on the clinician. There are two types of structured approaches: semi-structured and fully structured interviews (Rogers & Wupperman, 2007). Fully structured interviews specify the exact wording, order, and coding of each question. Questions must be read verbatim, with no variation or additions. In contrast, semi- structured approaches provide only general and flexible guidelines for conducting the interview, allowing clinicians more latitude in pursuing alternative lines of inquiry (Segal & Williams, 2014). Clinicians may even invent their own unstructured questions, allowing semi-structured interviews to appear more conversational than highly structured interviews (Rogers, 2001). Semi-structured formats have been referred to as interviewer-based interviews, as the clinician has some discretion in varying the wording and the ordering of questions (Angold & Fisher, 1999). In contrast, fully structured formats have been referred to as respondent-based interviews, as the client is required to interpret the meaning of the questions and decide on a reply with minimal or no assistance of the interviewer (Shaffer et al., 1999). Deciding which format to utilize is dependent on type of setting and purpose of the interview. Because more clinical judgment is needed in semi-structured interviews, these can only be administered by experienced clinicians with advanced training. Because more diagnostic categories are typically sampled in fully structured interviews, these require more time to complete. The following section reviews several structured and semi-structured interviews that have been updated to reflect DSM-5 diagnostic criteria. There are multiple structured and semi-structured interview formats available to clinicians and researchers, but most have not yet been updated to reflect DSM-5 criteria. For thorough reviews of interviews developed based on DSM-IV criteria, please see Rogers (2001) and Segal and Williams (2014).

Examples of Fully and Semi-Structured Interviews for DSM-5

The Diagnostic Interview Schedule for DSM-5 The Diagnostic Interview Schedule (DIS) was the first fully structured diagnostic interview to be developed. It is a broad-based measure, designed to assess a wide range of both current and lifetime diagnoses (Summerfeldt & Antony, 2002). The current version corresponds to DSM-5 diagnostic criteria (APA, 2013) and covers multiple disorders, including specific phobia, social phobia, agoraphobia, panic disorder, generalized anxiety disorder, posttraumatic stress disorder, depression/dysthymic disorder, manic/ hypomanic episode, schizophrenia/schizophreniform/schizoaffective disorder, obsessive-compulsive disorder, anorexia nervosa, bulimia nervosa, attention-deficit/hyperactivity disorder, oppositional defiant disorder, conduct disorder, antisocial personality disorder, and gambling disorder (Cottler, Striley, & North, 2018). The DIS-5 is fully computerized, in order to produce algorithm-based diagnoses, uses skip logic to minimize interviewer time, and allows customized selection of 2 Interviewing Strategies, Rapport, and Empathy 37

disorders (Cottler et al., 2018). Because it is a structured interview format, it may be administered by clinicians or nonclinicians. The DIS-5 website states that a 3-day training is held year-round on demand, either at the training location at the Department of Epidemiology at the University of Florida or at clinicians’ locations. The website states that training is required for first-time DIS users and is highly recommended as a refresher for those who have utilized prior versions of the interview. Training covers multiple areas, including how each DSM-5 criterion is operationalized by the DIS, how to effectively navigate the interview, and how to interpret resulting computer reports. The website states that training includes lectures, group practice with the DIS-5, and homework assignments. In addition, the training ends with a live interview with a respondent (Cottler et al., 2018). The prior version, the DIS-IV (Robins, Cottler, Bucholz, & Compton, 1995), has been widely used for epidemiological research and has been translated into over a dozen languages (Segal et al., 2008). Its psychometric properties have been reported as excellent (Compton & Cottler, 2004). Unfortunately, updated psychometrics were not available for the DIS-5 as of the time of the writing of this chapter.

The Structured Clinical Interview for DSM-5 (SCID-5) The SCID-5 is an updated version of the SCID-IV (First & Gibbon, 2004), in order to be commensurate with DSM-5 diagnoses. It is a broadband semi-structured interview, meant to assess a wide variety of diagnostic categories. There are 12 modules, each assessing multiple diagnoses (see Table 2.1). For the majority of disorders, interviewers can assess current and lifetime diagnoses, but, for a few disorders (e.g., premenstrual dysphoric disorder, insomnia disorder, and somatic symptom disorders), only current diagnoses are made. As a semi-structured interview, the SCID-5 uses prescribed questions initially and then allows interviewers to ad lib follow-up questions, in order to gather clinically relevant information. The sequencing of questions is designed to follow the process an experienced clinician would use for differential diagnoses (First, 2015). At present, there are no studies on the psychometric properties of the SCID-5, although Shankman et al. (2017) examined psychometric properties of an adapted version of the SCID-5. However, the SCID-IV has been utilized in over 1000 studies, and its psychometric properties have been reported to be excellent (First & Gibbon, 2004). The SCID-5 is designed to be administered by trained mental health professionals. First (2015) indicated that there is no minimum degree requirement for administration; instead, he suggested that SCID-5 users should have sufficient clinical experience to be able to conduct unstructured diagnostic interviews. Clinicians who are interested in being trained to administer the SCID-5 may seek training in a variety of ways. First, there are user’s manuals available for purchase on the SCID-5 website. Second, the lead author of the SCID-5, Dr. First, will travel to the clinician’s site and review administrations of live SCID-5 interviews with volunteer subjects. Alternatively, users may send in audio- or video-recorded SCID-5 38 C. Miller

Table 2.1 SCID-5 Coverage of Diagnostic Categories Modules Specific Diagnostic Categories/Symptoms Module A: Mood Episodes, Major depressive episode; manic episode; hypomanic episode; Cyclothymic Disorder, cyclothymic disorder; persistent depressive disorder (dysthymia); Persistent Depressive premenstrual dysphoric disorder; bipolar disorder due to another Disorder, And Premenstrual medical condition (AMC); substance/medication-induced bipolar Dysphoric Disorder disorder; depressive disorder due to AMC; substance/medication- induced depressive disorder Module B: Psychotic and Delusions; hallucinations; disorganized speech and behavior; Associated Symptoms catatonic behavior; negative symptoms Module C: Differential Schizophrenia; schizophreniform disorder; schizoaffective Diagnosis of Psychotic disorder; delusional disorder; brief psychotic disorder; psychotic Disorders disorder due to AMC; substance/medication-induced Psychotic disorder; other specified Psychotic Disorder Module D: Differential Bipolar I disorder; bipolar II disorder; other specified bipolar Diagnosis of Mood disorder; major depressive disorder; other specified depressive Disorders disorder Module E: Substance Use Alcohol use disorder; cannabis use disorder; inhalant use Disorders disorder; other hallucinogen use disorder; opioid use disorder; phencyclidine use disorder; sedative, hypnotic, or anxiolytic use disorder; stimulant use disorder; other or unknown substance use disorder Module F: Anxiety Panic disorder; agoraphobia; social anxiety disorder; specific Disorders phobia; generalized anxiety disorder; separation anxiety disorder; anxiety disorder due to AMC; substance/medication-induced anxiety disorder; other specified anxiety disorder Module G: Obsessive- Obsessive-compulsive disorder; hoarding disorder; body Compulsive and Related dysmorphic disorder; trichotillomania; excoriation disorder; other Disorders specified obsessive-compulsive and related disorder; obsessive- compulsive and related disorder due to AMC; substance/ medication-induced obsessive-compulsive and related disorder Module H: Sleep-Wake Insomnia disorder; hypersomnolence disorder; substance/ Disorders medication-induced sleep disorder Module I: Feeding and Anorexia nervosa; bulimia nervosa; binge-eating disorder; Eating Disorders avoidant/restrictive food intake disorder; other specified feeding or eating disorder Module J: Somatic Somatic symptom disorder; illness anxiety disorder Symptom and Related Disorders Module K: Externalizing Adult attention-deficit/hyperactivity disorder; intermittent Disorders explosive disorder; gambling disorder Module L: Trauma- and Acute stress disorder; post-traumatic stress disorder; adjustment Stressor-Related Disorders disorder; other specified trauma- and stressor-related disorder interviews to have them reviewed for administration errors. Users interested in these training opportunities can find more information on the SCID-5 website (http://www.scid5.org/). Currently, all versions of the SCID-5 are intended to be utilized with adults; the developers of the interview state on their website that a child version is in development, and First (2015) indicated that the SCID-5 need only be slightly 2 Interviewing Strategies, Rapport, and Empathy 39

Table 2.2 SCID-5 Versions Versions Translations SCID-5-Research Version English, Norwegian, and Spanish (SCID-5-RV) SCID-5-Clinical Trials English (SCID-5-CT) SCID-5-Clinical Version English, Chinese-Simplified, Dutch, German, Greek, (SCID-5-CV) Hungarian, Italian, Korean, Norwegian, Portuguese, Romanian, and Turkish SCID-5-Personality Disorders English, Danish, Dutch, German, Greek, Italian, Korean, (SCID-5 PD) Polish, Romanian, and Turkish SCID-5-Alternative Model for English Personality Disorders (SCID-5-AMPD) modified to be used with adolescents. The following five different versions of the SCID-5 are currently available for use with adult clients (see Table 2.2): 1. SCID-5-RV (Research Version; First, Williams, Karg, & Spitzer, 2015a): the SCID-5-RV is intended to be used in research studies. There are two versions of the SCID-5-RV: a core version and an enhanced version. The enhanced version includes all disorders included in the core version as well as the following optional disorders: separation anxiety disorder, hoarding disorder, body dysmorphic disorder, trichotillomania, and excoriation disorder, avoidant/restrictive food intake disorder, intermittent explosive disorder, and gambling disorder. Administration of the enhanced version is 45–180 minutes, depending upon the level of pathology. Administration of the core version is 45–120 minutes and is often utilized in an attempt to reduce the length and complexity of the SCID-5-RV. The SCID-5-RV is the most comprehensive version of the SCID-5, as it includes all of the major DSM-5 diagnoses as well as relevant subtypes and severity and course specifiers. Researchers are allowed to customize administration of the SCID-5-RV. According to the publisher’s website, the SCID-5-RV allows the researcher to remove unneeded elements (e.g., certain specifiers), alter the flow of the interview, or add additional scales (e.g., severity rating scales) of the researcher’s choosing. To maintain this flexibility, the SCID-5-RV is not published as a bound volume but instead is provided to researchers as a modifiable Microsoft Word document. The SCID-5-RV has versions available in English, Norwegian, and Spanish. 2. SCID-5-CT (Clinical Trials Version; First, Williams, Karg, & Spitzer, 2015b): The SCID-5-CT is an adaptation of the SCID-5-RV that has been optimized for use in clinical trials that utilize typical inclusion and exclusion criteria. There are five templates available for clinical trials with patients with schizophrenia, major depressive disorder, bipolar disorder, attention-deficit/hyperactivity disorder, or post-traumatic stress disorder. For an additional fee, a unique template can be configured which includes the specific diagnostic inclusion and exclusion criteria of any particular treatment protocol. Administration time for the SCID-5-CT 40 C. Miller

is 30–75 minutes, depending on the template utilized. According to the SCID-5 website, the SCID-5-CT is only available in English. 3. SCID-5-CV (Clinician Version; First, Williams, Karg, & Spitzer, 2015c): The SCID-5-CV is intended for use by clinicians and is an abridged version of the SCID-5-RV that covers the most commonly encountered diagnoses in clinical settings (e.g., depression, anxiety). Administration time for the SCID-5-CV is 30–120 minutes. The SCID-5-CV has versions available in English, Chinese- Simplified, Dutch, German, Greek, Hungarian, Italian, Korean, Norwegian, Portuguese, Romanian, and Turkish. 4. SCID-5-PD (Personality Disorders; First, Williams, Benjamin, & Spitzer, 2015): The SCID-5-PD allows interviewers to assess the 10 personality disorders in the DSM-5. Administration time for the SCID-5-PD is 30–120 minutes, depending on level of pathology. The SCID-5-PD has versions available in English, Danish, Dutch, German, Greek, Italian, Korean, Polish, Romanian, and Turkish. 5. SCID-5-AMPD (Alternative Model for Personality Disorders; First, Skodol, Bender, & Oldham, 2018): The SCID-5-AMPD allows interviewers to examine personality pathology via a conceptualization that is contained in the “Emerging Measures and Models” section of the DSM-5. This alternative model for personality disorders describes five broad trait domains: (a) negative affectivity (frequent and intense experiences of high levels of a wide range of negative emotions such as anxiety, depression, or guilt/shame); (b) detachment (withdrawal from interpersonal interactions and restricted affective expression); (c) antagonism (exaggerated sense of self-importance or callous antipathy toward others); (d) disinhibition (orientation toward immediate gratification); and (e) psychoticism (exhibiting a wide range of culturally incongruent odd, eccentric, or unusual behaviors, cognitions, or beliefs; Skodol, 2018). The SCID-5-AMPD is only available in English. Electronic administration of the SCID-5 is available through two companies: NetSCID-5 and eInterview. NetSCID-5 is a web-based version of all of the SCID-5 versions. According to NetSCID-5’s website, the SCID-5 interviews are easily accessible through any Internet-connected device, and data are stored on HIPAA- compliant databases. Users are able to download data in report form or as raw data to import into any statistical package. eInterview is a software program developed by Sunilion Software that is designed to run on most Windows-based devices. There are three main advantages to electronic administration of the SCID-5. First, administration is faster, with administration time being reduced by over 30% compared to paper administration. Second, diagnostic errors were eliminated. Third, 90% of clinicians surveyed about their use of computerized administration preferred the electronic version to its paper counterpart (Brodey et al., 2016). The Kiddie Schedule for Affective Disorders and Schizophrenia for DSM-5 (K-SADS-5) The K-SADS was developed by Puig-Antich and Chambers in 1978 as a semi-structured interview to assess children ages 6 through 18. Updates were published as the DSM was revised, for example, the K-SADS-PL (Present and Lifetime version; Kaufman, Birmaher, Brent, Ryan, & Rao, 1994) was published to reflect diagnostic categories in DSM-IV (American Psychiatric Association, 1994). Up until 2 Interviewing Strategies, Rapport, and Empathy 41 the release of the K-SADS-5, the K-SADS-PL has been the most commonly used semi-structured interview for diagnosing children and adolescents (de la Pena et al., 2018). The KSADS-5 was updated in 2013 to reflect DSM-5 diagnoses. The KSADS-5 consists of a screening section and six supplements. The screening contains an initial interview that reviews main symptoms of each disorder, whereas the supplements probe for any symptoms that were identified in the screening section. Supplement 1 includes depressive and bipolar disorders; supplement 2 includes psychotic disorders; supplement 3 includes anxiety, stress, and obsessive-compulsive disorders; supplement 4 includes disruptive behavior and impulse control disorders; supplement 5 includes substance use disorders and feeding and eating disorders; and supplement 6 includes neurodevelopmental disorders. Results allow users to determine episodes that have occurred within the last 6 months as well as past episodes (Kobak, Kratochvil, Stanger, & Kaufman, 2013). The KSADS-5 has been translated into Spanish (de la Pena et al., 2018), Brazilian-Portuguese (Caye et al., 2017), and Mandarin (Chen, Shen, & Gau, 2017). There are currently three computerized versions of the KSADS-5: a traditional clinician-administered version, a self-administered parent version, and a self- administered youth version (Barch et al., 2018; Kaufman, Townsend, & Kobak, 2017). Kobak et al. (2013) found that computerized K-SADS-5 works as well as the paper-and-pencil version, with percent agreement in diagnostic categories ranging from 88% to 96%. Good interrater reliability and construct validity have also been demonstrated (de la Pena et al., 2018).

The Mini International Neuropsychiatric Interview for DSM-5 (MINI-5) The MINI (Sheehan et al., 1997) was developed to be a very brief interview schedule, taking approximately 15 minutes to complete. The MINI 7.0.2 is the updated version of the original MINI, allowing clinicians to assess 17 DSM-5 diagnoses that are considered the most important to identify in clinical and research settings. The following diagnostic categories are covered in the MINI 7.0.2:

(a) Mood disorders (i.e., major depression, dysthymia, and mania) (b) Anxiety disorders (i.e., panic disorder, agoraphobia, social phobia, simple phobia, generalized anxiety disorder, obsessive-compulsive disorder, and posttraumatic stress disorder) (c) Psychotic disorders (i.e., general screen but no specific diagnoses) (d) Eating disorders (i.e., anorexia and bulimia nervosa) (e) Substance abuse disorders (i.e., alcohol abuse, alcohol dependence, drug abuse, and drug dependence) It has been widely used as an outcome measure in clinical psychopharmacology trials and epidemiological studies. According to the publisher’s website, the MINI is the most widely used semi-structured diagnostic interview instrument in the world, employed by mental health professionals and health organizations in more than 100 countries. The DSM-5 version of the MINI (MINI 7.0.2) has been 42 C. Miller translated into over 70 languages, including French, German, Japanese, Mandarin, Portuguese, and Spanish. The MINI is available in both a paper-and-pen and a web- based version. In addition to the MINI 7.0.2, there are two other versions available for use with adults: the MINI-Plus and the MINI-Screen. The MINI-Plus is a longer interview format, taking approximately 30 minutes to complete, allowing interviewers to assess up to 48 disorders. The MINI-Screen uses only screening questions to rule out major diagnoses; positive answers to any screening question should prompt the interviewer to use the MINI 7.0.2 as follow-up. There is one version for use with children, called the MINI-Kid (Sheehan et al., 2010). The MINI-Kid allows interviewers to assess 30 of the most common and clinically relevant childhood disorders. Parent and child are interviewed together, although the child is asked to be the primary respondent if at all possible. The MINI-Kid is available only in English currently. The Diagnostic Interview for Anxiety, Mood, and OCD and Related Neuropsychiatric Disorders (DIAMOND) The DIAMOND (Tolin et al., 2013) is a semi-structured interview that allows clinicians to assess several DSM-5 disorders, with the primary focus being anxiety, mood, and obsessive-compulsive and related disorders. To accurately diagnose these conditions, additional disorders are examined, including trauma- and stress-related disorders, schizophrenia spectrum and other psychotic disorders, feeding and eating disorders, somatic symptom and related disorders, substance-related and addictive disorders, and neurodevelopmental disorders (Tolin et al., 2016). In a study of 362 individuals, Tolin et al. (2016) found good to excellent interrater reliability coefficients (ranging from 0.62 to 1.00) and good to excellent 1-week test-retest reliability coefficients (ranging from 0.59 to 1.00). The DIAMOND begins with open-ended questions to obtain an overview of the presenting problem prior to inquiring about specific diagnoses. Examples of these open-ended questions include the following: “Can you describe what kind of problem or problems you are here to discuss?” and “Have you had mental health treatment before? If so, can you describe it? When did it occur?” The interview then moves into symptom-specific questions focusing on anxiety, mood, and obsessive-compulsive and related disorders. Symptoms generally are queried over the past month, except when diagnostic criteria require longer durations. The interviewer is allowed to ask clarifying questions about specific symptoms to gather additional information. Following symptom clarification, the interviewer asks questions about symptom-related distress and impairment. An example of such a question is “How much does this problem bother or distress you?” After these impairment-related questions, additional diagnoses are queried, in order to rule out other related diagnoses (e.g., schizophrenia, substance-related disorders). The authors of the DIAMOND stated that they deliberately placed questions about impairment before questions about additional diagnoses, in order to streamline the process and increase the efficiency of the interview format. Mean administration time for the DIAMOND is approximately 1 hour, with a range of 30–90 minutes (Tolin et al., 2016). 2 Interviewing Strategies, Rapport, and Empathy 43

The Anxiety and Related Disorders Interview Schedule for DSM-5 (ADIS-5) The ADIS-5 is a semi-structured interview that focuses primarily on the assessment of anxiety, mood, obsessive-compulsive, trauma, and related disorders (e.g., somatic symptom, substance use). The ADIS-5 was updated from the ADIS-IV (Brown, DiNardo, & Barlow, 1994), and there are two current versions of the ADIS-5: the Adult version (Brown & Barlow, 2014a) and the Lifetime version (Brown & Barlow, 2014b). Although it is true that the ADIS-5 does not have modules to assess many disorders that are comorbid with anxiety (e.g., hoarding disorder, trichotillomania, or excoriation disorder), or other disorders of interest (e.g., eating disorders or attention deficit/hyperactivity disorder; Tolin et al.,2016 ), the ADIS-5 does contain screening questions for many diagnoses, including hoarding disorder, impulse control disorders, eating disorders, attention deficit/hyperactivity disorder, dissociative disorders, and psychotic disorders. The primary disadvantage of the ADIS-5 may be its long administration time; Summerfeldt et al. (2010) reported that administration of the ADIS-IV is 2–4 hours for the lifetime version in clinical samples. As with the SCID-5, psychometric data for the ADIS-5 have not yet been published.

Summary of Specific Interview Approaches

In summary, several different structured interview formats exist which differ in terms of level of structure and breadth of diagnostic coverage. Irrespective of which specific measure is chosen, clinicians must establish the reliability of the instrument in their own particular site and must continuously monitor reliability in order to avoid the gradual process of interviewer drift (Orvaschel, 2006). In addition, clinicians must remain aware that even fully structured interview formats were never intended to be used in isolation; instead, clinicians should supplement interview findings with additional measures (Orvaschel, 2006). When deciding which structured interview to administer, clinicians should consider two main factors: (a) the purposes of the interview (Orvaschel, 2006) and (b) practical matters (Angold & Fisher, 1999). First, clinicians should review the particular needs the interview should meet. Some formats assess a broad range of diagnostic categories (e.g., SCID-5), whereas others assess a more narrowly defined range (e.g., DIAMOND), so determining the level of diagnostic coverage needed is essential. Second, clinicians should review practical issues, such as the time and money involved in training on administration and scoring of each interview. In general, fully structured interviews minimize the role of inference, thereby allowing lay persons, or those with minimal clinical training, to conduct these interviews. Semi- structured interviews, which allow greater interviewer latitude in determining question wording and order as well as in interpreting responses, require more clinically experienced interviewers (Segal & Williams, 2014). 44 C. Miller

Interpersonal Skills

Rapport and empathy have been called “the most inherently fundamental tenants requisite for successful intervention as a clinician” (Johnston, Van Hasselt, & Hersen, 1998). These important concepts, however, have been difficult to empirically define and to reliably assess. The terms are often used interchangeably in the literature, even though they are distinct concepts. This section will review the basic concepts of rapport and empathy, including how the different types of interviews may affect them.

Rapport

Rapport has been defined in many ways throughout the years (Vallano & Compo, 2015). Johnston et al. (1998) defined rapport as the establishment of a working relationship in which both parties are able to openly and easily express complicated or anxiety-provoking thoughts and feelings. O’Toole (2016) defined rapport as the development of a therapeutic relationship based on a reciprocal understanding on one another in terms of respect, empathy, and trust. Tickle-Degnen and Rosenthal (1990) stated that rapport includes three primary components: mutual attentiveness, positivity, and coordination. Overall, it has been characterized “by a sense of being ‘on the same wavelength’” (Gruba-McCallister, 2005, p. 42). Rapport is dynamic over time (Allison & Allison, 2017). The interpersonal relationship or connection between interviewer and interviewee gets established over time (Allison & Allison, 2017) and likely will change in depth and feeling over the course of an interaction (Hall, Roter, Blanch, & Frankel, 2009). Finally, it may be felt by one party but not the other at different times (Vallano & Compo, 2015). Because rapport is a subjective and largely internal experience, it has been difficult to measure objectively. Vallano and Campo (2015) reviewed two different assessment strategies, observation and self-report. Observation methods typically compare independent ratings of rapport with the parties’ self-reported experiences of rapport. Although this approach sounds promising, Vallano and Campo (2015) concluded that self-report measures are more likely to be successful in assessing rapport, due to the difficulties in conducting reliable and valid observations of internal states. They indicated that self-report measures are more likely to be successful in assessing rapport. Both parties should complete self-report measures, and discrepancies should be examined. One example of a self-report measure with versions for both clinicians and clients is the Working Alliance Inventory (WAI; Horvath & Greenberg, 1989). The WAI assesses three elements, with the last element being especially relevant to rapport: (a) the level of agreement between the client and clinician regarding the goals of therapy, (b) the level of agreement between the client and clinician regarding the activities to be used during therapy, and (c) the bond between the client and clinician. 2 Interviewing Strategies, Rapport, and Empathy 45

Clinicians should attempt to establish good rapport with clients for many reasons. The most important reason is that good rapport has a positive effect on client outcomes. First, rapport enables clinicians to elicit relevant information in order to establish accurate diagnoses and to make effective treatment decisions. Second, rapport has been found to increase the likelihood of clients adhering to their treatment plans. In addition to positive outcomes, clients who have good rapport with their clinicians report more satisfaction with their treatment and have reduced rates of malpractice suits or licensing complaints. Overall, good rapport promotes communication and collaboration with clients (Ross, 2013). Morrison (1995) stated that rapport is best developed by the clinician displaying a relaxed but interested and nonjudgmental environment. In other words, clinicians should convey an open attitude to whatever a client presents, a willingness to listen without judgment, and an overriding respect for the client’s perspective. Sattler (2014) advised that clinicians be well prepared for the interview so that they are able “to truly listen to what the interviewee says rather than worry about whether or not [they] are asking the right questions” (p. 168). Other ways to develop rapport with clients include orienting clients to the interviewing process, thoroughly discussing clients’ expectations for the interview, and coming to an agreement regarding the purpose and goals of the interview (Gruba-McCallister, 2005). In addition, rapport may be enhanced by clarifying client statements, using paraphrasing or summariz- ing to express understanding of client issues, handling emotionally sensitive material in a calm and understanding manner, being attentive and focused on client statements and behaviors in the session, and providing hope that change is possible. Identifying the client’s language and using it during sessions may also enhance rapport (Ledley & Rauch, 2005), as can mirroring the client’s body posture, specific gestures, facial expressions, and voice tone (Bell, Fahmy, & Gordon, 2016; Lakin & Chartrand, 2003; Wolf, 2005). Humor may at times enhance rapport, but it must be used carefully (Ledley & Rauch, 2005). Humor may be off-putting to some clients, particularly in the first few sessions, so clinicians may not want use humor excessively during the initial diagnostic interview (Segal & Williams, 2014). In particular, sarcasm or flippant remarks should be avoided (Sattler,2014 ). Finally, clinicians must learn to monitor their own feelings toward the client and attend to any discomfort or negative feelings in order to enhance rapport (Morrison, 1995). Ross (2013) stated that the ability to establish rapport is one of the most important skills for effective interviewing. As stated previously, some authors have cautioned clinicians that structured interviews may constrain the development of rapport between interviewer and respondent, particularly if the pacing of questions does not match the client’s comfort level (Fowler Jr. & Mangione, 1990; Ledley & Rauch, 2005). If clients perceive that questions are being asked only to complete a protocol rather than based on their concerns, if they believe that the clinician’s agenda is more important than their own, rapport may be damaged (Sattler, 2014). However, Rogers (2001) pointed to lack of training as the real threat to developing rapport. He advocated for comprehensive training in diagnostic criteria and interviewing skills, so that clinicians can utilize any type of interview and still develop good rapport with their clients. Rogers (2001) stated that “in unskilled hands, structured 46 C. Miller interviews may impersonalize the interview process and damage rapport. At the very worst, questions piled upon questions can pummel the client. The critical issue is not the structured interviews per se, but their unskilled use” (Rogers, 2001, p. 4).

Empathy

As with rapport, the concept of empathy is not well-defined, despite multiple attempts to pin down the construct (Cuff, Brown, Taylor, & Howat, 2016). Empathy has been defined as an ability to understand and accurately acknowledge the feelings of another, leading to an attuned response from the observer (Sinclair et al., 2017). Overall, it is considered to be “the ability to understand people from their frame of reference rather than your own” (Cormier & Nurius, 2003, p. 65) that results in “an emotional response that is congruent with a view that others are worthy of compassion and respect and have intrinsic worth” (Barnett & Mann, 2013, p. 230). Researchers have identified two types of empathy called cognitive and affective empathy (Cuff et al., 2016; Sinclair et al., 2017). Cognitive empathy, also known as empathic accuracy, is the ability to understand the content of another person’s mind, including how he/she feels. In this way, it has been compared to theory of mind (Cuff et al., 2016). Halpern (2003) stated that cognitive empathy involves imagining how it feels to be in another person’s situation. Affective empathy, on the other hand, is more concerned with resonance or emotional attunement (Halpern, 2003). Empathy has been associated with multiple positive results, including improved client outcomes and client adherence to treatment recommendations, as well as fewer medical errors and malpractice claims (Riess, 2017). Despite the benefits, there is a potential pitfall of empathy. If a clinician believes that he/she really understands what the client is experiencing, this may foreshorten the interview process. Clinicians may feel justified in not asking relevant questions, particularly in unstructured formats where clinician discretion is maximized, as they know what their client is feeling. Weiner and Auster (2007) pointed out that empathy may be based on ungrounded assumptions, which can lead to error and compromised client care. There is a common belief that empathy is inborn and immutable. However, neuroscience research has demonstrated that empathy changes over time and can be developed (Riess, 2010). For example, Riess, Kelley, Bailey, Dunn, and Phillips (2012) reported that medical students show a decline in empathy during medical training. They hypothesized that this decline in empathy may function to buffer medical trainees from patients’ psychological distress. Riess et al. (2012) also found that explicit training in empathy, in concert with self-regulation skills, can reverse this decline, demonstrating the malleability of empathy. Additional neuroscience research on empathy across cultures has found that brain regions associated with empathy are more activated when interacting with members of one’s own race (Armstrong, 2018). These results suggest that training in empathy should be a required part of clinicians’ graduate training and also ongoing continuing education. 2 Interviewing Strategies, Rapport, and Empathy 47

Summary and Recommendations

Effective interviewing involves not only technical skills but also interpersonal skills. Clinicians determine which questions to ask by the type of interview format they utilize: highly structured, semi-structured, or unstructured. They obtain useful and relevant answers to these questions by their skillful and continuous use of empathic responding and rapport-building behaviors. Both technical and interpersonal skills are important, although many authors seem to weight interpersonal skills more heavily. For example, Groth-Marnat and Wright (2016) stated that “clinicians achieve successful interviews not so much by what they say or do but by making sure they express the proper attitude” (The Assessment Interview and Case History, para. 5). Sattler (2014) stated that “interviewees usually are forgiving of interviewers’ mistakes, but not of interviewers’ lack of interest or lack of kindness” (p. 170). There are multiple interview formats available, and there is no one correct way to conduct an effective interview. Rogers (2001) cautioned against dogmatic adherence to either structured or unstructured interviews, stating that “strict adherence to [unstructured] interviews is likely to constrain the standardization and systematic coverage of clinical inquiries [whereas] strict adherence to structured interviews is likely to damage rapport and limit the relevance of any clinical conclusions” (p. 4). Sattler (2014) recommended that interviewers “view unstructured, semi-structured, and structured interviews as complementary techniques that can be used independently or together” (p. 168). Segal and Williams (2014) reported that the combination of unstructured and structured approaches to interviewing “reflects the best of the scientist-practitioner model in which the science and art of assessment are both valued and valuable” (p. 105). Unfortunately, there is little research available to help guide clinicians on the optimal method of conducting a clinical interview. For example, there is little research on the impact on rapport when utilizing more structured interview schedules or empathy when using an unstructured interview approach. Breton, Bergeron, Valla, Berthiaume, and St. Georges (1998), in a study on the reliability of the child version of the DIS, suggested that individuals who have not established rapport with the clinician may not disclose information or request clarification of confusing questions. How this may impact the ultimate diagnostic formulation is still unclear. Although many structured interviews have been translated into multiple languages, there has been little research directly assessing how rapport may be affected with clients from diverse backgrounds when structured interviews are utilized (Grills-Taquechel & Ollendick, 2008). Finally, researchers have not adequately examined the acceptability to clients of either an unstructured or structured approach to interviewing. Clinicians continue to utilize an unstructured approach, assuming that this format is more acceptable to clients, and avoid structured formats, assuming that these approaches will interfere with rapport, without testing these assumptions empirically. Studies assessing client satisfaction with both structured and unstructured approaches may help clinicians make more informed decisions for each client. 48 C. Miller

In the meantime, clinicians should become their own local clinical scientist (Stricker & Trierweiler, 1995). This means that clinicians should utilize a variety of interview formats and continually assess the impacts of each format on their clients. Clinicians could create short, setting-specific surveys of client satisfaction that could be administered at the end of the diagnostic interview. They would then need to utilize the resulting data to make more informed choices about which types of clients should receive structured versus unstructured interviews. Clinicians could record sessions with clients and review these recordings for the impact of various rapport-building behaviors and empathic responding. In short, clinicians must begin utilizing data, either from large-scale empirical studies or from systematic observations of their own practice, to make effective clinical decisions about each individual client.

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Thomas B. Virden III and Melissa Flint

Most clients approach the first interview with a clinician seeking assistance to address a specific problem. The task of the interviewer is to gather information about the client, the problem, the circumstances and context, as well as the history, in order to conclude the intake with a diagnostic impression. The diagnosis sets the stage for intervention, because the first step in addressing a problem is to define it, and it must be defined carefully and accurately. The most skillfully implemented intervention will fail miserably if it seeks to address the wrong problem. Therefore, the successful diagnostic interview sets the stage for conceptualizing the case, goal setting, as well as treatment planning (Sommers-Flanagan & Sommers-Flanagan, 2017). It also relies on the clinician having the ability to draft a clear, yet comprehensive, intake evaluation report (Segal & Hutchings, 2007). In this chapter, we discuss three highly important areas of a clinical or diagnostic assessment, namely, the presenting problem, history of the presenting problem, and social history.

Presenting Problem

After establishing an initial connection with the client and setting the stage for the interview, the interviewer should ask the client for information about the presenting problem. Obtaining a clear and depictive presenting problem is a critical part of the intake report (Segal & Hutchings, 2007). Defining the presenting problem is usually accomplished through general or open inquiry, such as “Please tell me what brought you here to see me today” or “How can I help you today?” The presenting problem may take a variety of forms, a symptom (e.g., trouble sleeping), a conflict (e.g., relationship discord), a stressor (e.g., unemployment), an emotion (e.g., anxiety), a

T. B. Virden III (*) · M. Flint Midwestern University, Glendale, AZ, USA e-mail: [email protected]

© Springer International Publishing AG 2019 55 D. L. Segal (ed.), Diagnostic Interviewing, https://doi.org/10.1007/978-1-4939-9127-3_3 56 T. B. Virden III and M. Flint behavior (e.g., fighting), or any of a number of other things. On occasion, the presenting problem may not even appear to be problematic (e.g., recent marriage), until more explanation is elicited. In any case, the interviewer must understand the presenting problem and how it poses difficulties for the client. Immediately upon learning the presenting problem, the interviewer should generate at least five diagnostic hypotheses. This list should include the most likely disorders that would lead a client to present with this problem. This is the beginning of the differential diagnostic process; the interviewer uses his or her knowledge of psychopathology and where symptoms occur in the lists of diagnostic criteria for various disorders to generate those disorders as likely hypotheses for the client’s eventual diagnosis. This is an important step in the interviewing process, because it guides the interviewer to seek specific information in the course of the interview that will either confirm or eliminate each of these hypotheses (Othmer & Othmer, 2002). Generating approximately five hypotheses will ensure that the interviewer considers several alternatives and will therefore investigate the hypotheses thoroughly. At this point in the interview, the diagnostic hypotheses may be either specific mental disorders or more broad categories of mental disorders. For instance, if the presenting problem is difficulty sleeping, the hypotheses may include the categories of sleep disorders, anxiety disorders, bipolar disorders, depressive disorders, substance-related disorders, and adjustment disorders, because difficulty sleeping appears as a symptom of several specific disorders within these categories. Within the sleep disorders categories, difficulty sleeping might be due to primary insomnia, primary hypersomnia, nightmare disorder, or sleep apnea. It may also be an indication of generalized anxiety disorder in the anxiety disorders. Similarly, it might indicate either major depressive or manic episodes in bipolar disorder, persistent depressive disorder, or cyclothymic disorder; it may be related to misuse of a psychoactive substance; and it may be a symptom of an adjustment disorder with depressed mood or anxiety. Alternatively, if the presenting problem is fighting, a much shorter list of likely hypotheses, in the form of specific disorders, may be generated. These hypotheses may include conduct disorder, adjustment disorder with conduct disturbance, intermittent explosive disorder, antisocial personality disorder, and substance-related disorders. Interviewers should remember that they may need to include disorders in their list of hypotheses that do not list the presenting problem as a symptom criterion but where it is reasonable to question whether the disorder might manifest in such a way as to lead a client to present this problem. For instance, hallucinations and/or delusions are not listed as symptom criteria for a manic episode, but many people experience psychotic symptoms such as hallucinations and delusions during episodes of elevated mood, so this is a reasonable hypothesis to explain presentation of psychotic symptoms. Generating diagnostic hypotheses from the presenting problem alone takes some practice, because doing so involves using knowledge of psychopathology differently than the way it was learned. When students study psychopathology, they learn about a category of disorders with common characteristics or features and learn the symptoms of each of those disorders, from the top down. When the interviewer uses 3 Presenting Problem, History of Presenting Problem, and Social History 57 this knowledge in order to generate diagnostic hypotheses, the evaluator must mentally scan the lists of symptom criteria across disorders and categories and identify disorders with the presenting problem in that list, from the bottom up. Learning to master this process takes time and practice. The interviewer holds these hypotheses in mind, and now follows up on the presenting problem to gather more specific information. It is important to understand exactly what the client means by the presenting complaint, so the interviewer asks about the specific characteristics (e.g., Jenkins,2007 ). “Fighting” could mean arguing, disagreements, angry outbursts, or physical altercations and assault. “Fits” might mean seizures, fainting spells, distress, or temper tantrums. “Without a cultural and contextual framework at the outset, presenting problems, medical and legal history, educational history, family history, and myriad other issues may lead well-intentioned clinicians to unintentionally misdiagnose, misunderstand, and develop inconsistent treatment options that are culturally incongruent with their clients” (Gallardo & Gomez, 2015). Even when interviewing someone from the same cultural background and language history, misunderstandings can be common, so it is wise to ask the client to expand the description of the presenting problem to ensure understanding. In general terms, there are several aspects of the presenting problem that the interviewer must understand, including the onset, duration, course, severity, and associated stressors (e.g., Watson & Gross, 1998). Specific questions are asked to determine these aspects, such as: • When did you begin having trouble sleeping? • How long has this been going on? • Has it been getting worse or better; going up and down? • How much sleep are you getting each night? • What else was going on in your life when this began? • Are there other factors that make the problem better or worse? Some presenting problems are discrete incidents of behavior or symptoms, such as fighting or panic attacks. Other problems are ongoing or continuous situations or symptoms, such as relationship discord or depressed mood. The interviewer needs to ask questions appropriate to the problem in order to assess onset, duration, course, severity, and associated stressors. The onset of the presenting problem may be date and time certain, for instance, “My first panic attack was May 14, 2016 at 2:00 p.m.” or it may be identified as a general time frame, “I believe I first noticed I had trouble sleeping when I began college in 2015.” The interviewer needs to tailor questions to identify onset depending upon the nature of the presenting problem, such as “When did you become dis- satisfied with your relationship,” “Do you remember your first fight,” or “When did you first have trouble sleeping?” For some problems with insidious or gradual onset, the interviewer will need to determine when the client noticed it had become a problem, while those with acute or sudden onset may be more specifically determined. Similarly, questions about duration and course need to be appropriate to the problem, such as “How long have you had trouble sleeping,” “Are there times when your 58 T. B. Virden III and M. Flint relationship improves, and how long does this last,” “Has it been getting worse the whole time,” or “How much time goes by in between episodes?” Assessing the severity of the presenting problem also requires consideration of questions specific to the problem. There are several factors that might be included in an assessment of severity, including frequency, intensity, and impact (Cormier & Cormier, 1991). Problems characterized by discrete events or episodes should be assessed for frequency, such as “How many panic attacks have you had in the past month” or “How many fights have you had?” Problems that are ongoing, continuous states cannot be described in terms of frequency and should be assessed in terms of amount or intensity, such as “How many hours do you sleep at night” or “How serious is your relationship problem?” The interview also investigates the severity of the problem by asking about its impact, such as “How much does the difficulty sleeping affect your ability to work,” “Are you experiencing legal problems as a result of fighting,” or “How has this affected your relationships?” The interviewer must also investigate associated stressors of the presenting problem. There are two aspects of this inquiry—events temporally related to the onset of the presenting problem and stressors resulting from or related to the presenting problem. This line of inquiry investigates the context of the problem and helps the interviewer to evaluate possible causes or precipitants of the problem. The interviewer will understand a client’s difficulty sleeping differently if it began when she moved to a new apartment near an airport or if it began when she discovered that her husband was having an affair, or if it began when her mother passed away. Questions, such as “What else was happening about the time you began having trouble sleeping,” “What was going on when you began to feel depressed,” or “What sorts of things seem to trigger these fights,” will help the interviewer evaluate stressors associated with the onset of the problem. To evaluate stressors resulting from the presenting problem, the interviewer can ask questions closely related to those assessing the impact of the problem, such as “Has the fighting produced any other problems for you” or “How do the panic attacks affect your work or your social life?” The stressors that function as precipitants of the client’s decision to seek intervention for the problem can be assessed by asking such questions as “What made you decide to seek help,” “What’s going on that led you to make this appointment,” or “Why now?” The next step in evaluating the presenting problem is to identify associated symptoms (Watson & Gross, 1998). The line of questioning will be guided by the list of diagnostic hypotheses, investigating the presence or absence of other symptoms the interviewer expects to observe in each of the other possible conditions. For instance, when the presenting problem is difficulty sleeping, we expect to find depressed mood or loss of interest in activities if the problem is depression, elevated mood if it is mania, excessive worry if the problem is generalized anxiety disorder, nightmares if it is post-traumatic stress disorder (PTSD), and so on. Many times, the client may volunteer this information as part of the initial assessment of the presenting problem, but other times, the interviewer needs to ask questions about these specific symptoms in order to evaluate the diagnostic hypotheses. It is prudent and efficient to ask about essential or most important symptoms associated with the 3 Presenting Problem, History of Presenting Problem, and Social History 59 hypotheses first. If the client reports neither depressed mood nor loss of interest in activities, the interviewer can rule out major depression without asking about appetite disturbance, excessive guilt, or psychomotor retardation. All clinicians must keep in mind the potential for error in assessment (Sommers- Flanagan & Sommers-Flanagan, 2017). Because we are merely humans, we are subjective beings. We filter information through the lens we know and, therefore, risk misidentifying information based on our experience rather than the phenomenology of the person in front of us (Sommers-Flanagan & Sommers-Flanagan, 2017).

Try this exercise: Take a piece of paper, write a presenting problem on the top, and draw two lines down the page to divide it into three columns. On the left side, write as many diagnostic hypotheses as you can generate (at least five), and in the middle column, write the associated symptoms you need to investigate in order to confirm or rule out that hypothesis. Now think about the questions to ask a client in order to determine the presence or absence of these associated symptoms, and write them in the right column. See the example in Table 3.1.

Table 3.1 Investigation of diagnostic hypotheses Presenting Problem: Difficulty Sleeping Hypotheses Associated Symptoms Questions Sleep disorders: Primary Difficulty going to sleep or How long does it take you to go to insomnia, Nightmare staying asleep, nightmares, sleep? Do you wake up frequently Disorder Sleep Apnea loud, irregular snoring during the night? Do you have nightmares? Has anyone ever told you that you snore loudly? Anxiety disorders: Excessive worry about a Do you worry about a lot of things? generalized anxiety number of issues, numbing Do you feel like you are emotionally disorder, acute stress or detachment, recurrent numb? Are you troubled by intrusive disorder, post-traumatic recollections of trauma memories of a horrifying event? stress disorder Mood disorders: major Depressed mood, loss of How is your mood? Have you lost depressive disorder, bipolar interest in activities, interest in things you used to enjoy? disorder, dysthymic elevated mood. Do you feel “on top of the world?” disorder, cyclothymic disorder Substance abuse or Use of a substance, How much do you drink? What drugs dependence tolerance, withdrawal, or are you using? Do you have to use compulsive use. more to feel the effect? What happens if you stop using? Adjustment disorder with Depressed mood, How is your mood? Are you feeling depressed mood or anxiety nervousness jittery or nervous? 60 T. B. Virden III and M. Flint

History of Presenting Problem

The History of Presenting Problem section should include information which helps to clarify and expand upon the presenting problems the clinician has already identified (Segal & Hutchings, 2007). This section is sometimes labeled “History of Current Illness” in medically oriented practices (Sommers-Flanagan & Sommers- Flanagan, 2017). It is important to determine if this presenting problem is the same or similar to problems experienced in the past or if this is the first time the client has had such a problem. Similar to the assessment of symptoms, the interviewer needs to determine when the problem first began, what impact it has had on the client’s well-being and functioning, and what course it has taken. Some mental disorders are characterized by episodes of symptoms with full recovery in between episodes, while others have a course of continuous disturbance and deterioration of function. Assessment of the onset, duration, course, severity, and associated stressors prompts review of the initial list of diagnostic hypotheses. This information will indicate which of these hypotheses are more likely, moving them up to the top of the list, and which are less likely or can be ruled out. It is important to determine if any associated symptom preceded development of the presenting problem or has been present at times when the presenting problem was absent. This will help the interviewer evaluate if these symptoms are related to or independent of the presenting problem. For instance, if the presenting problem is difficulty sleeping, and the client reports problem drinking soon after the onset of the difficulty sleeping, one might draw different conclusions about the relationship between alcohol consumption and sleep, rather than if the client reported problem drinking for several years before the onset of the current sleep disturbance. If there are several associated symptoms, the interviewer might ask if they are all related in their characteristics, for instance, “Did all of this begin about the same time,” or if any of these symptoms were experienced independent of the others. In the event that the presenting problem is one that has happened before, the interviewer will need to determine the beginning and course of each previous episode. It may be helpful to ask questions, such as “Have you ever felt this way before” or “Is this the first time you felt this way?” If previous episodes are reported, one can often elicit information about the onset, duration, and course simply by asking about the episodes, “Tell me about that,” since the client has just been answering questions about these factors. Otherwise, it may be necessary to prompt the specific information required to evaluate previous episodes, e.g., “Was it worse then,” “Did it last longer,” or “Did it feel much the same that time, or was it different then?” It is also important to understand the client’s explanation of the development of the problem, its causes or precipitants, the maintaining factors, and their attempts at resolution or treatment. This is often called insight—an evaluation of the client’s understanding of the development and maintenance of the problem which can provide diagnostic clues as well. The client may volunteer an explanation or the interviewer may ask a client directly: “What do you think caused this problem,” “What made it worse now,” and “What have you tried to do about it?” 3 Presenting Problem, History of Presenting Problem, and Social History 61

Information about previous treatment is also an important part of the assessment. This line of questioning should be inclusive to not only traditional medical and psychotherapeutic techniques but also alternative and nonprofessional treatment methods, such as meditation, acupuncture, or merely talking to friends. The interviewer should inquire about a history of interventions: when were they attempted, what impact did they have on the problem, have they been discontinued, and if so, why? A clinician can gain a great deal of insight into the client’s problem areas by listening carefully to how they convey answers to questions asked. For example, a client may state, “The doctor told me it’s all in my head, but I think that’s just because he can’t figure out what’s wrong with me,” indicating the presence of unexplained complaints as well as frustration with previous treatment attempts. Although this task can be time-consuming, obtaining additional records can shed light on important client issues and history. The questions about the history of the said problems provides a convenient time to ask for permission to contact any current or previous service providers to exchange information. History of treatment efforts for the presenting problem also provides diagnostic information; for instance, if the client has been in treatment for depressive symptoms continuously for the last year, an acute adjustment disorder can be ruled out. By this time, the interviewer has gained quite a lot of information about the client’s problem(s) to assist in the diagnostic process and has probably been able to narrow the list of diagnostic hypotheses. Perhaps the clinician has even expanded the list to include new possibilities! In order to further evaluate the list of hypotheses, the interviewer now needs to understand the client’s background, development, and strengths. Once the interviewer has arrived at this point, it is often helpful to summarize the presenting problem, asking the client to verify or correct his/her understanding of it. This not only allows the interviewer to check with the client about the perceived problem but also sets the stage to move to the next phase of the interview. It provides a sort of “punctuation mark” to demarcate the end of one phase and the transition to the next phase. For example, “As I understand it, you began having difficulty sleeping about two months ago, when you were laid off from work, and since that time you have also felt depressed, nothing is fun anymore, you feel irritable, tired, can’t seem to concentrate on anything, and you’ve lost about 15 pounds without dieting. Does that sound right?” At this point, the client may now either endorse the summary or add important details that have not been assessed. The interviewer may now move on to inquire about social history and other important aspects of the client’s development.

Social History

There are many areas of the client’s social history to be assessed, including developmental milestones, social and sexual functioning, diversity, educational, vocational, legal, family, substance use, trauma, and medical history. Because this 62 T. B. Virden III and M. Flint section contains an expansive breadth of information, it is important to consider how you can be thorough and well organized and provide clinically relevant highlights (Sommers-Flanagan & Sommers-Flanagan, 2017). These areas can be assessed by a variety of different methods and approaches. Some interviewers take each section separately and inquire about each one in turn, keeping in mind the questions they need to address to confirm or rule out their remaining diagnostic hypotheses. This can be rather time-consuming and requires frequent transitions from one topic to another, although if the interviewer has an “intake form” that requires filling out information on these areas sequentially, it can be convenient. However, we recommend a more global method that roughly resembles a chronological account of the client’s life (or a natural history-taking flow; Sommers- Flanagan & Sommers-Flanagan, 2017), during which the interviewer asks questions about all of these areas as the biography progresses. Then one can follow up with any missing information at the end without disrupting the general life story. To implement this “biographical” method of collecting the social history, the interviewer marks the transition with an introductory statement and inquiry, such as “Okay, now I need to understand some background information. Tell me about your childhood” or “Let’s go back a bit now to your childhood. When and where were you born?” The interviewer then progresses through the life span, directing the client to respond to specific queries about different areas of the social history during the narrative. In the course of this questioning, the interviewer must keep the list of diagnostic hypotheses in mind, to be sure to gather information relevant to each of them in the client’s social history. For instance, if a diagnostic hypothesis is antisocial personality disorder, evidence of conduct disturbance must be apparent prior to the age of 15, and a family history of major mood disorder may support an impression of bipolar disorder. While we recommend the chronological method of social history assessment, we will discuss the kinds of information to gather by topic area. No interviewer will collect all of this information for each client, but it is especially important to collect information that is out of the ordinary, unusual, or clinically relevant, in order to evaluate the diagnostic hypotheses or to understand the client’s strengths and challenges and to arrive at treatment recommendations.

Developmental Milestones

The interviewer may inquire about any difficulties the client’s mother experienced during pregnancy, such as gestational diabetes or eclampsia, or during childbirth, such as premature birth or forceps delivery. Some client’s may know about their Apgar score, a numerical indication of the newborn’s general health. Any unusual feeding problems in infancy, low birth weight, or difficulty gaining weight may be queried. Then the interviewer will want to ask about the achievement of a variety of developmental milestones, e.g., the age at which the client sat up unassisted, crawled, walked, talked, and ate solid food, and especially any delay in achievement 3 Presenting Problem, History of Presenting Problem, and Social History 63 of these milestones. Delay in speech development, if present, should be further assessed to determine if the delay was in vocalization, speech clarity, or forming sentences or involved loss of speech after apparently normal development. Assessment of the age and process of toilet training is also needed. The age at which the client no longer needed to wear diapers during the day and at night may be quite different, so ask about nocturnal bed-wetting in addition to toilet training. Any recurrence of bed-wetting after successful training should be noted. It is common for clients to report remembering nothing at all about their early childhood development nor hearing anything from their parents about it. This usually indicates that there was nothing remarkable about their achievement of developmental milestones, no significant delay, or unusual behavior. It is also important to bear in mind that there is a considerable degree of variability as to when or how a child achieves certain milestones (Morrison & Flegel, 2016). As such, it may be advisable that the interviewer consider a developmental delay or difficulty as diagnostically relevant only if it is particularly aberrant or resulted in some difficulty to the child or parent. Sample questions to ask: • Did your mother ever tell you anything about any problems during pregnancy or delivery with you? • Do you know if you sat up, crawled, and walked at the usual time? • Do you remember anybody telling you about your toilet training or bed-wetting? • Do you remember them saying anything about you learning to talk? • Are you aware of any health or development problems in your early childhood? • Do you remember anybody ever telling you anything unusual about your early childhood development?

Family of Origin History

There are at least two essential components of family history to assess: family functioning and family history of disorders. The interviewer should inquire about family members, their roles, ages, interactions, and changes over time. It is important not to limit inquiry to a traditional “nuclear” family but to inquire about who was living in the household while the client was a child, who filled parental roles, who were the siblings, and what extended family members were involved in daily and other family activities. It is best to begin with open and broad inquiry, such as “Tell me about your family,” and to follow up with questions to understand how the client defines family, rather than to impose a definition of family on the client by asking “Tell me about your immediate family” or “Tell me about your mother and father, brothers and sisters.” One can then learn about the composition of the client’s family and the client’s position within it, including factors such as birth order. 64 T. B. Virden III and M. Flint

Once the interviewer understands the composition of the client’s family of origin, it is time to inquire about its functioning. It is important to understand the child- rearing practices that the client experienced and the nature of the relationships in the family. Some areas of inquiry include methods of reward and discipline, patterns of communication, the warmth or difficulties in interaction with family members, and the closeness or distance in relationships the client experienced. The interviewer will also want to know about family traditions and practices surrounding holidays and important life events and transitions, such as the client’s first day at school or birthday celebrations, and any ceremonies marking transition in life phases. Inquiry about the nature and process of conflict resolution, or the lack thereof, is also needed. A fairly new component to intake assessments may include the use of technology. For both children and adults, it is important to inquire about computers, cell phones, texting, social networking, as well as the absence or use of video gaming in daily life (Morrison & Flegel, 2016). It is very important to know the effects of these activities on daily functioning, and any comprehensive evaluation should be inclusive of questions targeting technology, the Internet, and, in general, the cyber world we now live in (Morrison & Flegel, 2016). Rather than considering these inquiries more pertinent to only children and adolescents, each clinician is encouraged to evaluate these issues with their adult clientele as well. It is not uncommon to have cyber use interfere with holding down a job, or relating to other social activities. In the course of this line of inquiry, the client may volunteer information about family history of medical and psychological disorders or problems. If so, the interviewer will still need to check to see if there are any other problems in the family history beyond the ones reported. Sometimes clients do not volunteer information about disorders experienced by family members, and the interviewer needs to introduce the inquiry. It may be important to determine whether the family member with a reported problem or disorder is a blood relative, in order to assist in the diagnosis of disorders that have a genetic contribution to etiology. For instance, schizophrenic disorders have been shown to be far more prevalent in first-degree relatives of people with schizophrenia than in the general population (Chou et al., 2016). For some other disorders that are not known to have a genetic or familial pattern, the interviewer may need to inquire about how the disorder impacted the family functioning, e.g., frequent absences of a caregiver from the home, changes in disciplinary practices, or early assumption of adult responsibilities. Sample questions to ask: • Tell me about your family when you were growing up. • Who lived in the household? • How did you get along with them? • Who took care of the discipline, and how? • What sorts of family traditions did you observe? • Were you close to your (mother, father, brother, grandmother, etc.)? • How did you all show affection? • How did arguments get resolved in your family? 3 Presenting Problem, History of Presenting Problem, and Social History 65

• Did anyone in your family have psychological problems or major medical problems? • Did anyone in your family have alcohol or substance use problems? • How did that affect you?

Educational History

The essential elements to include in educational history are when the client started school, how far they went in school, and what particular strengths or difficulties they had in learning. Clients will usually respond to direct questions about education, such as “Where did you go to school” and “How far did you go in school?” In order to assess how well the client did in their schooling, it may be best to initially ask about strengths as well as weaknesses, “What were your best and worst subjects,” rather than a question that might be perceived as challenging, such as “What kinds of grades did you get in school?” The interviewer can then steer the inquiry to performance issues, difficulties learning material or learning disorders, or behavior problems. This information also gives the clinician a starting point from which to evaluate services received (or not) for any educational difficulties the client may have/have had. Educational history and performance information aid the differential diagnosis process in several different ways. In evaluating neuropsychological information, it is useful to have an idea about a client’s previous intellectual function, and education history can give a general impression of that, so that if a client is currently functioning at a very low level but had a college education with As and Bs, a deterioration of function since college may be indicated. On the other hand, a history of special education classes and poor academic performance in the same, low- functioning client may support a diagnostic hypothesis of intellectual disability or pervasive developmental disorder. Sample questions to ask: • When did you start school? • What subjects did you like best? And what subjects did you like the least? • Did you have any difficulties in school? • What was the last grade that you completed in school? • Have you participated in educational programs outside of school? • What were your strengths and challenges as a student?

Social and Sexual Functioning

The interviewer will need to ask the client about social relationships and development, romantic relationships, and sexual activity. Childhood friendships, after- school activities, membership in organizations, and participation in athletic or sport 66 T. B. Virden III and M. Flint activities all give the interviewer information about the client’s social development and degrees of relatedness. It is often convenient to ask about these activities while gathering information about the client’s educational activities, such as “Did you have a few close friends in school,” “Did you participate in organized sports while in school,” or “Were you a member of Scouts or something like that?” It is important to inquire about romantic or dating relationships in a culturally sensitive way, not assuming a heterosexual development of interest, or intruding unnecessarily on cultural or religious values or prohibitions. One can ask about the development of romantic interest, and about first sexual experiences in a rather open way, and then follow up with more specific questions: “Do you remember when you first developed a romantic interest in someone,” and then, “Who was that?” “When was your first sexual experience,” and then, “What was the sexual contact and activity?” Clients are often reticent to volunteer information about sexual activity, dysfunction, and abuse due to social and cultural norms that discourage such self-disclosure to strangers (Fontes, 2008). This information is clinically important, so the interviewer will need to inquire about it in a matter-of-fact, straightforward way, indicating that sensitive discussion of sexuality is accepted and expected. The interviewer will want to understand the client’s history of formal and informal liaisons, such as marriages or committed relationships, and whether or not the client has children. Note that this inquiry may initiate a discussion of pregnancy loss (e.g., miscarriage, stillbirth, or abortion) which is an important psychosocial component of the client’s history. Establishment of new family structures then needs to be understood, so the interviewer will want to ask some of the same kinds of questions to understand the new family functioning as were asked about the client’s family of origin, including child-rearing practices, division of responsibilities, methods of conflict resolution, and so on. Sample questions to ask: • Tell me about your childhood friends. • What sorts of social activities did you enjoy? • Did you belong to any clubs or organizations? • How about friendships now? • What do you do for fun? • Do you remember your fist romantic interest? Who was that? • When did you start dating? • When was your first sexual contact? What was it? With whom? • Have you been in a committed relationship or marriage? • Do you have any children? Do they live with you? • Who lives in your household now?

Vocational History

The client’s history of work activities should be assessed. This line of questioning may flow naturally after inquiry about educational history, as people often begin work after completing some course of education. The interviewer should not 3 Presenting Problem, History of Presenting Problem, and Social History 67 assume, however, that clients did not work while they were in school, or that they went to work after they were no longer in school. One might ask “Did you have a job while you were in school,” and “Then what did you do” to inquire about occupations after formal schooling. The nature of work activities informs the diagnostic process as well: occupations that do not appear to be consistent with their educational achievements or a series of jobs of short duration rather than a career of rather stable positions in the same or similar fields may indicate maladaptive patterns consistent with personality disorders. It is important to inquire about military service and the nature of all employment activities, such as exposure to trauma and occupational hazards and stressors. Some occupations require exposure to solvents, while others include frequent exposures to dangerous conditions. It is also important to understand periods of unemployment in the chronology and what led to the unemployment or changes in occupation. All of this information helps the interviewer understand and interpret the client’s behavior and functioning. Sample questions to ask: • What kinds of work or jobs have you done? • Have you served in the military? • How about volunteer work or positions? • What was the longest period of time you ever held a job? • What did you do while you were unemployed?

Diversity

Diversity is defined here in its broadest sense, including but not limited to race, ethnicity, culture(s), age, disability, gender and gender identity, language, national- ity, religion, socioeconomic status, and sexual orientation. This does not mean that the interviewer needs to ask the client for an explanation of each of these factors, but the interviewer needs to understand the context of the client’s life and experience. Understanding diversity issues helps the interviewer to understand and interpret the client’s history, behavior, and outlook. Despite the interviewer’s knowledge and experience with diversity and diverse groups, the client is the expert on his or her own experience. The purpose of the diagnostic interview is to identify and assess any psychopathology, but it is equally important to identify and assess “normalcy” and not to misunderstand and misinterpret difference as psychopathology (Fontes, 2008). Information about racial, ethnic, and cultural backgrounds is usually obtained during inquiry about the client’s family of origin. One should not rely on assumptions about racial identity from appearance but inquire about the client’s self-identification of race. The interviewer will need to ask about the client’s first language and what language was spoken at home. It is also important to understand regional and cultural differences in language, in “accent” and word usage. For instance, people living in the Northeast or Midwest USA may find a “Southern drawl” charming but are 68 T. B. Virden III and M. Flint unaware that commenting on it can be offensive. While investigating social history, as stated previously, the interviewer should avoid making assumptions about gender identity and sexual orientation and ask about it, instead, in a sensitive way. Asking about religious upbringing and current practice or lack thereof is an important area of inquiry which helps the interviewer understand issues regarding spirituality. Information about socioeconomic status helps one to understand the resources available both in the client’s history and currently. Significant changes in resources, increases, decreases, or both, over the life span can create significant stress and place strains upon the client’s coping strategies. Age can be calculated from the client’s date of birth or asked directly, and developmental issues related to age are important, but age has many implications for life experiences as well. Women born in the 1940s and 1950s are likely to have a very different gender experience than women born in the 1980s and 1990s. Similarly, men who reached the age of 18 in the 1960s had different stressors and experiences than men who reached that age in the 1980s, because of the military draft and the Vietnam War. In addition, not all disabilities are apparent, and the interviewer should ask about abilities and experienced difficulties, their history and development, and how they experience the impact of any conditions. Not all conditions that may be termed “disabling” are experienced as disabilities. For instance, many hearing-impaired persons do not perceive deafness as a disability, but rather as a different set of abilities, so one might view such a person as different in culture, language, and experience, but not as disabled. Sample questions to ask: • How do you describe your race and ethnicity? • What language was spoken at home when you were growing up? • How would you describe your sexual orientation? • Were you raised in an organized religion? • Are you practicing a religion now? • How would you describe your family’s economic status? And now? • How would you describe your current age and phase of life? • Do you have any conditions that interfere with your life or ability to function?

Legal History

Clients are sometimes reluctant to report violations of legal restrictions, so the interviewer needs to ask about it directly, whether the client has volunteered information or not. In addition to asking about a history of arrests, convictions, misdemeanors, and felonies, it is important to ask about civil actions as well. The interviewer will need to inquire about difficulties in childhood, adolescence, and adult life and about interactions with law enforcement personnel, the judicial system, and attorneys. One might start with a general question about involvement in the legal system, “Tell me about any legal problems,” and then follow up with specific questions, “Have 3 Presenting Problem, History of Presenting Problem, and Social History 69 you ever been arrested,” “Have you filed any lawsuits,” or “Have you been incarcerated?” Some disorders are characterized by violations of legal restrictions, including conduct disorder and antisocial personality disorder, whereas other disorders may include an increased likelihood of violations, such as substance use disorders or pathological gambling. One very common legal proceeding that clinicians often overlook are divorce proceedings. A divorce is a civil legal matter and will have resulting documentation which you will need to be aware of. This is especially important when the couple has children as these documents will prescribe visitation schedule and, more importantly, which parent can make medical decisions—including those needed for mental health treatment. A history of victimization is important to understand. Crime victims have not only experienced the distress or trauma of being targeted, they also may have had experiences with the legal system that are sometimes as distressing as the crime itself. While some clients may have had a very supportive and satisfying experience with law enforcement and the court system, others may report frustration and anxiety, or even feeling as if they were victimized again. It is not the interviewer’s role to right any wrongs or to determine the worth or merit of any complaints, but to understand the perspective and the experience of the client and how that experience has impacted their functioning, their support system, and their outlook. Many clients who are ordered by the court to obtain a psychological evaluation will explain at length the circumstances of the charges, the court and legal proceedings, and so on, making it difficult to focus on the purpose of the interview, usually to screen for the presence of psychopathology. At such a time, the interviewer will need to refocus the line of inquiry toward other areas of social history. Sample questions to ask: • What sorts of legal problems have you had? • Tell me about any arrests and convictions. • Have you been in jail or prison? • Have you filed legal complaints or lawsuits against anyone? • Have you been sued? • Have you been the victim of a crime? • What was your experience with the legal system?

Trauma and Abuse History

The interviewer should not assume that clients will spontaneously offer information about a history of trauma or abuse. Even though such a history may appear to be clinically relevant, clients are often reluctant to reveal this information, because talking about it makes them uncomfortable. For this reason, all interviews should include inquiry about traumatic events and possible abuse, even if the interviewer has no diagnostic hypotheses about acute stress disorder, post-traumatic stress 70 T. B. Virden III and M. Flint disorder (PTSD), or the abuse codes. The American Psychiatric Association (APA, 2013) notes that rates of PTSD are generally higher in Veteran populations, as well as in persons whose vocations increase their trauma exposure (e.g., law enforcement, emergency personnel). The highest rates are found in individuals who are survivors of rape and military combat (with or without captivity), as well as among individuals who have been exposed to ethnically or politically motivated captivity and/or genocide (APA, 2013). It is best to avoid using the words “abuse” and “rape” in questions during the interview, because the client’s own definitions of these terms may not match the interviewer’s concepts. A client may state he/she has never been raped but then report having been forced to engage in sexual intercourse; the client’s idiosyncratic definition of the word “rape” may include only forced sexual contact with strangers, violent assaults, or vaginal penetration. Men may assume that rape is something that only happens to women. Similarly, a client may deny a history of abuse, and then report severe beatings as child resulting in serious injury, because the client perceived this as discipline rather than abuse. Instead, the interviewer should inquire about a history of physical or sexual assault or abuse by using descriptions, such as “Have you been kicked, slapped, punched, pushed, or beaten” and “Have you ever had sexual contact when you didn’t want to, because you were forced or coerced?” Then the interviewer can follow up any endorsements of these events to get specific details and evaluation of the events. In addition to assault and abuse by others, clients may have experienced other traumatic events, such as natural disaster, fire, accident, combat, terrorism, or other violent crime. Clients may have witnessed traumatic events that occur or happen to others and experienced vicarious trauma as a result. It is also important to investigate how the client has dealt with any traumatic events in order to assess coping skills and resources. All of this information is clinically important. Sample questions to ask: • Have you ever been beaten, slapped, shoved, kicked, or punched? • Have you had sexual activity when you didn’t want to, because someone forced you, or you didn’t think you could refuse? • Have you experienced a disaster, accident, or serious injury? • Did any of these things happen to someone you know, or did you see anything like this happening?

Substance Use and Misuse History

While it may be argued that almost everyone has used some sort of psychoactive substance during their lifetime, it is important to determine a history of substance use and abuse. Because this issue is so pervasive, each and every client should be assessed no matter the client’s presenting problem, gender, or age (Morrison, 2014). Barnhill (2018) reflected that some clients present to our practices with a “loud” 3 Presenting Problem, History of Presenting Problem, and Social History 71

(obvious) substance use disorder, while others present more quietly, speaking of their mood or anxiety symptoms with more concern. Substance-related and addictive disorders (APA, 2013) should almost always be included in the interviewer’s list of diagnostic hypotheses, because substances can mimic almost any other mental disorder and produce symptoms that are very similar to those of other disorders. When a client is brought to the emergency room in an agitated state, evidencing hallucinations and odd and rapid speech, it is difficult to differentiate among diagnostic hypotheses of manic episode, schizophrenic disorder, and amphetamine intoxication or psychosis. Inquiry about substances needs to include alcohol, caffeine, both prescription and over-the-counter medications (both legal and illegal), as well as unusual substances. According to the DSM-5 (APA, 2013), the substance-related disorders include ten separate, yet related, classes of substances or drugs. These include alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives, hypnotics and anxiolytics, stimulants, tobacco, and other (or unknown) substances. Since many adults in the USA have some experience with alcohol or other drugs, it is better to ask, “How much alcohol do you drink” rather than “Do you drink?” Similarly, the interviewer may ask, “What substances do you use” rather than “Do you use drugs?” Again, clients are likely to have different definitions of the terms “substance” and “drugs” than the interviewer. Remember to ask about the use of tobacco and caffeine. A client complaining of anxiety symptoms may not realize a connection between those symptoms and drinking a pot or two of coffee every day. Similarly, clients often supplement their treatment regimen with herbal remedies without understanding potential effects, mistakenly believing that anything “natural” must necessarily be benign. The use of herbs and dietary supplements (HDS) in isolation or along with prescribed medications can increase the risk of adverse events (Tsai, Lin, Simon Pickard, Tsai, & Mahady, 2012). Unfortunately, most clients are unlikely to spontaneously reveal their intake of herbal supplements, largely because they do not understand the effects. The interviewer is well advised to specifically ask something akin to: “Are you currently using herbs or taking other alternative remedies?” It is important to inquire about the age at which the client began using a substance, how much and how often, and under what circumstances. The impact of substance use must also be assessed in order to evaluate diagnostic hypotheses of a substance use disorder. Some questions to ask include: “In an average month, on how many days do you have at least one drink of alcohol?”, “Has drinking ever caused you to be absent from work? Late to work?”, “How much do you drink, on average, now?”, “How long have you gone without a drink?”, or “Do you sometimes feel guilty about how much you drink?” (Morrison, 2014). Questions like these may be helpful to evaluate both alcohol and other substance used. When a client has used or abused multiple substances, it is important to determine their preferences. Most substances can be classified as stimulants or depressants, and users often have a preference for one over the other, and for one class of substances, like sedatives, over others with similar effects. 72 T. B. Virden III and M. Flint

Sample questions to ask: • How much alcohol do you drink, on average? • What substances do you use? • Have you ever used tobacco, cigarettes, cigars, or snuff? • Are you taking vitamins, herbs, or food supplements? • How old were you when you started? • When did you use the most? And how much were you using at that time? • What’s your current drug or substance of choice? • How much coffee, tea, and caffeinated soda do you drink? • Have there been periods of time you didn’t use (substance)? • Do other people complain about your use? • Does it interfere with work or relationships?

Medical History

The interviewer may not need to generate a checklist of common childhood diseases or tabulate every cold or minor injury, but it is important to understand the client’s health and history of significant illnesses or injuries. Some medical conditions can produce symptoms of psychological disturbances and disorders (APA, 2013), while health problems are psychosocial stressors that may influence the development of other disorders. The diagnosis of cancer, heart disease, or diabetes is likely to be upsetting to anyone; a history of brain injury may explain a client’s memory lapse. The well-trained and ethical clinician must take under consideration all of the potential causes for a client’s symptomatology—including medical conditions that might masquerade as psychiatric conditions (Zuckerman, 2010). General questions about health concerns, “How would you describe your health now” and “Have you had serious illnesses or injuries, been hospitalized or had surgery?”, can be followed by specific inquiry about illness and injury, “Have you ever had seizures, periods of high fever, been hit in the head and lost consciousness?” As with other areas of history, one must then determine when this illness or injury occurred, how long it lasted, whether or not it is ongoing, and what impact it had (or continues to have) on client functioning. Along with this identification of health problems, it’s important to ask about treatments or interventions the client has received or pursued, and what sorts of health professionals have been involved in treatment efforts. Some clients rely on vitamins and food supplements or are reluctant to take prescription medications, while others seek advice and intervention only from traditional health practitioners and prescriptions. The interviewer can ask the client “Who is treating you for this condition” or “What treatment are you receiving for it?” One also needs to understand the perceived effectiveness or outcome of the treatment received, “How did that work for you?” 3 Presenting Problem, History of Presenting Problem, and Social History 73

Sample questions to ask: • How would you describe your health? • Have you been diagnosed with a serious illness? • Have you been in a medical hospital or had surgery? • Any history of significant injuries or broken bones? • How has this condition been treated? • What was the outcome? Was the treatment effective?

Technique

On occasion, the client’s speech may become hesitant, he or she may begin to avoid eye contact, or some other indication may emerge to give the impression that the client is not providing you with a complete picture. This, of course, may spring from a variety of sources, such as an inability to recall certain details or an unwillingness to discuss particular events. In the latter case, a client may be encouraged by simply acknowledging the resistance and reaffirming the interview’s goal with a statement such as “This may be a difficult topic for you to discuss. I appreciate all the information you can give me in order to help you.” A statement such as this not only emphasizes the importance of gaining sufficient information to reach a reasonable conceptualization but emphasizes understanding and empathy on the part of the interviewer (Sommers-Flanagan & Sommers-Flanagan, 2017). Remember that there is an art to shifting from the symptom-oriented section of the interview to a more history-oriented interview that is important (Sommers- Flanagan & Sommers-Flanagan, 2017). Simply starting by bluntly asking “Were you abused as a child?” may do little more than produce defensive silence. Beginning with such benign questions as “Where were you born?” and gradually increasing the sensitivity of the question (for example, “Where were you raised?” or “Did you like it there?”) often aid in building rapport and decreasing defensiveness. It is very rare for any of us to accurately recall all things at all times, so the client will likely experience some lapses of memory. This is to be expected and is not necessarily an indication of amnesia, cognitive difficulty, or resistance. Occasionally, however, a client may either refuse or be unable to recall any information to account for significant periods of time. Such amnestic events may warrant a referral for further evaluation. In addition, however, it is often prudent to explore the emotional meaning behind the memory lapse. Human memory is not perfect and, over time, the events a client has experienced are subject to reinterpretation (Sommers-Flanagan & Sommers-Flanagan, 2017). In addition, if there appears to be some indication that the client is not being entirely truthful or has some extrinsic motivation to avoid disclosure, it may be helpful to explain confidentiality issues, the consequences of misleading the interviewer, or even to gently confront the client with questions about the accuracy of self-report. In some cases, the use of collateral informants may be of great benefit to understanding the information obtained in the clinical interview (Sommers-Flanagan & Sommers-Flanagan, 2017). 74 T. B. Virden III and M. Flint

In contrast to not recalling sufficient information, some clients may be quite verbose, recounting events in grueling detail over an extended period of time. While the event that the client is describing is clearly important and needs to be thoroughly explored, a situation such as this often occurs at the detriment of exploring other important areas of the client’s life and problems. This can be minimized by gently redirecting the client with phrases such as, “That’s very important to know. I’d like to switch gears for a moment to get a well-rounded picture of you, so that I can help.” Sometimes simply reminding the client of time constraints and asking for their assistance to meet them will be helpful, such as “Okay, we only have about 15 minutes left, and I want to be sure I understand everything important to know about you today.”

Conclusion

At this point in the interview, examine the list of diagnostic hypotheses again. It is likely that enough information has been gathered to rule out many hypotheses on the list, and possibly to confirm a diagnosis. However, the interviewer should be wary of reaching a premature conclusion, and even new hypotheses can be generated during the assessment of social history. Important information will be gathered in the process of the mental status examination that will support or disconfirm diagnostic impressions. Before closing, the interviewer should consider what historical information would assist in ruling out or evaluating any of the diagnostic hypotheses still on the list. Then, one may ask about that information, even though it may appear to be off-topic, simply by saying, “I’m sorry, I forgot to ask you about something.” It is better to follow up on necessary diagnostic information during the interview than to write an interview report with several “rule-outs.” Scanning the list of diagnostic hypotheses and evaluating those diagnostic impressions before closing this part of the interview should help the interviewer feel more confident about the diagnosis. Even with a thorough discussion of the client’s history, whether the information was gathered as a chronological account or by topic area, there may be important pieces of information left out. The interviewer may close this section of the interview by inquiring about anything else the client would like to convey about the presenting problem or history. The interviewer will often use an open question or comment about this, such as “What else should I know about you,” “Have we covered everything,” or “What else do you want to tell me?”

Summary

Evaluating the presenting problem, history of presenting problem, and social history forms the bulk of the clinical and diagnostic interview. It may appear to be daunting, looking at the lengthy list of information to be included, yet in practice, it 3 Presenting Problem, History of Presenting Problem, and Social History 75 may often be completed in less than 1 hour. With practice, the interviewer will be able to guide the questioning through consideration of diagnostic hypotheses, directing inquiry to the areas of social history that will inform the differential diagnostic process and allow for an accurate diagnostic impression by the end of the interview.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Barnhill, J. W. (2018). The initial interview. In J. D. Avery, J. W. Barnhill, & R2 Digital Library, & American Psychiatric Publishing (Eds.), Co-occurring mental illness and substance use disorders: A guide to diagnosis and treatment. Arlington, VA: American Psychiatric Association Publishing. Chou, I. J., Kuo, C. F., Huang, Y. S., Grainge, M. J., Valdes, A. M., See, L. C., & Zhang, W. (2016). Familial aggregation and heritability of schizophrenia and co-aggregation of psychiatric illnesses in affected families. Schizophrenia Bulletin, 43(5), 1070–1078. https://doi.org/10.1093/ schbul/sbw159 Cormier, W. H., & Cormier, L. S. (1991). Interviewing strategies for helpers: Fundamental skills and cognitive-behavioral interventions (3rd ed.). Belmont, CA: Wadsworth. Fontes, L. A. (2008). Interviewing clients across cultures. New York, NY: Guilford Press. Gallardo, M. E., & Gomez, D. I. (2015). The clinical interview with Latina/o clients. In K. F. Geisinger (Ed.), Psychological testing of hispanics: Clinical, cultural, and intellectual issues (2nd ed., pp. 171–188). Washington, DC: American Psychological Association. Jenkins, S. (2007). Unstructured interviewing. In M. Hersen & J. C. Thomas (Eds.), Handbook of clinical interviewing with adults (pp. 7–23). Thousand Oaks, CA: Sage. Morrison, J. (2014). The first interview (4th ed.). New York, NY: Guilford Press. Morrison, J., & Flegel, K. (2016). Interviewing children and adolescents: Skills and strategies for effective DSM-5 diagnosis (2nd ed.). New York, NY: Guilford Press. Othmer, E., & Othmer, S. C. (2002). The clinical interview using DSM-IV-TR: Vol. 1 fundamentals. Washington, DC: American Psychiatric Publishing, Inc.. Segal, D. L., & Hutchings, P. S. (2007). Writing up the intake interview. In M. Hersen & J. C. Thomas (Eds.), Handbook of clinical interviewing with adults (pp. 114–127). Thousand Oaks, CA: Sage. Sommers-Flanagan, J., & Sommers-Flanagan, R. (2017). Clinical interviewing (6th ed.). Hoboken, NJ: Wiley. Tsai, H. H., Lin, H. W., Simon Pickard, A., Tsai, H. Y., & Mahady, G. B. (2012). Evaluation of documented drug interactions and contraindications associated with herbs and dietary supplements: A systematic literature review. International Journal of Clinical Practice, 66(11), 1056–1078. https://doi.org/10.1111/j.1742-1241.2012.03008.x Watson, G. S., & Gross, A. M. (1998). History of the presenting complaint. In M. Hersen & V. B. Van Hasselt (Eds.), Basic interviewing: A practical guide for counselors and clinicians (pp. 57–71). Mahwah, NJ: Lawrence Erlbaum. Zuckerman, E. L. (2010). Clinician’s thesaurus (7th ed.). New York, NY: Guilford Press. Chapter 4 Mental Status Examination

Brenna N. Renn and Samantha E. John

The mental status examination (MSE) is a structured assessment of the clinically relevant areas of a client’s behavioral, emotional, and cognitive functioning. It includes descriptions of the client’s overall appearance, comportment, and behavior; it also describes a client’s thought and perceptual processes and content, emotional state, and cognitive abilities, including level of consciousness, orientation and attention, and insight. By coalescing these important domains, the MSE paints a picture of the client at a given point in time. Consider the following two examples: The client was a 69-year-old Hispanic man who appeared younger than his stated age. He was trim and dressed appropriately in tailored slacks and a button-up shirt. Intact grooming and hygiene were noted, as evidenced by neatly trimmed hair and fingernails and a closely clipped beard. He was cooperative but responded in a very concise manner to the examiner’s questions without much elaboration. Over the course of the interview, he became more forthcoming and at times tearful. He evidenced an anxious affect, and sat with his hands clenched and often averted eye contact to stare at the floor. A 42-year-old German American woman presented 10 minutes late to her appointment at the mental health clinic, brought in by her adult daughter. Grooming and hygiene were inadequate. She was obese and disheveled, wearing a tight hot pink midriff top over tight jeans that allowed her stomach to bulge out. Her clothes appeared unwashed and stained, and her hair appeared unwashed and unbrushed. She left her sunglasses on during the interview and would rise frequently from her chair to walk around the room and mutter incom- prehensibly. She had a notable body odor of stale cigarette smoke. She appeared apathetic and evidenced poor insight, responding to the examiner’s questions with phrases such as “I don’t know. You’re the doctor.”

B. N. Renn (*) Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA e-mail: [email protected] S. E. John Department of Neurology and Goizueta Alzheimer’s Disease Research Center, Emory University School of Medicine, Atlanta, GA, USA

Without knowing more about each client’s symptoms or problems, these brief examples begin to illustrate the unique presentations and potential difficulties experienced by each individual. Each vignette raises different clinical hypotheses and suggests different lines of inquiry during the interview. The MSE is used to help a clinician form a working hypothesis about a client’s psychiatric diagnosis. Focused questions and observations about the client’s functioning and behavior can reveal either unremarkable or pathological findings. A standardized approach allows the clinician to assess multiple domains and patterns across domains, in order to best conceptualize the client. Any indications of abnormality should be reported and described. Although individual observations may be important to consider in isolation, remember that the MSE is only one component of a comprehensive examination and is most meaningful in the context of a thorough evaluation. The information derived from the MSE is best combined with a psychosocial history, a review of psychiatric symptoms, and a medical evaluation to inform the most accurate diagnosis, which then often leads to an initial treatment plan. In the context of an intake interview, the MSE reflects the clinician’s first impressions of the client’s functioning and possible severity of the client’s disorder or problem, relative to other individuals from the same population or setting. In a treatment context, this impression may change over time and with the benefit of repeated interactions with the same client; the written MSE within subsequent progress notes is a concise but comprehensive snapshot of changes that take place over the course of a disorder or treatment. Noting these impressions and changes helps to prepare other health-care providers for working with the client and documents the progress and development within your own work. In this chapter, we review key components of the MSE (see Table 4.1), describe assessment procedures for conducting the evaluation, and remark on special considerations for representative settings and special populations. We also offer case examples throughout to illustrate the important elements of assessment across different client presentations.

Table 4.1 Components of the mental status exam General Factors influencing observations Thinking Emotion Cognition interpretation Arrival Thought Mood Orientation (to include Reliability processes level of consciousness) Appearance Thought content Affect Intellectual functioning Insight Speech and Perceptions Adaptive and social Judgment language functioning Behavior and Suicidal and Attention psychomotor homicidal activity ideation Attitude Memory Abstract reasoning 4 Mental Status Examination 79

Components of the Mental Status Exam

General Observations

Within the context of a thorough evaluation, the MSE offers the clinician a unique opportunity to interpret observations about a client. The MSE includes both objective evidence and subjective interpretation, capturing the patterns of client behavior throughout the interview and highlighting the idiosyncratic characteristics of the person in the room. Together, these observations describe the client at a given moment in time. The general observations of the MSE include a broad range of characteristics that are immediately observable to the clinician. These are described in detail within the MSE to inform understanding of how the client presents himself to the world and, reflexively, how he is perceived by others. Features of the client’s appearance and behaviors may fluctuate over the course of the evaluation or remain static—each may be noteworthy. Independently, each of these features, even if unusual or pathological, may be incidental and unworthy of interpretation; however, the combined effect of multiple observations guides the attentive clinician toward a thorough and accurate conceptualization.

Arrival The clinician notes the timing of the client’s arrival (e.g., early, on time, late) and whether or not he or she came to the appointment alone or with a family member, friend, or caregiver. Late arrivals may be an indication of poor planning or may even suggest resistance to treatment. If the client is accompanied by a family member or other caregiver, this can offer information about the client’s support system and level of independence in daily functioning. Initial interactions with administrative staff can reflect the client’s ability to navigate large, complex healthcare systems and to engage in social interactions with strangers. Familiarity with the setting and location may imply intact recall of prior or related appointments, whereas difficulties with check-in may imply the novelty of the appointment to the client’s typical routine. Details about the client’s attitude toward the session can be observed and inferred from the client’s behavior in the waiting room or lobby prior to the start of the appointment.

Appearance With regard to physical appearance, the clinician should note anything out of the ordinary that might represent a departure from the social or cultural norms of the particular setting or context. Basic hygiene, grooming, and dress can inform myriad factors, including impressions about overall health and well-being, organization, and awareness of environmental and contextual cues, such as weather and formality of the setting. More importantly, each feature of the client’s physical appearance presents an opportunity for the clinician to engage in client-centered questioning that emphasizes the clinician’s attention to and care for the client, facilitating the growth of rapport. Descriptions of hygiene and grooming should include observations of body stature (e.g., healthy, overweight/obese, malnourished, etc.), skin, hair, and teeth, as well as the presence or absence of body odor. Evaluating a client’s style and manner of dress incorporates several aspects of physical presentation 80 B. N. Renn and S. E. John beyond simple clothing choices, including details such as jewelry or other worn accessories, body art like tattoos and piercings, and use of cosmetics. Beyond health, well-being, and overall attention and care to appearance, these factors can provide clues about client income and spending habits as well as her adherence to cultural norms and popular trends. Attention to details of appearance aids the clinician in understanding how this client is likely to be perceived by others. Physical evidence of bodily injuries or scars, particularly those that are new or recent, contributes to the clinician’s impressions about client health and safety. Injuries can serve as possible indicators of self-harm, abuse, neglect, or falls and mobility problems. Of note, clinicians should present objective and specific observations in this section to avoid appearing judgmental. For example, rather than writing that a client is unattractive and does not take good care of herself, a more useful description may observe the client was disheveled and apparently lacking in grooming and hygiene, presenting to the appointment with stained clothes, food in her teeth, and notable body odor.

Speech and language Clinicians must attend to the characteristics or quality of a client’s spontaneous speech, which may reveal unique aspects of the client’s psychological and cognitive functioning. Although speech and thought are intimately related in the interpretation of client presentation, these characteristic displays contribute independent information. Speech content is more often a reflection of underlying thought processes and content; it is therefore included in the section titled “Thinking.” The quality of spontaneous speech is best evaluated through description of the rate, tone, volume, and prosody of the client’s speech. Speech rate refers to the speed with which the client responds to questions from the clinician, which may be absent or described as slow, normal, fast, or even pressured. Speech tone is often evaluated as either static or variable. A monotone (all one tone) client exhibits a single, unchanged vocal expression regardless of the emotional quality or content of speech. A client with a variable tone, described as “within normal limits,” exhibits the culturally normative pattern of voice inflection, such as that used to appropriately emphasize content or signal a sentence’s type and end (e.g., a question versus a statement). The tone of client speech may also be an indicator of the client’s overall mood and affect as well as her emotional connection to the spoken content. Volume is a measure of how quietly or loudly the client speaks and must be interpreted with regard to the appropriateness of the situation. Hypophonia, or soft speech, may be caused by lack of coordination of vocal muscles and is commonly seen in neurologic populations, such as Parkinson’s disease. Prosody of speech describes the client’s overall spoken rhythm, including the cadence both within and across sentences, the articulation of words and grammatical inflections, and the latency between thoughts or sentences within the same response. These features of spontaneous speech, when taken together, suggest the ease and fluency of language for the client. Other features of speech should also be considered, including the client’s average length of utterance, the syntactical structure, grammatical accuracy, choice of vocabulary, and presence of any regional accents. Such features may imply a level 4 Mental Status Examination 81 of knowledge and familiarity with the language itself, which would be expected to vary for a native speaker compared to a client for whom English is a second language. In some cases, evaluating such features of language can serve as an informal assessment of premorbid functioning and educational or occupational attainment. In addition to observing speech as part of the overall picture of current functioning, there are some presentations of abnormal speech and language that may suggest specific psychiatric and neurologic conditions in the client. Anomia (word-finding difficulty) in spontaneous speech, for example, may be an early indicator of cognitive decline, as with Alzheimer’s disease. Decreased articulation of speech, described formally as dysarthria, may be suggestive of Parkinson’s disease. Fast or pressured speech with little to no regard for syntactical structure may be common in mania or in psychotic disorders (and is discussed below in the section on thought process, as speech is the outward manifestation of thinking). Loss or reduction of speech production, Broca’s aphasia, is an acquired speech disorder seen frequently in stroke presentations or as a result of neurodegenerative disease or other acquired brain injury to the left frontal lobe.

Behavior and psychomotor activity The easiest way to evaluate client behavior and psychomotor activity is through simple observation of the presence and frequency of symptoms. As with observations in other MSE domains, clinicians should note even subtle indicators of abnormality. Excessive or absent psychomotor activity, referred to as positive and negative symptoms, respectively, should be described. In some cases, excessive or absent movements by the client may be characteristic of a neurologic or movement disorder. In the absence of such a contribution, excessive, slowed, or absent movements may suggest psychotic features, the influence of psychoactive substances, major depressive disorder, a hypomanic or manic state, or simple discomfort with the situation, as with anxiety or guardedness. Clients with trichotillomania (hair pulling) or other body-focused repetitive behaviors may evidence such patterns during the interview, particularly to relieve tension or distress. It is also important to note any incongruence between a client’s physical state and her expressed thoughts and emotions. At times, clients may verbally deny symptoms of psychological distress yet may demonstrate characteristic behaviors that suggest underlying distress. Specific features to note include the level and quality of eye contact, any idiosyncratic mannerisms, and the overall posturing of the client during the interview. These features provide indications of the client’s internal state, including affect and her comfort in the session and with the clinician. The clinician may observe details such as the size of the client’s pupils, which can provide information about the quality of engagement or interest in session content as well as the presence of substance use or psychosis (e.g., as in the case of unusually constricted or dilated pupils). The depressed client may slouch forward and stare at the floor; the guarded client may cross her arms in front of her body while leaning away from the clinician; the anxious client may twirl her hair or bite her nails while speaking. Each of these behaviors contributes to the clinician’s impression. 82 B. N. Renn and S. E. John

Psychomotor activity, though inclusive of the aspects above, also includes formal assessment of neurologic symptoms, which may present as gait or motor abnormalities. Depending on the clinical setting of the interview, clinicians may want to familiarize themselves with the common motor symptoms exhibited in different neurologic conditions. For example, idiopathic Parkinson’s disease is most likely to present with motor manifestations of tremor (particularly resting tremor), stiffness or rigidity, akinesia (the reduction or absence of voluntary movement), and pos- tural abnormalities (Thenganatt & Louis, 2012). Huntington’s disease is associated with chorea, a full-body jerking movement typified by an undulation of the trunk or head and neck that is unstoppable and exhausting for the individual to control. Many advanced dementias as well as encephalopathy may result in unbalanced, unsteady, or shuffling gait patterns. Clients with multiple sclerosis may exhibit reduced or weakened muscle control as well as paresthesia (numbness and tingling) of the face, trunk, or extremities. For patients who have suffered a stroke, persisting motor deficits such as hemiparesis (one-sided weakness) may result. Observation can glean many of these details; however, formal testing can help to assess the severity of the deficit and establish a diagnosis. Clients who use neuroleptic medications may demonstrate tardive dyskinesia, a neurological side effect characterized by involuntary and abnormal movements of the mouth, jaw, and tongue. Such clients may appear to be grimacing, sticking out their tongue, or sucking during the interview. Those with prolonged use of such medication (particularly so-called first-generation antipsychotic medication) may evidence other extrapyramidal side effects seen in neurological populations, such as dystonia (abnormal muscle contractions), bradykinesia (slowness of movement), rigidity, and tremor. These types of medications are typically prescribed for psychotic disorders, bipolar disorder, and for symptoms of agitation and hyperactivity.

Manner of relating and attitude toward the clinician The client’s manner of relating is an overarching description of the clinical interaction from the perspective of the interviewer. It provides information about how the client presents and expresses himself to others and attempts to capture the client’s interpersonal style and expressed perception of the interview setting. These variables are best described as observable indicators of the client’s attitude within the interpersonal dynamic. Receptiveness to treatment may be observed from the client’s overall comportment and through her responses to inquiry. Clients may be cooperative and friendly, guarded and suspicious, outwardly and blatantly hostile, or excessively open and willing to share. An overall judgment about the client’s manner of relating may be evaluated through behavioral observations as well as features of client speech and speech content. Eye contact, motor behavior, emotional transparency, and compliance with the clinician can all be assessed. The client may have an aggressive, hostile, indifferent, guarded, cooperative, pleasant, manipulative, suspicious, open, negativistic, passive, or overbearing way of relating to others. In many cases, these various shades of comportment will be consistent with patterns of social behavior typified by different psychiatric disorders. For example, the client with schizophrenia may be most likely to regard the clinician with suspicion; the client with 4 Mental Status Examination 83

borderline personality disorder may fluctuate between excessive dependence on and dissatisfaction with the clinician at different points in time; and the client with depression may be cooperative and compliant, but passive. The following is an example of some general observations about a new client: Ms. Martin is a 71-year-old woman presenting for initial evaluation in the context of persistent symptoms of depression, following her recent diagnosis of Parkinson’s disease. She arrived for her appointment on time and was unaccompanied. She ambulated with the assistance of a rolling walker; her gait was slow with shallow steps. She exhibited fluctuating dyskinesia of the head, neck, and trunk throughout the day, which worsened with the timing of her medication dose. Oral comprehension was intact as evidenced by Ms. Martin’s responses to interview questions. Her spontaneous speech was fluent and prosodic, but slowed and hypophonic with mildly decreased articulation. Ms. Martin was friendly and cooperative and remained engaged with the clinician throughout the interview.

Thinking

Although all aspects of the MSE are important when conceptualizing a client, assessment of thought is paramount for detecting and differentiating certain psychiatric symptoms and disorders. Clients without psychopathology, as well as those with significant psychological problems (e.g., anxiety or depressive disorders), are often able to express themselves in an organized and realistic fashion. Disturbances in thinking should raise suspicion of a psychotic disorder but may also suggest a manic episode or severe depression. Because thought is an internal dialogue that occurs in the client’s mind, much of this information is gleaned through observation of the client throughout the interview. Nonetheless, clinicians must also directly assess the presence of perceptual disturbances (e.g., hallucinations) and risk of harm.

Thought process Thought process (or thought form) is the way a person thinks, as evidenced by how he links ideas and associations. Clinicians assess the logic, relevance, organization, flow, and coherence of thought in response to general questioning throughout the interview. Client responses can be described in myriad ways (see Table 4.2 for a summary of these terms). For example, normal thought processes are reflected by tight associations, in which ideas and responses are logical, linear, and coherently linked. Both the rate and flow of thought are evaluated throughout the interview. Extremely rapid thinking manifests as flight of ideas, in which an individual jumps from one topic to another with fragmented ideas and only superficial associations between them. This disconnected rambling from subject to subject may occur most notably during a manic phase of bipolar disorder. Conversely, a client may exhibit slow or hesitant thinking. Termed bradyphrenia, this slowness of thought is characteristic of Parkinson’s disease and can be a side effect of some antipsychotic medications. The mental fog of severe depression may also produce slowed thought, and some clients with this experience indicate that friends or family members have noticed the problem. 84 B. N. Renn and S. E. John

Table 4.2 Characteristics of thought process and content Term Definition Loose associations Switching from one topic to another (also known as derailment or disjointed speech) Tangentiality Answers to questions are obliquely related Circumstantiality Responses are overelaborate but are ultimately relevant Flight of ideas Repeated rapid successive change from one idea to another associated idea Word salad Severely disorganized, incomprehensible speech (also known as incoherence) Perseveration Repetition of a word, phrase, or idea Clang associations Words or phrases based on rhyming sounds (also known as clanging) Echolalia Extensive or exclusive repetition of what clinician has said Neologism Spontaneously made-up words Thought blocking Losing track of a thought before it is completely expressed, as evidenced by mid-sentence pause and failure to resume answer Thought insertion Belief that alien thoughts have been implanted in one’s mind Thought Belief that one’s thoughts have been removed by an outside force withdrawal

The flow of thought refers to how thoughts are connected and may be described somewhere along the continuum from goal-directed to incoherent or disorganized. The clinician may note loose associations, which is a lack of a logical relationship between ideas. This is typical of a psychotic state. In effect, the client expresses confusing, diffuse, or illogical thoughts without any clear connections. Flow of thought also incorporates the continuity of thought, with descriptors such as tangential, circumstantial, evasive, or perseverative. The loss of goal-directed thought process is evidenced in tangential and circumstantial thinking. To understand tangential thought (or tangentiality), think back to geometry, in which a tangent describes a line which touches a circle at just one point and then continues on without ever rejoining. Similarly, tangential thought is evidenced by the client moving from the original thought in a somewhat related way but never getting back to the point. Circumstantial thought, or circumstantiality, is noted when the client includes many unnecessary details and parenthetical comments but eventually answers the question or expresses his point. Thought blocking occurs when the train of thought is seemingly interrupted before a thought can be completed. Note that this is different than sheer distractibility in that an individual with blocking cannot recall what was being said. Clinicians can also remark on the quality of thought process, such as in the case of poverty of thought. A client with poverty of thought will respond to questions with the minimum number of words required and offer very little of the spontaneous speech typical of normal thought processes. The clinician will find himself asking more questions than usual because the client offers very little elaboration. Asking open-ended questions is an effective way to elicit a flow of spontaneous speech, preventing a simple yes or no answer. Importantly, the clinician must assess whether this type of client is evidencing poverty of thought (a symptom of a psychotic or 4 Mental Status Examination 85 thought disorder) or presenting as guarded or hostile. A related term is alogia, or a lack of speech caused by impaired thought process. This extreme example of thought poverty is a negative symptom of schizophrenia. Some clients may evidence copious amounts of spontaneous speech but communicate very little meaning. Such poverty of content might occur when the client speaks in an overly abstract manner. For example, he might answer a direct question from the clinician as such: “Doctor, the answer to your question relates to what I’ve been saying before. I think we were conversing about this topic and such, and I agree that it is a good question. Of course, this is all dependent on our communication, and I would like to communicate with you, as you very well understand. I would love to talk more about this.” Although the client produced speech, the clinician’s question has not been answered. Importantly, this is not because the client veered away from the topic at hand, such as in the case of loosening of associations or tangentiality. A related disturbance is perseveration in which the client dwells on a single idea or preoccupation. You may observe such impoverished thought in individuals with dementia or psychosis. Of course, this pattern is most meaningful when observed throughout the course of an interview, and not just in response to a particular line of inquiry, which might suggest evasiveness. Another impairment is word salad, which occurs when the client utters an incoherent or incomprehensible mixture of seemingly random words and phrases, remi- niscent of a tossed salad full of different vegetables all thrown together. In such cases, it may feel as though the client is speaking a made-up language. Indeed, word salad may include neologisms (new words spontaneously invented by the client, often by combining or condensing other words) and clang associations (linking thoughts by rhyming words). Such severely disorganized thinking is suggestive of schizophrenia. Finally, echolalia is the meaningless repetition of another’s speech, such as the client parroting back what the clinician has just said. This may be evident in clients with head trauma, autism, or other psychiatric conditions. Consider the following example which describes some of the problems with thinking described in this section: Mr. Washington, a 21-year-old man, responded to the clinician’s inquiry about his emergency room visit with the following rapid stream of flight of ideas: “I got here in a cab. A taxi cab. The cab was made by Ford. Ford was at one point the largest auto manufacturer in the world. The world has seven-and-a-half billion people in it. All these people are causing climate change. Yuma has been devastated by drought but wetlands have been reintroduced. I was introduced to a famous movie producer once…”

Thought content Thought content refers to themes of an individual’s thought. Disturbed thought content typically refers to delusions but may also include ruminations, obsessions, fears or phobias, or hypochondriacal symptoms or preoccupations. Delusions are erroneous fixed beliefs, meaning they do not change in light of conflicting evidence, and are not supported by the person’s culture. The content of delusions may be persecutory, bizarre, referential, somatic, religious, or grandiose. Persecutory delusions, the most common in psychiatric populations, are characterized by the belief of being harmed or harassed by an individual or organization. 86 B. N. Renn and S. E. John

Individuals with schizophrenia often misinterpret social cues, and thus, symptoms such as persecutory delusions may emerge as a misinterpretation of social interactions and events. Referential delusions are the belief that certain gestures, comments, events on the news, and so forth are directed at the client. It may be as mundane as the client’s belief that strangers are talking about him, or in a more severe form, that the broadcasters on the radio or television are speaking to him directly, sending special messages. Other paranoid delusions include delusions of control, in which an individual believes he is being controlled by an outside force, and Capgras syndrome, which is a delusion of replacement in which an individual believes a family member, close friend, or significant other has been replaced by an imposter. A nihilistic delusion is the belief that everything is unreal and that things or people, including the client, do not exist. Somatic delusions are the fixed belief that an individual has a medical illness or that he is being poisoned, in the absence of medical evidence. Such disturbed thought content should be differentiated from illness anxiety disorder (formerly hypochondriasis); the latter denotes a preoccupation with illness and accompanying worry. However, the individual with illness anxiety disorder can typically entertain the idea that he does not have the feared illness. Conversely, a somatic delusion is a fixed belief typically focused on a symptom that is obviously not supported by clinical findings (e.g., the belief that one’s body is infested with parasites, or that one’s heart or brain has been removed) and often with an intense or extreme quality. Grandiose delusions are the erroneous beliefs that one has special powers or abilities and will accomplish extraordinary things. This thinking often has religious content, such as a client’s belief that he or she is God or God-like (e.g., a prophet or Messiah). Such delusions may occur in the context of a manic episode. Erotomanic delusions are less common but take the form of the individual believing another person, typically of higher status (e.g., a celebrity) is in love with him or her. Delusions are classified as bizarre if they are clearly implausible and not understood within one’s cultural context. For example, some persecutory delusions, such as the government wiretapping the client’s phone, are unlikely but not considered bizarre. Conversely, delusions about alien invasion or mind reading are thought of as bizarre. Questions to assess disturbed thought content, if not evidenced during the rest of the interview, include general questions (“What do you think about when you’re sad [or angry]?” “What’s been on your mind lately?”) and assessment of obsessions (“Do you have intrusive or repetitive thoughts or ideas?”) or ruminations (“Do you find yourself dwelling on things?”). You can also ask if the client has had thoughts or images that have been difficult to get out of his head, or if he is worried, scared, or frightened about anything. Here we offer an example of disturbed thought content observed in a client: Mr. Ali is a 57-year-old man with a psychotic disorder, experiencing homelessness, who was hospitalized for complications secondary to a large inguinal hernia. He did not want physicians to operate, as he believed the protrusion and resultant swelling in his scrotum was evidence of special sexual prowess given to him by alien beings. He reported that the male surgeon was jealous and only wanted to operate to remove the client’s advantage with women. 4 Mental Status Examination 87

Suicidal and homicidal ideation Assessment of suicidality and homicidality is a unique and essential aspect of client thought content that deserves special attention by the clinician. Such assessment is crucial in every clinical interview as it represents one of the major areas of risk for clients in mental health settings (not to mention clinician liability). It is routinely documented in the MSE, whether present or absent. Clinicians should ascertain the nature of a client’s suicidality, whether it be passive ideation, such as a desire to “not wake up,” versus an intention to actively end one’s life. These various levels of intensity require different assessment, response, and ongoing management. Details of any plan, access to means (e.g., stockpiled medication, firearms), and intention to act on such thoughts need to be assessed. Importantly, details on whether an individual has taken any steps to exe- cute a plan (e.g., acquiring means, giving away possessions) or engaged in any behavioral rehearsal (e.g., tying a knot in a rope to practice hanging) are crucial to assessing risk and keeping the client safe. Whether or not a client endorses current suicidality, it is important to assess past history of suicidal attempts and self-harm. Recent serious attempts confer greater risk than less serious actions that have not occurred for years or decades. Direct and straightforward questioning is advised. For example, the ninth item of the Patient Health Questionnaire (PHQ-9; Spitzer, Williams, Kroenke, Hornyak, & McMurray, 2000), which is routinely used for depressive symptom screening, asks about the presence and frequency of “thoughts that you would be better off dead, or of hurting yourself in some way.” A clinician can also assess passive suicide ideation in conversation (“In the past couple of weeks, have things gotten so bad that you’ve had thoughts that life is not worth living, or that you’d be better off dead?”) and follow up affirmative responses by assessing for active ideation (“Have you had any thoughts about hurting yourself or thoughts of suicide in the past couple of weeks?”; Raue, Brown, Meyers, Schulberg, & Bruce, 2006). Homicidal thoughts or intention to assault someone else can be assessed in essentially the same way. Individuals with antisocial personalities are the most likely to plan violence, but women with postpartum depression or psychosis may also have thoughts of infanticide. Similarly, individuals with psychotic disorders characterized by delusions or auditory command hallucinations (see Perception, below) ordering them to kill others may be vulnerable to committing violent acts.

Perception Perceptual disturbances occur when there is an impairment of sensory information. Hallucinations, false or internally generated perceptions, are the disturbances most relevant to a psychiatric intake or MSE. Clinicians must differentiate hallucinations from illusions, which are not internally generated perceptions but rather misattributions of vague or ambiguous external stimuli (e.g., the client mis- heard someone else’s speech and assumed that person was talking about him). Hallucinations may occur in any sensory modality, and clinicians should assess and note the sensory system involved (i.e., auditory, visual, olfactory, gustatory, or tactile). Auditory hallucinations are the most common perceptual disturbance in psychiatric clients and are experienced as hearing voices distinct from the client’s own thoughts. It is important to assess the nature and quality of the hallucination. 88 B. N. Renn and S. E. John

For example, command auditory hallucinations are a type of auditory hallucination in which the client hears voices telling him to take certain action (e.g., jump in front of a bus). The clinician should determine if the client has felt compelled by or has acted on such voices. Hallucinations in other sensory modalities are atypical in psychosis. For example, while visual hallucinations may occur in individuals with psychotic disorder, they are also prevalent in delirium, dementia with Lewy bodies, and Charles Bonnet syndrome (Teeple, Caplan, & Stern, 2009), where they suggest neurological dysfunction. Olfactory hallucinations may be reported as a secondary symptom of psychosis but are also common symptoms of temporal lobe epilepsy, brain injury, and migraine (Stevenson, Langdon, & McGuire, 2011). Gustatory hallucinations are rare and poorly studied, although they may co-occur with olfactory hallucinations and signal neurological dysfunction. Tactile hallucinations, such as the feeling of bugs crawling on or under the skin (formication) are associated with stimulant intoxication, alcohol withdrawal, neurological conditions such as Parkinson’s disease, and certain infectious diseases such as Lyme disease and her- pes zoster (shingles). Like thought disturbances, hallucinations are internal experiences that must be inferred from what the client reports. The following are example questions to assess for the presence of hallucinations: “Do you ever see (visual) or hear (auditory) things that no one else could see or hear, such as voices or visions?” “Have you ever smelled (olfactory), tasted (gustatory), or felt (tactile) things that are not really there?” “Have you experienced any other strange sensations that others do not seem to experience?” Consider the following example describing perceptual disturbances in a client: Mr. Kim is a 31-year-old man who reports hearing near-constant voices that command him to kill himself. He hears 3 different voices, all male and unfamiliar. The voices are highly personalized and routinely comment on his thoughts and actions, usually in an abusive and derogatory fashion (i.e., “You’re worthless!”). When he walks across a freeway overpass, one of the voices urgently tells him to jump off, and he has difficulty resisting.

Emotion

Emotional disturbance is a central feature in many common psychiatric disorders, and thus is an important domain for both observation and inquiry during the clinical interview. The client’s emotional experience may color her speech, physical appearance, and nonverbal behavior throughout the interview, yielding important diagnostic information. Although the overall emotional tone of a client is usually obvious, accurately observing the gradations and subtleties of emotional expression is a skill that develops over time and with client-focused inquiry and use of reflection.

Mood Mood is a sustained emotional experience (over days or weeks), typically characterized by the state the client describes in her own words. Mood tends to color the person’s perception of the world, such as in the case of pessimistic 4 Mental Status Examination 89

attitude in someone with depressed mood. Although mood is typically a prolonged state, it may be labile (easily altered; e.g., as in the case of someone with borderline personality disorder who experiences extremes in mood and emotional dysregulation) and fluctuate between extremes (as in the case of someone with bipolar disorder). The best way to elicit a client’s mood is usually to ask directly with questions like “How do you feel right now? How has your mood been the past few days (or weeks)?” Indeed, the clinician often uses the client’s own description of her mood placed in quotes in the write-up of the MSE. If the client answers in vague terms, the clinician may need to ask further questions to refine an understanding of the mood. For example, if a client remarks that her mood has been “Not so great…”, the clinician could follow up by asking, “Can you give that feeling a name?” or “Can you give that feeling an emotional label, like sad, nervous, angry, or so on?” Some individuals, such as those from older cohorts or cultures less socialized to Western values of emotional disclosure, may have difficulty naming their emotional experience, or may resist clinical terms for their mood, such as “depressed.” In such cases, the clinician may consider other variants, such as describing sadness as feeling “down” or “blue,” and use questions to elicit the enduring mood based on the client’s description in her own words. Of note, individuals with different psychiatric conditions, including some personality disorders, may evidence alexithymia, an inability to identify and describe emotions in the self.

Affect Compared to mood, affect is an individual’s emotional state at present, inferred by the clinician and described by the observed expression of inner feeling. Some clinicians find it helpful to think about affect as the weather (i.e., the immediate expression) and mood as the season (i.e., a more prolonged emotional experience). Such a metaphor demonstrates that mood is considered more stable than affect, the latter of which may change moment to moment and is more influenced by context than mood. Mood and affect are typically concordant; however, individuals with psychiatric disorders may evidence affect discordant from mood. Similarly, clinicians may note the appropriateness of affective responses to the situation or topic of discussion. For example, it would be unexpected and incongruent for a client to laugh while talking about the recent death of a loved one, or smiling while describing an abuse history. Such a presentation may suggest anxiety or discomfort disclosing painful emotions or thoughts; at the extreme, such incongruence may occur in individuals with schizophrenia. Affect is typically described by the quality of the observed emotional expression. Common adjectives include depressed (or sad, dysphoric, morose, or sullen), anxious (or worried, tense, apprehensive, terrified), angry (or irritable, hostile, annoyed), and indifferent (or apathetic, aloof, uninterested, or detached). Clients may also present with normal or unremarkable affect—in such cases, clinicians should consider using other, more specific, descriptors, such as euthymic, calm, relaxed, or happy. The other end of the spectrum would include elated or euphoric affect and would be just as important to note in an MSE, as such presentation suggests a particular diagnostic picture of mania or hypomania. 90 B. N. Renn and S. E. John

In addition to the quality of affect, the fluctuations, range, and intensity of the client’s observed emotional experience are important to note in the MSE. Just as mood can fluctuate, clinicians should note any fluctuations of affect during the clinical encounter. Compared to even or stable affect, labile affect during a clinical encounter is characterized by repeated, rapid, or abrupt shift in emotional display. Individuals with histrionic personality disorder or schizophrenia may evidence such instability in emotional range. Extreme lability (e.g., swinging from laughing to sobbing uncontrollably within minutes, particularly in the absence of amusement or sadness) could signify pseudobulbar affect, a condition that affects individuals with brain injury or other neurological conditions such as post-stroke symptoms. A normal or broad range of affect describes a client who evidences a full range of emotional experiences appropriate to the situation including congruent variation in facial expression, body language, and tone and pitch of voice. A restricted range of affect is noted when the client had a clear reduction in her expressive range of emotions. Intensity of affect is typically described as normal, blunted, or flat. Blunted affect is evidenced by a severe reduction in the intensity of affective expression. A client with blunted affect may describe the death of a significant other by primarily stating the facts and very little emotional detail, displaying only occasional and mild expressions of sadness. Flat affect is even more severe, in which the client displays virtually no sign of affective expression, as evidenced by a monotone voice and immobile face. Blunting and flattening of affect may occur in schizophrenia, severe depression, post-traumatic stress disorder, or in a neurological condition like Parkinson’s disease. Secondary blunting may arise from use of antipsychotic or antidepressant medication. Here is an example of one client’s affective presentation in the context of a manic episode: Ms. Patel is a 52-year-old woman with a history of bipolar I disorder who presents to the hospital emergency room accompanied by her son. When questioned about her mood, she reported extreme happiness and a sense that “I feel high as a kite.” She evidenced expansive and exaggerated affect throughout the interview, often presenting as euphoric but at times alternating with irritability.

Cognition

Evaluating a client’s cognition entails evaluating his thinking ability or his ability to acquire and utilize information. This may be done either informally (e.g., conversa- tionally) or formally (e.g., using validated assessment instruments); depending upon the interview setting, one or more of these may be the best way to reliably obtain detailed information and objective scores necessary for certain treatment decisions. Clinicians in certain settings (e.g., psychiatric emergency rooms) will not likely have the flexibility, time, or resources to conduct formalized cognitive testing. In this section, we discuss the assessment and observation of cognitive variables without the use of standardized tests. The aspects of cognition delineated below, as 4 Mental Status Examination 91 well as the strategies for assessing them, are useful for a variety of settings that require quick evaluations (for additional information about the use of formal neuropsychological assessment, see Chap. 5).

Orientation The first and perhaps easiest aspect of cognition to assess is the client’s orientation to person, place, time, and situation, as well as level of consciousness. For the cognitively normal client, the quick and familiar “alert and oriented ×4” classification is a necessary snapshot of client presentation that is meaningful across healthcare disciplines. Clients may be largely oriented, but without the ability to specify details about time or place, as with the client who suffers from dementia. Others may report correct orientation to place and time but may falter in their description of a session’s purpose and the situation that prompted initial referral. Level of consciousness is typically summarized by a single word, indicating the extent of alertness and ability to respond to questions (e.g., alert and responsive, awake, asleep, lethargic). Clinicians should be aware that level of consciousness may change or fluctuate during an interview or even over the course of a hospital stay, particularly in inpatient settings (e.g., secondary to delirium or medication side effects) or in specific populations (e.g., in someone with dementia with Lewy bodies). In such cases, cognitive fluctuations should be noted and described over time. It may be necessary to ascertain details of orientation through direct questioning, such as asking clients to provide the date (including day, date, and year), the name of the place in which they are being seen, and the reason for their visit. Asking the client for relevant details about the broader context of time may be useful for assessing his connection to aspects of current culture and community (e.g., “Who is the president right now?” or “Tell me about a recent story in the news.”).

Intellectual functioning Clinicians use the MSE to provide gross estimates about the level and range of cognitive abilities possessed by the client. While multiple theories and constructs of intelligence have been proposed and supported, for our purposes, we will consider intellectual functioning to be a summary description of premorbid or current abilities that include fact-based, semantic knowledge (i.e., crystallized intelligence), as well as flexible and creative problem-solving skills. These aspects of intelligence can be informally assessed through observation of language and vocabulary use, thought content, and general fund of knowledge, as demonstrated by references in conversational speech. In addition to such observation, much can be gleaned by inquiring about the client’s exposure and access to formal education, the quality of that education, and the client’s ability to excel in those environments. In the absence of formal assessment measures, statements about intellectual functioning should be phrased tentatively and should indicate estimated levels or ranges of functioning only (e.g., “The client appears to be within the expected range of intellectual functioning, consistent with his educational and occupational attainment, with no evidence of intellectual disability or cognitive deficit.”). Avoid using standardized qualitative descriptors of functioning typically associated with formal cognitive or neuropsychological testing, such as impaired, average, or superior, which may mislead the reader about the extent of assessment in this portion of the MSE. 92 B. N. Renn and S. E. John

Useful questions for assessing intelligence include, “How far did you get in school?”, “Where were you educated?”, “What kinds of grades did you get?”, and “What was your favorite (or least favorite) course in school?”

Adaptive and social functioning For certain client populations and referral questions, it may be critically important to assess both the client’s adaptive functioning, his ability to independently function in everyday life, and the client’s social functioning, his understanding of social norms and societal expectations about behavior. Older adult clients who may be experiencing cognitive decline, clients with schizophrenia who may be struggling with recurrent or ongoing psychotic symptoms, individuals who are severely depressed or manic, and clients who have limited or diminished physical or mental capacity may need assistance with functional tasks and interpersonal relationships. Assessing a client’s adaptive and social functioning helps the clinician understand how the client functions in the world and what external supports or skills training he may need as part of the treatment. In the context of a brief MSE, the clinician can ask about the client’s ability to independently perform instrumental activities of daily living (IADLS; such as financial management, driving or navigating public transportation, medication management, and organizing responsibilities like appointments). To assess social functioning, the clinician may pose hypothetical scenarios to the client and ask him to describe the actions he would take to solve the problem or complete the task. The client’s responses are then evaluated to ensure that the client understands all relevant safety concerns and social demands. Inquiry into the client’s vocational choices, daily health and hygiene habits, and hobbies or extracurricular activities can provide a context to specific scenarios. Some example questions include, “If you saw a customer in line at the register drop a hundred-dollar bill from his pocket, what would you do?”, “Why is it important to take your medication as prescribed?”, and “If you were home alone and heard a knock on the door at night, but weren’t expecting any guests, what would you do?”

Attention Assessment of a client’s attention may include auditory, visual, and tactile perception, as well as an estimate of overall attentional capacity. Auditory attention is easily assessed through conversation with the client; if the client is responsive in conversation and compliant with clinician requests or commands, simple auditory attention and language comprehension can both be assumed intact. Visual attention may be assessed through requests for the client to identify and describe visually presented stimuli. Tactile attention and perception may be assessed by asking the client to close his eyes and discern the name of an object placed in his hands or the number or letter drawn onto his palm with a fingertip. The client’s overall attentional capacity and ability to work with information in immediate consciousness can be assessed through serial subtractions (e.g., serial sevens, or counting down from 100 by seven), recitation of alternating number-letter sequences (e.g., oral Trail Making Test), or by asking the client to spell W-O-R-L-D backwards. Forward and backward digit span sequencing is also an efficient and meaningful assessment of immediate attention and working memory capacity. 4 Mental Status Examination 93

Memory The client’s memory may be one of the more difficult aspects of cognition to infer in the absence of standardized assessment. Frequently, the client will serve as the sole historian during the clinical interview, making it challenging for the clinician to verify details of remote or autobiographical memory. If the clinician suspects that the client may not be a reliable or accurate historian for details about the relevant history pertaining to his disorder, the clinician should consider obtaining consent to speak with a collateral informant and obtain prior medical and psychological records. There are several aspects of memory that may be relevant for the clinician to assess, including remote or autobiographical memory, short- and long- term memory, and prospective memory. Intact remote and autobiographical memory is a necessity when clients are reporting details about the history, frequency, and course of their symptoms. The clinician must translate these details into a diagnosis or category of potential differential diagnoses; however, the nature of certain conditions will prevent some clients from being able to produce these details with accuracy. For example, the client with dementia or even mild cognitive impairment may not be able to recall the onset of his memory problems and may forget recent instances in which his memory caused difficulty in daily functioning. Clients with psychosis or those fluctuating between manic and depressive states may struggle to accurately characterize the length of time for each phase of symptoms. Some clients may exhibit confabulation, a symptom of memory difficulty that manifests as inaccurate, but plausible information provided by the client out of confusion or forgetfulness. Such fabrication is nonpurposive but may be easily confused with the type of exaggeration demonstrated by clients who are attempting to elicit additional concern or attention from clinicians. For example, a client with histrionic personality disorder may recount events in an exaggerated or dramatic fashion. To verify the accuracy of remote memory, the clinician can ask the client to recall objective facts or events that can be readily accessed in the public domain or confirmed by an additional source. For example, clients may be asked to recite not only the current president but also the preceding presidents, in succession, up to about five. Of course, questions about a general fund of knowledge should be considered in the context of the client’s culture, for example, a recent immigrant may not be aware of the previous US presidents. Thus, when possible, the clinician can rely on topics that are of interest and relevance to the client and inquire about those. For the client who expresses interest in sports, questions about a team’s roster over time, the highlights or outcome of a recent game, or the most recent draft or trade acquisitions are all examples of verifi- able information that can confirm remote memory. To assess a client’s short- and long-term memory, the clinician may ask the client to repeat several words immediately after hearing them. Asking for the same words 30 seconds to 3 minutes later can provide a quick measure of immediate memory. If the clinician inserts a longer delay period, up to 30 minutes, the clinician can later ask the client to repeat these words as a measure of long-term storage and retrieval. More nuanced measures of information encoding and retrieval can be assessed through a series of increasingly more assistive steps. A category cue can be provided 94 B. N. Renn and S. E. John to the client to help elicit recall of those words not spontaneously produced (e.g., “One of the words on the list was a type of fruit.”). If additional structure is needed to facilitate recall, a set of three, multiple-choice options can be presented to the client. Many of these brief assessment methods are embedded within formal assessments of cognition and mental status, including the modified Mini-Mental State Exam (MMSE) and the Montreal Cognitive Assessment (MoCA). A client’s memory for future events, meaning events that have not yet occurred, is known as prospective memory. Prospective memory is an essential aspect of everyday functioning that will predict a client’s ability to consistently attend appointments, take medications, pay bills on time, and maintain a calendar of events. To assess prospective memory, the clinician can ask the client about when his next appointment is and with whom he is meeting. Inquiring about the methods that clients use to remember important events, such as calendars, automated reminders, sticky notes, and other similar strategies, can provide context into both memory and daily functioning.

Abstract reasoning The quality of the client’s higher-order thinking and reasoning ability can also be assessed during the interview and conveyed in the MSE. This would include aspects of creative or novel problem-solving as well as evaluation of concrete and abstract thinking patterns. Abstract thinking is an important developmental process necessary for understanding complex concepts as well as the broader relationships among things, beyond physical or tangible properties. Abstract reasoning can be assessed directly by asking the client to identify similarities between two objects or concepts (e.g., “In what way are a bike and a train alike?”). The client’s response should ideally capture the broad relationship and commonality between the two entities. In the above example, the client should understand that both entities are modes of transportation. Clients who are incapable of abstract reasoning may define each term separately, focusing on the ways in which the concepts are distinct or opposite from one another. Alternatively, some clients may produce overly concrete and simplistic descriptions of tangible properties (e.g., they both have wheels). Consider this example of a client with some of the cognitive difficulties presented above: Mr. Smith was alert and oriented to the place, year, and situation, but struggled to produce details about the time (month/day/date). Auditory attention was intact and Mr. Smith was able to repeat 4 digits forward and 3 digits in reverse order. Mr. Smith’s premorbid intellectual functioning was within expected limits, as evidenced by his vocabulary use and the grammatical structure of his speech.

Factors Influencing Interpretation of the MSE

Several factors, including the client’s insight, credibility, trustworthiness, and accuracy as a historian, will influence both the interpretations within the MSE and the diagnostic interview in general. Intact cognitive abilities are a necessary but not 4 Mental Status Examination 95 sufficient requisite for adequate reliability, insight, and judgment. However, some clients with normal, or even superior, cognitive abilities will display difficulty with reliability, insight, and judgment because of their psychiatric disorder. Thus, it is important for clinicians to comment on these factors in the MSE.

Reliability Specific client populations as well as individual personality factors will influence the reliability of information that is presented during the MSE. Though reliability and honesty of the client cannot be directly measured through interview alone, certain behaviors from the client can signal the need for a cautious interpretation. For example, clients may exaggerate or over-endorse symptoms, resulting in inconsistent or atypical depictions of common disorders. On rare occasion, clients may present a history or list of symptoms that appears to be rehearsed. Clients who are emotionally tied to receiving a specific outcome or diagnosis from the clinician, as in cases where secondary gain is possible, may be particularly well-practiced in providing the diagnostic criteria for a specific condition. Formal research has suggested that even certain aspects of client appearance and presentation may suggest unreliability (e.g., the “sunglasses sign”; Bengtzen, Woodward, Lynn, Newman, & Biousse, 2008). Those with suspected memory or cognitive issues, those suffering from the more severe and chronic mental disorders, and those for whom impression management is particularly important will present unique challenges for gathering and interpreting reliable information. In cases where reliability appears limited, additional sources of information can be sought following the MSE. For example, a clinician may request permission to contact collateral informants and/or conduct objective personality and cognitive assessment, including measures of symptom validity and client effort.

Insight and judgment The client’s insight is a qualitative decision made by the clinician that captures an overall sense of the client’s personal awareness of symptoms and prognosis. Insight is typically described through one of several ranked descriptors, ranging from absent, poor, limited or partial, fair, to good. The determination will depend upon the client’s understanding of her disorder or particular problem(s), how pervasive symptoms are in her daily life, and any deleteri- ous influence on social, educational, or occupational functioning. Details about the client’s level of insight may be communicated through her descriptions of current emotional outlook, any future plans or goals, and through evaluations of current circumstances. A client’s judgment, as an extension of insight, describes her capacity to make appropriate decisions over a period of time, given her understanding of both self and relevant external factors. Many clients with psychiatric disorders, especially the more severe ones, show patterns of impaired judgment, which are often targeted as part of the treatment plan. Judgment is reflected through the client’s behaviors in daily life. As such, the clinician’s statements about client judgment are best captured by statements that include, “as evidenced by” with references to illustrative client behavior (e.g., “The client’s judgment is impaired as evidenced by her decision to discontinue her antipsychotic medication against medical advice following 96 B. N. Renn and S. E. John expected symptom improvement.”). Helpful questions for assessing insight include open-ended probes, such as “What brings you here today?”, “What seems to be the problem?”, “What do you think is causing your problems?”, and “How do you understand your problems?”, all of which elicit the client’s own opinion of herself and current functioning. Consider this clinical example describing some of these factors: Ms. Gonzalez did not appear to be an accurate historian for details related to her recent stroke and the associated symptom course that followed. She struggled to spontaneously recall details from her hospital stay and repeated herself several times during the overall interview, having forgotten previous portions of the conversation. Ms. Gonzalez noted her forgetfulness and word-finding difficulties, demonstrating fair insight into recent cognitive changes.

Conducting the Assessment

Procedures for Gathering Information

As clinicians, we regularly interact with people with mood and anxiety disorders and those experiencing emotional distress, thought disturbances, impaired cognitive abilities, difficulty with functioning, variable insight and judgement, and otherwise altered mental states. The goal of a psychiatric evaluation, psychotherapy intake, neuropsychological assessment, or other clinical activity is to identify and specify these abnormalities and difficulties. The MSE is one element of a diagnostic interview that provides such details and evidence for a clinical formulation. Indeed, specifying the behavior on which key interpretations and conclusions are based is important for MSE reliability. Moreover, genuine concern for the client, including awareness of his cultural background and some degree of individualization of the overall interview, is necessary to set the client at ease, develop rapport, and increase the likelihood that the data gathered is comprehensive, reliable, and valid. Clinicians do not typically conduct a separate examination to assess a client’s mental state; rather, the MSE comprises elements observed and inquired about throughout a clinical encounter, such as during a formal intake interview. However, a standardized approach in writing the MSE, such as the framework discussed herein, can serve as a heuristic for the clinician while conducting the interview. A structure also facilitates communication about the client and makes it easier to identify subsequent changes in the client’s presentation and functioning. Furthermore, it aids in assessing the severity of the client’s problems or psychopathology by establishing a standard of comparison across clients. Although most of the information contained in the MSE is collected by observation and specific lines of questioning throughout the interview (e.g., inquiring about mood, thought content, perceptual disturbances, and suicidal and homicidal ideation), clinicians may use certain brief assessments 4 Mental Status Examination 97 to gather information about mental status and cognitive functioning and to direct further evaluation. For example, clinicians may use a brief screening tool to assess global cognition, such as the Mini-Mental State Exam (MMSE; Folstein, Folstein, & McHugh, 1975), Montreal Cognitive Assessment (MoCA; Nasreddine et al., 2005), or the Saint Louis University Mental Status exam (SLUMS; Tariq, Tumosa, Chibnall, Perry, & Morley, 2006). The clock drawing test is another quick assessment of global functioning that is quick and easy to administer and can be scored either qualitatively or using standardized criteria. As an initial screen of cognitive abilities, the test is nonthreatening to most clients, familiar and interpretable across disciplines, and easy to incorporate within even very brief interviews (Strub & Black, 1977). See Fig. 4.1 for client examples of

Fig. 4.1 Client clock drawing examples, demonstrating varying cognitive status and ability A. A client response within normal limits, accurately depicting “10 minutes after 11” B. A client response with an error in hand placement (11:10), demonstrating stimulus-bound behavior C. A client response with an error in numbering, demonstrating perseverative thinking D. A client response with an error in spacing of the numbers (depicting “20 minutes to 4”), demonstrating planning difficulties 98 B. N. Renn and S. E. John the clock drawing test, demonstrating both intact and impaired responses. Quick visual assessment of the client’s response can provide details about his level of current functioning, planning abilities, sensory neglect, and other deficits. Additional tests of attention and memory were discussed in the relevant sections above and can provide objective data to support the impressions provided in an MSE.

Contextual Factors

Settings The diagnostic interview in general, and the MSE in particular, may vary somewhat depending on the clinical setting, client population, and referral source. The format of the MSE will depend on both the clinician’s specialty training and the intended audience of the final clinical documentation. For example, clinicians who work in hospital emergency rooms and inpatient psychiatric settings may be more familiar than their outpatient counterparts with assessing and noting thought disorders and perceptual disturbances, as they may encounter more individuals in a psychotic, manic, or severely agitated state. Clinicians in outpatient mental health clinics see the gamut of mental health conditions but often encounter individuals with a degree of stability and functional success that allows them to live in the community. Nonetheless, such clinicians will likely be aware of the importance of querying for latent symptoms of psychosis, personality disorders (particularly borderline personality disorder), substance use, and suicidality. Neuropsychologists and neurologists will likely be attuned to signs of motor disturbances and cognitive impairment. Providers across many disciplines and settings (e.g., clinical psychology, psychiatry, social work, primary care/family medicine, neurology, private practice mental health) use some form of an MSE, although the write-up of the intake evaluation or clinical encounter may take a different form depending on the setting. Most importantly, the language of the MSE should facilitate communication among the many professionals who may interact with both the clinical documentation and the client. Clinicians should ground all observations of clients in evidence from the interview; this is critical for other readers of the MSE and may be done through statements such as, “as evidenced by…,” “with…,” “characteristic of…,” “noteworthy behaviors include…,” and the like. The clinician’s goal is to produce a meaningful description of the client, based on observable evidence from the session, which can be easily interpreted by the relevant audience for a given setting. Moreover, a clinician establishes credibility as an interviewer through the ability to cite and describe the various pieces of evidence that support the somewhat subjective nature of this assessment.

Populations

Aging Developmental processes must also be considered throughout a diagnostic interview, and, in particular, during an MSE. Many mental disorders may manifest differently in older age and require age-appropriate assessments (see Segal, Qualls, 4 Mental Status Examination 99

& Smyer, 2018). For example, older adults with depressive symptoms are less likely to report sadness and are more likely to endorse somatic and cognitive complaints (Fiske, Wetherell, & Gatz, 2009). Such a differential presentation may hinge on the historical context of the person’s birth cohort, such as the reluctance of older gen- erations (i.e., the GI Generation [also referred to as the “Greatest Generation”] and the Silent Generation) to outwardly disclose any emotional vulnerability coupled with the steadfast value of stoicism. As a result, clinicians may fail to recognize instances of depressed mood or other mood disturbances in older adult clients. Similarly, clinicians may have implicit ageist beliefs or assumptions and therefore fail to follow lines of inquiry about substance use, sexual behaviors, suicidal or homicidal thinking, or other impairments. Ageist beliefs may lead clinicians to perceive their older clients as frail or cognitively impaired. While older adults do, of course, carry an increased risk of cognitive decline, impairments to memory and thinking ability are but one of many possible client concerns.

Cultural considerations Many aspects of the MSE are subjective and influenced by a client’s cultural exposure and background. For example, a general fund of knowledge (e.g., reciting recent US presidents) may not be assumed for an immigrant or newcomer to the USA or individuals from impoverished backgrounds. Likewise, non-native English speakers may rely on different vocabulary to convey mood and other subjective experiences. Clinicians must consider cultural factors such as quality of and access to education in their assessment of intelligence and other cognitive abilities. For example, non-White racial and ethnic minorities often perform comparably to their White counterparts on visuospatial tasks and performance-based measures but may experience a disadvantage on certain assessment paradigms that were originally developed and normed in White-only samples. If standardized personality or neuropsychological assessment is necessary, clinicians should select measures and normative data based on appropriate client specific factors, including age, race, educational attainment, and cultural affiliation. There is tremendous potential for our own cultural backgrounds as clinicians to color our assessment. We must realize that there is a major distinction between “different” and “pathological” and that the former is a subjective determination best contextualized by the culture of the client. This may be the case with cultural concepts of distress, such as ataque de nervios, a constellation of physical and emotional responses to a stressor endorsed by Hispanic/Latino individuals (particularly Puerto Rican, Dominican, and Cuban individuals; Lewis-Fernández & López, 2016). Similarly, individuals from Asian cultures may be more likely to report somatic symptoms of distress rather than emotional symptoms (Haroz et al., 2017). Clinicians can best clarify their understanding of a client’s experience by reflecting back the client’s own language and choice of vocabulary during the session, with an attempt to understand the client’s meaning. 100 B. N. Renn and S. E. John

Summary

The mental status exam (MSE) is an important foundation upon which to develop impressions of a client’s psychiatric diagnosis. By observing and assessing overall appearance and behavior, quality of thought and speech, and emotional and cognitive functioning, a clinician begins to develop a working hypothesis of diagnostic impressions and specific avenues for further assessment and inquiry. Functioning across the domains of the MSE is best understood through an integrative biopsychosocial approach that emphasizes reciprocal relationships among these factors. This chapter summarizes the core elements of the MSE, with the aim of structuring the assessment and providing the reader with a common vocabulary for describing the various components of the evaluation. Suggestions for conducting the assessment across various settings and client populations are intended to facilitate communication across interdisciplinary professionals. The MSE is intended to paint a description of the client and contribute to a diagnosis, facilitating treatment decisions and a patient-centered approach to care. Conducting a thorough MSE improves with clinical experience, particularly as clinicians encounter an increasingly diverse array of client populations in various settings.

Acknowledgments Preparation of this chapter was supported by the National Institute of Mental Health (grant T32MH073553). The authors also thank Brittany Mosser, MSW, and Nova Rivera, MSW, MPH, for their thoughtful suggestions for this chapter.

Appendix

Case Example of a Structured Mental Status Exam

General Ms. Nguyen, a 23-year-old Vietnamese American woman, presented on observations: time and alone to her intake for outpatient psychotherapy. She was petite arrival and and appeared younger than her stated age, casually dressed for the hot appearance weather in a tank top, athletic shorts, and ponytail. Grooming and hygiene appeared intact, with no apparent odor. Upon introduction, she was polite and offered a weak handshake. She was cooperative throughout the interview, although she appeared preoccupied and offered only fleeting eye contact, preferring instead to stare at her lap or the floor. Behavior and Her gait was normal, but she trailed behind the interviewer while walking psychomotor to the clinic room. During the session, she occasionally tapped her foot and activity wrung her hands, particularly during emotionally intense content. Otherwise, psychomotor behavior was unremarkable. Emotion: mood Ms. Nguyen reported her mood as “totally down” and “hopeless.” She and affect displayed a gloomy and dysphoric affect throughout session, as evidenced by her slouched posture and frequent tearfulness. Her affective range was normal and appropriate to the situation and content of discussion. 4 Mental Status Examination 101

General Rate of speech was normal, but Ms. Nguyen evidenced a hesitant flow of observations: speech, particularly when discussing her mood and related difficulties with Speech her family. She was soft-spoken throughout the interview, although she spoke with clarity and offered an appropriate amount of spontaneous speech. Thinking: Thought Her thought process was logical and goal-directed, and there was no process and evidence of thought disturbance. She denied auditory and visual content, hallucinations. There was no evidence of delusions, obsessions, or ideas of perceptions, and reference. Thought content was positive for depressive and anxious suicidality ruminations, particularly centered on thoughts of worthlessness and all-or-nothing thinking related to her career ambitions (e.g., “I must get into medical school and become a geneticist or else I have failed my family.”). She reported a remote history of suicidality in her teenage years (approximately age 15) but denied current suicidal or homicidal ideation or intent. However, she endorsed recent episodes of non-suicidal self-injury using a pizza cutter to make superficial cuts on her forearms, particularly when emotionally dysregulated. Cognition: She was alert and oriented × 4, and her cognitive abilities were intact, with orientation, no difficulty noted in attention, concentration, or memory domains. Ms. intelligence, and Nguyen is judged to be of above-average intelligence, based on her recent functioning graduation from Stanford University and her aspirations to become a geneticist. Factors influencing She evidenced fair insight into her difficulties and was a reliable historian. interpretation However, her judgment is questionable, as demonstrated by her self-harm attempts at emotional regulation. She is also insistent on taking on a second part-time job in addition to her very demanding work as a research analyst, despite her current emotional state and difficulty with distress tolerance, as she believes this is her “only way” to please her parents.

References

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mild cognitive impairment. Journal of American Geriatrics Society, 53(4), 695–699. https:// doi.org/10.1111/j.1532-5415.2005.53221.x Raue, P. J., Brown, E. L., Meyers, B. S., Schulberg, H. C., & Bruce, M. L. (2006). Does every allusion to possible suicide require the same response? A structured method for assessing and managing risk. Journal of Family Practice, 55(7), 605–612. Segal, D. L., Qualls, S. H., & Smyer, M. A. (2018). Aging and mental health (3rd ed.). Hoboken, NJ: Wiley/Blackwell. Spitzer, R. L., Williams, J. B., Kroenke, K., Hornyak, R., & McMurray, J. (2000). Validity and utility of the PRIME-MD patient health questionnaire in assessment of 3000 obstetric- gynecologic patients: The PRIME-MD Patient Health Questionnaire Obstetrics-Gynecology Study. American Journal of Obstetrics and Gynecology, 183(3), 759–769. Stevenson, R. J., Langdon, R., & McGuire, J. (2011). Olfactory hallucinations in schizophrenia and schizoaffective disorder: A phenomenological survey. Psychiatry Research, 185(3), 321– 327. https://doi.org/10.1016/j.psychres.2010.07.032 Strub, R. L., & Black, F. W. (1977). The mental status examination in neurology. Philadelphia, PA: F.A. Davis Company. Tariq, S. H., Tumosa, N., Chibnall, J. T., Perry, M. H., & Morley, J. E. (2006). Comparison of the Saint Louis University mental status examination and the mini-mental state examination for detecting dementia and mild neurocognitive disorder—A pilot study. The American Journal of Geriatric Psychiatry, 14(11), 900–910. https://doi.org/10.1097/01.JGP.0000221510.33817.86 Teeple, R. C., Caplan, J. P., & Stern, T. A. (2009). Visual hallucinations: Differential diagnosis and treatment. The Primary Care Companion to the Journal of Clinical Psychiatry, 11(1), 26–32. https://doi.org/10.4088/PCC.08r00673 Thenganatt, M. A., & Louis, E. D. (2012). Distinguishing essential tremor from Parkinson's disease: Bedside tests and laboratory evaluations. Expert Review of Neurotherapeutics, 12(6), 687–696. https://doi.org/10.1586/ern.12.49 Chapter 5 Consideration of Neuropsychological Factors in Interviewing

Brian P. Yochim and Stephanie Potts

The goal of this chapter is to accomplish two purposes: (1) to provide an introduction to neuropsychological factors of which to be aware when conducting diagnostic interviews and (2) to give an introduction to the art and science of conducting neuropsychological assessment interviews. The chapter serves as an overview of how cognitive or brain dysfunction can manifest in a diagnostic interview and also provides an introduction to neuropsychological interviewing for general clinical psychology students or students focusing in clinical neuropsychology. The chapter focuses on neuropsychological assessment with adults. Pediatric neuropsychology will not be explored, but interested readers are referred to Sattler (2008, 2014) for information on assessment interviews with children. Before proceeding, it may be helpful to cover some terminology. As of this writing, there are several terms used to describe the cognitive disorders that may be of concern to patients and clinicians: mild cognitive impairment, dementia, major neurocognitive disorder, and mild neurocognitive disorder. “Dementia” is a long-used term that refers to impairment in memory and one or more other cognitive domains, which is severe enough to interfere with one’s ability to perform instrumental activities of daily living (IADLs) such as managing money, medications, or transportation. The term “dementia” in itself only refers to this syndrome, and there are many underlying causes of this, with the most common being Alzheimer’s disease (AD). “Dementia” and “Alzheimer’s disease” are often used interchangeably, which can be misleading, and patients often receive conflicting explanations of these terms. The term “mild cognitive impairment” refers to a decline in memory or other cognitive abilities that is not yet severe enough to interfere with IADLs. It is usually associated with Alzheimer’s disease but can be caused by other conditions as well. When the DSM-5 was published (American Psychiatric Association, 2013), it incorporated the term “neurocognitive disorder” which can be “major” or “mild.”

B. P. Yochim (*) · S. Potts VA Saint Louis Health Care System, St. Louis, MO, USA e-mail: [email protected]

By doing this it brought recognition to the idea that conditions other than Alzheimer’s disease (e.g., Lewy body disease) can cause cognitive impairment, particularly in younger adults (e.g., traumatic brain injuries). Also, by incorporating the terms “major” and “mild,” it highlighted the concept that patients with conditions such as Alzheimer’s disease can have varying levels of cognitive impairment ranging from mild to major. This chapter will use all of these terms, because they are all still in use at the present time. Figure 5.1 provides an illustration of these terms.

Part 1: Factors That Might Suggest to Any Psychologist That Cognitive or Brain Dysfunction Is Occurring and the Need for a Neuropsychological Evaluation

Behavioral Observations

There are certain behaviors exhibited by clients that can suggest the presence of brain dysfunction and the need for further evaluation by a neuropsychologist. These observations are noted in a “Behavioral Observations” section of a report, and this section tends to be present in any mental health evaluation. The behaviors to note often overlap with what is typically included in a “Mental Status Exam,” and both labels are often used for this section of an assessment report. Chapter 4 covers elements of the mental status exam in detail, so this chapter will only provide a brief overview. When clients repeat questions or seem to forget things you have told them (e.g., where the bathroom is, what time the evaluation will be over), this suggests that a neurological disorder such as Alzheimer’s disease may possibly be present. If this disease is indeed present, the client may not be a good historian. When clients

Fig. 5.1 Conceptualization of the terms dementia, mild cognitive impairment (MCI), and major or mild neurocognitive disorder and their underlying causes 5 Consideration of Neuropsychological Factors in Interviewing 105

perseverate on a topic of conversation (i.e., have difficulty changing the topic of conversation) or give tangential or circumstantial answers to questions, this also suggests that a neurocognitive disorder may be present. Clients who are hostile or easily irritated or, at the other extreme, attempting to be flirtatious or making inappropriate sexual remarks about staff also may be experiencing brain dysfunction that will need to be addressed during the assessment and treatment process. These behaviors may be caused by damage to the frontal lobes from a brain injury or a disease process such as a brain tumor or frontotemporal dementia. If the client shows a face devoid of expression (i.e., a masked face), speech that is slow and quiet (i.e., hypophonic), and delayed answers to questions, this suggests that Parkinson’s disease may be present. If the client seems easily angered, has depressed affect, and has uncontrollable movements (choreiform movements), she or he may have symptoms of Huntington’s disease. Other important behavioral observations from a neuropsychological standpoint include elements of speech such as fluency, comprehension, and word-finding. Problems in these areas can indicate the presence of aphasia caused by a stroke or brain injury or a progressive dementia such as primary progressive aphasia. Often clients have subtle deficits in their ability to comprehend language, which can interfere with functioning, and these deficits are often mistaken for a “memory” problem. During an interview, it is often useful to ask about current events by asking, for example, “Can you tell me what’s been going on in the news lately?” This can be followed up with more specific questions such as “are we currently at war somewhere?” or asking about specific recent events such as “was there a natural disaster somewhere recently?” or “is there a particular issue the president is struggling with lately?” Asking about current events is often illuminating as to the client’s orientation and ability to remember episodic events. That is, if the client cannot remember recent major events, he or she may have a set of symptoms indicative of neurocognitive disorders such as delirium or dementia. In summary, these are all elements of a mental status exam or behavioral observations that can indicate the presence of cognitive or brain dysfunction that will affect the diagnostic interview process and subsequent treatment. If problems are notably present, the client should be referred to a neuropsychologist and/or a neurologist for further evaluation and intervention.

Relevant Medical or Neurological History

Another factor that may surface and suggest cognitive dysfunction is when the client reports any history of a neurological problem such as a head injury, stroke, brain tumor, or self-observed memory problem that has not been addressed by a neuropsychologist. Whereas these problems are often assessed and treated by medical professionals such as general practitioners or neurologists, clients are usually not referred to neuropsychologists for evaluation of how these problems have affected cognitive functioning. For example, a client may have had a head injury from a car 106 B. P. Yochim and S. Potts accident with a loss of consciousness of 2 hours. The client may have been seen in the emergency department, found to be stable after a couple of hours, and sent home without any notification that their cognitive abilities may have been affected. Clients may struggle for months or years with problems at work or interpersonal domains without having the knowledge of the link to this possible brain injury and ways to accommodate their deficits. It is also possible that clients, particularly older adults, may have experienced changes such as abnormal gait or frequent headaches that could indicate a slowly developing brain tumor. Clinicians will often find that they are the first to discover that a client has a history of a traumatic brain injury (TBI). TBIs can have subtle or major effects on a person’s daily life and it is important that the cognitive effects of TBIs get evaluated so that clients can be aware of areas that may prove to be a struggle for them and ways to accommodate these limitations. The clinician can discern whether the client has a possible history of TBI by asking if the client has ever had a head injury in which she or he lost consciousness. The severity of a TBI, whether “Mild,” “Moderate,” or “Severe,” is classified using specific criteria, and these parameters, such as length of loss of consciousness, may assist in a clinician’s determination of whether to refer a client to neuropsychology for further evaluation. Table 5.1 outlines the specific criteria used in classifying the severity of TBI. The majority of TBIs are mild, with loss of consciousness less than 30 minutes, and usually do not lead to permanent deficits. Recovery from a mild TBI, often known as a “concussion,” typically occurs within 3 months post-injury without any persisting cognitive sequelae. Thus, when clients present with a history of concussion, it is likely that he or she has recovered from the injury depending on how much time has passed since the event. However, if clients have lost consciousness for longer than 30 minutes, their head injury would be more severe with potential lingering deficits. Unlike the generally fast recovery course from a concussion, a client recovering from a moderate to severe TBI may take 1 year to show the most cognitive improvement after the injury, with the majority of recovery taking place within 2 years (King, Rolin, & Frost, 2017). Any further improvement is often modest in comparison and variable by client. Even with marked cognitive improvement in the first 2 years post-injury following a moderate to severe TBI, he or she may never return to their premorbid cognitive baseline prior to the injury. Therefore, clients with moderate to severe TBIs may have persisting cognitive deficits that impact their ability to live independently or return to work.

Table 5.1 Classification of traumatic brain injury (TBI) by severity range Traumatic Brain Injury Loss of Consciousness Length of Posttraumatic Glasgow Coma (TBI) Severity Range (LOC) Amnesia (PTA) Scale (GCS) Mild TBI/Concussion <30 minutes <24 hours 13–15 Moderate TBI 30 minutes to 24 hours 1 day – 7 days 9–12 Severe TBI >24 hours >7 days 3–8 5 Consideration of Neuropsychological Factors in Interviewing 107

If the client has a suspected history of moderate or severe TBI, this can affect the interview process in several ways. He or she may have poor temper control and may get easily annoyed with questions that do not seem pertinent or important to them or that are of a personal nature. On the other hand, she or he may show a lack of initiative or interest and not be very invested in the assessment process. Both of these presentations can be related to frontal lobe damage. Clients with TBIs can be slow to respond and slow to generate an answer to a question. This would be related to the diffuse axonal injury (DAI) or the stretching and other damage to axons that occurs in a TBI. Sometimes the patient may also lack awareness into the severity of his or her cognitive deficits. In addition, memory problems may be present that interfere with the client’s ability to take in new information or to recall recent information. When assessing for TBI, if the individual is reporting a history of TBI and is presenting with persistent cognitive problems, a full neuropsychological evaluation would be helpful in determining what deficits a person may have resulting from a TBI and in making a proper diagnosis. Another form of brain injury that can impact a clinical interview is a history of stroke, or cerebrovascular accident (CVA). The clinician may find that a client has had symptoms of strokes that may have left the client with lingering deficits. Chief symptoms of stroke include sudden weakness or numbness on one side of the body, sudden change in speech or vision, sudden onset of severe headache pain, and, generally, any sudden change in behavior. Clients and professionals need to be aware of these symptoms and should seek treatment immediately if these symptoms are present. A clinician may see a client who has experienced these symptoms in the last week, and the client should be told to seek urgent or emergency treatment. Depending on the length of time since symptom onset, treatment can be given that opens up a closed artery or relieves pressure on the brain from a hemorrhaged blood vessel.

Impacts of Cognitive Symptoms on the Interview

If the clinician finds that a client may have a neurocognitive disorder, or if this is known from a prior neuropsychological evaluation, then there are some ramifications for the successful completion of the interview. The client may be a poor historian, providing inaccurate information. Sometimes clients give no behavioral indication of dementia and the clinician assumes the client’s report to be accurate, only to find later that much of their understanding of the client is inaccurate. The client’s memory problems will also interfere with recall of things that the clinician may tell the client. Dementia also often affects people’s interpersonal functioning. The client may be less inhibited from saying offensive statements or may cross certain social boundaries, such as asking about the clinician’s personal life or commenting on their physical features. Fortunately, clinicians should be accustomed to dealing with clients with deficient social skills and should understand that these may be behavioral manifestations of underlying brain damage. 108 B. P. Yochim and S. Potts

Sometimes clients may not have cognitive problems of their own, but they may be caregivers for someone with a neurocognitive disorder. In this case, the client may not be in need of evaluation or treatment for cognitive issues per se, but she or he may be significantly affected by someone else’s cognitive disability. In this situation, the person who has the cognitive problems should be evaluated and treated, and the clinician should evaluate how the cognitive problems play a role in the client’s presenting problems. Caring for someone with a cognitive disability can significantly impact a client’s mental health (Segal, Qualls, & Smyer, 2018), and the burden of this may be a major focus of treatment. Many neuropsychologists come in contact with clients who have misconceptions of the nature of dementia stemming from interactions with other medical professionals. This may result from inaccurate information being provided by other clinicians or from the client misunderstanding what has been told to him or her. For example, one client reported that she was told that “You don’t have Alzheimer’s disease, but you have age-related dementia.” Those with current knowledge of neurocognitive disorders know that “age-related dementia” is a poor choice of terms but that one cause of dementia that increases in prevalence with advanced age is Alzheimer’s disease. Clients very frequently ask for clarification on the terms “dementia” and “Alzheimer’s disease,” have typically not heard the term “neurocognitive disorder,” and usually appreciate explanation of these terms. Clients who need education about these terms should be given it by a clinician who is familiar with this area, especially since our knowledge of the causes of neurocognitive disorders is changing rapidly.

Referring for Neuropsychological Evaluation

Table 5.2 summarizes factors that should lead a clinician to make a referral to a clinical neuropsychologist. The discussion so far has focused on factors that would lead a clinician to suspect cognitive dysfunction, leading to an appropriate referral. When referrals are made to a neuropsychologist, certain information should be included in order to lead to a successful arrival at an answer to the question posed by the referring provider. Any time a referral is made to a neuropsychologist, the referring provider should mention the condition (suspected or known) that may be causing cognitive impairment. This should be paired with some description of the cognitive problems the client is thought to be experiencing (memory problems, getting lost while driving, difficulty comprehending instructions, etc.). Some examples of useful referral questions are as follows: “75 year-old woman with memory complaints; please evaluate if she has Alzheimer’s disease” and “client was in car accident 3 years ago and has had trouble working since then; please evaluate if he has cognitive impairment from a head injury.” 5 Consideration of Neuropsychological Factors in Interviewing 109

Table 5.2 Factors that may lead a clinician to refer a client for neuropsychological evaluation Client reports: Declining memory or other cognitive ability, or change in behavior, of unknown etiology Medical history includes: Traumatic brain injury Stroke Brain tumor Possible cognitive effects resulting from neurological diseases such as Parkinson’s disease, Huntington’s disease, multiple sclerosis, etc. Client displays certain behaviors suggestive of neuropsychological dysfunction: Repeating questions during interview or forgetting information given to him/her. Showing difficulty managing a medication regimen. Poor comprehension of things said to her/him (if acute, client should seek emergency evaluation for stroke). Difficulty speaking (if acute, client should seek emergency evaluation for stroke). Socially inappropriate behavior that may be caused by brain damage. Client is confused about current diagnosis or treatment for it: Client’s understanding of dementia reflects outdated knowledge (e.g., “age-related dementia” vs. Alzheimer’s disease). Client’s treatment regimen does not fit with their understanding of diagnosis (e.g., taking dementia medications but having the understanding that he or she does not have dementia). Client has seen several professionals who reportedly have not been able to arrive at a diagnosis.

Part 2: Clinical Neuropsychological Interviewing

Introduction

We will now turn to the second part of this chapter, which is an introduction to the complicated process of conducting a neuropsychological assessment interview. This is a skill which begins with readings such as this but can only be learned through observation of skilled interviewers and the experience of performing multiple interviews. Readers are referred to works by other authors (Donders, 2005; Lezak, Howieson, Bigler, & Tranel, 2012; Strauss, Sherman, & Spreen, 2006; Vanderploeg, 2000) that also serve as excellent introductions to neuropsychological interviewing. There are three main sources of information in a neuropsychological assessment: history, behavioral observations, and test data. The clinical interview provides two of these sources of information, so it is very important to neuropsychological assessment. Neuropsychological testing is only conducted to test hypotheses that are generated before and during the interview. There are times when it becomes clear during the interview that test data are unnecessary to answer the referral question, and in these situations it is hard to justify the client’s time and effort in undergoing testing. For example, the client may be clearly delirious, may have severe dementia, may be under the influence of alcohol or other substances, or otherwise may be 110 B. P. Yochim and S. Potts psychiatrically unstable, and testing would be an unnecessary and perhaps an uneth- ical use of time. The majority of the time, however, test data are very important pieces of the neuropsychological assessment puzzle. The history and behavioral observations gathered in the interview, and the test data, are combined by the neuropsychologist and used to arrive at a diagnosis and formulation of the client’s problems. This information then is connected to two factors: (1) to anatomical regions of the brain, or neuropathological processes, that are likely to be involved in the client’s difficulties and (2) to external daily living ramifications and recommendations. This model is depicted in Fig. 5.2. There are many different styles of interviewing; some clinicians vary greatly in their styles from one client to the next, whereas others use the same approach with every client. Some clinicians use the interview simply to query the client’s responses on a form they have already completed. One approach is to send a detailed history form to the client ahead of the appointment, along with a letter reminding them of the appointment and explaining what to expect in the evaluation. When the client comes to the appointment, the interview consists of a discussion of the reason for referral, current symptoms, and then clarifying information that they provided on the form. This method has several advantages: (1) The client can look up phone numbers, dates, and other specifics from their medical history without having to remember them during the appointment. The form also prompts them to bring in

Fig. 5.2 Model of neuropsychological assessment 5 Consideration of Neuropsychological Factors in Interviewing 111 any past neuropsychological assessment reports and copies of other important records. (2) If the client completes the form as desired, it can save considerable time on the day of the interview. (3) The form can be completed by a caregiver who may not be able to accompany the client to the appointment. However, many clients neglect to complete the history form ahead of time, and thus no time is saved. Also, some content areas (current mental health, description of current cognitive symptoms) are best addressed during an in-person interview, and thus these areas would not be covered on this history form.

Standard Areas to Cover in a Neuropsychological Assessment Interview

There are several areas that are typically covered in a neuropsychological assessment interview. Any one of these may represent the primary problem or cause of cognitive dysfunction.

Medical History

One important area to cover is the client’s medical history. Here, the interview in a sense serves as a substitute for having actual medical records. If the clinician can obtain medical records ahead of time, then she or he should review these records in detail to obtain a solid understanding of the client’s medical conditions. If the clinician can do this ahead of time, it will decrease the amount of time spent discussing medical issues in the interview. Unfortunately, in many settings, the clinician cannot obtain these records until the client arrives to the clinic and signs release of information forms, which are then sent to medical clinics. Medical facilities vary in their responsiveness to requests for records, so a clinician may never be sure that he or she will be able to obtain these records. This means that the clinician must ask the client or caregiver for their description of the medical history. Medical records often provide information that was inaccurately reported by the client. For example, a client reported that after having a stroke, she was unconscious for 3 days. A review of medical records found her to be alert at the time of the stroke, with no mention of any loss of consciousness in the following days. The client was unlikely to be lying; rather, she probably simply had a poor memory of the event or misunderstood the question asked of her. Another way medical records make a valuable contribution is that they offer documentation of when memory problems began. Clients and their caregivers often have poor recollection of when memory problems began, whereas clinicians can often find mention of memory problems in medical chart notes. For example, notes from years ago may say something like “client reports increasing memory problems, and word-finding difficulties are present during the interview.” Information such as this can help the neuropsychologist establish a diagnosis and prognosis for the client. 112 B. P. Yochim and S. Potts

There are certain medical conditions that are related to cognition and some that are less related. Obviously, any disease or injury related to the brain is an important information to have. Problems with other organ systems can have cognitive effects too. Problems with the circulatory system (e.g., hypertension, diabetes, heart diseases such as atrial fibrillation, and high cholesterol) can lead to poor circulation in the brain. Major events in this system such as myocardial infarctions or heart surgery should be noted, as these sometimes trigger cognitive problems. Problems with the liver and kidney can also lead to cognitive dysfunction. Disorders with the prefix “hep-” (e.g., hepatitis) are usually related to the liver, and “renal” problems imply the kidneys. If possible, the clinician should strive to obtain lab results. High white blood cell counts can imply an infection of some sort, which can lead to delirium. A high thyroid-stimulating hormone (TSH) count can imply an underactive thyroid gland, which can affect cognitive functioning. Other important lab values to note are vitamins B1 (thiamine) and B12. Clients typically are unaware of these lab values, or that they have even been drawn, so clinicians must obtain these values from medical charts. Other medical conditions that can impact cognition include a known history of stroke, brain tumors, AIDS, and recent surgeries. Surgeries in older adults can trigger a delirium that can last for days afterward or can disrupt blood supply in the brain, leading to cognitive deficits. When interviewing a client, an attempt should be made to see if the onset of cognitive problems is related to parts of their medical history. For example, the client may have started to experience cognitive problems soon after a fall. This would suggest that the client may have experienced a traumatic brain injury that has caused cognitive changes. A list of current medications should also be obtained from the client. This can be facilitated by having the client bring all her or his medications to the appointment or viewing a list on a recent medical document (though these can certainly be inaccurate!). Likewise, it is helpful if the client writes down a list of medications ahead of time and brings it to the appointment. Medications that can impact cognitive functioning, as reviewed by Houston and Bondi (2006), include tricyclic antidepressants, sedative/hypnotic medications such as benzodiazepines and barbiturates, antiepileptic drugs (particularly first-generation medications), and older, sedating antihistamines(e.g., diphenhydramine, hydroxyzine).

Mental Health

Every psychologist, including neuropsychologists, has the specialized training and responsibility to evaluate clients’ current mental health. Again, prior records should be reviewed if possible. Whether or not the client’s prior history is known, the clinician can simply ask “how has your mood been lately?” One can also ask “Do you still enjoy activities that you’ve enjoyed before?” These two questions assess two main symptoms of major depressive disorder. Questions about anxiety and symptoms of schizophrenia (hallucinations and delusions) should also be asked. Interviewing about mental health problems is covered in other chapters of this book. 5 Consideration of Neuropsychological Factors in Interviewing 113

Clinicians should also inquire as to what treatments clients have received for mental health problems, whether psychotherapeutic or psychopharmacological, and specifics such as how long the treatment occurred, how effective it was, and if there were side effects of pharmacological treatment. All clients should also be asked if they have ever seen a neuropsychologist before. If they have, those assessment results are extremely valuable in serving as a baseline to compare to current test results.

Substance Use

Substance use is another area every psychologist should have some expertise assessing. A helpful way to begin this line of questioning is to ask “How much alcohol do you drink?” This immediately normalizes the regular ingestion of some amount of alcohol and can make the client less defensive, with the goal of obtaining as accurate an answer as possible. If the clinician instead asks “do you drink any alcohol?”, the client may simply respond “no” in order to avoid discussing this area, and the clinician will neglect to obtain important information. In this area, the clinician should assess the classic variables of frequency, duration, and intensity. The clinician should find out how often the client has an alcoholic drink, how much he or she drinks at a given time, and how long they have kept this pattern. Clinicians should inquire as to whether there were times in the past when the client used alcohol excessively or “maybe more than you should have?” Clinicians also should not assume that people drink less alcohol as they age. On the contrary, alcohol abuse is a problem in older adults as well and is more of a problem because of its contribution to disabling conditions and the slower recovery from them (Johnson-Greene & Inscore, 2005). Current alcohol abuse can lead to symptoms of dementia that may resolve with substantial decrease in alcohol use. Lifelong alcohol abuse unfortunately can lead to a form of dementia, often called Korsakoff’s syndrome or alcohol- induced persisting dementia, and chronic alcohol abuse can lead to lifelong cognitive deficits. Patients with this may display a lack of awareness of their own deficits, saying “I’m just stressed” when confronted with the difficulties they are having. Alcohol is notable for its problematic effects on cognition. Less is known about the effects of other drugs on cognition. Nonetheless, clinicians should obtain a history of use of other substances such as marijuana, cocaine, methamphetamines, LSD, and heroin, as well as misuse of prescription medications such as opioid pain medications. While the direct effects of these substances on the brain are less clear, a lifestyle marked by heavy use of these substances or addiction to them can have detrimental effects on brain functioning.

Developmental History

The client’s developmental history should be assessed, and this is more important the younger the client. Early childhood risk factors, including problems at birth and childhood diseases, should be evaluated. Any deviation from normal development 114 B. P. Yochim and S. Potts should be noted. Especially important for neuropsychological assessment, the clinician should obtain some details about the client’s schooling. The quality and quantity of education should be assessed, and any difficulty in particular subjects or any history of special education should be noted. The quantity and quality of education will determine the population to whom the client is compared when evaluating their neuropsychological test data. Thus, this piece of information, along with the client’s age, is critical and must be a piece of information gathered from every single neuropsychological assessment client. The clinician can inquire into this by asking “how far did you go in school?” It is important that the clinician translate this into a number of years of education. Neuropsychological tests are normed by years of education, not degrees completed. Thus, if a client finished high school, this is coded as 12 years of education. If they left high school a month before graduating, that is coded as completing 11 years of education. The key is how many full years the client completed. The quality of education provided to the client should also be assessed. The disparities in quality of education provided to African Americans versus European Americans in the South are well documented (Manly, 2006). Thus, 12 years of education for someone from an impoverished environment is not equivalent to 12 years of education from a more enriched environment. Likewise, clients who were educated in other countries should be asked about the quality of their education. Clients from rural backgrounds may have had shorter school years than clients from more urban backgrounds. This assessment of quality of education is important because neuropsychologists must compare a client’s test performance to performance by people of similar backgrounds. If a client with less education is compared to a population of the same age with more education, the client may be misdiagnosed as impaired when in fact he or she has no impairment.

Occupational History

Occupational history should also be assessed in all clients, for several reasons. This provides the clinician a sense of the baseline functioning of the individual, to serve as a comparison for current functioning. Clients who have a history of short durations at any job, who are now seeking disability compensation, may have personality characteristics that interfere with their ability to stay in a job for very long and they may be seeking a way to reduce their need for employment. Also, a description of the client’s occupation and how her or his cognitive problems have manifested at work can be elucidating for the clinician in arriving at diagnostic hypotheses.

Legal History

Legal history should be assessed, especially for clients currently involved in the legal system, to determine if there is any secondary gain to be had if the client is found to have cognitive impairment. The clinician should keep in mind that the base 5 Consideration of Neuropsychological Factors in Interviewing 115 rate of malingering in forensic settings is high. Also, the clinician should know if there is a strong probability that the assessment findings will be presented in court and if there is a chance that the clinician will have to testify. Of course, every report should be written with the assumption that it could be presented in court. For excellent guides to forensic neuropsychological assessment, the reader is referred to Larrabee (2012) and Bush (2017).

Daily Functioning

Lastly, if clients are reporting cognitive problems the clinician should assess the effect of the disorder on daily life. This will help in two ways: (1) It often helps in arriving at a diagnosis. For example, if the client reports that she often forgets conversations with co-workers and it is interfering with her job, this may be a classic symptom of Alzheimer’s disease. (2) It is always helpful to see how the disorder interferes with each client’s particular needs. For example, the effects of a TBI on a client’s social behavior may be very important for a client whose job has high social demands, whereas a nighttime security guard may be less affected by social behavior changes than by decreased attention skills.

The Interview Process

It cannot be overstated that one important purpose of the interview is to develop rapport with the client. Rapport serves as the foundation upon which all clinical work is completed. If the clinician does not have rapport with the client, then the interview may be unsuccessful in obtaining necessary information. Without rapport, the client also may not feel motivated to expend sufficient effort during the testing phase. If the client does not give sufficient effort, then the test data may be invalid and thus may be a useless venture. If rapport is not established and the interview and testing do not yield useful data, then the client has not been served. Fortunately, most psychologists are well-skilled in establishing rapport with clients. Some things should be done at the start with a client in order to establish rapport, and the first meeting with the client is critical in this regard. Clients should be greeted with a smile and welcomed to the clinic. They should know that their comfort is a priority; thus, they should be informed where the restroom is and offered a drink of water. Clinicians may wish to keep snacks on hand so clients do not feel hungry. Some clinics offer coffee and tea to clients, but other clinics avoid this in order to set firmer boundaries with clients. Efforts should be made to have frequent eye contact with the client, and it can be helpful to share a laugh at least once. It can be helpful to clinicians to find something they have in common with a client and to point that out to the client. This can be a place in common where they have both lived (without discussing where the clinician currently lives), a favorite pastime, favorite restaurant, favorite sports team, or other commonality that can be discussed without 116 B. P. Yochim and S. Potts crossing professional boundaries. Even though brief, this time spent leads to development of rapport, which is the basis of all clinical work. We recommend that neuropsychologists utilize a hypothesis-testing approach when conducting an interview and during the entire evaluation and report write-up. That is, as the client begins to report information, the clinician should generate hypotheses to explain the client’s difficulties. These hypotheses should be tested and either refuted or confirmed. For example, a standard hypothesis to test in the evaluation of cognitive dysfunction in older adults is that the client is experiencing delirium (a medically caused temporary impairment in cognition). This can be easily refuted if the clinician finds that cognitive problems have been present for months, or that there is no acute medical condition (e.g., an infection) that can be causing the dysfunction. The reason all the background information, discussed above, is collected is that this information is used to test hypotheses. It is also important that clinicians do not simply seek information that confirms their hypotheses. Clinicians should also seek information that would refute their hypotheses. For example, if the clinician thinks Alzheimer’s disease is the cause of the client’s problems, the clinician should also seek evidence for other causes of cognitive dysfunction. Vanderploeg (2000) discusses the importance of being aware of “confirmatory bias”; this is the tendency to seek and prioritize findings that supports one’s hypothesis while ignoring or minimizing evidence that contradicts one’s hypothesis (Greenwald, Pratkanis, Leippe, & Baumgardner, 1986). The clinician is operating as a scientist in this regard. Vanderploeg explains that: If the neuropsychologist focuses on evidence consistent with working hypotheses and minimizes contradictory data, then hypotheses will always be confirmed, whether correct or not. The corrective measure to confirmatory bias is to systematically list both confirmatory and disconfirmatory information and to consider alternative explanations for observed behaviors. (p. 8) Vanderploeg (2000) and Donders (2005) discuss the method of starting the interview with general, open-ended questions (e.g., “so what brings you here today?”) and gradually moving toward specific questions. This method allows the examiner to observe how the client reacts to ambiguous stimuli and how the client structures an unclear situation. Valuable behavioral observations can be made, such as the client’s ability to find words when communicating freely, her or his ability to stay on topic, ability to respond to your needs, etc. This also gives the client the opportunity to express certain needs, problems, or concerns that are most important to her or him (e.g., an older adult saying “My daughter is trying to put me in a home” or “My memory is shot and I just know I’ve got Alzheimer’s disease” or a younger adult saying “I really want to be able to go back to work” vs. “I am unable to work and I’m trying to get disability compensation”). This gives the examiner valuable insight into the client’s thought processes. As the interview proceeds, the clinician can probe for details into relevant areas and ask about areas that have not been covered. It is important to be flexible and responsive to the client’s wishes for the order in which information is covered. If the client brings up a topic that the clinician planned to address later, the clinician may wish to let the client discuss the topic right then, 5 Consideration of Neuropsychological Factors in Interviewing 117 instead of asking the client to wait until later to discuss it. For example, substance use may be typically covered in the middle of an interview, but if the client says something like “my wife thinks my memory problems are worse when I’m drinking a lot,” then the clinician may wish to take advantage of that open door and discuss substance use at that time rather than waiting until later. Similarly, if the client says “I have a family history of Alzheimer’s disease,” then the clinician may wish to discuss family history of neurological problems at that time rather than revisiting the topic later. Along the same lines, the client may move into a different topic area before the clinician feels finished with the first topic. Here the clinician must decide if it will harm rapport if the clinician asks the client to come back to the first topic. For example, the client may say something like “it could be that these problems are related to the time I was knocked out in a fight, but I think that the stale air in my building is interfering with my work. Let me tell you about the building where I work…” At some level, the clinician may wish to have the client direct the interview, especially for the goal of establishing rapport, but this need must be balanced with the need for the clinician to maintain control and obtain critical information to help the client. Some clinicians prefer to interview the client without having any caregivers in the room, whereas others interview the client and caregiver simultaneously. It is certainly important to get information from both parties, but each method has its strengths and weaknesses. If the client is interviewed alone, it is possible that their cognitive impairments or motivations will lead them to report information that is inaccurate, and the clinician may not realize this. This can be ameliorated by interviewing a caregiver at a different time and checking for accuracy. Sometimes, for reasons of practicality, the client and caregiver are interviewed together. Donders (2005) points out that in this case, care must be taken to allow the client to answer questions independently without being interrupted by the caregiver. The clinician must also show that the client’s opinions are valued as much as, if not more than, those of the caregiver. Many clinicians make the mistake of speaking primarily to the caregiver, seeming to ignore the client in the room. This practice, which can be disrespectful to the client, can lead the client to feel unimportant or untrustworthy and thus interfere with rapport. On the other hand, the client may defer to his or her caregiver and make little effort to provide his or her own answer. Here the clinician should also make efforts to encourage the client to provide her or his own opinion on things. The clinician must strike a balance between guiding the interview to include enough relevant detail and also maintaining rapport with the client. This can be challenging when clients’ answers to questions go on tangents about information that is not relevant to the evaluation. For example, a client may give extreme detail about the job he or she held 20 years ago, or a client may complain excessively about the health-care system. The clinician must be able to interrupt in a polite fashion to move the client toward providing information that will be more helpful for the evaluation (and, thus, the client’s needs). This can be done by interrupting and saying something like “I’d like to hear more about that if we have time later, but right now I wanted to ask you about something else” (and then, before allowing the client 118 B. P. Yochim and S. Potts to comment, moving on to the next question). Interrupting the client can seem intimidating to less-experienced clinicians, but they must remember that the interruption is being done for the client’s best interests. If a loquacious client were permitted to talk freely about everything they desired, the evaluation may never be completed and the client will not be served. Sometimes the very nature of the disorder the client has (e.g., dementia) makes the client more prone to such tangential conversation and more prone to anger if interrupted by the examiner. The examiner must establish adequate rapport to guide the interview in this way. Sometimes it may help to warn the client at the outset that “we have a lot to cover in a small amount of time, so I may have to interrupt you to make sure you’re able to leave on time. I apologize ahead of time if I have to do this.” On the other hand, rather than rambling, some clients may not provide sufficient information to answer the clinician’s questions and may be resistant to providing more detail. For example, a victim of an assault or other traumatic event may prefer to avoid discussing the nature of the event that caused a head injury, and the clinician must decide whether it is worth pressing for more information at the expense of possibly sacrificing rapport. Most of the time in neuropsychological assessment, rapport with the client is a higher priority than obtaining all the information desired in an interview. Rapport is necessary to obtain accurate test data. Background information can always be obtained from another source or at a later time.

Reason for Referral

One of the key components, and overall goals, of all neuropsychological interviews is clarifying the reason for referral. The reason for referral generally falls into one of two categories: (1) evaluate the extent, if at all, of cognitive change related to a known neurological condition such as a stroke, head injury, brain tumor, multiple sclerosis, or a multitude of other conditions that affect cognitive functioning or (2) evaluate whether a cognitive disorder is present and, if so, what condition is causing it. This differs from the first category in that the client or referring professional does not know if a medical problem is present or not. It can be surprisingly difficult to establish the reason for referral. Referring professionals may not express exactly what information they wish to obtain. They may not point out important information, such as the client appearing in court in several weeks to have a guardian put in place. They may not supply information that they already know which would be useful to the neuropsychologist. For example, a case manager may refer a 48-year-old woman for evaluation of possible cognitive decline, without mentioning a history of intellectual disability or brain tumor. Clients may have no knowledge of the purpose of the evaluation, other than “My doctor/lawyer sent me here.” If the client is impaired, and without a caregiver present at the evaluation, they may not be able to surmise why they were sent to the evaluation. In cases such as this, the clinician must make her or his best attempt to infer what the referral question may be. 5 Consideration of Neuropsychological Factors in Interviewing 119

It is best to clarify the reason for referral before the client even comes to the appointment. This can be completed in a 5- or 10-minute conversation with the referring professional ahead of time and can prevent a great deal of confusion on the day of the evaluation. Preparatory work like this ahead of time should be done to decrease the amount of time the client needs to spend in the evaluation. In a neuropsychological interview, the clinician should arrive at the reason for referral while also having the goal of evaluating what we know needs to be evaluated. That is, if we know certain factors should be evaluated in the context of a given reason for referral, we should evaluate those factors even if not specifically requested. For example, clients referred for dementia evaluations should also be screened for depressive symptoms, even though clients or referring providers may not request this. If a client is reporting difficulties at work since a TBI, we should evaluate his or her work history before the TBI to assess if there truly has been a change. In other words, we should not just evaluate what the client or referring provider wants to have evaluated. When we go to see a physician, we hope and assume that the physician evaluates things we have not thought of, with the goal of best practice for us. Vanderploeg (2000) discusses this below: By imagining what it is you would want and need to know if you were responsible for the client’s care (or if you were the client), it is possible to develop meaningful evaluation questions and begin to structure a useful evaluation. The neuropsychologist should answer not only the referral questions that were asked, but also those that should have been asked. (p. 7) The clinician will be able to deduce the client’s understanding of what occurs in a neuropsychological evaluation after asking about the reason for referral. Clients typically have incomplete knowledge of what occurs in a neuropsychological evaluation, and often they have no knowledge at all. They may think they are going to have blood drawn, or they may think they are about to have an MRI scan. This should be clarified at the start of the evaluation. Much education can be provided in a one-page form letter sent to clients ahead of time. An example of such a letter is presented in Fig. 5.3. Anyone can appreciate the value of knowing what a medical procedure will involve ahead of time. Before testing, they also need to be informed that they will be asked to perform activities that they likely will be unable to do completely successfully. For example, they may feel very frustrated at their inability to learn all 16 words on a list-learning task, unless they know ahead of time that hardly anyone is able to do that. Neuropsychological evaluations can be likened to a vision exam, in which almost no one can read the smallest words on an eye chart, and it is completely normal if one cannot read the smallest words. The goal of the vision exam is not to make one feel incompetent, but to arrive at proper accommo- dations for the client. Clinical neuropsychology is very similar in this regard. Once the reason for referral is established, the clinician can move into asking questions most pertinent to the referral question. A useful exercise for clinicians to undergo can be to ask oneself “If I only had five minutes to do the interview, what information would I want to get?” This can force oneself to prioritize the most important areas to cover. This often comes down to obtaining a history of the current problem at the expense of more distal information. 120 B. P. Yochim and S. Potts

Dear NAME,

You have been scheduled for a neuropsychological evaluation on Wednesday, DATE at 8:30 A.M. The evaluation should last about 3 ½ hours.

A neuropsychological evaluation is a way of checking for symptoms suchas memory loss, or difficulties with speaking, reasoning, or paying attention. You may not have any of these problems; sometimes they are only suspected. The examination consists primarily of answering questions, completing paper-and-pencil tasks, and solving various kinds of problems. This evaluation is structured to help us determine if you are having difficulties that may be important for your caregivers and health care providers to consider in your diagnosis and treatment.

The interview and evaluation will take approximately 3 ½ hours, with ample rest periods and/or rescheduling if you feel fatigued prior to completion. You may be asked to return on another day for further evaluation if we feel it is warranted. Please be well-rested and eat breakfast before coming in. Please take any medications as you normally would that morning.

If you wear glasses, dentures, or a hearing aid, please bring them with you to your appointment.

Enclosed is a questionnaire with instructions. Please complete this and bring it with you on the day of your evaluation. This information can help us finish the evaluation sooner.

[Include summary of policy on cancellation fees.]

If you have any questions, feel free to call me at [name of clinic] at [phone number].

Sincerely,

NAME Title Name of clinic

Fig. 5.3 Sample letter to send to clients ahead of evaluation date

The presenting problem should guide what historical information should be obtained by the clinician. Two examples of presenting problems will be presented: traumatic brain injuries and dementia. To the extent possible, all information should be obtained from both the client and her or his caregiver.

Traumatic Brain Injuries

The evaluation of traumatic brain injuries (TBIs) has at least two goals: (1) to reconstruct a history of the event and (2) to evaluate the effects of the injury on cognition and behavior. Reconstructing a history of the event must also involve gauging the 5 Consideration of Neuropsychological Factors in Interviewing 121 severity of the event, because the severity of the event plays a large role in the outcome for the client’s life. As discussed earlier, severity of TBI is classified using specific criteria noted in Table 5.1 and can be established in several ways. One measure used to assess severity of head injury is the Glasgow Coma Scale (GCS) (Teasdale & Jennett, 1974). The Glasgow Coma Scale is a measure of the motor, verbal, and eye opening response of a person who has just sustained an injury to the head, and it is often assessed by emergency personnel on the scene or upon arrival of a person at the hospital. Therefore, the Glasgow Coma Scale can often be obtained from medical records. A GCS score in the 3–8 range is considered severe, 9–12 is moderate, and 13–15 corresponds to a concussive injury (Rimel, Giordani, Barth, & Jane, 1982). Another criterion used in defining severity of TBI is if the client has no memory of events surrounding the injury, known as posttraumatic amnesia. If the client lacks memory for events after the injury, especially for more than 24 hours afterward, this injury would be classified as a moderate or severe TBI. Importantly, the client’s actual memory of the event must be distinguished from what the client has been told about the event. By the time the client sees the neuropsychologist (possibly months or years after the event), the client may have learned a great deal about what happened in the injury. They may confuse this knowledge of the event with actual memory of the event, and the clinician must take great care to differentiate between the two. This can be helped by the clinician asking the client about the first thing the client recalls following the injury. A general open-ended question about what the client is able to recall about the injury may also elicit length of posttraumatic amnesia. Lastly, the duration of time that the client was unconscious can serve as another gauge of the injury severity. This is always hard for the client to estimate, but gross estimates are often enough for this purpose. If the client is uncertain to the duration of loss of consciousness, the clinician may be able to obtain a gross estimate of loss of consciousness by asking if the client has been informed by others at the scene how long they were unconscious. If the client reports a loss of consciousness less than 30 minutes, then the injury is considered a concussion, whereas a reported loss of consciousness of greater than 30 minutes is considered a moderate or severe brain injury, according to the Mild Traumatic Brain Injury Committee of the Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine (1993). Along with establishing the severity of the brain injury, another priority of the clinical interview for a client with TBI is to reconstruct the history of the event. The neuropsychologist performs this through a combination of reviewing medical records of the event, interviewing the client, and interviewing his or her caregivers. Additionally, the neuropsychologist must learn the nature of the injury and the location of damage in order to assess what cognitive abilities may be affected by the injury. Head injuries can be divided into two types: open (or “penetrating”) head injuries, in which a foreign object penetrates the brain through the skull, and closed head injuries, in which the skull remains largely intact and no foreign object enters the brain. These two types of head injuries are associated with certain neuropathological processes and also predict recovery differently (i.e., a closed head injury is 122 B. P. Yochim and S. Potts associated with better outcome than an open head injury). The neuropsychologist must also know if certain parts of the brain were affected more than other parts, in order to assess what cognitive abilities may have been affected. For example, if the left hemisphere were damaged in an injury, the neuropsychologist would know that a detailed assessment of language is in order. If the left hemisphere was largely unscathed in the injury, the neuropsychologist would need to spend less of the client’s time evaluating language abilities. Different locations in the brain correspond to different cognitive abilities, and the neuropsychologist’s knowledge of the client’s specific injury should be combined with knowledge of general neuroanatomy in order to surmise what cognitive abilities may have been affected and thus which should be evaluated. Another large area to consider in the interview with a person with TBI is the changes that have occurred in her or his functioning since the accident. It is important to compare his or her functioning after the accident to his or her functioning before the accident. Oftentimes the clinician will find that problems that have been present since the injury were actually present before the injury, and thus are likely not to be an effect of the injury. For example, a client may have difficulty maintaining employment since an injury, but this may represent baseline functioning. Some of the standard components of any diagnostic interview should be assessed in clients with TBI: medical history, occupational or academic functioning, substance use, psychiatric functioning, social functioning, etc. The clinician should assess for changes in these domains. Hence, clinicians should inquire how these areas were before the accident in addition to how they have been since the accident. This was an introduction to conducting an interview with clients with a history of TBI. TBIs are similar to other clinical situations in which the client has a known history of something that can cause brain damage. Other situations like this are a history of stroke, Parkinson’s disease, brain tumors (adult and pediatric), and pediatric problems such as genetic malformations or fetal alcohol syndrome. With these conditions, the clinician is charged with evaluating the effects of this known condition on cognitive and behavioral functioning. Common elements to the interview for these conditions are that the clinician must assess functioning both before and after the neurological event (with the exception, of course, of problems present since birth) and that the clinician should seek information both from the client and his or her caregivers.

Dementia/Neurocognitive Disorder

The discussion will now turn to evaluation of problems in which a neurological condition is only suspected, rather than known. In these situations, a neurological condition may or may not be present. The neuropsychologist first must determine whether cognitive dysfunction is present. If it is present, only then does the neuropsychologist need to link the current problems to underlying brain dysfunction. The most common example of this situation is the evaluation of suspected dementia. 5 Consideration of Neuropsychological Factors in Interviewing 123

Another example is the evaluation of suspected neurodevelopmental disorders in children. For neurodevelopmental disorders, it may be impossible to arrive at an etiology of deficits, but the client can still be helped by the evaluation. Our understanding of dementia, however, is advanced enough that clinicians can usually establish with reasonable certainty an underlying cause of the cognitive deficits. Interviews should be conducted with both the client and a collateral source of information. However, when the client is clearly cognitively impaired, or uncoop- erative, the neuropsychologist can obtain this information solely from the caregiver. Either way, the areas of information discussed below should be obtained from both sources to the extent possible. Interviews with clients suspected of having dementia should start with assessing the client’s knowledge of the reason for referral, as outlined above. The interview should also include discussion of specific cognitive difficulties the client or their caregiver has noticed. This should start by asking the client what sort of problems they have been experiencing. Clinicians should probe for examples of cognitive difficulties, which can be very informative. The caregiver may provide a response such as “well, for example, yesterday he asked me five times if I’ve paid the electric bill.” If the caregiver is unable to explain what difficulties the client is having, or to generate examples, one helpful way to elucidate this information is to ask “Let’s say you had to leave town for a few days. Would you feel safe leaving your loved one at home alone?” This often can lead the caregiver to give specific examples of the client’s difficulties. For example, this may lead the caregiver to say “No, there’s no way I could leave him home alone. He would forget to turn the stove off and to take his medications!” If the client or caregiver cannot independently generate examples of everyday problems, then the neuropsychologist can offer examples to see if the client shows these problems. Examples of everyday manifestations of cognitive problems can be gleaned from the Everyday Cognition Scale by Farias et al. (2008). The main cognitive area to inquire into during the evaluation of dementia is memory functioning. The hallmark of Alzheimer’s disease is impaired ability to remember information after a delay. This can manifest in everyday life as forgetting conversations, repeating statements, misplacing items, or forgetting one’s intentions while driving or entering a room. The clinician should inquire with the client and his or her caregiver whether the client has displayed symptoms such as these. If the client seems to have difficulty learning new information (e.g., what the plans are for the upcoming weekend) but seems to retain the small amount that is learned, this could suggest another process such as Parkinson’s disease. Another cognitive area to explore is language functioning; for example, how well does the client understand what is spoken to her or him? Does the client have trouble thinking of the right word to say in conversations or have difficulty speaking in general? If difficulty is reported in these areas, it could be due to a process involving the left frontotemporal area, such as primary progressive aphasia or vascular damage to this area, and may be independent of Alzheimer’s disease. Another area to cover is executive functioning, which is defined in many different ways. Some everyday skills that can be categorized as executive functioning include appropriate social behavior (e.g., inhibiting oneself from offensive behaviors), initiating 124 B. P. Yochim and S. Potts appropriate activity during one’s day (e.g., preparing healthy meals, keeping up with bills), and planning ability (e.g., structuring a day’s errands in an efficient manner, planning a holiday meal). Impairments in these abilities may reflect damage to the frontal lobes, caused by frontotemporal dementia, vascular damage to this area, or advanced stages of Alzheimer’s disease. For example, one client with frontotemporal dementia began a new behavior of shoplifting small items like cookies and candy bars and became hostile to a security guard when caught. Sometimes clients can report that their skills in general are fine but that everything they do takes longer than it used to. This slowness of processing can be extremely disabling and can be frustrating and embarrassing when trying to engage in conversation with others. Slowed processing speed can be due to disorders of the basal ganglia such as Parkinson’s disease or progressive supranuclear palsy or strokes in specific locations. There are several elements of the history of the presenting problem that should be assessed in clients suspected of having dementia. The history of onset of symptoms is essential information. How long have the problems been present? If they have developed gradually over a year or more, the symptoms may be due to Alzheimer’s disease (AD). Sometimes symptoms of AD are present for months or years but not prominent until some crisis occurs. The “crisis” could be a family vacation, death in the family, medical situation, or other situation outside of normal functioning in which the client was pushed beyond her or his capabilities. Often, the client or family cannot pin down a specific time that symptoms began. Vascular dementia, on the other hand, tends to begin with a specific event such as a stroke or myocardial infarction. Clients with vascular dementia tend to have vascular diseases in their medical history, such as hypertension, diabetes, or atrial fibrillation, but these diseases can be present in clients with other types of dementia. The course of symptoms should also be assessed. Clients with vascular dementia theoretically have a stepwise course of decline, in which they are stable for some time, then decline, then are stable, and then decline again. AD, on the other hand, is characterized by a gradual decline. In reality, clients with vascular dementia often do not show a stepwise pattern of decline, and clients with AD often show a steep decline after an abnormal event (e.g., a hospitalization), but the clinician should nonetheless be aware of these possible differences in course. Clients who show variability in symptoms throughout the course of the day may be suffering from Lewy body dementia. Neuropsychologists are often requested to evaluate whether an older adult is experiencing symptoms of depression or dementia or both. It is important to know that depression and dementia frequently co-occur, particularly in the early stages of dementia (Segal et al., 2018). During the interview, several factors can help to differentiate between depression and dementia. Older adults with depressive symptoms are often aware of memory problems or even exaggerate problems that may not even be present. Clients with dementia, on the other hand, are often unaware of their cognitive difficulties. Another obvious but important thing to assess is current and past history of depressive symptoms. This can help elucidate whether current depressive symptoms are contributing to cognitive impairment. 5 Consideration of Neuropsychological Factors in Interviewing 125

The clinician should ensure that the interview is ended appropriately. Donders (2005) points out that it is often useful to summarize the main concerns noted in the interview, assess for correctness with the client, and then ask the client if there are any other concerns the client would like to add or questions he or she would like to ask before proceeding with the evaluation. One benefit to this is that the client may mention something that the clinician may have neglected to inquire into. The clinician should also expect that there will be questions he or she forgot to ask, and these questions can be asked later in the evaluation, or even over the phone on a later date.

Conclusion

It should be clear after reading this chapter that the clinical interview is an essential part of the neuropsychological assessment process. It is also a complex set of skills that develops by conducting many interviews over time. Students should seek out opportunities to observe multiple experienced clinicians conducting interviews to develop this skill and to glean aspects of multiple clinicians’ styles of interviewing. This, combined with experience conducting numerous interviews, will enable the clinician to learn this valuable skill.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, DC: American Psychiatric Association. Bush, S. S. (2017). APA handbook of forensic neuropsychology. Washington, DC: American Psychological Association. Donders, J. (2005). The clinical interview. In S. S. Bush & T. A. Martin (Eds.), Geriatric neuropsychology: Practice essentials (pp. 11–20). New York, NY: Taylor & Francis. Farias, S. T., Mungas, D., Reed, B. R., Cahn-Weiner, D., Jagust, W., Baynes, K., & DeCarli, C. (2008). The measurement of everyday cognition (ECog): Scale development and psychometric properties. Neuropsychology, 22(4), 531–544. https://doi.org/10.1037/0894-4105.22.4.531 Greenwald, A. G., Pratkanis, A. R., Leippe, M. R., & Baumgardner, M. H. (1986). Under what conditions does theory obstruct research progress? Psychological Review, 93, 216–229. Houston, W. S., & Bondi, M. W. (2006). Potentially reversible cognitive symptoms in older adults. In D. K. Attix & K. A. Welsh-Bohmer (Eds.), Geriatric neuropsychology: Assessment and intervention (pp. 103–129). New York, NY: Guilford Press. Johnson-Greene, D., & Inscore, A. B. (2005). Substance abuse in older adults. In S. S. Bush & T. A. Martin (Eds.), Geriatric neuropsychology: Practice essentials (pp. 429–451). New York, NY: Taylor & Francis. King, J. H., Rolin, S. N., & Frost, R. B. (2017). Moderate to severe traumatic brain injury. In S. S. Bush (Ed.), APA handbook of forensic neuropsychology (pp. 201–222). Washington, DC: American Psychological Association. https://doi.org/10.1037/0000032-008 Larrabee, G. J. (2012). Forensic neuropsychology: A scientific approach (2nd ed.). New York, NY: Oxford University Press. Lezak, M. D., Howieson, D. B., Bigler, E. D., & Tranel, D. (2012). Neuropsychological assessment (5th ed.). New York, NY: Oxford University Press. 126 B. P. Yochim and S. Potts

Manly, J. J. (2006). Cultural issues. In D. K. Attix & K. A. Welsh-Bohmer (Eds.), Geriatric neuropsychology: Assessment and intervention (pp. 198–222). New York, NY: Guilford Press. Mild Traumatic Brain Injury Committee of the Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine. (1993). Definition of mild traumatic brain injury. Journal of Head Trauma Rehabilitation, 8, 86–87. Rimel, R. W., Giordani, B., Barth, J. T., & Jane, J. A. (1982). Moderate head injury: Completing the clinical spectrum of brain trauma. Neurosurgery, 11, 344–351. Sattler, J. M. (2008). Assessment of children: Cognitive foundations (5th ed.). San Diego, CA: Jerome M. Sattler, Publisher. Sattler, J. (2014). Foundations of behavioral, social, and clinical assessment of children (6th ed.). San Diego, CA: Jerome M. Sattler, Publisher. Segal, D. L., Qualls, S. H., & Smyer, M. A. (2018). Aging and mental health (3rd ed.). Hoboken, NJ: Wiley-Blackwell. Strauss, E., Sherman, E. M. S., & Spreen, O. (2006). A compendium of neuropsychological tests: Administration, norms and commentary (3rd ed.). New York, NY: Oxford University Press. Teasdale, G., & Jennett, B. (1974). Assessment of coma and impaired consciousness. Lancet, ii, 81–84. Vanderploeg, R. D. (2000). Interview and testing: The data collection phase of neuropsychological evaluations. In R. D. Vanderploeg (Ed.), Clinician’s guide to neuropsychological assessment (2nd ed., pp. 3–38). Mahwah, NJ: Erlbaum. Part II Specific Disorders Chapter 6 Anxiety Disorders

Cierra B. Edwards, Amber L. Billingsley, and Shari A. Steinman

Description of the Disorders

Anxiety is an emotional experience that includes alterations in physical sensations (e.g., elevated heart rate), negative future-oriented thoughts (e.g., “I could die if I ride in an airplane”), and escape and avoidance behaviors (APA, 2013). Anxiety and fear become clinically significant when symptoms cause distress and/or functional impairment in daily living. When anxiety reaches this point, accurate diagnosis becomes imperative to the treatment process. Anxiety disorders are incredibly common; as many as 31% of people will experience an anxiety disorder over the course of their lives (Kessler et al., 2005; Merikangas et al., 2010). These disorders typically onset by adolescence or early adulthood. With each of the anxiety disorders, the symptoms must have been present for at least 6 months (unless otherwise noted, below). We begin by examining the cognitive behavioral model, why anxiety disorders develop, and how they are maintained.

Development and Maintenance of Anxiety

Cognitive behavioral models of anxiety posit that thoughts, feelings, and behavior are interrelated and these factors are influenced by situations occurring in an individual’s environment (Barlow, 2004). Anxiety occurs in response to a situation that provokes an alarm or fear reaction (e.g., speaking in front of a crowd) and is interpreted as threatening (e.g., “everyone will think I am boring”). When these situations arise, one reflects about the anxiety and may choose an avoidant way to cope with the situation, such as escaping or avoiding it (e.g., not speaking in front of large

C. B. Edwards · A. L. Billingsley · S. A. Steinman (*) West Virginia University, Morgantown, WV, USA e-mail: [email protected]

© Springer International Publishing AG 2019 129 D. L. Segal (ed.), Diagnostic Interviewing, https://doi.org/10.1007/978-1-4939-9127-3_6 130 C. B. Edwards et al. groups or ending a speech quickly). The avoidant coping alleviates the anxiety in the short run but prevents the individual from obtaining information to disconfirm that the situation is harmful or threatening (e.g., he/she does not notice that the audience looked attentive or people saying they liked the speech afterward). Future situations involving the same or similar situations may be avoided because the individual has learned that avoidance decreases the fear reaction, creating a cycle of negative reinforcement (avoidance behaviors are increased over time because avoidance seems to reduce anxiety). Processing after an anxiety-provoking situation can lead to negative thoughts and beliefs about similar situations occurring in the future, anticipatory fear, and information processing biases in which external and internal cues are misinterpreted as threatening (Beck & Clark, 1997; Rapee & Heimberg, 1997). Although each anxiety disorder has unique characteristics, they are all maintained in part through this cycle of cognitions, behaviors, and feelings, as shown for panic disorder (PD) in Fig. 6.1. Here, PD continues because the individual has learned that avoiding situations in which panic attacks have occurred in the past reduces anxiety in the moment. A conditioned fear and avoidance of bodily sensations (and their possible catastrophic meanings) maintain the cycle. While the exact situation may differ, this pattern of interpreting benign information as threatening and avoiding the apparent threat is common across anxiety disorders. With this foundation in mind, we next consider the distinctive symptoms associated with the different anxiety disorders.

Fig. 6.1 Cycle of cognitions, behaviors, and feelings that maintains anxiety disorders as applied to PD 6 Anxiety Disorders 131

Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) is typified by excessive worrying about a wide variety of situations (e.g., family, health, money). While everyone worries from time to time, individuals with GAD have worry that is uncontrollable and beyond the scope of normal, everyday stress (Hallion & Ruscio, 2013). People with GAD tend to be “nervous people” and to view their constant worrying as a form of problem-solving. Those with GAD report physical symptoms associated with their anxiety, including muscle tension and restlessness. People with GAD may also avoid situations that make them worry or try to plan ahead to prevent uncertain outcomes for routine activities. An intolerance of uncertainty (perceiving uncertain situations and negative outcomes as unacceptable) and future-oriented thinking (e.g., what if I am late for a meeting, what if my child gets hurt at soccer practice) are cognitive sequelae of GAD (Dugas, Gosselin, & Ladouceur, 2001). These “what if” thoughts tend to be catastrophic and highly unlikely to actually occur, but nonetheless they persist. Notably, the worry in GAD is out of proportion to any actual threat posed by the situation.

Panic Disorder

PD is distinguished by physical symptoms of autonomic hyperarousal during panic attacks, such as a pounding heart, feeling unsteady, and sweating. Panic attacks occur over a brief period of time and generally resolve within 20 minutes. They can occur suddenly or in response to feared stimuli or other stressors. While people with other anxiety disorders and without a mental disorder may experience panic attacks from time to time, those with PD have recurrent panic attacks and they worry about having future attacks (APA, 2013). The first panic episodes may occur during a time of stress, but subsequent attacks often occur due to catastrophic misinterpretations of bodily sensations (accelerated heart rate and chest pain with a panic attack may signal they are having a heart attack). People with PD may avoid situations in which they have had a panic attack in the past or have concern about the possible implications of having a panic attack (e.g., panic attack may mean they are going crazy). This avoidance or worry following a panic attack must occur for at least 1 month. Individuals with PD may be hypervigilant for signs of an impend- ing panic attack, which may strengthen the association between physical symptoms and catastrophe in the person’s mind (Barlow, 2004). This cycle of body sensation misinterpretations and avoidance is known as the “fear of fear” model. In this model, panic attacks in PD are maintained by the fear, anticipatory anxiety, behavioral avoidance, and past memories of the physical sensations associated with fear. 132 C. B. Edwards et al.

Agoraphobia

In previous versions of the DSM, agoraphobia was diagnostically linked with PD; however, in the DSM-5, agoraphobia is a separate diagnosis that can co-occur with PD or on its own (Asmundson, Taylor, & Smits, 2014). Individuals with agoraphobia avoid specific, public situations that elicit fear such as waiting in lines, using public transportation, or being in open places (e.g., parking lots). Those with severe agoraphobia may avoid being outside of their home alone, while those with mid- range agoraphobia may avoid certain situations like travel or shopping. With agoraphobia, there is a fear that escape may be difficult or that getting help if needed, such as in the event of a panic attack or falling down, will not be possible or will cause embarrassment. The avoidance is extreme and out of proportion to the danger posed by the situation, and a diagnosis of agoraphobia is made irrespective of whether the person meets criteria for PD.

Social Anxiety Disorder

A diagnosis of social anxiety disorder may be indicated when someone has significant fear of social situations in which he or she may be evaluated by others and has anxiety and avoidance related to future feared social situations. Most people experience anxiety in social situations from time to time; however, an intense fear of evaluation is exhibited in clinically significant social anxiety. In social anxiety disorder, the fear is that one will act in a way that will be negatively evaluated by others, such as by coming across as dumb or boring or by exhibiting physical symptoms of their anxiety like sweating or blushing (Heimberg & Magee, 2014). The social situations are settings in which the individual may be observed by others (e.g., eating or shopping), is performing (e.g., playing a musical instrument or undergoing a job interview), or is having day-to-day interactions (e.g., having a conversation or meeting someone new). If the individual is only fearful of social situations related to performance, they are given the performance-only specifier; however, most individuals with social anxiety disorder are fearful of multiple social situations. Social anxiety disorder tends to follow a developmental trajectory in which a person may have early unfavorable social experiences and avoid subsequent opportunities for social engagement during childhood (Ollendick & Hirshfeld-Becker, 2002). These early aversive social experiences can result in the development of poorer interpersonal skills and maintain avoidance of social situations.

Specific Phobia

In specific phobias, there is marked anxiety about a specific object or situation that provokes intense, disproportionate fear in the individual. The DSM-5 notes five types of specific phobia: animal, natural environment, blood-injection-injury, situational, 6 Anxiety Disorders 133 and other (APA, 2013). In specific phobia, the anxiety-provoking stimulus is actively avoided to the point of causing significant impairment and/or distress. This is what distinguishes a specific phobia from ordinary fear: most people fear things which have a potential for harm to some degree, such as snakes and flying, but people without specific phobia do not experience the fear as so distressing to cause dysfunction (e.g., they will not decline a promotion because it requires working on a higher floor of an office building like someone with acrophobia, fear of heights, might). If the phobic situation is not actively avoided and/or endured with great distress, it is not considered a phobia. Similarly, if it is a situation the person is unlikely to encounter or need not engage in (e.g., snakes, if the person is an area where he/she wouldn’t expect to see snakes), then a diagnosis is not appropriate.

Separation Anxiety Disorder

Although most anxiety disorders have an average age of onset in adolescence or early adulthood, separation anxiety disorder and selective mutism, while not exclusively found in children, typically present in children between the ages of 2 and 7 years old. Separation anxiety is typified by excessive fear of separation from an attachment figure, usually a parent or caregiver, which results in avoidance and/or refusal to be parted from the person to whom the individual is attached. Children with separation anxiety disorder may refuse to go to school, sleep in their bed alone, or participate in any number of activities, causing significant impairment in their daily lives. With separation anxiety disorder, there may be uncontrollable worry and even nightmares related to losing or being parted from an attachment figure (e.g., accident happening to parent, getting lost; Bögels & Zigterman, 2000). Somatic symptoms such as nausea or headaches can occur in response to separation.

Selective Mutism

Selective mutism is similar to social anxiety disorder in that it is characterized by excessive fear and anxiety in social situations, specifically by a repeated inability to speak in specific settings, such as at school (Bergman, Piacentini, & McCracken, 2002). Unlike most other anxiety disorders, symptoms and behavior must have occurred for at least 1 month to meet criteria for selective mutism. Despite being unable to speak in some situations (e.g., to strangers, at daycare), those with selective mutism do not lack the ability or knowledge to speak and often converse com- fortably with close others (e.g., parents, siblings). Physically, children with selective mutism may freeze up or become expressionless when in settings where communication is required (APA, 2013). Selective mutism is generally severe, but does vary across people; some children may be entirely mute whereas others may speak to family and close friends but not peers and teachers. 134 C. B. Edwards et al.

Next, we examine how to collect information to determine whether an anxiety disorder is present, and if so, which one is of primary interest.

Procedures for Gathering Information

We recommend the use of evidence-based assessment, which means using research to guide the selection of assessment measures and constructs (Hunsley & Mash, 2007). In evidence-based assessments, clinicians choose psychometrically sound measures (e.g., reliable, valid) that, when possible, have been validated in the population they are assessing. Additionally, clinicians select constructs to assess (e.g., worry, avoidance) based on empirical research and theory. Face-to-face clinical interviews are often the first interaction between a provider and client. Clinical interviews can either be structured or unstructured (see below). During a clinical interview, the clinician inquires about a client’s current psychological symptoms to determine if they meet diagnostic criteria for any disorders. Additionally, the clinician obtains information about the client’s psychiatric history, developmental history, medical history, family history, and social history, which can help identify any functional impairment and additional stressors playing a role in current symptomatology.

Structured and Semi-structured Interviews

In a structured or semi-structured clinical interview, a clinician has a set list of questions that often includes a script, example responses, and a decision-tree-style format to help guide the clinician to respond thoroughly and appropriately depending on the client’s answers. These types of interviews cover critical topics (e.g., specific diagnostic criteria for a given disorder) and are widely considered to be the most reliable and valid way to come to an accurate diagnosis (Basco et al., 2000; Miller, Dasher, Collins, Griffiths, & Brown, 2001). Of note, structured interviews can be lengthy (e.g., up to 4 hours) to complete, and some must be purchased or require a permission fee to use, potentially precluding their use in settings with limited time and fewer financial resources.

Unstructured Interviews

In unstructured clinical interviews, clinicians allows their clinical judgment and the flow of the conversation to guide the direction of the interview, while still covering key information (e.g., presenting symptoms, medical history). In general, these 6 Anxiety Disorders 135 interviews consist of open-ended (rather than closed-ended) questions. Allowing the client to talk freely may lead to a discussion of information that a clinician may not have otherwise asked about. However, diagnoses from unstructured interviews may not be as reliable as those obtained from structured or semi-structured interviews (Basco et al., 2000; Miller et al., 2001). Nonetheless, rich idiographic information is often obtained in unstructured clinical interviews.

Additional Interview Considerations

When an anxiety diagnosis is suspected, clinicians should ask about feelings (anxiety, fear, distress, physical symptoms), thoughts (negative future-oriented thoughts), behaviors (escape, avoidance, safety behaviors), and functional impairment (i.e., in what ways the client’s symptoms cause difficulties in their life). Clinicians should specifically ask about physical symptoms that commonly occur in anxiety, such as a racing heart, shortness of breath, an upset stomach, or dizziness. Some clients with anxiety disorders may only report physical sensations related to anxiety rather than emotions related to anxiety; this is particularly common in older adults and children (APA, 2013, 2014; see below). Further, medical problems (e.g., endocrine conditions) or medications (e.g., corticosteroids) can cause anxiety-like symptoms and must be ruled out when considering an anxiety disorder diagnosis. Other common medical conditions that mimic anxiety symptoms include asthma, cardiovascular disease, anemia, and inflammatory bowel disease (Testa et al., 2013). Clinicians should ask the client about any specific worries or thoughts they have that bother them. Asking questions such as, “What do you think will happen?” or “What is going through your head in that moment?” will allow the clinician to better understand the root of the client’s negative thoughts. Clients often report anxious thoughts throughout the clinical interview (e.g., not only when directly asking about them) and may report some while discussing family or social history (e.g., “I’m taking a test next week, and I’m sure I will fail” or “I’m worried my boss will fire me”). Regarding behavior, clinicians should inquire about both overt and subtle covert avoidance and escape behaviors to better understand how the client’s anxiety is likely being maintained. A simple way to identify anxious behaviors is to simply ask the client what they do in response to their anxiety. Clinicians should also be vigilant for avoidance behaviors that the client may exhibit during the interview (e.g., avoiding eye contact, attempting to skip over specific topics, or denying anxiety by reporting “I stopped doing that activity, so it’s not a problem for me anymore”). Noting avoidance behaviors informs diagnostic impressions and these behaviors may later become intervention targets in treatment. 136 C. B. Edwards et al.

Recommendations for Formal Assessment

Clinical Interviews

Below, we briefly describe commonly used structured/semi-structured clinical interviews. See Table 6.1 for advantages and disadvantages of each interview. Structured Clinical Interview for DSM-5 (SCID-5; First, Williams, Karg, & Spitzer, 2016) The SCID-5 is a semi-structured clinical interview that covers the major DSM-5 diagnoses. This interview takes 30 minutes to 2 hours to complete and is commonly used in both clinical and research settings.

Anxiety Disorder Interview Schedule for DSM-5 (ADIS-5; Brown, Barlow, & Di Nardo, 2014) The ADIS-5 is a structured clinical interview that primarily covers anxiety, obsessive-compulsive, trauma, mood, and related disorders, such as substance use. This interview takes approximately 2–4 hours to administer (based on data from ADIS-IV; Summerfeldt & Antony, 2002).

Mini-International Neuropsychiatric Interview for DSM-5 (Sheehan, 2015) The MINI-7 is a brief structured clinical interview that covers fewer disorders and lasts less time than the SCID-5. Notably, some of the disorders we discuss above are omitted, including specific phobia and separation anxiety disorder.

Table 6.1 Advantages and disadvantages of specific structured/semi-structured clinical interviews for adults Interview Advantages Disadvantages SCID-5 Covers many different DSM-5 disorders Long administration time (up to Widely used and accepted 2 hours) Can be confusing to novice clinicians ADIS-5 Provides detailed information about Long administration time (up to anxiety disorders 4 hours) May be good to use if already ruled out Does not include disorders that are many other disorders often comorbid with anxiety, such as trichotillomania MINI-7 Shortest structured/semi-structured Covers fewer disorders than other clinical interview to administer interviews (e.g., does not assess Less staff training is needed due to separation anxiety disorder) simple format Brief format may lead to paucity of information DIAMOND Covers a range of DSM-5 diagnoses, Long administration time (up to including some that are omitted from 1.5 hours) other interviews (e.g., hoarding) Newer interview with less research Includes information/questions about support differential diagnoses and impairment 6 Anxiety Disorders 137

Diagnostic Interview for Anxiety, Mood, and Obsessive-Compulsive and Related Neuropsychiatric Disorders (DIAMOND; Tolin et al., 2018) The DIAMOND is a semi-structured clinical interview that covers anxiety, mood, and obsessive-compulsive and related disorders, as well as substance use and attention- deficit/hyperactivity disorder. This interview takes approximately 30–90 minutes to complete.

Self-report

Self-report assessments typically ask clients to report on the severity and/or frequency of their symptoms. When selecting a self-report for anxiety, a clinician can choose whether they want to use a scale that provides an overall picture of general anxiety symptoms and/or a scale that assesses diagnosis-specific symptoms. Both general and disorder-specific self-report measures often provide recommended clinical cutoffs to help guide clinicians when assessing clients; however, self-report screening instruments alone should not be used to diagnose an individual. Specific examples of self-report measures are provided in Table 6.2.

Self-monitoring

Self-monitoring is a way to obtain information about a client’s symptoms in which clients are asked to track specific anxiety symptoms over a specified period of time (e.g., number of panic attacks for an individual with suspected panic disorder; anxious thoughts experienced during social situations for an individual with suspected social anxiety disorder). Self-monitoring provides a more objective view of the client’s symptoms which may be more accurate than relying on memory/recall at the time of interview (Craske & Tsao, 1999). Importantly, asking clients to self-monitor may therapeutically benefit clients, as it gives them better insight into their own anxiety and reveals the way symptoms influence the way they think, feel, and act (Borkovec & Ruscio, 2001).

Informants

Another way to obtain information about a client’s symptoms is through the use of informant-report. Informants include anyone who interacts with the client regularly, including romantic partners, parents, children, teachers, or friends (Silverman, Saavedra, & Pina, 2001). Informant-reports provide different perspectives of a client’s symptoms from people who have seen them behave in a variety of settings. 138 C. B. Edwards et al.

Table 6.2 Information about different self-report measures for anxiety Indication(s) Measure Items What does it tell you? Source General anxiety Beck Anxiety 21 How much the client is Beck, Epstein, symptoms Inventory bothered by anxiety Brown, and Steer (1988) State-Trait Anxiety 40 Current and general Spielberger, Inventory levels of anxiety Gorsuch, Lushene, Vagg, and Jacobs (1983) Depression Anxiety 42 Symptoms of Lovibond and Stress Scales depression, anxiety, and Lovibond (1995) stress Transdiagnostic Distress Tolerance 15 Tolerance of negative Simons and Gaher constructs Scale emotions (2005) Intolerance of 12 Difficulty handling Carleton et al. Uncertainty Scale uncertainty (2007) Anxiety Sensitivity 16 Fear of anxiety-related Taylor et al. (2007) Inventory-3 sensations Social anxiety Liebowitz Social 24 Fear and avoidance of Liebowitz (1987) disorder Anxiety Scale various social situations Social Phobia and 45 Severity of social Turner et al. (1989) Anxiety Inventory anxiety symptoms Specific phobia Fear of Spiders 18 Client’s fear of Szymanski and Questionnaire situations involving O'Donohue (1995) spiders Fear Survey Schedule 108 Specific phobic fears Wolpe and Lang (1974) PD and Panic Disorder 7 Severity of panic Shear et al. (1997) agoraphobia Severity Scale disorder symptoms Agoraphobic 10 Intensity of fearful Chambless et al. Cognitions cognitions relevant to (1984) Questionnaire panic and agoraphobia GAD Penn State Worry 16 An individual’s Meyer et al. (1990) Questionnaire tendency to excessively worry Generalized Anxiety 10 Whether an individual Newman et al. Disorder meets diagnostic criteria (2002) Questionnaire-IV for GAD based on their self-report

Further, they can be especially helpful in cases in which a client may have poor insight into their own behaviors (Tolin, Fitch, Frost, & Steketee, 2010) or in cases in which the clinician is concerned about truthful reporting. Of note, informants may be biased and different informants may perceive the same symptom differently (Briggs-Gowan, Carter, & Schwab-Stone, 1996). 6 Anxiety Disorders 139

Behavioral Observations

An additional way to obtain information about a client’s symptoms is through the use of behavioral observation. Observation provides an objective assessment of a client’s symptoms and can be helpful to avoid overreliance on self-report for making diagnoses. Behavioral observations should be collected throughout the assessment process and can include appearance (e.g., dress, grooming, hygiene), tics (e.g., clearing their throat repeatedly, tapping their foot), eye contact, fidgeting, speech or language habits (e.g., frequent digressions from the topic, speech volume), and anything else that is notable.

Behavioral Avoidance Tasks Behavioral avoidance tasks (BATs) are a way to conduct objective behavioral observations of a client in the presence of a feared stimulus. In a BAT, a clinician asks a client to progressively approach the feared stimulus until he/she no longer wishes to continue. Since a well-constructed BAT requires that a client be able to take multiple graduated steps, this type of assessment is well suited for disorders that focus on specific, identifiable stimuli, such as specific phobia. Given that the goal of a BAT is to provide an objective assessment of a client’s baseline fear level, clinicians should be especially careful to avoid inadvertently encouraging the client (e.g., “You’re doing great!”) or explicitly telling them to keep going. Further, instructions should be worded to avoid accidentally influencing the client’s behavior (e.g., saying something like “You can stop the task once it feels too scary” may encourage a client to push themselves to continue further than they normally would if they usually avoid situations).

Case Illustrations

Next, we will look at two case examples of individuals with anxiety disorders. Of note, we assume the clinicians in the following case illustrations have multiple hours to devote to assessment. In the real world, assessments may be time-limited and less involved. When assessments are time-limited, we recommend, at a minimum, conducting a clinical interview and administering a few relevant self-report measures.

Sue’s Case

Sue is a 28-year-old married first-generation Southeast Asian woman living in America, who presented at our clinic with complaints of high anxiety. She reported weekly panic attacks, fears of choking, fear of having a heart attack, and a fear of crowds. In their first session together, her clinician conducted the SCID-5 to determine if she met diagnostic criteria for any psychological disorders. 140 C. B. Edwards et al.

From the SCID, the clinician learned that Sue experienced at least one severe panic attack per week, beginning approximately 2 years ago. Her panic attacks tended to last about 15 minutes, and consisted of escalating feelings of choking, shortness of breath, rapid heartbeat, dizziness, and sweating. Sue tended to have panic attacks in response to physical exertion (e.g., exercise) and when she felt like something was stuck in her throat (e.g., when eating peanut butter). However, she also had occasional panic attacks that seemed to occur spontaneously or out of the blue. Sue reported that she thought the panic attacks were signs that she was having a heart attack or choking and would have her husband rush her to the hospital when they occurred. Sue also modified her diet to avoid eating any foods that felt “sticky” to her and stopped going to the gym, an activity she used to enjoy. Although Sue expressed a fear of crowds, in the Agoraphobia section of the SCID, she noted that she regularly attended crowded concerts without much distress. Follow-up questions revealed that Sue felt uncomfortable in crowds, but did not avoid them or experience significant distress when in them. Consequently, Sue did not meet diagnostic criteria for agoraphobia. Additionally, although the clinician considered diagnosing Sue with a specific phobia of choking, this was ruled out because Sue’s fear of choking was explained by her PD. No other diagnoses were revealed through the SCID. At the end of the first session, the clinician had Sue complete three self-reports: a measure of general anxiety and mood (the Depression, Anxiety, and Stress Scales- Short Form; Lovibond & Lovibond, 1995), a measure of panic disorder severity (the Panic Disorder Severity Scale-Self Report; Shear et al., 1997), and a measure of anxiety sensitivity, a transdiagnostic factor related to the development and maintenance of panic disorder (the Anxiety Sensitivity Index-3; Taylor et al., 2007). Results from the self-reports were consistent with results from the SCID; the Depression, Anxiety, and Stress Scales-Short Form revealed minimal levels of depression and stress, but high levels of anxiety; the Panic Disorder Severity Scale indicated severe panic disorder; and the Anxiety Sensitivity Index revealed a high level of anxiety sensitivity or “fear of fear.” Each of these scales not only aids in diagnostic decision-making but also provides potential targets for treatment (e.g., Sue’s high levels of anxiety sensitivity suggest that therapeutic techniques to reduce her catastrophic misinterpretation of bodily sensations might be beneficial). During the second session, the clinician introduced Sue to a self-monitoring form, so that she could keep track of when and where she had panic attacks each week, along with what bodily sensations and thoughts she experienced. The clinician also had Sue complete a brief BAT, in which she breathed through a thin straw while plugging her nose, which elicits feelings of dizziness and difficulty breathing (derived from Barlow and Craske’s 1994 treatment manual). The clinician timed how long Sue was willing to do this activity and then asked her to report her anxiety on a scale of 0 (“none at all”) to 10 (“extreme anxiety”) following the activity. This provided an objective, behavioral measure of Sue’s fear and avoidance, which could be used as a baseline measure in future treatment. Taken together, the clinical interview, self-reports, self-monitoring, and BAT provided a thorough assessment of Sue’s PD. 6 Anxiety Disorders 141

Jeff’s Case

Next, let’s discuss Jeff, a 46-year-old single, Black man. Jeff presented at our clinic, reporting that he thought he might have an anxiety disorder or obsessive-compulsive disorder (OCD), due to constant thoughts about his performance at work and the need to repetitively ask his supervisors for reassurance that he was not going to get fired. His clinician decided to use the ADIS-5 (Brown et al.,2014 ). The ADIS revealed that Jeff not only worried about work performance but also constantly worried over his future financial security and his relationships with friends. He reported that his worries felt uncontrollable and excessive and were often accompanied by tension in his shoulders and jaw, difficulty concentrating, and feeling irritable. He reported worrying for as long as he could remember. Of note, his worries were in line with his self-image; it was important to Jeff to be a hard worker, a good friend, and financially secure. He denied experiencing repetitive, distressing intrusive images, urges, or thoughts (other than his worries) and also denied other repetitive behaviors (other than reassurance seeking). Given the information collected during the DIAMOND, the clinician suspected that Jeff should receive a diagnosis of GAD, but not OCD. To gather additional evidence to aid in differential diagnosis, the clinician had Jeff complete self-reports of worry (Penn State Worry Questionnaire; Meyer, Miller, Metzger, & Borkovec, 1990), obsessions and compulsions (Obsessive-Compulsive Inventory–Revised; Foa et al., 2002), and intolerance of uncertainty, a transdiagnostic factor implicated in anxiety disorders (Intolerance of Uncertainty Scale-Short Form; Carleton, Norton, & Asmundson, 2007). Results from the Obsessive-Compulsive Inventory–Revised suggested minimal levels of obsessive-compulsive symptoms, while the Penn State Worry Questionnaire indicated very high levels of worry. Additionally, the Intolerance of Uncertainty Scale-Short Form revealed that Jeff had a strong fear of the unknown and difficulty tolerating situations that lacked certainty. At the end of the session, the clinician taught Jeff how to monitor his worry- thoughts using a thought log. In the thought log, he recorded each time he worried. Specifically, he wrote the situations that triggered his worry, his specific worry- thoughts, his accompanying physiological sensations, and behaviors he did in response to the worries. This provided the clinician with a more thorough picture of his anxiety. After reviewing results from the clinical interview, self-reports, and thought log, the clinician decided to diagnose Jeff with GAD and referred him to an expert in cognitive behavioral therapy for GAD.

Impact of Gender, Race, Culture, Age, and Other Aspects of Diversity

Individual difference factors (e.g., sex, race, age) can influence clinical presentations of anxiety disorders. For example, more women than men have anxiety disorders. Women are nearly twice as likely to have any anxiety disorder as men are 142 C. B. Edwards et al.

(McLean, Asnaani, Litz, & Hofmann, 2011). This may be partially due to biological differences in the neurochemistry that underlies anxiety and fear; however, differences are also found because of gender-role socialization and parental expectations in coping with emotions (Craske, 2003). For example, some evidence suggests that women are more likely to use emotion-focused coping (e.g., talking or writing about one’s feelings) rather than problem-focused coping (e.g., examining the cause of the problem) than men (Matud, 2004). The greater prevalence of anxiety disorders in women may be due to providers’ implicit biases in diagnosing and the expectation that women are more likely to have anxiety (Chapman, Kaatz, & Carnes, 2013). It is important to be aware of the greater prevalence of anxiety in women while not using this information to inadvertently preclude an anxiety diagnosis for a client who is a man or to over-diagnose anxiety in women.

Older Adults

By older adulthood (i.e., those who are 65 years+), gender differences in anxiety are greatly reduced, perhaps owing to the fact that fewer people in general meet criteria for an anxiety disorder and to a larger number of individuals exhibiting sub-clinical levels of symptoms (Byers, Yaffe, Covinsky, Friedman, & Bruce, 2010). Assessing for anxiety disorders among older adults can be tricky because of differences in how they describe their anxiety, greater stigma against mental health problems in this population, and co-occurring physical health problems that can mimic or obscure anxiety symptoms (APA, 2014). Older adults are more likely to describe their anxiety in terms of physical symptoms such as muscle tension or tingling. They may use different terminology than other adults like having “nerves” or an “anxiety attack.” Most standardized measures of anxiety, including structured diagnostic interviews, have not been normalized in older adults and may not be appropriate for use in this population (though see Edelstein et al., 2007, for a discussion of well-validated measures to use with these samples). Two popular and well-validated self-report measures for use with older adults are the Geriatric Anxiety Scale (Segal, June, Payne, Coolidge, & Yochim, 2010) and the Geriatric Anxiety Inventory (Pachana et al., 2007). Older adults may not seek treatment for anxiety as often as younger adults because of generational differences in seeking professional help for mental disorders (Conner et al., 2010). In addition, health problems are much more common in older adults, some of who have symptoms that mirror anxiety (Wolitzky-Taylor, Castriotta, Lenze, Stanley, & Craske, 2010). For instance, chronic obstructive pulmonary disease (COPD) is more common in this population, and symptoms of COPD may look similar to panic (e.g., shortness of breath, dizziness). The average number of prescription medications one takes tends to go up as we age too, and some medications may have side effects that increase anxiety. Understanding anxiety in older adults with dementia is particularly challenging because other situational factors, such as chronic pain, thirst, and infections, may be driving anxiety. 6 Anxiety Disorders 143

A stepwise approach to assessment and intervention for older adults with dementia may reduce the use of ineffective psychotropic medications in this population (see Pieper et al., 2016).

Children and Adolescents

Childhood and adolescent anxiety is often experienced and presented differently from adult anxiety. Children and adolescents often experience significant psychosocial impairment from anxiety disorders (Southam-Gerow & Chorpita, 2007). For example, children and adolescents with social anxiety disorder may struggle with connecting with peers, maintaining friendships, academic difficulties, and noncom- pliance due to their anxiety (Puliafico, Comer, & Pincus,2012 ). Similar to older adults, children and adolescents often characterize their anxiety in terms of physical symptoms; common complaints include stomach pain, headaches, or gastrointestinal distress (APA, 2013). As mentioned earlier, some anxiety disorders are found almost exclusively in children (i.e., separation anxiety disorder and selective mutism). Nonetheless, any of the other anxiety disorders may, and often do, onset in childhood or adolescence. Specific phobia typically emerges by age 7 and social anxiety disorder by age 13; and the median age of onset for any anxiety disorder is 11 years old (Kessler et al., 2005). While not uncommon in children, GAD usually onsets in early adulthood. GAD-like symptoms in children are often indicative of another, more circumscribed anxiety disorder, such as social anxiety disorder (Wood, Piacentini, Bergman, McCracken, & Barrios, 2002).

Influence of Race

In the United States, there is evidence that there are differences among racial groups in anxiety disorder prevalence. White individuals are more likely to be diagnosed with anxiety disorders than any other racial group, Black and Hispanic people have the next highest risk, and Asian individuals have the lowest risk (Asnaani, Richey, Dimaite, Hinton, & Hofmann, 2010). This pattern in which racial minorities have a lower risk for anxiety disorders than White individuals has been replicated in various national samples, and these differences emerge early in childhood and are more concrete in younger age cohorts (Breslau et al., 2006). Significantly, international evidence suggests a higher degree of risk for some anxiety disorders in individual- istic cultures like the United States and Russia and lower risk in collectivistic cultures, such as India and China (Hofmann, Asnaani, & Hinton, 2010). It appears likely that racial minorities in the United States have protective factors like racial identification and religious participation that lower their risk for developing internalizing disorders (Breslau et al., 2006). 144 C. B. Edwards et al.

Racial differences in risk for anxiety disorders hold when taking into account age and socioeconomic status (Woodward et al., 2012). While true differences may exist among racial groups in the United States, these differences may be partially explained by racial disparities in the detection and treatment of anxiety disorders in some of the settings in which diagnoses are made, such as in primary health care visits (Stockdale, Lagomasino, Siddique, McGuire, & Miranda, 2008). For example, it could be that anxiety is experienced at the same rate for White and Asian people, but due to others’ perceptions of Asian culture as having fewer mental health symptoms, they are not diagnosed as often. Additionally, one’s experience of racial discrimination is associated with higher risk for anxiety (Chou, Asnaani, & Hofmann, 2012).

Cultural Factors

In addition to gender, age, and race playing significant roles in our understanding of anxiety disorders, cultural influences also play a role in the development of anxiety. The DSM-5 explicitly details how to make a cultural formulation (i.e., a framework for considering cultural factors in the assessment process) and contains information on cross-cultural variations in the presentation of disorders (APA, 2013). When making a differential diagnosis for an anxiety disorder, one must also consider whether a culturally bound diagnosis that mimics anxiety may be appropriate. Culture-bound disorders, geographically limited and population specific, are found in the cross-cultural considerations section of the DSM-5, and several have features that are characteristic of anxiety. Ataque de nervios, which translates roughly to “an attack of the nerves,” is one such culture-bound disorder. People with ataque de nervios are usually Spanish-speaking Latino individuals living at or near the Caribbean or Puerto Rico who have symptoms similar to panic attacks, dissociative experiences, and aggression (APA, 2013).

Socioeconomic Status

Socioeconomic status, particularly one’s income level, is a significant risk factor for the development of any mental disorder (Hudson, 2005). This is understandable given more frequent stressors for individuals with less tangible (e.g., childcare) and financial resources. Even in more privileged environments, such as within-university communities, those who have lower socioeconomic status are more likely to experience clinically significant anxiety (Eisenberg, Gollust, Golberstein, & Hefner, 2007). Compounding this increased risk are socioeconomic disparities in the detection and treatment of anxiety disorders. Those with lower socioeconomic status are less likely to have their anxiety diagnosed or treated due to structural barriers to seeking treatment (Roy-Byrne, Joesch, Wang, & Kessler, 2009; Young, Klap, 6 Anxiety Disorders 145

Sherbourne, & Wells, 2001). These inequities are further perpetuated in our understanding and knowledge of anxiety disorders, as little research is undertaken in community samples with low socioeconomic status (Peterson, 2001).

Other Considerations

Additional vulnerable populations, including prisoners and women and men in the perinatal period, experience significant anxiety. There is limited research on anxiety disorders in the perinatal period (i.e., during pregnancy through 1 year after childbirth); however, perinatal anxiety appears to be even more common than perinatal depression (Matthey, Barnett, Howie, & Kavanagh, 2003). Furthermore, women are at a greater risk for new onset of anxiety during the postpartum period (Goodman, Watson, & Stubbs, 2016). A handful of studies have examined treating perinatal anxiety, but little information is available on anxiety diagnosis and treatment in new fathers (Loughnan et al., 2018). When working with expecting and new parents, addressing concerns about anxiety is essential given these disparities in detection and treatment. Similarly, quality of care among the incarcerated and former prisoners is low, making understanding of past legal history a critical query when conducting a clinical interview (Wilper et al., 2009).

Information Critical to Making a Diagnosis

Differential Diagnosis

Anxiety disorders are frequently comorbid with one another and with other disorders, especially depressive and substance use disorders (APA, 2013). It can be difficult to assign just one diagnosis in a case in which multiple ones appear to fit symptom presentation equally well. That is why it is essential to make a differential diagnosis by weighing the evidence for disorders that have a similar presentation to arrive at the one that best explains the presenting problem and the impairment a client is experiencing. When a differential diagnosis is arrived at and there are still significant co-occurring problems better characterized with another diagnosis, one might choose to describe the predominant clinical picture with the primary diagnosis and follow-up with secondary diagnoses. One common anxiety disorder often comorbid and confused for other disorders is GAD. Making a differential diagnosis between GAD and OCD can be difficult. GAD worry differs from intrusive thoughts in OCD in that GAD worries are often verbal in nature, less circumscribed, and ego-syntonic (in harmony with self-image). That is, people with GAD have anxiety about the everyday, and their worries are consistent with how they see themselves (Ehring & Watkins, 2008). Obsessional 146 C. B. Edwards et al. thoughts in OCD on the other hand can be urges, impulses, images, or thoughts and are experienced as dissonant and in direct contrast to one’s self-image. Like differentially diagnosing between GAD and OCD, making the distinction between PD and specific phobia with panic attacks can be challenging. In both cases the individual has panic attacks, but in PD the panic attacks occur spontaneously and bodily sensations mirroring panic are avoided. Some people with PD even wake up at night with a panic attack. In specific phobia with panic attacks, the panic would occur in response to the phobic stimulus and the individual would be worried about the feared stimuli rather than the panic sensations themselves.

Transdiagnostic Factors

Several transdiagnostic factors, such as intolerance of uncertainty, perseverative thought, and distress tolerance, have been theorized to play a role across anxiety disorders (Ehring & Watkins, 2008; Leyro, Zvolensky, & Bernstein, 2010). Intolerance of uncertainty is a predisposition to thinking that ambiguity is negative and that negative outcomes are more likely in uncertain situations (Carleton et al., 2007). Across anxiety disorders and depression, intolerance of uncertainty is linked to higher symptom severity and impairment (Dugas, Buhr, & Ladouceur, 2004). Similarly, rumination, or repeated, uncontrollable dwelling upon past negative events, is a risk factor for GAD, depression, trauma-related disorders, and OCD (McLaughlin & Nolen-Hoeksema, 2011). Finally, distress tolerance is one’s ability to handle and withstand aversive emotional states and is considered a risk factor for a range of psychopathologies, including anxiety disorders (Leyro et al., 2010). The presence of one of these transdiagnostic traits can lead credence to a case in which self-report is a primary method of collecting data about the individual.

Heterogeneity Within Disorders

Although there are similarities between the anxiety disorders, there is plenty of heterogeneity among the anxiety disorders and within an individual disorder. People presenting with the same anxiety disorder may have completely different symptoms but still receive the same diagnosis (Costello, Egger, & Angold, 2005). Imagine Riley who is an 11-year-old boy who is shy and anxious in most social situations; he would likely meet criteria for social anxiety. Then consider Gina, a 28-year-old who would like to go back to school to become a teacher. Gina becomes extremely anxious when she has to speak in front of large groups of people but is fine when she is talking to a small group; she also avoids lengthy conversations with new people and is concerned her anxiety will keep her from being a successful instructor. She would probably also be experiencing social anxiety. While both of these possible cases would likely receive the same diagnosis, their presenting problems and 6 Anxiety Disorders 147 anxiety-provoking social situations are quite different. Similarly, the degree of impairment and the length of time since the onset of the problem differ for these two people as it will for everyone you assess. Let’s consider another example of heterogeneity within GAD. Aaron is a 33-year- old man who worries about his job, finances, and relationship with his wife. He has a difficult time going to sleep at night because he tries to figure out what he will do if different situations come up the next day. Aaron reports that he has always been a “worrier” but has noticed an uptick in his anxiety since beginning his current job last year. He thinks his anxiety is putting a strain on his marital relationship and causing him to be irritable at work. Now imagine Margie a 70-year-old woman who lives alone but interacts with her children daily either by phone or in person. She worries about the health of her children and grandchildren and cannot bear to go more than a few hours without hearing from a family member. Margie is also concerned about her frequent muscle tension and health concerns, her part-time job, and the amount of time she is spending worrying. She reports that she has always struggled with anxiety but that it was more manageable before her spouse passed away over a decade ago because he would distract her from her worries. Aaron and Margie both appear to meet diagnostic criteria for GAD; however, their clinical presentations are unique. Both are significantly impaired by their symptoms of GAD, although, Margie’s case has been going on for a much longer time and is likely the more severe of the two. As you can see from these case examples, clinical presentations are specific to the individual even within the same diagnosis. Next, we make recommendations for diagnostic interviews for anxiety and synthesize the information we have reviewed so far.

Dos and Don’ts

There are general best practices when diagnosing for any disorder, but these guidelines are especially true for anxiety disorders given their distinct cognitive, behavioral, and emotional sequelae. Diagnosticians should be on the lookout for future-oriented thoughts and cognitive distortions related to the likelihood, outcome, and the importance of potentially threatening situations when evaluating for anxiety. Clients will often provide clues that they may be suffering from an anxiety disorder from the outset of an evaluation with verbal report that exhibits these cognitive biases (e.g., an individual with social anxiety disorder may state that they are nervous speaking with you or are worried about how they are coming across to you). Clinicians should also look for behavioral indicators of anxiety. Individuals with anxiety may report that they avoid the situations they fear and perform worse on BATs. In addition to biased thinking and avoidance behaviors, those with anxiety report intense feelings of intense anxiety. In GAD particularly, feelings of anxiety and concern may occur frequently throughout day-to-day life. The emotions associated 148 C. B. Edwards et al.

Table 6.3 Recommendations for making anxiety disorder diagnoses Dos Don’ts Read and be aware of APA Ethics Code Section Rule out other explanations or diagnoses 9 on assessments, consent, and confidentiality based only on a client’s self-diagnosis even when not treating Meet face to face for the clinical interview Evaluate a client you have not met with Use formal assessments when possible (e.g., Rely on self-report alone for assessment SCID-5, ADIS-5) Use behavioral assessments, particularly Use assessments that have not been validated behavioral avoidance tasks, when possible or are outdated Obtain data over a course of time (e.g., Discount comorbid depression or other 1–2 weeks rather than a one-time meeting) diagnoses Note time since onset of the problem, and use Ignore active listening, empathy, and provisional diagnoses when appropriate self-reflection skills during the interview process Obtain information from previous providers if Begin therapy before assessing the individual possible Use informants, family/friends/teachers, to Assess at the outset only; assessment should gather info when possible be an ongoing process if treating Consider mental status and observable behavior Permit the client to direct the course of an during an interview (e.g., psychomotor agitation interview or assessment; the provider role is may be increased for individuals with anxiety) much more directive here than in individual therapy Assign appropriate severity codes where Assess without making appropriate referrals applicable for treatment Be aware that OCD and related disorders and Allow high-energy, observable nervousness trauma-related disorders are no longer included on the client’s part to influence your behavior as anxiety disorders in the DSM-5 Provide explanations of assessment Give assessments you will not score or appropriately with the person you are evaluating interpret or that do not add incremental validity to the evaluation Consult with supervisors or other clinicians, as Use assessments you are unfamiliar with or needed are inappropriate for the client’s population with anxiety are accompanied by bodily sensations specific to the individual; no two people “feel” their anxiety in exactly the same way. Take care to understand what your client’s anxiety looks like for them individually; it might not be what you would expect! In Table 6.3, we provide additional recommendations for diagnosing anxiety disorders.

Summary

In this chapter we have discussed general guidelines for assessing people for anxiety disorders. Given the similarities found across anxiety disorders (i.e., avoidance, negative future-oriented thinking, fear, and anxiety), there are some tools specific to 6 Anxiety Disorders 149 anxiety disorders (e.g., ADIS-5, behavioral avoidance tasks) that you should consider becoming familiar with if you will have much contact with individuals with anxiety disorders. In addition, it may be useful to keep in mind other factors common to anxiety, like intolerance of uncertainty and rumination. Knowing the distinctions between anxiety disorders is helpful, although, many individuals will meet criteria for more than one anxiety disorder (Kessler et al., 2005). A deeper understanding of the clinical presentation of anxiety comes with practice, and there are several resources that can be used as a quick reference even for master clinicians (see APA, 2014). Most, if not all, of the diagnostic interviewing skills you apply in other case presentations will also be helpful with anxiety disorders and many of these practices are outlined in the Do’s and Don’ts section above. Although we have emphasized the commonalities across mental disorders and among anxiety disorders in particular, it is notable that there is significant heterogeneity between and within anxiety disorders. A thorough assessment for anxiety will look beyond surface “symptoms” like avoidance and truly examine the reason why the presenting problem is occurring, the extent of functional impairment, and individual difference factors.

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Michelle L. Davis, Elizabeth McIngvale, Sophie C. Schneider, Wayne K. Goodman, and Eric A. Storch

Obtaining an accurate diagnosis of an obsessive-compulsive and/or related disorder is complicated by many factors. These factors include (1) symptom overlap and high comorbidity with numerous other mental health diagnoses, (2) extremely diverse presentation of symptom content across individuals, (3) potential lack of insight of the individual into their symptoms and their role, and (4) potential for stigma or embarrassment surrounding certain thoughts and behaviors that commonly occur. These factors can prevent accurate reporting (for review, see Moulding, Hughes, Byrne, Do, & Nedeljkovic, 2016). Perhaps due to these diagnostic complications, there are many discrepancies in the literature regarding the prevalence and incidence of OCD (for review, see Fontenelle, Mendlowicz, & Versiani, 2006). An effective diagnostic interview is one in which the interviewer is capable of probing with specific questions to differentiate the form and function of symptoms, while also fostering an environment in which the individual feels safe to disclose symptoms that may be controversial or irrational in nature. Given that these disorders are often under-recognized or misdiagnosed, it is critical that clinicians are informed of the best assessment practices for specific purposes, settings, and individuals. This chapter provides an overview of the obsessive-compulsive and related disorders, recommendations for both formal and informal diagnostic interviewing and assessment, and tips for attaining the necessary information to make an accurate diagnosis. Additionally, we describe several cases as examples for how to engage in effective diagnostic interviewing with an array of symptom presentations.

M. L. Davis (*) · E. McIngvale · S. C. Schneider · W. K. Goodman · E. A. Storch Baylor College of Medicine, Menninger Department of Psychiatry and Behavioral Sciences, Houston, TX, USA

Description of the Disorders

Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is a common mental disorder with a lifetime prevalence of approximately 2–3% in the United States (Kessler et al., 2005). Untreated, this disorder is often chronic and associated with severe distress and impairment (American Psychiatric Association, 2013). OCD involves two primary features: obsessions which are characterized as thoughts, images, or impulses that reoccur and that the individual finds distressing and unwelcome and compulsions, characterized as repetitive rituals or behaviors (external or mental) that the individual feels strongly compelled to enact, either in response to an obsession or due to a rigid set of internalized rules. Individuals with OCD can present with only obsessive symptoms, only compulsive symptoms, or (most commonly) both. OCD has a unique manifestation in that the presentation of symptoms can vary widely between individuals. The focus and content of obsessions and compulsions are diverse; however, there are four common themes (or dimensions) of content that are consistent across cultures (see Abramowitz et al., 2010). Though these themes are not specified in the formal OCD diagnosis, it can be helpful to understand the common obsessions and compulsions of each content area both in order to accurately make an OCD diagnosis and for treatment planning. These themes are summarized in Fig. 7.1 and a brief overview of common obsession and compulsion content is provided below.

Contamination OCD content related to contamination often involves obsessive thoughts about being contaminated due to contact with, or proximity to, specific situations, places, or people (e.g., bathrooms, toxic materials, mold, individuals with AIDS, chemicals, bodily waste, or fluids). Contamination-related OCD often involves concerns about becoming ill or spreading contamination to others (e.g., individuals may worry about cross-contamination or spreading of contamination from one object or person to another). Typical emotional reactions to these obsessions include anxiety, disgust, and distress. Common compulsions include excessive or ritualized hygiene habits (e.g., washing, showering, sanitizing, and cleaning), avoidance of situations or stimuli following a certain routine to avoid contamination (or cross-contamination), seeking reassurance from others, or asking others to engage in compulsions with or for them or to help them avoid (i.e., accommodation). Individuals with concerns about contamination are often highly avoidant of “contaminated” situations or stimuli and may experience strong feelings of disgust relating to potential contaminants.

Responsibility for harm Harm-related OCD involves concerns that an individual may harm themselves or others due to not being careful enough. For example, they might have obsessive concerns that they will (or have) hit a pedestrian while driving or that someone will get injured because they provided them with incorrect 7 Obsessive-Compulsive and Related Disorders 157

Common Thoughts/Feelings Common Behaviors Being contaminated with Washing hands or using hand germs or illness sanitizer; cleaning objects Concerns About Germs Spreading contamination Changing clothes and Contamination Following routines or avoiding due to contamination concerns Making a mistake that could Checking things (e.g., locks, harm others wallet) more often than is necessary Preventing bad luck by doing things a certain way Reassurance seeking that something bad didn’t (or won’t) Concerns Losing something important happen About Being that is unlikely to be lost Responsible Mentally reviewing events to for Harm, make sure a mistake wasn’t Injury, or Bad made Luck

Following a special routine, count to certain numbers, or avoid certain numbers to prevent something bad from happening Unpleasant, intrusive thoughts Repeating action or following about sex, immorality, or routine because of abad violence thought

Unacceptable Doing (unwanted) awful, Mentally performing an action Thoughts improper, or embarrassing or saying prayers to get rid of things unwanted thoughts

Avoidance of triggers of unwanted thoughts Need for symmetry, evenness, Repeating a routine action until Concerns balance, or exactness it feels “just right” or “balanced” About Symmetry, Feeling that something isn’t Counting senseless things Completeness, “just right” and the Need Unnecessary arranging of for Things to things Be “Just Right” Repeating words/phrases until it feels “just right”

Fig. 7.1 Common OCD content themes. (Adapted from Abramowitz et al., 2010) 158 M. L. Davis et al.

information. Responsibility for harm can also include fears of being responsible for terrible events occurring; for example, someone with harm-related OCD may obses- sively worry that they left the faucet running (resulting in a flood causing damage to their home). They often engage in compulsive checking behaviors, such as repeatedly checking to make sure the stove is off to prevent a fire, making sure locks are engaged to prevent robbery, or repeatedly returning to a previously driven route to ensure that they didn’t accidentally harm someone while driving. They may have thoughts that they can prevent harm (or bad luck) by doing something in a certain way or avoiding certain things.

Unacceptable, taboo thoughts Many individuals with OCD experience unwanted and distressing thoughts, images, or impulses related to sex, violence, and/or immorality. They may also occur as thoughts about doing some terrible or an embarrassing act that one does not want to do. These types of thoughts are viewed as intrusive and are extremely distressing and unwanted, often leading individuals with OCD to go to great lengths to try to avoid or suppress the thoughts. Importantly, these thoughts are “ego-dystonic” or conflicting with one’s self-image, values, and goals (compared to ego-syntonic thoughts, which are consistent with one’s self-image, values, and goals). See Fig. 7.2 for examples of ego-dystonic and ego-syntonic thoughts—this distinction will also be relevant in making an informed differential diagnosis. This discrepancy is highly important in understanding unacceptable thoughts in OCD, as individuals with OCD may have received negative feedback when disclosing the thoughts to others who did not understand the unwanted, ego- dystonic nature of these thoughts. Indeed, stigma and shame may be particularly high regarding unacceptable thoughts (McCarty, Guzick, Swan, & McNamara, 2017). To aid these individuals in disclosing symptoms without shame, and to reduce stigma around OCD-related unacceptable thoughts, it is essential to not only understand that the distress associated with these thoughts differentiates individuals with OCD from individuals who wish to engage in unacceptable behaviors (and that having thoughts does not make an individual with OCD more likely act on thoughts) but also inform the interviewee or patient of these facts. Individuals with OCD related to unacceptable thoughts will often perform actions or routines (either physically or mentally) to try to get rid of or “neutralize” a bad thought. They often also avoid situations or stimuli that could trigger these unwanted thoughts. For example, an individual experiencing intrusive, unwanted sexual thoughts (e.g., mental images of performing sexual acts on a child) may go out of their way to avoid children or objects and situations that trigger thoughts of children (e.g., schools, child-related aisles in grocery stores, television shows fea- turing children). Below are descriptions of the most common (and most stigmatized) categories of taboo thoughts occurring in patients having OCD. It is important to note that there may be a wide range of unacceptable thoughts which occur outside of these categories. As noted previously, unacceptable thoughts may be experienced as verbal cognitions, mental images, or impulses. 7 Obsessive-Compulsive and Related Disorders 159

Ego-dystonic thoughts Ego-syntonic thoughts

• Perceived as alien, or out of • Perceived as concordant or in- line with one's self-concept line with one's self-concept

• Extremely distressing and/or • Not distressing and/or threatening threatening

• Unacceptable; attempts to • No desire to avoid or block avoid or block thought thought

Example 1: Example 1: Aheterosexual man with OCD Ahomosexual male having the having the thought "I want to have thought "I want to have sex with sex with another man" another man"

Ego-dystonic response: Ego-syntonic response: Distress; may try to suppress the No distress; no effort to control thought or avoid stimuli associated thoughts or avoid situations or with homosexuality (e.g., rainbow stimuli flags, homosexual individuals)

Example 2: Example 2: An individual with harm-related An individual with antisocial OCD having an intrusive mental personality disorder and a violent image of stabbing her husband criminal history having an intrusive mental image of stabbing her husband Ego-dystonic response: Distress; may try to suppress the Ego-syntonic response: image or avoid contact with knives No distress; no effort to control the mental image

Fig. 7.2 Ego-dystonic versus ego-syntonic thoughts

Sexual thoughts Individuals with intrusive sexual thoughts may have repeated thoughts or images about engaging in sexual acts with forbidden or improper individuals (e.g., family members, children, religious figures). Many individuals with OCD experience excessive concern about their sexuality, such as repeatedly wondering or fearing that they may be gay or experiencing intrusive thoughts or images about individuals of the same sex (despite acknowledging that they are not sexually attracted to individuals of the same sex). Similarly, they may be concerned about 160 M. L. Davis et al. their gender identity. Common compulsive behaviors include reassurance seeking (e.g., asking their partner to reassure them that they are not gay or attracted to children), avoidance (e.g., avoiding members of the same sex, images of children, etc.), or rituals (e.g., prayer, watching opposite sex pornography compulsively). These types of sexual thoughts can be differentiated from paraphilic thoughts (sexual fantasies or urges that are atypical, inappropriate, or extreme) in that they are experienced as very distressing and ego-dystonic.

Violent thoughts Some examples of violent intrusive thoughts or images are having a sudden mental image of a rotting corpse, fear of impulsively stabbing someone with a knife, concerns about suicide or mental images of cutting oneself with a knife, or mental images of violent car crashes or disfigured bodies. These types of thoughts are common and often result in avoidance of situations due to concerns that having these thoughts may cause some undesired action (e.g., because I keep having thoughts about shooting myself in the head, I may actually do it). Similar to sexual unwanted thoughts, these individuals can be differentiated from violent individuals in that the thoughts are ego-dystonic, highly distressing, and the individual does not want to engage in violent actions (and may go to great lengths to avoid doing so).

Immoral thoughts Immoral thoughts include excessive concern about committing sacrilege or blasphemy, sudden intrusive images of religious figures in sexual situations, or thoughts that they may not truly have faith or may not achieve salvation. These types of concerns are often referred to as scrupulosity or excessive concerns about adherence to religious principles which exceeds that of their peers within the same religious group. Individuals may also experience fears or obsessive thoughts that they are possessed by Satan or a demon or that they did not say prayers or complete religious rituals perfectly. Rituals include excessive religious rituals (e.g., washing, praying, repeated baptism), reassurance seeking (consulting with pastors about salvation, asking others whether they are moral or “good”), and avoidance (e.g., avoiding “666,” images of the devil, objects associated with other religions, etc.).

Symmetry or “just right-ness” Concerns about symmetry, completeness, or the need for certain things to be “just right” are another common OCD presentation. Individuals with “just-right” OCD may repeat an activity multiple times until it feels as though they have completed it perfectly, symmetrically, or until it feels “right.” They may count or rearrange objects, groom themselves excessively to ensure “perfection” in appearance, worry about handwriting being “perfect,” or rearrange objects until they are properly aligned. Obsessions with the need for symmetry or exactness can also be accompanied by magical thinking or a false belief that actions will cause an unwanted event. For example, a child with “just-right” OCD may hold the false belief that if their shoelaces are not tied in a perfectly even manner, his/her parent might die. 7 Obsessive-Compulsive and Related Disorders 161

OC-Related Disorders

OCD was originally classified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-4), as an anxiety disorder; however, in the most recent addition, the DSM-5 (American Psychiatric Association, 2013), OCD and disorders that are distinct but related (i.e., OCD and related disorders) were included in their own separate chapter, distinguishing them from the anxiety disorders. OCD- related disorders include body dysmorphic disorder, hoarding disorder, trichotillomania, excoriation disorder, obsessive-compulsive and related disorder due to another medical condition, other specified obsessive-compulsive and related disorder, and unspecified obsessive-compulsive and related disorder. Below we provide a brief overview of the features of these related disorders (summarized in Fig. 7.1) and how they can be differentiated from an OCD diagnosis. The rest of this chapter will focus primarily on OCD, as more information regarding diagnostic interviewing and assessment is available, and there is considerable overlap in the diagnostic procedures (Table 7.1).

Table 7.1 OCD-related disorder assessment tools Diagnosis Measure Type Reference Body Dysmorphic YBOCS-BDD Semi-structured Phillips, Hollander, Disorder (BDD) clinician- Rasmussen, and administered scale Aronowitz (1997) Appearance Anxiety Self-report Veale et al. (2014) Inventory (AAI) Body Image Disturbance Self-report; Cash, Phillips, Santos, Questionnaire (BIDQ) screening and Hrabosky (2004) instrument Hoarding Disorder Hoarding Rating Scale Semi-structured Tolin, Frost, and (HRS) clinician interview Steketee (2010) Saving Inventory-Revised Self-report Frost, Steketee, and (SIR) Grisham (2004) Trichotillomania Trichotillomania Diagnostic Semi-structured Rothbaum and Ninan Interview interview for (1994) DSM-4 criteria Y-BOCS-Trichotillomania Semi-structured Stanley, Breckenridge, (Y-BOCS-TM) clinician- Snyder, and Novy administered scale (1999) Psychiatric Institute Semi-structured Winchel et al. (1992) Trichotillomania Scale clinician- (PITS) administered scale Massachusetts General Self-report Keuthen et al. (1995) Hospital Hairpulling Scale (MGH-HPS) Excoriation Skin Picking Scale (SPS) Self-report Keuthen et al. (2001) Disorder Milwaukee Inventory for the Self-report Walther, Flessner, Dimensions of Adult Skin Conelea, and Woods Picking (MIDAS) (2009) 162 M. L. Davis et al.

Body dysmorphic disorder Similar to OCD, body dysmorphic disorder (BDD) involves obsessions and compulsions; however, BDD is characterized by preoccupation with flaws in one’s physical appearance that appear slight or non-existent to others (i.e., are not clearly noticeable physical defects). For example, BDD concerns may be related to perceived wrinkles or acne, thinning or excessive head or body hair, or the size or shape of virtually any body part. Muscle dysmorphia, a specifier of BDD, is seen almost exclusively in males and involves the preoccupation that one’s body is not lean or muscular enough (though they have “normal” body types or are muscular; Pope, Gruber, Choi, Olivardia, & Phillips, 1997). Individuals with BDD also engage in compulsions related to their physical appearance obsessions, such as repetitive behaviors enacted to improve appearance (e.g., excessive grooming, skin picking, reassurance seeking, or checking of appearance), avoidance (e.g., avoiding mirrors or certain clothing or attempting to hide body parts), or mental acts (e.g., frequently comparing their appearance to that of others). BDD is considered distinct from OCD and other related disorders due to its focus on obsessions and compulsions related to physical appearance only. Additionally, individuals with BDD often have poorer insight (i.e., stronger belief that their physical appearance is flawed or deformed) than those with other OCD-related disorders. Individuals with BDD often present in the offices of dermatologists, cosmetic sur- geons, or dentists and orthodontists long before seeking mental health care. Finally, suicide risk assessment is an important factor in BDD assessment, as BDD is more strongly linked with suicidality than OCD or eating disorders (Angelakis, Gooding, & Panagioti, 2016).

Hoarding disorder Hoarding disorder consists of persistent difficulty in getting rid of items or possessions, due to both the distress caused by loss of the possession and the perceived necessity of saving them. These symptoms result in the accumula- tion of items (i.e., hoarding) which make living areas difficult to use due to clutter. If hoarding behaviors are judged to be directly related to obsessive thoughts (e.g., fears of contamination, responsibility for harm, or feelings of incompleteness), a diagnosis of OCD would be given instead. Similarly, if the function of hoarding behaviors is secondary to obsessions and/or compulsions (e.g., if hoarding stems from the inability to discard items due to contamination fears), an OCD diagnosis would be given. OCD-related hoarding behaviors are also often highly distressing to the individual, and they are less likely to excessively acquire items. Individuals with hoarding disorder may have restricted insight into their symptoms and, perhaps due to the less distressing nature of the disorder (compared to hoarding-related OCD), may be less interested in receiving treatment.

Trichotillomania Trichotillomania, or hair-pulling disorder, involves the excessive pulling of one’s own hair, leading to hair loss (for review, see Duke, Keeley, Geffken, & Storch, 2010). Individuals with trichotillomania want to stop hair- pulling but struggle to do so. Hair-pulling may occur in any area of the body, most commonly on the scalp and face (e.g., eyebrows, eyelashes, beards, and other facial hair), with other areas including the arm/leg, the pubic region, and the chest. 7 Obsessive-Compulsive and Related Disorders 163

Additional rituals may occur alongside hair-pulling, such as oral behaviors (e.g., eating the hair, biting off the root, etc.), playing with the hair, or saving the hair. Trichotillomania literature has identified subtypes of hair-pulling, differentiating automatic hair-pulling (i.e., hair-pulling while doing other activities or out of one’s awareness) and focused hair-pulling (i.e., hair-pulling as a function of focused attention). Automatic hair-pulling is more commonly seen in trichotillomania, and individuals can engage in both types of hair-pulling (for review, see Duke et al., 2010). Focused hair-pulling has more overlap with OCD symptoms, as individuals often engage in compulsive or ritualistic behaviors around hair-pulling in response to intense urges to pull hair. Differential diagnosis can be difficult, as hair-pulling behaviors can occur as symptoms of other disorders (e.g., OCD, BDD). If individuals engage in hair- pulling in an attempt to remedy a perceived flaw in physical appearance, a diagnosis of BDD would be given. Hair-pulling in trichotillomania differs from OCD-related rituals in that they are performed in response to a strong, ego-syntonic, internal urge or desire to pull (rather than in response to distressing ego-dystonic thoughts). In fact, hair-pulling is typically perceived as gratifying and usually occurs during times of heightened stress. Further, hair-pulling rituals in trichotillomania do not tend to change or switch focus to other rituals over time (unlike OCD, in which obsessions and compulsions frequently evolve over the course of the disorder).

Excoriation disorder Excoriation disorder involves repetitive excoriation, or skin-picking, resulting in wounds on the skin. Individuals with excoriation disorder may pick at healthy (unflawed) skin or may pick at pimples, scabs, calluses, or other skin irregularities. Common triggers for picking include a strong internal urge to pick, negative emotions, visible skin irregularities or blemishes, or sensations on the skin. Picking is compulsive and tends to result in urge reduction and/or a sense of relief or pleasure. Though the extent of damage due to picking can vary, in most individuals, excoriation disorder leads to noticeable skin damage, which may lead to embarrassments or attempts to conceal skin. Similar to trichotillomania, if skin-picking behaviors are utilized to attempt to fix a perceived physical appearance flaw, BDD would be diagnosed instead of excoriation disorder. If the individual is engaging in excessive washing rituals (e.g., in response to contamination thoughts), which lead to lesions or wounds on the skin, OCD would be diagnosed.

Other OCD-related disorders The DSM-5 specifies four additional diagnoses that don’t meet criteria for the aforementioned OCD and related disorders: substance/medication-induced obsessive-compulsive and related disorder, obsessive- compulsive and related disorder due to another medical condition, other specified obsessive-compulsive and related disorder, and unspecified obsessive-compulsive and related disorder. The substances that are most often recognized as causing OCD-like symptoms are amphetamines, cocaine, and other stimulants. OCD symptoms can also be part of delirium, which can sometimes result from substance or 164 M. L. Davis et al. medication use withdrawal. OCD has also been associated with other medical conditions thought to cause psychiatric symptoms, with the most prominent being streptococcal infections. Children displaying OCD symptoms should be tested for streptococcal infections to rule out Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS). Disorders classified under “other specified obsessive-compulsive and related disorder” include body dysmorphic-like disorders (i.e., disorders which do not meet criteria for BDD due to the presence of observable flaws in appearance or the absence of repetitive behaviors); body-focused repetitive behavior disorders (i.e., disorders which do not meet criteria for trichotillomania or excoriation disorder but involve repetitive body-focused behaviors like nail biting or lip chewing); non- delusional obsessional jealousy; and culture-specific disorders such as shubo-kyofu (i.e., fear of having a bodily deformity), koro (anxiety that sexual organs or nipples will recede into the body), and Jikoshu-kyofu (also known as olfactory reference syndrome or fear of having offensive body odor).

Procedures for Gathering Information

Diagnostic interviewing procedures will vary depending on the setting, time restrictions, and clinician preferences, as well as the overall purpose of the diagnosis. Generally, using structured, evidence-based interviews and assessment tools is preferable due to increased validity and decreased subjectivity. In research settings, this is particularly important to ensure the diagnostic status of participants. In clinical settings, however, there may be time restrictions that prevent complete reliance on these tools. However, we strongly recommend that if unstructured clinical interviews are conducted, they should be informed and/or guided by a structured interview or assessment tool. An example of how to utilize an evidence-based assessment tool into an unstructured clinical interview is provided in a case illustration below. Below we highlight the most commonly used clinical interviews, clinician-rated instruments, and self-report instruments. Table 7.2 provides a summary of this information, describing the psychometric properties and the time required to conduct each assessment tool in order to aid in the selection of appropriate materials.

Recommendations for Formal Assessment

Semi-Structured Diagnostic Interviews

Semi-structured clinical interviews involve specific sets of questions designed to assess for the diagnostic criteria outlined in the DSM-5. These interviews can often take significant time to administer, but are highly useful for making an accurate 7 Obsessive-Compulsive and Related Disorders 165

Table 7.2 Evidence-based clinician-administered OCD assessment tools Type Description Strengths Weaknesses Anxiety and Diagnostic Semi-structured + Excellent − Time intensive Related interview interview with detailed reliability − Requires Disorders symptom queries for + Diagnostic training Interview for each DSM-5 anxiety utility (for DSM-5 and related disorder anxiety (ADIS-5) disorders) + Detailed descriptions of disorders Structured Diagnostic Structured interview + Contains brief − Time- Clinical interview with specific questions screener to select intensive Interview for assessing criteria for relevant modules − Requires DSM-5 (SCID-5) all DSM-5 diagnoses + Child/parent training version available + Diagnostic utility (especially for differential diagnosis/ comorbidity) The Yale-Brown Clinician- Semi-structured + Considered the − Poor Obsessive- administrated interview assessing the “gold standard” discriminant Compulsive measure presence, frequency, measure for validity (overlap Scale (YBOCS) and severity of OCD with symptoms and obsessions and + Assesses of depression) The Yale-Brown compulsions. Second symptom − Requires Obsessive- version includes a frequency and training Compulsive symptom checklist severity Scale – Second + Child version Edition available (YBOCS-II) (CYBOCS) + Use of a symptom checklist has clinical utility Dimensional Self-report 20-item scale + Useful as a − Correlated Obsessive- assessing four brief screening with measures of Compulsive dimensional aspects of assessment depression Scale (DOCS) OCD severity + Easy to administer in a clinical setting + Groups symptoms into four useful dimensions (continued) 166 M. L. Davis et al.

Table 7.2 (continued) Type Description Strengths Weaknesses Obsessive- Self-report 28-item scale + Useful as a − No separate Compulsive producing six brief screening severity scale Inventory – subscales assessment − Compulsions Revised (OCI-R) + Provides more heavily cut-off scores weighted than (for diagnostic obsessions utility) + Can compare symptom severity across categories Florida Self-report 20-item scale + Useful as a − Correlated Obsessive- assessing presence and brief screening with measures of Compulsive severity of symptoms assessment depression Interview + Good (FOCI) psychometric properties; supported by factor analyses Adapted from Grabill et al. (2008) diagnosis, providing a more comprehensive clinical picture, ruling out potential differential diagnoses, and informing other comorbid diagnoses. These tools dramatically reduce subjectivity. Interviewers can administer the entire clinical interview or, to reduce clinician or patient burden, administer only the OCD-related modules and those of suspected differential/comorbid diagnoses. The most frequently used semi-structured interviews for assessing for the DSM-5 diagnostic criteria of OCD and related disorders are the Anxiety and Related Disorders Interview Schedule for DSM-5 (ADIS; Brown & Barlow, 2014) and the Structured Clinical Interview for DSM-5 (SCID-5; First, Williams, Karg, & Spitzer, 2015).

OCD-Focused Clinician-Rated Instruments

The most commonly used clinician-rated instrument in research and clinical settings is the Yale-Brown Obsessive-Compulsive Scale (YBOCS; Goodman et al., 1989) and its second edition, the YBOCS-II (Storch et al., 2010). This instrument is considered the gold standard for OCD symptom assessment. It consists of a clinical checklist, asking about all potential content areas of obsessions and compulsions, as well as avoidance behaviors. Clinicians then rate the severity of symptoms (i.e., obsessions and compulsions) separately to yield a final total score. There is also a child version of the YBOCS, the Children’s Yale-Brown Obsessive-Compulsive Scale (CYBOCS; Scahill et al., 1997), and its second edition, the CYBOCS-II (Storch et al., 2019). 7 Obsessive-Compulsive and Related Disorders 167

Self-Report Measures

Self-report measures can be useful to provide additional information which may guide differential diagnosis, or as brief screening tools to assess whether further diagnostic questioning about OCD is necessary. We recommend the following commonly used measures, which assess for OCD symptom presence and/or severity: the self-report version of the YBOCS (YBOCS-SR; Baer, Brown-Beasley, Sorce, & Henriques, 1993), the Dimensional Obsessive-Compulsive Scale (DOCS; Abramowitz et al., 2010), the Obsessive-Compulsive Inventory-Revised (OCI-R; Foa et al., 2002), the Vancouver Obsessional Compulsive Inventory (VOCI; Thordarson et al., 2004), the Maudsley (Hodgson & Rachman, 1977), and the Florida Obsessive-Compulsive Interview (FOCI; Storch et al., 2007).

Child/Parent-Specific Measures

It is quite common in clinical practice and research settings to obtain parent or caregiver ratings of their child’s behavior on measures such as the Child Obsessive Compulsive Impact Scale (Piacentini, Peris, Bergman, Chang, & Jaffer, 2007), a measure of parental/caregiver perception of impairment, and the Obsessive Compulsive Inventory – Child Version (Foa et al., 2010), which assesses parental/ caregiver perception of the frequency and severity of OCD symptoms.

Family Assessment and Gathering Additional Information

It is also important, if family members are closely involved with the patient and/or their OCD symptoms/management, to get a sense of the level of family involvement in symptoms. We recommend, if family members live with the patient and are closely involved, that they come in for the assessment to provide collateral information and complete questionnaires. Given that individuals with OCD can sometimes have fair to poor insight and may not be able to reflect on the frequency and severity of their symptoms, having family members present can be extremely helpful. The Family Accommodation Scale (FAS; Calvocoressi, Lewis, Harris, & Trufan, 1995) is often given to family members to assess how much others (spouses, partners, parents, other family members, roommates, etc.) accommodate the patient’s obsessions and compulsions. Accommodation involves attempting to help the patient ameliorate his or her distress by providing them with reassurance, helping them to complete compulsive behaviors, helping them to avoid OCD triggers, and changing family behaviors and routines because of the OCD. It is especially important to assess for family accommodation when performing diagnostic interviews for the purpose of treatment planning, as high levels of family accommodation may interfere with treatment (Storch et al., 2007). 168 M. L. Davis et al.

Case Illustration

The following case example details a hypothetical unstructured clinical interview and highlights a number of important features discussed here thus far: (1) the importance of differential diagnosis and how to ask questions to make these clarifications, (2) the importance of making the patient feel comfortable in talking about thoughts and behaviors that he or she may find odd or embarrassing, and (3) how to integrate a more standardized assessment into an unstructured clinical interview. Interviewer: Tell me about what brings you to therapy. Maya: Well, I’ve been really stressed and I can’t seem to get out of my head. I feel like I’m constantly thinking and I can’t stop myself no matter how hard I try. Interviewer: It sounds like that’s been difficult for you. Can you tell me about what types of thoughts you’re having? Maya: I don’t know, just really negative thoughts…thoughts that really bother me. Interviewer: I see…when was the last time you had one of these thoughts? Maya: I have them all the time! I had them when I was in the waiting room before our appointment. Interviewer: Okay, what was going through your mind in the waiting room? Maya: Just really negative, dark thoughts. I don’t know if I can talk to you about them yet…it’s really embarrassing. Interviewer: I understand. We just met and it’s difficult to talk about personal topics to a stranger. I want to reassure you that you can’t shock me. I’ve seen a lot of clients over the years and have heard just about everything you can imagine! Also, we all have strange or embarrassing thoughts from time to time. It’s important for me to understand the types of thoughts that are bothering you so that we can get a clear picture of what’s going on with you. Maya: I know I need to tell you…not only is it embarrassing, I just feel like if I say the thought out loud it makes it worse. Interviewer: How might it make it worse? Maya: Thinking the thought is already bad enough, I’m afraid if I say it, it might come true. Interviewer: I see, so this is a thought about something bad that could happen? Maya: Yes…not something I want to happen, but I just can’t stop thinking about it. Interviewer: What do you do when you have the thought? It sounds like it is distressing to you…do you try to do anything to get rid of the thought or make sure the bad thing doesn’t happen? Maya: I try so hard to stop thinking about it but I can’t. Then I’ll pray to God so that he knows I don’t want to have the thought and I pray for it not to come true. Interviewer: You said these thoughts occur all the time…do you pray every time you have the thought? How much time do you spend praying? 7 Obsessive-Compulsive and Related Disorders 169

Maya: I pray in my head all day long! Every time I have the thoughts I say a specific prayer that a preacher told me to say to ask God to take away the thought. I’ve added my own Bible verses and words to it over the years so it’s gotten pretty long but I have to say the whole thing every time. Interviewer: The types of symptoms you’re talking about, having these bother- some thoughts that come over and over again that you try very hard to get rid of or make sure the thought doesn’t come true, sounds similar to what people with obsessive-compulsive disorder experience. Have you heard of obsessive-compulsive disorder, or OCD? Maya: I’ve heard of people being OCD like trying to keep things really organized and clean, but I’m not like that. Interviewer: Right, that’s a common way the term OCD is used, but the disorder is actually much more than that. Do you mind if I tell you a little bit more about OCD? Then I can give you a list of common types of thoughts that people with OCD have and you can let me know if any of those are similar to the types of thoughts that you’re having…that might be easier than saying it aloud to me. Maya: Sure. The interviewer could then provide definitions for obsessions and compulsions and use the YBOCS symptom checklist to get a sense of the types of thoughts Maya is having. In an unstructured diagnostic interview, the client is typically asked broadly to explain their presenting problem. Clinicians should have an arsenal of questions ready to determine whether symptoms (i.e., thoughts and behaviors) are OCD- related (i.e., are obsessions and compulsions) or not. For instance, when Maya first described being bothered by “constantly thinking” and “not being able to get out of her head,” some initial potential diagnoses come to mind—the ruminative, persistent negative thinking seen in depressive disorders; the inability to stop worrying that is characteristic of generalized anxiety disorder; or intrusive, repetitive thoughts. To perform a differential diagnosis, it is important to know the content of the thoughts. When the interviewer probed about the thought content, Maya was hesitant to disclose the nature of her thoughts. While this is not definitely indicative of the presence of OCD, it is quite common for individuals to feel embarrassed about the types of thoughts that they’re having or to not want to speak the thoughts aloud due to various beliefs about the thoughts. Here, the interviewer tried to normalize the experience of having embarrassing thoughts and reassure Maya that he/she will not be shocked. When Maya again was unable to speak about the specific content of the thoughts, the interviewer probed more about what she does in response to them, which elicited behaviors that seem consistent with compulsions. At this point, the interviewer leaned more heavily toward an OCD diagnosis, and chose to integrate a more structured assessment into the interview, not only to get a clearer diagnostic picture, but 170 M. L. Davis et al. also to provide Maya with a list of common thoughts (via the YBOCS symptom checklist) that she can simply point to. This checklist can also normalize embarrassing or strange thinking, and many patients will remark that they did not know other people had thoughts like this. The interviewer can then reassure the patient that these types of thoughts are common, not just for individuals with OCD, but that everyone has strange thoughts at times.

Impact of Gender, Race/Culture, Age, and Other Aspects of Diversity

Gender

Though the prevalence of OCD is similar between males and females, there are some gender differences in age of onset, comorbidity, and content of symptoms. Males tend to have an earlier symptom onset than females and are more likely to have comorbid tic disorders than females. Accordingly, it may be important to inquire about tic disorders in your clinical interview. Additionally, males are more likely than females to have OCD symptoms related to symmetry and unwanted thoughts, while females are more likely than males to have symptoms related to cleaning.

Race/Culture

Despite being a relatively heterogeneous disorder between individuals, there is similarity across cultures in OCD symptom structure. As noted previously, the four common OCD content areas (i.e., contamination and germs, symmetry, responsibility for harm, and unwanted thoughts) are consistently seen across cultures. However, certain aspects of culture can “shape” the content of OCD symptoms. For individuals who have obsessions and/or compulsions related to their religious or spiritual beliefs, symptom content may differ depending on the specific values, customs, and doctrines of that religion. For example, a Muslim individual with OCD may have compulsions related to completing prayers perfectly, a Hindu individual with OCD may have compulsive washing rituals, and a Protestant Christian individual with OCD may have obsessive doubts about whether he or she truly accepts Jesus as their savior. Some research has indicated that Christianity, due to its emphasis on beliefs (i.e., regarding a relationship with God and salvation), may be associated with higher levels of thought-action fusion or the belief that thinking something is equivalent to acting upon that thought. Conversely, the Jewish and Muslim religions, due to their emphasis on behaviors and action, may be associated with compulsive behaviors (e.g., properly fulfilling commandments or excessive cleansing due to concerns about impurity). 7 Obsessive-Compulsive and Related Disorders 171

It is also vital to ensure cultural sensitivity when considering an OCD diagnosis. For example, African American individuals with OCD are understudied and under- represented in the literature, and there is evidence that they can be misdiagnosed as psychotic due to lack of cultural understanding or racial biases/discrimination (for review, see Williams, Proetto, Casiano, & Franklin, 2012). Understanding cross- cultural differences in symptom presentation (and that some cultures may not present with the most common or typical OCD symptoms) is highly important to both detecting OCD among less frequently studied populations and avoiding potentially harmful and stigmatizing misdiagnosis.

Age

Though some individuals may present with very early onset (i.e., ages 6–7; Albert et al., 2015), research suggests that there may be two periods during which OCD symptoms may be most likely to occur: just before puberty (i.e., ages 10–12) or late adolescence (i.e., ages 18–23). Some have even suggested that early onset and late onset may actually reflect distinct subtypes of OCD. There is some evidence that there may be differences in symptom presentation among those with earlier-onset OCD and later-onset OCD. OCD is also diagnosed postpartum and is often characterized as postpartum OCD. As mentioned previously, males tend to have earlier- onset OCD. There is mixed research suggesting that earlier symptom onset is associated with increased symptom severity.

Information Critical to Making a Diagnosis

Does the Patient Meet Diagnostic Criteria for OCD?

Criterion A To meet diagnostic criteria for OCD, individuals must experience either obsessions (recurrent and persistent thoughts, images, or impulses that are experienced as intrusive and unwanted and cause anxiety or distress) or compulsions (repetitive behaviors that the individual feels compelled to perform in response to an obsession or rules that must be applied rigidly). The individual should indicate an attempt to ignore, suppress, or neutralize the obsessions, and the compulsions should be performed in an attempt to reduce distress or prevent something bad from occurring. The compulsive behaviors should either not be realistically connected with what they are enacted to neutralize or prevent or be excessive in nature.

Criterion B Obsessions and compulsions should be time-consuming (i.e., more than 1 hour per day) or cause clinically significant distress or impairment in functioning. 172 M. L. Davis et al.

Anxiety disorders Depressive disorders •Generalized anxiety disorder: •Thoughts usually mood- content of thoughts linked to congruent (depressed) real-life worries/concerns •Thoughts not necessarily viewed •Specific phobias/social anxiety as intrusive/distressing disorder: content of thoughts circumscribed to specific •Thoughts are not linked to situations/stimuli compulsions •Thoughts are not linked to compulsions

Others •Eating disorders: concerns limited to weight/food •Tic disorders: movements not aimed at neutralizing obsessions •Psychotic disorders: do not have obsessions/compulsions; have other psychotic features (e.g., hallucinations or formal thought disorder)

Fig. 7.3 Common differential diagnoses

Criterions C and D Symptoms should not be attributable to a substance, medicine, or withdrawal symptoms and should not be better explained by another medical or mental health disorder. It is important to assess for the presence of other disorders, both to establish any important comorbid diagnoses and to conduct an effective differential diagnosis. There is significant overlap in symptoms of OCD and other disorders that involve problematic thoughts and avoidant or repetitive behaviors. We have already differentiated OCD from the OCD-related disorders; other common differential diagnoses are highlighted in Fig. 7.3. A good diagnostic interview will also assess for the presence of common comorbid conditions: anxiety disorders, depressive disorders, tic disorders, OCD-related disorders, Tourette’s disorder, and disorders of impulsivity (such as attention-deficit hyperactivity disorder and oppositional defiant disorder). OCD is also more common in individuals with other severe mental health problems, such as schizophrenia, schizoaffective disorder, bipolar disorder, and eating disorders (APA, 2013). Additionally, an OCD diagnosis should include a tic specifier if symptoms are tic-related (i.e., if the individual has a current or past history of a tic disorder 7 Obsessive-Compulsive and Related Disorders 173 diagnosis). Individuals with tic-related OCD appear to have more comorbid diagnoses (e.g., attention-deficit hyperactivity disorder, BDD, trichotillomania, and mood and anxiety disorders) and may have an earlier age of onset (and thus, greater prevalence in males; de Alvarenga et al., 2012).

What Is the Patient’s Level of Insight into Their Disorder?

An OCD diagnosis should include a specifier indicating the amount of insight the individual has into their symptoms. This specifier is important, as individuals with OCD vary widely in their perception of the validity of their OCD-related beliefs. For example, individuals “with good or fair insight” are able to recognize that their OCD-related beliefs, or the content of their obsessions or the necessity of their compulsions, are definitely or probably not true. For example, they may express complete awareness that their excessive washing behaviors are unnecessary and illogical, though they are still compelled to perform them. Other individuals “with poor insight” think that their OCD-related beliefs probably hold some truth. For example, an individual with obsessions about blasphemy may have difficulty differentiating their OCD-related thoughts from their religious beliefs. Finally, individuals “with absent insight/delusional beliefs” are completely convinced that their OCD- related beliefs are true. Understanding the patient’s level of insight is vital for treatment planning; those with poor or absent insight may be ambivalent about the need for treatment.

Could there Be Another Cause for OCD-Related Symptoms?

As noted previously, it is vital to assess for other mental health diagnoses that have symptom overlap with OCD and related disorders. Additionally, it is important to rule out the possibility that there could be a medical condition, substance/medication, or withdrawal-related cause for the onset of symptoms. For example, as noted earlier, stimulant medications/drugs can result in obsessions, compulsions, or body- focused repetitive behaviors (e.g., skin picking, hair-pulling, etc.). If organic/ substance-related causes are suspected, it is recommended that the patient be referred for a medical evaluation. It is also important to get a timeline of symptom onset and assess for any major medical problems, medication use, and substance use. If caused by a substance or withdrawal symptoms, the OCD-related symptoms should resolve alongside ceasing substance/medication use or the end of the withdrawal period. 174 M. L. Davis et al.

Dos and Don’ts

Our suggested list of do’s and don’ts for the assessment and interviewing of OCD and related disorders is presented in Fig. 7.4. In general, it is important to keep two key elements in mind: make sure you are getting relevant, accurate information and ensure that patients are comfortable with disclosing potentially sensitive information. In regard to the first element, knowing what to ask (either through experience or by using a standardized, evidence-based assessment), who to ask (i.e., gathering collateral information when necessary), and how to ensure that you are getting accurate information (partly by educating clients about symptoms and the role of avoidance) are fundamental. Above all, it is important to convey empathy, sensitivity, and a nonjudgmental attitude toward the client, for whom the interview can be a very distressing process.

Dos Don’ts

Use information from multiple sources or Further contribute to stigma surrounding OCD informants with consent (family members, parents, by becoming alarmed about symptom content previous providers) (e.g., thoughts about committing violent acts or sexual crimes). The key is to establish that these Familiarize yourself with common OCD content so thoughts are viewed as intrusive, unwanted, and that you can speak openly about “embarrassing” or ego-syntonic thoughts (see Fig. 2). Reporting a “weird” contents of obsessions or compulsions. Don’t client to authority figures simply forhaving OCD- dance around certain topics—use straightforward driven thoughts is extremely stigmatizing and language to ask about symptoms. This normalizes the damaging to the patient experience for the patient and reassures them that you are comfortable Rely solely on clinical judgment to form an OCD diagnosis or assessment of severity. As previously Use evidence-based assessment tools as part of described, several evidence-based assessment the diagnostic interview measures exist, and many are quick and easy to implement into clinical practice. Not only will this When leaning toward an OCD diagnosis, ensure that increase the validity of your assessment, but it can patients have a good understanding of also form a baseline measurement to gauge “obsessions” and “compulsions” before continuing improvement over the course of treatment to ask about symptoms. This can not only provide them with psychoeducation but ensures that they are Forget to show empathy. Sometimes the content accurately reporting on questions about time spent of obsessions and compulsions can seem illogical engaging in symptoms, for example or silly, but to the patient, these thoughts and behaviors are extremely distressing and serious Though a general principle of OCD treatment is to encourage the client not to avoid, it may be necessary Overlook avoidance. Individuals with OCD are to placate their requests for reassurance seeking or often highly avoidant of triggering obsessive attempts at avoidance in order to get the information thoughts or compulsive behaviors. Talking directly necessary to obtain a diagnosis and inform treatment. about such thoughts and behaviors may be Since they are not in treatment yet, the fundamental extremely difficult, and patients maybe highly goal is to allow the patient to be comfortable motivated to gloss over certain areas or leave out enough to engage in an open, productive important information. A symptom checklist can conversation about their symptoms help ensure you are getting all relevant symptom information

Fig. 7.4 Dos and don’ts of diagnostic interviewing in OCD 7 Obsessive-Compulsive and Related Disorders 175

Summary

Determining whether someone meets diagnostic criteria for OCD or an OCD- related disorder can be a difficult undertaking. It is complicated by several factors, including the potential for lack of insight on behalf of the patient, symptom overlap with several other mental health disorders, frequent comorbidity, and the frequent presence of stigma and embarrassment around OCD symptoms. Despite these challenges, the importance of obtaining an accurate and informed diagnosis of OCD and related disorders cannot be understated. Under-diagnosis is extremely common, and research suggests that over 50% of American individuals with OCD do not receive any treatment (much less evidence-based treatment) for their disorder (Ruscio, Stein, Chiu, & Kessler, 2010). Given that the majority of individuals with OCD experience significant functional impairment and suffering, it is important to detect for the presence of OCD, both in clinical practice and in health-care settings. Toward this end, the development of more abbreviated screeners to detect for OCD among nonmental health-care providers in medical and other settings is an important avenue for future research. We have highlighted the importance of utilizing evidence-based assessment tools when conducting diagnostic interviews among individuals with OCD and related disorders. This increases the validity and reduces the subjectivity of the assessment, and ensures that the clinician has detailed information about symptoms for treatment planning, if the purpose of the interview is to inform future treatment. Additionally, we have highlighted the importance of getting a sense of the level of insight one has into their disorder and the role of the family in accommodating the individual. Further, it can be helpful to think about the influence that culture and diversity factors may play on symptom presentation. In sum, it is our hope that this chapter provides you with an overview of valid methodology for conducting evidence-based diagnostic interviews for OCD and related disorders across a wide array of settings and for various purposes.

References

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Osnat Lupesko-Persky and Lisa M. Brown

Description of the Disorders

Most people experience at least one traumatic event during the course of their lifetime. Although research indicates that up to 80% of those exposed to traumatic events will be at increased risk for developing post-traumatic stress disorder (PTSD), only a small, yet significant, number will actually go on to develop the disorder (Birur, Moore, & Davis, 2017). Moreover, those who don’t eventually meet full diagnostic criteria for PTSD will often develop a partial, also called subsyndromal or subthreshold, presentation of PTSD symptoms (Cukor, Wyka, Jayasinghe, & Difede, 2010). Despite not meeting full criteria for PTSD, partial symptoms can significantly impair function and adversely affect quality of life (Cukor et al.,2010 ). In addition to PTSD, there are two other trauma and stress-related disorders for adults that are included in the Trauma and Stress-Related Disorders category of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association [APA], 2013). Mental health professionals are likely to encounter people who have experienced traumatic events. Therefore, clinicians should be knowledgeable and skilled in diagnosing, assessing, and treating trauma and other stress-related disorders. This section will review the core definitions, criteria, and prevalence of each of these disorders.

O. Lupesko-Persky · L. M. Brown (*) Palo Alto University, Palo Alto, CA, USA e-mail: [email protected]

Core Trauma-Related Definitions

The Definition of Psychological Trauma

Although the word “trauma” is derived from Latin and means “physical wound,” toward the end of the nineteenth century the definition of the term was expanded to include “mental wounds” (Lasiuk & Hegadoren, 2006). Broadly, psychological trauma can be defined as an overwhelmed response to a traumatic or stressful event that exceeds available resources. Responses to traumatic events can range from slight to significant (Courtois & Gold,2009 ). Some experiences may be traumatic for one person and not another. For example, two people may be in the same car accident, but their subjective perception of the accident may vary greatly. The expression of distress in response to trauma is also highly variable. Some people may exhibit symptoms of anxiety, fear, or dysphoria (internalized expressions), whereas others may predominantly display aggression and anger toward others (externalizing expressions) (APA, 2013). The definition for psychological trauma is broad because it encompasses a myriad of responses to one-time events, (e.g., car accident), prolonged or reoccurring events (e.g., soldiers engaged in military action), exposure to multiple traumas, also referred to complex trauma (e.g., childhood abuse and community violence), and collective trauma (e.g., a community destroyed by a disaster) (Courtois, 2008; Courtois & Gold, 2009). While traumatic stress can result from either natural (e.g., tsunami, hurricane, earthquake) or human-caused events (e.g., terrorism, industrial accident, interpersonal abuse), research shows that human-caused events of betrayal or interpersonal violence are more likely to elicit severe reactions (Courtois & Gold, 2009).

The Definition of Stress

While sometimes used interchangeably, stress and stressor are not synonymous: Stress results from a combination of biological, psychological, and social factors, whereas stressors are an environmental event or stimulus that can be perceived as positive or negative (Carter, 2007). For example, a negative perception of a stressor could induce a stress reaction that in turn could develop into either a trauma or stress-related mental disorder. These disorders are described in Table 8.1.

Post-traumatic Stress Disorder

Frequently described as embodying “the invisible wounds of war,” PTSD is one of the more prevalent, yet complex, disorders. The DSM-5 reflects significant alteration in the criteria for PTSD from its former version in the Diagnostic and Statistical Manual of Mental Disorders (4th ed. APA, 2000; DSM-IV-TR) (Hoge, Riviere, 8 Trauma and Stressor-Related Disorders 181

Table 8.1 Comparison of diagnostic features for PTSD, acute stress disorder, and adjustment disorder PTSD Acute stress disorder Adjustment disorder Traumatic event (terms Traumatic event (terms Stressors (terms not defined, defined) defined) stressor identifiable) Recurrent, involuntary, and Recurrent, involuntary, and Marked distress that is out of intrusive distressing memories intrusive distressing memories proportion to the severity or intensity of the stressor (cultural factors and external context should be considered) Recurrent distressing dreams Recurrent distressing dreams Significant impairment in social, in which the content or affect in which the content or affect occupational, or other important are related to the event are related to the event areas of functioning Dissociative reactions in Dissociative reactions in Duration: beginning of distress which the individual feels or which the individual feels or within 3 months of stressor’s acts as if the event recurring acts as if the event recurring onset. Intense/prolonged Intense/prolonged Duration: symptoms do not psychological distress at psychological distress at persist for more than 6 months exposure to internal or exposure to internal or after stressor/consequences external cues that resemble an external cues that resemble an terminated. aspect of the event aspect of the event Avoidance or efforts to avoid Persistent inability to distressing memories/ experience positive emotion thoughts/ feelings with the event Avoidance/efforts to avoid An altered sense of reality of external reminders that arouse one’s surroundings or oneself distressing memories, thoughts of the event Inability to remember an Inability to remember an important aspect of the event important aspect of the traumatic event Persistent and exaggerated Efforts to avoid distressing negative beliefs or memories/thoughts/feelings expectations about oneself, closely associated with the others, or the world. event Persistent, distorted Efforts to avoid external cognitions about the cause or reminders that arouse consequences of the event distressing memories/ thoughts/feelings with the event Persistent negative emotional Sleep disturbance state Markedly diminished interest/ Irritable/angry behavior participation in activities Feelings of detachment from Hypervigilance others Persistent inability to Problems with concentration experience positive emotions (continued) 182 O. Lupesko-Persky and L. M. Brown

Table 8.1 (continued) PTSD Acute stress disorder Adjustment disorder Irritable/angry behavior Exaggerated startle response Reckless/self-destructive Duration of disturbance: behavior 3 days to 1 month Hypervigilance Exaggerated startle response Problems with concentration Sleep disturbance Duration of disturbance >1 month Note. Adapted from the DSM-5 (APA, 2013)

Wilk, Herrell, & Weathers, 2014). One major change was moving PTSD from the anxiety disorders chapter and placing it in a new chapter: Trauma and Stressor- Related Disorders (Hoge et al., 2014). It was argued that this change was warranted because while there is significant comorbidity between post-traumatic stress and anxiety, the two disorders are inherently different. Additional changes included revision and expansion of the trauma criterion (discussed below) as well as adding three symptoms to the existing 17 and division of the existing avoidance cluster (Hoge et al., 2014). Criterion A defines exposure to traumatic event. Not disregarding academic calls for the elimination of Criterion A altogether in the upcoming DSM-5, the subcom- mittee on PTSD eventually determined that exposure was an essential component of the PTSD construct (Friedman, 2013). Exposure was once defined in very general terms. With DSM-5 revisions, the definition of a traumatic event now specifically includes “sexual violence” in addition to actual or threatened death or serious injury. DSM-IV-TR criteria included “a threat to the physical integrity of self or others,” but in light of the significant percentage (approximately 30%) of women diagnosed with PTSD as a result of sexual violence (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995), inclusion of “sexual violence” was warranted. The revisions to Criterion A both expanded its meaning and provided more specificity. With DSM-5, an individual no longer has to personally experience or witness the traumatic event. Subsection 3 notes that exposure to traumatic event includes “learning that the traumatic event(s) occurred to a close family member or close friend” (APA, 2013, p. 271). However, the event must have been violent or accidental. In addition, repeated or extreme exposure to “aversive details of the violent act” as part of one’s employment or volunteer responsibilities, such as those experienced by first responders collecting human remains, crisis counselors listening to details of a traumatic event, or law enforcement working in sexual or violent crimes, are now also considered exposure. However, watching traumatic events via electronic media or TV is not sufficient for meeting Criterion A. While the requirements included in Subsections 1 through 4 of Criterion A are not exhaustive, they do provide structure and set expectations regarding what can be considered an exposure for the purposes of diagnosing PTSD. 8 Trauma and Stressor-Related Disorders 183

Criterion B (also known as cluster B) requires the presence of at least one intrusion symptom out of five possibilities. The five intrusive symptoms include (1) “Recurrent, involuntary, and intrusive distressing memories of the traumatic event” (APA, 2013, p. 271), which apply only to distressing sensory recollection (e.g., specific sites, smells, touch, etc.) rather than abstract thoughts (Friedman, 2013); (2) “Recurrent distressing dreams in which the content…are related to the traumatic event(s)” (APA, 2013, p. 271) that includes both trauma-related dreams and replay of the traumatic event (Friedman, 2013); (3) “Dissociative reactions (e.g. flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring” (APA, 2013, p. 271), where flashbacks are in a continuum ranging from no awareness to total awareness; (4) “Intense or prolonged psychological distress…to internal or external cues that symbolize or resemble…the traumatic event(s)” (APA, 2013, p. 271), for example, a combat veteran who experiences psychological distress (anxiety, irritation, fear) when hearing July 4 fireworks; and (5) “Marked physiological reactions to internal or external cues that symbolize or resemble…the traumatic event(s)” (APA, 2013, p. 271), for example, a violent robbery victim who was robbed while walking by himself at night now experiences panic symptoms in the form of heart palpitation, sweaty palms, and tremors every time he needs to walk by himself at night. Criterion C requires at least one avoidance of stimuli symptom associated with the traumatic event. Similar to Criterion B (intrusion), Criterion C (avoidance) has always been considered a core element of PTSD. Either (1) “Avoidance of or efforts to avoid distressing memories, thoughts or feelings associated with the traumatic event(s)” (APA, 2013, p. 271) or (2) avoidance of external reminders, such as people, activities, places, etc. that arouse distressing experience in the form of memories, thoughts, or feelings associated with the traumatic event has to be reported by the patient. An example of avoidance is a car accident survivor who refuses to drive on the road where the accident took place. Traveling on the road triggers distressing memories of the car accident which the survivor attempts to avoid. Negative alterations in mood and cognition, as defined under Criterion D, are symptomatic of individuals with PTSD (Friedman, 2013). Two or more of the following seven criteria need to be met: (1) an inability to remember an important element of the traumatic event, usually in the form of dissociative amnesia. Derived from hysteria disorders in the nineteenth century, dissociative amnesia in trauma developed through the years without a specific definition. Nijenhuis and Van der Hart (2011) defined the term as follows: “Dissociation in trauma entails a division of an individual’s personality, that is, of the dynamic, biopsychosocial system as a whole that determines his or her characteristic mental and behavioral actions” (p. 418). Geared toward surviving the trauma, an individual’s personality is reorga- nized into two or more dissociative parts that are kept separate and experience the world differently (Nijenhuis & Van der Hart, 2011). Trauma-caused dissociation is manifested through negative or positive symptoms. The former includes dissociative amnesia and loss of affect and will, while the latter includes dissociative flashbacks or the re-experiencing of the traumatic events (Nijenhuis & Van der Hart, 2011); (2) alteration in cognition in the form of persistent and exaggerated negative 184 O. Lupesko-Persky and L. M. Brown perception about self, others, or the world (e.g., “I am bad” or “People are bad”); (3) alteration in cognition in the form of persistent and distorted negative perceptions about the cause or consequences of the traumatic event (“e.g., “If I hadn’t worn this dress the rape would not have happened”); (4) persistently experiencing negative mood, such as sadness, fear, anger, etc.; (5) diminished participation in significant activities in comparison to period prior to the trauma; (6) detachment or estrange- ment from others with whom the individual was close prior to the trauma; and (7) “Numbing inability” (Friedman, 2013, p. 551) in the form of an inability to experience positive emotions such as happiness or loving feelings (APA, 2013). Criterion E clusters symptoms of marked alterations in arousal and reactivity associated with the traumatic event. Similar to Criterion D, two or more of the following six symptoms need to be met: (1) irritability and anger outbursts in the form of verbal or physical aggression toward others or objects. The behavior does not need to be triggered by provocation; (2) reckless or self-destructive behavior, such as non-protected/unsafe sexual relations, suicidal attempts, reckless driving, etc. (Friedman, 2013). Due to the high comorbidity, substance use may also be included here; (3) hypervigilance is manifested through maladaptive, heightened sensitivity, and attentional bias toward cues of potential threats or dangers in the environment (Kimble et al., 2014); (4) exaggerated startle response in the form of increased physiological reactivity (i.e., even as minor as frequent eye blinking in response to certain sounds) to events or thoughts associated with the trauma; (5) problems with concentration, including short-term memory problems; and (6) difficulties sleeping in different forms (e.g., difficulty falling asleep or waking up multiple times during the night). Criterion F requires that Clusters B–E appear for more than 1 month after the traumatic event (APA, 2013). If PTSD symptoms are evident immediately after the trauma, another disorder such as acute stress disorder should be considered. Although it is important to detect the relevant symptoms to establish a correct diagnosis, it is similarly important to identify how the symptoms interfere with an individual’s daily functioning. Criterion G requires that the clinician compares their client’s daily functioning before and after the traumatic event and then determine whether these changes interfere with daily functioning. In making the comparison, the clinician should explore different areas of an individual’s life, such as work (e.g., has work experience changed, employment-related issues), family (e.g., relationship with significant others, children, parents, siblings), social (e.g., maintaining friendships, altercations with friends), and other important areas, such as pleasurable activities (e.g., has the individual stopped exercising, attending concerts, watching TV). In addition, the clinician should verify that the symptoms or disturbance in daily functioning is not due to any type of substance use (e.g., prescribed or non-prescribed medication, illegal substance, alcohol) or a medical condition that could better account for the symptoms and disruption in daily functioning. While this is a standard criterion that is included in almost all DSM-5 disorders, it is important to rule out the possibility that the symptoms are the result of substance use because of the high comorbidity between substance use (especially opioids) and PTSD. 8 Trauma and Stressor-Related Disorders 185

Depersonalization and derealization, subtypes of dissociation, may accompany PTSD symptoms and if so should be indicated as specifiers. These subtype additions to PTSD were first introduced in DSM-5. Depersonalization is a distortion in perception in which the individual experiences detachment/dissociation from reality, similar to an “out-of-body experience” (APA, 2013). Like depersonalization, derealization also describes a distortion in perception where the individual loses a sense of reality or the external world (e.g., things seem to change shape or size) (APA, 2013). While dissociation symptoms are not considered a “classic” criterion for PTSD, it is still essential to assess as their presence suggests increased symptom severity, functional impairment, and risk for suicide (Friedman, 2013).

Prevalence of PTSD

As discussed in detail above, a traumatic event is a prerequisite to developing PTSD. As noted earlier, research indicates that most people will experience at least one traumatic event during their lifetime. A national comorbidity survey with a total of 8098 respondents revealed that 60.7% of men and 51.2% of women experienced at least one traumatic event during their lifetime (Kessler et al., 1995). Other research suggests even larger estimates with up to 80% of the population exposed to a significant traumatic stressor (Birur et al., 2017). Research examining the prevalence of PTSD in the US population shows that only a small percentage of those who experience a traumatic stressor go onto develop PTSD. A systematic review of 41 studies that assessed for PTSD in over seven million primary care patients found that 12.5% of the sample met criteria for PTSD (Spottswood, Davydow, & Huang, 2017). More specifically, of the seven million primary care patients, the study found 11.1% prevalence among the civilian population, 12.5% prevalence in the special-risk population, and 24.5% among US military veterans, more than double the prevalence of PTSD among civilian population. Ellis and Zaretsky (2018) reported lower, yet still significant, PTSD rates of 14–18% for deployed US military service members. Slightly lower PTSD prevalence is provided by Kessler, Chiu, Demler, and Walters (2005), where the study analyzed data provided by the National Comorbidity Survey and found that approximately 7% of the population endorsed chronic PTSD symptoms. Similar rates were provided by Difede, Olden, and Cukor (2014) indicating that 8–9% of the population was at risk for experiencing PTSD during their lifetime. Higher rates of PTSD ranging between 10% and 40% are estimated when severe or complex trauma such as surviving the Holocaust, rape, or abuse was experienced (De Kloet, Joëls, & Holsboer, 2005). While multiple studies reveal PTSD rates that are close to 8% in the general population, it is important to remember that such estimates are based on US samples. Among Germans, a study by Perkonigg, Kessler, Storz, and Wittchen (2000) provided both lower trauma exposure and PTSD rates. The study reported that only 26% of men and 17.7% of women were exposed to a traumatic event during their lifetime (in comparison to well over 50% in US population), and of those who were 186 O. Lupesko-Persky and L. M. Brown exposed, only 1% of men and 2.2% of women endorsed full PTSD symptomology (Perkonigg et al., 2000). Research on German military service members also found significantly lower rates of PTSD when compared to their US servicemember counterparts, including those who participated in combat as well as those who experienced noncombat traumatic events (Bandelow et al., 2012). There is very compelling evidence that interpersonal violence, in contrast to accidents and natural disasters, increases risk for developing PTSD (Ellis & Zaretsky, 2018). Rothbaum, Foa, Riggs, Murdock, and Walsh (1992) found that 47% women rape survivors experienced PTSD symptoms approximately 3 months following their assault. Importantly, while the women showed significant reductions in PTSD symptoms from week 1 and week 4 (from 94% to 65%, respectively), women who met criteria for PTSD after week 4 did not continue to experience significant improvement in symptoms over time. Similar findings revealing an increased likelihood of developing PTSD as a result of interpersonal violence were found in Germany (Butler, Moffic, & Turkal, 1999) and Italy (Favaro, Degortes, Colombo, & Santonastaso, 2000).

Acute Stress Disorder

A diagnosis of acute stress disorder helps to identify individuals who are at increased risk for developing PTSD (Bryant, 2003). Studies suggest that approximately 80% of those who are diagnosed with acute stress disorder eventually develop chronic PTSD (Bryant, 2003; Bryant, Moulds, Guthrie, & Nixon, 2005). Criterion A of acute stress disorder is identical to Criterion A of PTSD. Although both disorders require some type of exposure to a traumatic event, there are key differences in required symptoms and their duration (see Table 8.1). First, symptoms needed to make a PTSD diagnosis are listed in categories (i.e., B through E) with specific requirements regarding the number of symptoms needed for each (e.g., Cluster B requires at least one symptom, while Cluster E requires at least two), whereas Criterion B for acute stress disorder requires the presence of any nine symptoms out of the following categories: intrusion, negative mood, dissociative symptoms, avoidance symptoms, and arousal symptoms. For acute stress disorder, the intrusion category provides several ways to note how the individual re-experiences the traumatic event: (B1) re-experiencing the trauma through unwanted, recurring, and intrusive memories of the traumatic event where the memories can be manifested through sensory, emotional, or physiological distress; (B2) re-experiencing the trauma through recurring dreams related to the traumatic event that cause distress. For example, a war veteran could experience recurring nightmares about being shot; and (B3) re-experiencing the trauma through dissociative reactions (APA, 2013). Dissociative reactions, depersonalization, and derealization were discussed in detail in the PTSD section of this chapter. In the minutes and hours after a traumatic event, it is expected that those who have been exposed will be very distressed. To avoid pathologizing strong but normal reactions, a diagnosis of acute stress disorder is not made until at least 3 days after 8 Trauma and Stressor-Related Disorders 187 an event. Dissociative responses that persist beyond 3 days that should be considered include (B4) re-experiencing the trauma through intense or prolonged psychological (e.g., fear, sadness, shame) or physiological (e.g., panic symptoms) distress where the distress is triggered by internal or external cues that resemble those of the traumatic event. The negative mood category (B5) requires that the individual finds it impossible to experience positive state of mind (e.g., intimacy for a sexual violence survivor) or has unremitting negative mood (e.g., sadness, anger, shame) after the trauma. The dissociative symptoms category requires alterations in awareness in the form of (B6) the presence of depersonalization (e.g., the individual does not feel in control of their own reactions, as if looking at oneself from the outside) or derealization (e.g., the individual views the environment differently where shapes change their form or time slowing) and (B7) inability to remember important aspects of the traumatic event (i.e., dissociative amnesia) (APA, 2013). The avoidance symptoms category can be divided into efforts to avoid internal and external stimuli associated with the traumatic event: (B8) efforts to avoid internal stimuli includes refusal to talk about memories about the traumatic event, share thoughts, or feelings (e.g., refusing to use psychological treatment); (B9) efforts to avoid external stimuli associated with the traumatic event include avoidance of going to places or meeting with people that remind the individual of the trauma (e.g., using an elevator after experiencing an assault in an elevator). Individuals with acute stress disorder experience heightened arousal in the form of (B10) sleep disturbance in various forms (e.g., due to nightmares, difficulties sleeping, or waking up during the night with difficulties falling asleep); (B11) angry outbursts or irritability (e.g., anger eruption with no apparent reason or a disproportionate reaction to a trigger; (B12) hypervigilance in the form of heightened sensitivity to potential threats, whether related or unrelated to the traumatic event; (B13) concentration problems including difficulties attending to tasks that require focus or remembering daily events; and (B14) exaggerated startle in response to unexpected stimuli (e.g., jumpiness in response to loud sound) (APA, 2013). Second, the duration of symptoms for each of the two disorders is different. For an acute stress disorder diagnosis, Criterion C notes that symptoms need to be present for at least 3 days but no more than 1 month (APA, 2013). If symptoms are present beyond 1 month, then a diagnosis of PTSD should be considered. Similar to nearly all DSM-5 disorders, the symptoms are expected to result in significant distress or impairment in social, work, and family relationships (Criterion D). In addition, it is always necessary, pursuant to Criterion E, to rule out other causes that could better explain the presence of symptoms, such as substance use, medical conditions, or psychological disturbances such as brief psychotic disorder (APA, 2013). While the DSM-5 views acute stress disorder as a precursor to PTSD and therefore is placed alongside PTSD in the same section (trauma and stress related disorders), the World Health Organization (WHO) takes a different view of acute stress. In the WHO’s 11th edition of International Classification of Diseases (ICD-11, 2018), acute stress is defined as a possible reaction following traumatic event and hence placed under “problems associated with harmful or traumatic events.” 188 O. Lupesko-Persky and L. M. Brown

Moreover, the ICD-11 defines acute stress reaction as “normal given the severity of the stressor, and usually begins to subside within a few days after the event.”

Prevalence of Acute Stress Disorder

Research examining acute stress symptoms was initiated 3 days after the September 11 terrorist attacks. A national telephone survey conducted with 560 adults revealed that events reminding them of the attacks triggered anger (30%), repeated and dis- turbing memories, thoughts or dreams associated with the attacks (16%), difficulties concentrating (14%), sleep-related problems (11%), and irritability or angry outbursts (9%) (Schuster et al., 2001). Overall, 44% of respondents reported experiencing at least one or more symptoms of acute stress (Schuster et al., 2001). The study also found that 50% of women, in comparison to 37% of men, reported substantial stress reactions following the terror attacks (Schuster et al., 2001). Recent studies which measured acute stress disorder’s prevalence can be differentiated by the specific type of trauma the respective samples experienced; Kassam-Adams, Fleisher, and Winston (2009) found that 12% of 334 parents to children with traffic-related injuries met criteria for acute stress disorder. McKibben, Bresnick, Wiechman Askay, and Fauerbach (2008) assessed acute stress disorder among 178 burn victims upon their hospital discharge and found prevalence of 23.6%. In Israel, Yahav and Cohen (2007) examined acute stress symptoms during the “Second Lebanon War,” a time when Israel’s residents were exposed to daily missile attacks. Telephone interviews were conducted with 199 adults living in Jewish and Arab communities. 95.5% of the Jewish Israeli and 100% of the Arab Israeli participants experienced at least one of the four acute stress symptoms: dissociation, re-experiencing trauma, avoidance, and arousal (Yahav & Cohen, 2007). However, only 5.5% of the Jewish participants and 20.3% of the Arab participants met full criteria for acute stress disorder (Yahav & Cohen, 2007). Existing studies on acute stress disorder are primarily focused on evaluating how symptoms of distress evolve over time from acute stress disorder to PTSD and the likelihood of that happening (Isserlin, Zerach, & Solomon, 2008). A study of 157 violent crime victims (i.e., actual or attempted sexual assault or bag snatching) living in England and Wales found that 19% of the participants met criteria for acute stress disorder (as defined in the DSM-III-R), with a nonsignificant trend of higher frequency among women than men (31% vs. 15%, respectively) (Brewin, Andrews, Rose, & Kirk, 1999). Six months later, when 138 of the study participants were reassessed, the researchers found that more acute stress disorder symptoms predicted greater likelihood of developing PTSD. Nearly all of the acute stress symptoms, individually and together, predicted PTSD well over 50% of the time (Brewin et al., 1999). 8 Trauma and Stressor-Related Disorders 189

Adjustment Disorder

Lorenz, Bachem, and Maercker (2016) defined adjustment disorder as “a transient mental health condition occurring after serious but non-traumatic life stressors” (p. 775). Adjustment disorder Criterion A requires an exposure to a stressor. However, while the stressor has to be identifiable, unlike acute stress disorder and PTSD, it does not have to be a traumatic event (e.g., exposure to actual death, threatened death, or severe injury). An infinite number of stressors meet the requirements of Criterion A such as loss of employment, difficulty adjusting to college, or a move to a new city. In addition, the stressor can be experienced as a one-time (e.g., one- time divorce) or a continuing or recurring event (e.g., seasonal business crises). Moreover, the stressor can affect an individual, a community, or an entire country (APA, 2013). Symptoms are required to start within 3 months from the beginning of the stressor and end within 6 months of the onset. The following symptoms are required for meeting Criterion B: (B1) marked distress that is disproportionate to the severity or intensity of the stressor, while taking into account relevant cultural considerations that may impact symptom severity and presentation. In other words, the individual’s reaction to the stressor should exceed “what normally might be expected, when cultural, religious, or age-appropriate norms are taken into account” (APA, 2013, p. 287); (B2) the reaction to the stressor significantly impairs important areas of functioning, whether family, social, occupational, or other (APA, 2013). For example, a person who was in a close relationship and is now going through a difficult breakup spends the next 5 months in solitude, avoids going out with friends, and is not interested in meeting new people. Similar to PTSD and acute stress disorder, the clinician should make sure that the adjustment disorder symptoms do not meet criteria for another disorder that may take precedence such as major depressive disorder (Criterion C). The clinician should also try to identify whether there is any disorder that preceded the stressor (e.g., dysthymia) and whether current symptoms could be an exacerbation of a preexisting disorder. Criterion D requires that the clinician avoids confusing the presenting symptoms with normal bereavement. Criterion E sets a relatively brief time limit, up to 6 months, for presentation of symptoms. If symptoms persist for a period longer than 6 months, other diagnoses should be considered. The following specifiers can be used with adjustment disorder: depressed mood, anxiety, mixed anxiety and depressed mood, disturbance of conduct, mixed disturbance of emotions and conduct, and unspecified (APA,2013 ).

Prevalence of Adjustment Disorder

Relative to PTSD, there is paucity of research on adjustment disorder. It is likely that because of the relatively short span allowed for the disorder’s symptoms, there is less interest in its prevalence. Moreover, in comparison to both PTSD and acute stress disorder, the symptoms of adjustment disorder are nonspecific, vague, and open for interpretation. For instance, after the loss of a family member, one clinician 190 O. Lupesko-Persky and L. M. Brown may consider a highly distressed response as part of normal bereavement, whereas another clinician may view it as marked distress that meets criteria for adjustment disorder. These differing perspectives are less likely when evaluating the presence or absence of symptoms for PTSD or acute stress disorder. The DSM-5 estimates that between 5% and 20% of individuals receiving outpatient mental health care are diagnosed with adjustment disorder (APA, 2013). Other studies report similar findings. Among clients receiving care in an outpatient mental health setting, approximately 10–30% had an adjustment disorder (Ingersoll & Burns, 2001). According to Rundell (2006), the rate of adjustment disorder among US military psychiatric evacuees (i.e., service members evacuated from a foreign country back to the USA due to psychiatric disorders) who participated in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) was 37.6%, a rate which exceeded mood disorders (22.1%). However, a later review of that study suggested that the elevated rate of adjustment disorder could be the result of measurement issues because the screening tool classified depressive symptoms as adjustment disorder (Carta, Balestrieri, Murru, & Hardoy, 2009)

Procedures for Gathering Information

A strong working alliance between the mental health professional and the client is necessary when assessing for mental health problems and working toward achieving treatment goals. This is especially true when assessing for trauma-related disorders because the phenotype of PTSD is often confusing and difficult to identify, as it can be masked or exacerbated by other disorders such as traumatic brain injury, depression, substance use, or anxiety disorder (Ellis & Zaretsky, 2018). In addition, people may not realize they have PTSD because they view their symptoms as a sign that they are having difficulty coping (Ellis & Zaretsky,2018 ). Trauma-related disorders are influenced by biological factors (i.e., genetics), psychological considerations (i.e., emotional and behavioral responses) and social elements (i.e., breadth and depth of the supportive environment) (Damir & Toader, 2014). The foundation of a good therapeutic alliance is a collaborative relationship where an affective bond between the clinician and the client develops and facilitates the process of agreeing on and progressing with selected treatment goals (Lilienfeld, Lynn, & Lohr, 2012). To elicit good information, it is worthwhile taking the time to create a sense of safety so that the client feels comfortable sharing private details about their thoughts, feelings, and behaviors. Ways to establish a therapeutic alliance early on are to express compassion, show a real interest in the client’s concerns, and engage the client as a collaborator in treatment. Client’s collaboration can be obtained through mutually setting goals for treatment, as well as sharing impressions of the treatment and progress. Reviewing with the client the results of their assessments as well as providing psychoeducation has the potential to enhance the therapeutic alliance as it can assuage client’s concerns about the source of their distress and their ability to cope and change. It is incumbent to continue gathering relevant information and monitoring progress at each stage of therapy. 8 Trauma and Stressor-Related Disorders 191

An unstructured interview—a form of interview that does not have a fixed format or require the use of a sequenced set of questions—may provide useful information and help to start a therapeutic alliance. However, structured or semi-structured interviews are recommended as the best method for reaching a well-informed diagnosis (Segal & Williams, 2014). Structured and semi-structured clinical interviews can be used to obtain a client’s history of symptoms and current problems in functioning. Most structured and semi-structured interviews were developed using psychometric approaches that included evaluations of validity and reliability (Segal & Williams, 2014). Using a structured or semi-structured interview with good validity and reliability minimizes the risk of arriving at dissimilar diagnoses between researchers and mental health professionals. When appropriate, it is also important to gather information from collateral sources such as family members, spouses, partners, or close friends as they can shed light on the client’s behavior and current concerns. However, any interviews with a third party should be done with the client’s informed consent. Because of the clinician’s primary legal and ethical responsibility to maintain client’s confidentiality, it is advisable not merely to obtain a client’s verbal consent but also to secure a client- signed release of information (ROI) form. The ROI should detail specific individuals or institutions from whom the clinician can request information or records, the scope of release of information (i.e., what information the clinician can disclose to others), expiration date of the ROI, and the client’s right to revoke the ROI at any time. Such stipulation not only protects the clinician from potential legal problems but also protects the client by clearly informing them of their rights. While interviews are the first step in forming a diagnosis, it is also important to let the client actively participate in the evaluation process. Information from cognitive and mood assessments can inform case conceptualization and guide treatment planning, if the client has given their best effort in responding and is forthcoming when completing measures. Self-report measures, where the client, rather than the clinician, rates their distress levels and endorses the presence and magnitude of various symptoms are the most widely used measurement tools in psychology (Haeffel & Howard, 2010). Indeed, there are a variety of PTSD self-report measures that can be used to identify PTSD symptoms, rate the symptoms’ onset and severity, as well as monitor for any change in diagnosis throughout treatment. Some self-report measures can help both the clinician and client monitor whether the treatment is effective.

Recommendations for Formal Assessment

Structured and Semi-structured Interviews

General Interview: The Structured Clinical Interview for DSM

One of the most widely used semi-structured interviews used to determine a diagnosis is the Structured Clinical Interview for the DSM (SCID). The most recent edition is the SCID-5 (First, Williams, Karg, & Spitzer, 2016), which contains 12 192 O. Lupesko-Persky and L. M. Brown modules that mirror the DSM-5’s organizational structure. The five different versions of the SCID-5 include research version (RV), clinician version (CV), clinical trial (CT), personality disorders (PD), and alternative model for personality disorders (AMPD). Each version is also accompanied by a user’s guide. PTSD, acute stress disorder, adjustment disorder, and other specified trauma and stressor-related disorder are included in Module L of the SCID-5. Psychometric properties of the SCID-5 are not yet available (Vermetten, Germain, & Neylan, 2018). However, in a study by Zanarini et al. (2000), the test-retest and interrater reliability of the SCID-I was tested for the DSM-IV. The study found excellent test-retest reliability for PTSD, alcohol use, and substance use (Test/Retest Kappa = 0.78, 0.77, and 0.76, respectively). Per the SCID-I validity, Rush, First, and Blacker (2008) suggest that more than 85% of patients who showed psychotic symptoms disclosed them during the SCID-I interview. In addition, SCID-IV module for PTSD demonstrated high interrater reliability for lifetime and current diagnoses (Interrater Kappa = 0.94 and 0.87, respectively), as well as strong sensitivity (0.81) and specificity (0.89) when compared with PTSD diagnosis (Vermetten et al., 2018). The length of time to administer the SCID is dependent on the client’s personal history, relevant disorder, as well as other potential comorbid disorders or rule-outs that emerge during an initial interview. Administering the SCID-5 may take between 30 min and 2 h. The SCID uses a combination of mandatory probes with a decision- tree approach. The clinician is expected to use professional judgment and skip irrelevant questions or entire sections of the SCID if criteria has not been met for specific probes. Because the administration of the SCID involves decision-making, it is important that the person administering the SCID be trained to conduct the interview.

General Interview: The Mini-international Neuropsychiatric Interview

The Mini-International Neuropsychiatric Interview (MINI) is a brief structured diagnostic interview for major psychiatric disorders as defined in DSM-III-R, DSM-IV, DSM-5, as well as ICD-10 (Sheehan et al., 1998). The MINI was designed to assess 17 of the most common psychiatric disorders, including PTSD, mania and hypomania, major depressive disorder, panic disorder, agoraphobia, social phobia, substance use disorder, and more (Sheehan et al., 1998). Specifically developed to be brief, administration of the MINI takes approximately15 min, which is significantly shorter than the SCID which at minimum could take 30 min (Sheehan et al., 1998). In addition, the MINI was designed to be used by trained interviewers rather than physicians or mental health professionals (Sheehan et al., 1998). There are more than 15 versions of the MINI, each addressing a different disorder and different population (e.g., adults, children, clinician-rated or patient-version). The most appropriate module for PTSD appears to be the Standard MINI, which assesses all 17 disorders. Psychometrically, the MINI is a sound instrument and aligned with both the SCID-IV and ICD-10 for all 17 disorders. Specifically, the PTSD module shows 8 Trauma and Stressor-Related Disorders 193 significant sensitivity (>0.70) and very good positive predictive value (>0.75). Research also shows that the MINI has excellent interrater reliability (Interrater Kappa = 0.95) and good test-retest reliability (Test/Retest Kappa = 0.73) (Sheehan et al., 1998). The measure has gained popularity among researchers worldwide and has been translated into multiple languages. This measure is useful for research purposes and as a supplemental measure of a more thorough interview, for diagnostic purposes.

General Interview: The Psychiatric Diagnostic Screening Questionnaire

The Psychiatric Diagnostic Screening Questionnaire (PDSQ) (Zimmerman & Mattia, 1999) is a self-administered questionnaire usually provided in outpatient settings. The PDSQ consists 126 questions which cover 13 of the most common DSM-IV Axis I disorders, among them PTSD as well as disorders likely to be comorbid, such as anxiety, depression, and substance use disorders (alcohol and substance use disorders). The PDSQ also maintains a psychosis screen. Administering the measure takes approximately 15 min (Rush Jr et al., 2008) which is much shorter in comparison to both the SCID-5 and the MINI. In addition, while the results (i.e., scores of the questionnaire) have to be reviewed by a mental health professional, scoring the measure can be done quickly by a nonprofessional (Rush Jr et al., 2008). The PDSQ shows moderate to high internal consistency reliability (α = 0.82) as well as good test-retest reliability (r = 0.84). The measure’s validity is also strong: Its convergent validity (i.e., measuring correlation between the scale and other scales measuring the same disorder) was 0.64. The PDSQ also showed strong mean subscale sensitivities in three cut points (80%, 85%, and 90%) as well as specifici- ties (78%, 73%, and 66%, respectively) (Rush Jr et al., 2008).

Trauma-Related Specific Interviews

Clinician-Administered PTSD Scale

Originally developed by Blake, Weathers, Nagy, Kaloupek, Klauminzer, Charney, and Keane (1995), the Clinician-Administered PTSD Scale (CAPS) is one of three measures recently updated by the Veterans Affairs (VA) National Center for PTSD to be aligned with DSM-5 criteria. The CAPS is considered the gold standard of PTSD structured interviews. The CAPS-5 is a 30-item questionnaire (while the prior version included 17 items) which also measures, through a single score, each symptoms’ severity based on its frequency and intensity. There are currently three versions of CAPS-5: past month, worst month/past month and past week. The clinician is expected to use their professional judgment coupled with background information provided by the client to determine which version is most appropriate. 194 O. Lupesko-Persky and L. M. Brown

The CAPS demonstrates strong psychometric properties: It is highly reliable, with strong internal consistency for the individual subscales (α = 0.76–0.88). Joint reliability was particularly excellent among rape and motor vehicle victims (Kappa = 0.84) (Rush Jr et al., 2008). The CAPS also showed to correlate well with other PTSD self-report measures, including the Mississippi Scale (MSS) (r = 0.73), as well as with the Minnesota Multiphasic Personality Inventory PTSD Scale (MMPI-PTSD) (r = 0.74) (Rush Jr et al., 2008). A clinician interested in administering the interview should consider that it takes 45–60 min to administer, which is much longer than other instruments such as the PTSD Symptom Scale-Interview (PSS-I) which takes only 20 min. In addition, because answering the CAPS-5 interview questions can be intense, mental health professionals are expected to complete a 4.5 h training before administering the measure. Training by the Veterans Affairs National PTSD Center can be found on their website. Often it is useful to supplement the CAPS-5 with a trauma-focused assessment like the Life Events Checklist (LEC-5), which measures the frequency and intensity of the client’s exposure to a range of traumatic events (see below for a description of the LEC-5).

PTSD Symptoms Scale Interview

The PTSD Symptoms Scale-Interview (PSS-I) is a semi-structured interview developed by Foa, Riggs, Dancu, and Rothbaum (1993) to obtain a valid and reliable diagnosis of PTSD. The PSSI-5 is an updated version to match the DSM-5 (Foa et al., 2016). Designed as a flexible semi-structured interview, the PSSI requires familiarity with its manual and scoring process, knowledge of PTSD symptomatology, ability to make a differential diagnosis, and sound professional judgment. During the administration of the interview, the clinician must determine which questions can be skipped. The PSSI-5 was developed to assist in diagnosing PTSD as well as provide an estimate of the severity of symptoms using a 5-point scale (from 0 = not at all to 4 = 6 or more times a week/severe). The PSSI has excellent psychometric properties with strong internal consistency (α = 0.89), test-retest reliability (r = 0.87), high interrater reliability for the total severity score (Intraclass Correlation Coefficient = 0.98), and good interrater agreement for PTSD diagnosis (Interrater Kappa = 0.84) (Foa et al., 2016). A cutoff score of 23 for PTSD was determined by a Receiver Operating Characteristic (ROC).

Trauma-Related Self-Report Measures

Life Events Checklist

Developed by the National Center for PTSD, the Life Event Checklist (LEC) is a 17-item self-report measure that is aligned with DSM-5 criteria (Blake et al., 1995). Unlike the majority of PTSD assessments that assess for most recent or current 8 Trauma and Stressor-Related Disorders 195 events, the LEC-5 assesses for potentially traumatic events across the life span. The person is asked if the event happened to them, was witnessed, was learned about from others, or if they are not sure or the event does not apply. The LEC-5 was originally intended to be used co-jointly with the CAPS. In a study by Gray, Litz, Hsu, and Lombardo (2004), the LEC was validated for use as an independent measurement for trauma events. With respect to the LEC’s reliability, the study found that all items except for one achieved a kappa above 0.50, while the test-retest correlation was particularly high (r = 0.82). As for validity, the study found strong convergence between the LEC and the Traumatic Life Events Questionnaire (TLEQ) scale, where only two of the nine items did not achieve a kappa of 0.40 (Gray et al., 2004). It is important to note that while the LEC is mostly useful for identifying traumatic events as defined by PTSD or acute stress disorder, it can also be used to assess severity of symptoms for an adjustment disorder.

PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders

The PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders (PCL) was originally developed by Weathers, Litz, Herman, Huska, and Keane (1993) and later redesigned by Weathers, Litz, Keane, Palmieri, Marx, and Schnurr (2013) to accommodate the DSM-5. It is a 20-item self-report measure used to help make a provisional diagnosis of PTSD and to assess symptoms severity. Respondents are asked to rate, on a scale from 0 (not at all) to 4 (extremely), how bothered they have been by each of the 20 items that correspond with DSM-5 criteria for PTSD. The two versions of the PCL-5—one for civilian and the other for military— are available in two formats, one which includes Criterion A (trauma) and one without. The PCL-5 was not developed as a stand-alone diagnostic tool. It can be used to supplement other, more structured, clinician-rated assessments and is quick and easy for clients to complete. It is also useful for monitoring symptoms over time as the client can easily provide a self-report every few sessions. Psychometric studies of the PCL prior to the DSM-5 version found the instrument to be of high reliability and validity (Keen, Kutter, Niles, & Krinsley, 2008). Blevins, Weathers, Davis, Witte, and Domino (2015) examined the psychometric properties of the current version and found excellent internal consistency (α = 0.94), strong test-retest reliability (r = 0.82), and good convergent and discriminant validi- ties (rs = 0.74–0.85 and rs = 0.31–0.60, respectively). In another study, the PCL-5 similarly showed good internal consistency (α = 0.96) and test-retest reliability (r = 0.84) (Bovin et al., 2016).

The National Stressful Events Survey Acute Stress Disorder Short Scale

The National Stressful Events Survey Acute Stress Disorder Short Scale (NSESSS) is a self-report 7-item measure that assesses the severity of acute stress symptoms among adults (Kilpatrick, Resnick, & Friedman, 2013). All the items on the NSESSS 196 O. Lupesko-Persky and L. M. Brown are aligned with DSM-5 criteria for PTSD (i.e., flashbacks, emotional or psychological distress, detachment, avoidance, hypervigilance, startle response and irritability/anger). The NSESSS is a monitoring rather than a diagnostic assessment tool. It is easy and quick to complete (approximately 5 min) and can be used to monitor progress for clients diagnosed with acute stress disorder. However, mental health professionals should be aware that the instrument addresses symptoms experienced in the past 7 days. Because the NSESSS is a relatively new measure, its psychometric properties are still examined by the American Psychiatric Association. This screener can be reproduced without permission and is available at the American Psychiatric Association’s website.

Case Illustrations

Two vignettes are provided below to illustrate the wide spectrum in which symptoms of trauma-based disorders preside. The first vignette features Erick, a Marine combat veteran, who experiences symptoms of distress following battles he took part in during his military service. The second case vignette is of Lily who also experiences symptoms of emotional and physical distress following a car accident. When reading these vignettes, the reader is encouraged to identify cultural considerations such as gender, race, and family status that can affect symptom presentation. While Erick and Lily’s symptom presentations are vastly different, they both encounter common challenges when processing their respective traumas.

Erick: Marine Combat Veteran

Erick is a 28-year-old male veteran who lives with his wife, Diana, and their 3-year- old daughter. Erick is currently unemployed. Six months ago, he lost his job as a carpenter for a construction company. He decided to attend therapy because his marriage was falling apart, and his wife was threatening to leave if he did not get help. The first session with his clinician was held with both Eric and Diana. During that session, Diana stated she was willing to stay in the marriage only if Erick agreed to receive ongoing mental health treatment. She described Erick as “unbear- able” and indicated that unless he got help and changed his behavior that she would leave the marriage and take custody of their daughter. Diana stated that Erick went from an outgoing and friendly person to increasingly angry—one who is easily provoked and lashes out over his own and other people’s mistakes. He shows little interest in going out with friends or even engaging in fun activities with their daughter. She reported that Erick’s irritability and anger cost him his job as he yelled at his supervisor at work over a remark he made about his work. After the first session, Erick attended the next three sessions alone. The clinician learns Erick enlisted in the Marines at age 22 and has served in multiple tours of 8 Trauma and Stressor-Related Disorders 197 war. He has had four deployments to Afghanistan and Iraq. He shares with you that during his last month in Iraq, an improvised explosive device detonated next to his jeep, and he witnessed the death of his commander. Erick was also injured and was honorably discharged from the Marines several months later. He has a Veterans Affairs 30% service-connected physical disability. Eric describes ongoing difficulty with his sleep manifested through waking up multiple times during the night. When pressed, Eric shares a recurring nightmare he has, where his direct commander, all bloody and injured, tries to reach out and grab him. Eric admits to being reluctant to talk about his experiences in Iraq with anyone, stating “It’s not going to do me any good…I have to be strong for my family and just move on…that is what a man supposed to do.” Erick admits to being more irritable with others and shares with you his regret for lashing out at his 3-year-old several times “over nothing.” He also reveals to you that he smokes marijuana twice a week to “calm down my nerves” when his wife is at work and his daughter is at day care.

Lily: Car Accident Survivor

Lily is a 30-year-old single female, who works as a psychiatric nurse at a university teaching hospital. Three months ago, Lily was involved in a serious car accident where she suffered minor injuries. She reported that her life has not been the same since her accident. Lily reports that the night of the accident she went out with two girlfriends, Susan and Marry, to a bar after work. Susan offered to be the designated driver. However, during the course of the evening each of the girls had several drinks. On the way back from the bar, Susan ran a red light and crashed into the car of an elderly couple. While the girls were not seriously injured, the elderly couple died instantly. Since the accident, Lily describes having recurring memories of the accident at different times during the day. These memories include screaming and images of the dead elderly couple as they were moved from their car into the ambu- lance. Lily also described experiencing heart palpitations and sweaty palms whenever she drives or is a passenger in a car. As a result, Lily avoids traveling in a car and has started using public transportation. This has increased her daily commute time to the hospital from 20 min to over an hour each morning. Lily blames herself for the accident and feels responsible for the death of the elderly couple stating, “I should not have let Susan drive… if I was at the wheel this accident would not have happened.” Feeling angry, guilty, and ashamed, Lily cut contact with Susan and Marry. She refuses to go out to meet her friends or go out on dates. Since the accident, Lily describes difficulties falling asleep and intrusive memories of the crash. After she mistakenly administered the wrong medication to a patient in the hospital, Lily realized that she should seek help. 198 O. Lupesko-Persky and L. M. Brown

Comment on Cases

While both Erick and Lily might meet criteria for the same disorder (PTSD), the symptoms they experience are significantly different, if not opposite. Erick copes with his distress through external behaviors such as irritability toward others and substance use. Lily, on the other hand, does the opposite—she experiences shame and self-blame as well as physical sensations (i.e., heart palpitation). While the presentations of their symptoms are vastly different, both of these presentations embody a dysfunctional way of processing the trauma which impacts their respective important areas of life: For Erick, it is his relationship with his family and quality of life (e.g., sleep), while for Lily it is her relationship with her friends as well as quality of life (e.g., spending 2 h on the bus daily while she could have spent 40 min).

Impact of Culture, Sex, Race, Age, and Other Aspects of Diversity

Culture informs the psychological process. It is an imperative factor that should be considered by the clinician from the diagnostic phase and throughout treatment. The perception of culture usually refers to race or gender. However, culture can be defined around common themes such as age, religion, social standing, education, financial resources, or veterans’ status. Culture is complex and multi-faceted. For example, an individual may define herself as Hispanic, female, veteran, and Catholic. She belongs to multiple cultural groups, rather than just one. Multiple cultural identities may play a significant role in an individual’s comprehension, understanding, and presentation of their mental health symptoms as well as influence the treatment process and outcomes. Mental health professionals are responsible for being knowledgeable and sensitive to cultural considerations and their potential impact on assessment, case conceptualization, and treatment. Cultural competency is especially relevant when providing treatment for trauma-related disorders: While the self-cognition (e.g., “who I am”) of individuals from independent cultures (e.g., the USA or Europe) who experienced trauma is significantly defined by the trauma, it is much less so for individuals who experienced trauma from interdependent cultures (e.g., South America or Southeast Asia) (Jobson & O’Kearney, 2008). These findings are both theoretically and clinically important. Theoretically, the findings highlight how the perception of trauma is influenced by social norms. Clinically, the findings buttress the existing recommendation that mental health professionals strive to be culturally competent (i.e., knowledge, skills, and attitude). 8 Trauma and Stressor-Related Disorders 199

Gender and Age

Ample research suggests a positive correlation between gender, age, and posttraumatic symptoms. In fact, a meta-analysis of 77 studies revealed that both the risk of experiencing traumatic events and endorsing PTSD symptomatology were significantly associated with being female, younger, and lower social class status (Brewin, Andrews, & Valentine, 2000). A later study by Ditlevsen and Elklit (2010) supported these findings in a sample of 6548 Nordic people using the Harvard Trauma Questionnaire-Part IV (HTQ-IV). The study found that 27.5% of female and 13.8% of men endorsed PTSD symptoms (Ditlevsen & Elklit, 2010). In other words, the findings from this study suggest that women were twice as likely as men to endorse PTSD symptoms after a traumatic event. In addition, women of all ages had higher HTQ scores than men. Research also indicates that PTSD has different developmental trajectories for men and women (Ditlevsen & Elklit, 2010; Reynolds, Pietrzak, El-Gabalawy, Mackenzie, & Sareen, 2015). Overall, multiple studies suggest that PTSD prevalence is lower among both men and women in late life (Brewin et al., 2000; Ditlevsen & Elklit, 2010; Reynolds et al., 2015). However, men showed a decline in HTQ scores in their 40s and a lowest potential for PTSD risk in their 60s to mid-80s (Ditlevsen & Elklit, 2010). In the late 1980s to 1990s, higher rates of PTSD were evident for men (Reynolds et al., 2015). Among women, a decrease in PTSD symptoms occurred a decade later than men (Ditlevsen & Elklit, 2010) and continued to decline steadily into late life (Reynolds et al., 2015).

Racial and Ethnic Minorities

In general, studies indicate that racial and ethnic minorities experience more mental health diagnostic inaccuracies as well as disparities in treatment when compared to their White counterparts (Fortuna, Porche, & Alegría, 2009; Samnaliev, McGovern, & Clark, 2009). Do these findings also apply to PTSD diagnosis and treatment among US minorities? The answer seems to be at least partially positive. Data from a structured diagnostic interview administered to 34,653 adults revealed that minorities reported lower exposure to traumatic events in comparison to Whites (Roberts, Gilman, Breslau, Breslau, & Koenen, 2011). However, the lifetime prevalence of PTSD was found to be highest among African Americans (8.7%) in comparison to Whites and Hispanics (7.4% and 7.0%, respectively) and lowest among Asians (4.0%) (Roberts et al., 2011). The relatively high prevalence of lifetime PTSD among Blacks may be explained by factors such as discrimination, racial stigmatization and racial-based abuse, as well as lower socioeconomic conditions (Roberts et al., 2011). While Blacks are at greater risk for developing PTSD than Whites or other minorities, they are less likely to seek and receive mental health treatment for their trauma. Only 35.3% of Blacks with PTSD symptoms sought any type of 200 O. Lupesko-Persky and L. M. Brown treatment (e.g., physician or psychologist) versus 53.3% of Whites with similar symptomology (Roberts et al., 2011). Also, only 42% of Hispanics and 32.7% of Asians sought any form of treatment for the disorder. The comparatively low percentage of minorities using mental health treatment for their PTSD symptoms can be explained by a number of factors such as negative mental health stigma, cultural beliefs, poor quality or limited availability of resources, and racism or bias in treatment settings (Conner et al., 2010). A recent study also found a significant negative association between stigma and mental health treatment among American Middle Eastern (i.e., Arab or Israeli) (Clement et al., 2015). Additional explanations, other than stigma, for lower percentage of treatment seeking and use among minorities can be attributed to socioeconomic issues (e.g., health insurance plan with coverage for adequate mental health treatment) and knowledge (e.g., education about the options available).

Sexual Minority Adults

Lesbian, gay, bisexual, transgender, queer (LGBTQ) people living in the USA are more likely to encounter sexual abuse, crime, verbal harassment, and various types of discriminations in comparison to their heterosexual counterparts (Herek, 2009; Rothman, Exner, & Baughman, 2011). The higher likelihood of victimization explains why sexual minorities also have higher risk for PTSD (Roberts, Austin, Corliss, Vandermorris, & Koenen, 2010). In a large study of 34,653 noninstitution- alized adults living in the USA, Roberts, Austin, Corliss, Vandermorris, and Koenen (2010) found that the PTSD prevalence among (self-defined) gay and bisexual men who were exposed to a potentially traumatic event was 13.38% and 9%, respectively, in comparison to 5.03% among heterosexual men with no same-sex attractions or partners. The study also found that PTSD prevalence among lesbian and bisexual women was 18.04% and 25.68%, respectively, in contrast to 12.50% among heterosexual women without same-sex attractions (Roberts et al., 2010). These differences in rates for gay, lesbian, bisexual, and heterosexual people are consistent with findings reported by earlier studies (Gilman et al., 2001; Herek, Gillis, & Cogan, 1999). Mental health professionals should be aware that new patients may be reluctant to disclose their sexual orientation for a variety of reasons. A recent study found that only a third (33%) of gay, lesbian, and bisexual veterans who used Veterans Health Care Administration (VHA) services were willing to disclose personal information about their sexual orientation (Simpson, Balsam, Cochran, Lehavot, & Gold, 2013). A significant number of the sample reported avoiding using at least one (25%) or two or more (15.4%) VHA services despite their need for treatment due to fear of stigmatization (Simpson et al., 2013). 8 Trauma and Stressor-Related Disorders 201

The Armed Forces

Post-traumatic stress disorder and other trauma-related disorders have been extensively studied among military service members and veterans returning from war. Violent combat exposure has been associated with serious mental illnesses such as post-traumatic stress, depression, substance use, and risk for death by suicide (Boscarino, 2008; Prigerson, Maciejewski, & Rosenheck, 2002). Recent US military Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) research examining the prevalence of PTSD among service members and veterans post deployment found a strong positive correlation between participation in battle and PTSD (Ramchand et al., 2010). A meta-analysis of 22 studies examining PTSD and other trauma-related disorders among service members returning from OEF and OIF found significant variability in rates for PTSD (Ramchand et al., 2010) ranging from a high of 60% among Army National Guard soldiers serving in Iraq (Stecker, Fortney, Hamilton, & Ajzen, 2007) to a low of 1.6% among Marines serving in Iraq and Afghanistan (Larson, Highfill-McRoy, & Booth-Kewley,2008 ). While the prevalence of PTSD varied among the studies, there were additional studies where service members completed Department of Defense (DoD) Post Deployment Health Assessment questionnaires within 2 weeks of returning home from service in Iraq. These studies estimated that PTSD rates were approximately 10% (Hoge, Auchterlonie, & Milliken, 2006; Milliken, Auchterlonie, & Hoge, 2007). However, Ramchand, Karney, Osilla, Burns, and Caldarone (2008) also reported that reassessment of same participants 6 months after their return from Iraq showed higher PTSD rates. Possible explanations for this increase could be underreporting of symptoms or gradual development of symptoms when reintegrating into society (Ramchand et al., 2008). Studies have also found a positive correlation between trauma and health-related problems. Specifically, chronic PTSD was associated with heart disease, as well as with increased risk of developing inflammatory and autoimmune diseases (Boscarino, 2006; Boscarino, 2008). To summarize, while PTSD and trauma-related disorders are extensively studied among the service members and veterans, there is still a lot more to learn. Although different studies often produce different or conflicting results, sometimes due to the use of different measures, the sample studied, or the duration of the study (e.g., single or multiple time points), it is evident that service members and veterans are at higher risk for PTSD than the civilian population.

Integrating Cultural Considerations into Case Conceptualization

Cultural awareness should be a standard part of clinical practice. Learning about your client’s race/ethnicity, primary language, sexual orientation, religious beliefs, and military service are all necessary for case conceptualization and treatment 202 O. Lupesko-Persky and L. M. Brown planning. Familiarity with recent research concerning the client’s culture and potential idioms of distress is also recommended. The client’s sex and gender can influence reporting of symptoms. For example, a study found that men who worked in high-stress jobs, such as firefighters, tend to underreport symptoms of trauma (Skeffington, Rees, Mazzucchelli, & Kane,2016 ). Similarly, women refugees from Southeast Asian descent were likely to underreport symptoms of trauma resulting from rape because of stigma and shame (Yang et al., 1989). The DSM-IV (APA, 1994) was the first to introduce the Outline for Cultural Formulation (OCF) in 1994 with the purpose of helping clinicians organize and integrate cultural considerations of their clients into case formulation (Lewis-Fernández et al., 2014). The OCF was revised into a semi-structured interview format and included in the DSM-5 Cultural Formulation of Diagnosis (APA, 2013). The purpose of the CFD is to operationalize the process of cultural considerations as part of the case formulation (Lewis- Fernández et al., 2014). More psychometrically sound assessment tools are needed to detect cultural considerations that should be integrated into diagnosis and treatment.

Information Critical to Making a Diagnosis

Comorbid Disorders

When evaluating a client for a PTSD diagnosis, it is often the case that symptoms stemming from other disorders are also endorsed (Kessler et al., 1995). Disorders that occur conjointly with PTSD are known as comorbid disorders. Comorbid disorders may start prior to onset of PTSD symptoms, appear concurrently, or after PTSD symptoms are evident. Multiple studies have identified several disorders that are likely to appear comorbidly with PTSD, either as a primary or secondary disorder (Courtois & Gold, 2009; Perkonigg et al., 2000). A landmark study by Breslau, Davis, Andreski, and Peterson (1991) identified the rates of PTSD-comorbid disorders as agoraphobia (21.5%), drug abuse or dependence (21.5%), alcohol abuse or dependence (31.2%), major depression (36.6%), and any substance abuse or dependence (43.0%). Notably, being diagnosed with PTSD significantly increases the likelihood (82.8%) of being diagnosed with a second disorder (Breslau et al., 1991). Other studies have reported similar findings (Kessler et al.,1995 ; Perkonigg et al., 2000). Research also suggests that there is a significant positive correlation between PTSD and suicide. Sareen, Cox, Stein, Afifi, Fleet, and Asmundson2007 ( ) found that 20% of the study participants who were diagnosed with PTSD also endorsed suicidal ideation, and 6.5% reported that they had attempted suicide during the past year. 8 Trauma and Stressor-Related Disorders 203

Disorders Masking PTSD Symptoms

A disorder that shares similar symptomatology with PTSD (e.g., substance abuse, depression) could mask the presence of PTSD (Ellis & Zaretsky, 2018). Symptoms that are masked can result in an incorrect or partial diagnosis of PTSD and lead to the use of a wrong pharmacological or psychological treatment. When making a differential diagnosis, Wilson and Keane (2004) recommend considering (1) pre- morbidity (i.e., review the client’s psychiatric history to determine presence of a preexisting disorder; (2) possible history of substance use prior to or after the traumatic event; (3) specific changes in personality and behavior prior to or after the traumatic event; (4) type of interaction between premorbid disorder, traumatic event, and PTSD—to better understand how the premorbid condition could influence presentation of PTSD symptoms; and (5) need for multiple diagnoses, when warranted, if necessary as PTSD can coexist with other disorders.

Emerging Issues: Complex PTSD, Complicated Grief, and Moral Injury

Complex PTSD is defined as “exposure to an event or series of events of an extremely threatening or horrific nature, most commonly prolonged or repetitive events from which escape is difficult or impossible (e.g., torture, slavery, genocide campaigns, prolonged domestic violence, repeated childhood sexual or physical abuse)” (ICD-11, 2018). While the term is not formally acknowledged as a disorder in the DSM-5, it is officially included in ICD-11 as a disorder. Because of the trauma’s unique characteristics, there is also a growing body of research evaluating psychotherapies for effectiveness in treating Complex PTSD (Cloitre et al., 2011; Courtois & Gold, 2009). Complicated grief is an extreme and continuous form of bereavement marked by severe distress in daily functioning. Complicated grief is associated with stress- related disorders because of mutual symptoms such as avoidance of thoughts about deceased, survivor guilt, social detachment, hallucinations, and somatization (Horowitz et al., 2003; Prigerson et al., 1995). These symptoms, in addition to preoccupation through thoughts and behavior related to the deceased’s passing, predict long-term dysfunctionality (Prigerson et al., 1995). According to van Denderen, de Keijser, Stewart, and Boelen (2018), 10–15% of bereaved individuals experience chronic grief symptoms in the first year after a significant loss. Horowitz et al., (2003) described symptoms of complicated grief as (1) intrusive symptoms such as (a) unbidden memories or intrusive fantasies related to the lost relationship, (b) strong spells or pangs of severe emotion related to the lost relationship, (c) distress- ingly strong yearnings or wishes that the deceased were there and (2) signs of avoidance and failure to adapt that include (a) feelings of being far too much alone or 204 O. Lupesko-Persky and L. M. Brown personally empty, (b) excessively staying away from people, places, or activities that remind the subject of the deceased, (c) unusual levels of sleep interference, and (d) loss of interest in work, social, caretaking, or recreational activities to a maladaptive degree (Horowitz et al., 2003). Despite the fact that it is not included in the DSM as a disorder, multiple studies have been conducted examining the characteristics of complicated grief as well as potential treatments. Moral injury is a fairly new concept that was developed to describe psychological distress that is experienced by an individual and results from an event where one’s actions are not aligned with their morals. Shay (2014) defined moral injury as: (a) “A betrayal of what’s right; (b) By someone who holds legitimate authority (e.g., commander in the military) (c) In a high stakes situation” (p. 183). Moral injury is not yet included in the DSM possibly because its specific symptoms (i.e., the individual experiences distress, severity of distress) need to be clarified. Moreover, some have questioned whether there is a substantial difference between moral injury that is not captured by PTSD symptom criteria, other stress-related disorders, or even depression. However, it is possible that treatments that may work for PTSD (e.g., exposure therapy) or depression (e.g., psychodynamic therapy), may not be effective with moral injury (Litz et al., 2009). While PTSD without additional issues such as impulsivity or substance use does not significantly increase risk for harm to self (i.e., suicide) or harm to others (i.e., homicidally), moral injury has been shown to increase risk for suicidal thoughts and behaviors (Shay, 2014).

Malingering

The definition of malingering in the context of trauma-related disorders refers to “the intentional exaggeration or production of feigned physical/psychological symptoms of PTSD in order to obtain some external reward (i.e., avoiding criminal responsibility, compensation, attention” (Peace & Masliuk, 2011). Studies suggest that malingering or exaggeration of PTSD symptoms by veterans is more likely when disability compensation is involved (Freeman, Powell, & Kimbrell, 2008; Richardson, Frueh, & Acierno, 2010). The possibility of malingering reinforces the importance of administering a structured interview, along with other relevant evidence-based assessments that measure exaggeration and can serve to corroborate the presence of symptoms, such as the Minnesota Multiphasic Personality Inventory (MMPI-2). Some consider malingering a maladaptive call for help. People who are feigning or exaggerating symptoms are likely feeling psychologically, financially, and/or socially distressed and would benefit from treatment to help manage their concerns and promote adaptive coping. 8 Trauma and Stressor-Related Disorders 205

Dos and Don’ts

• Do develop a therapeutic alliance, that is, a relationship built on trust that is used for the benefit of the client. The clinician’s efforts to build that relationship should take place during the first session and continue throughout treatment. While building rapport is a long-term process, its benefits can be immediate and demonstrated by the client being able to honestly and openly disclose information, collaborate and give best effort in completing assessments, and engage in treatment. • Do set aside an appropriate amount of time for giving an unstructured and (semi) structured interview before administering assessments, making a diagnosis, and proceeding with treatment. During the interview, conduct an informal mini mental status exam by being attuned to verbal descriptions, nonverbal body, and facial expressions (e.g., sadness, anger), motor activity (e.g., slow or fast motions), and affect (i.e., is it congruent with the client’s stated mood?). • Do explain to the client the process of diagnosis, assessment, and treatment before you begin therapy. Providing informed consent at the start of therapy can help alleviate client’s fears by addressing concerns, as well as setting expectations. It is also important to “check-in” with the client throughout the intake and diagnosis process to see if they have questions or clarification. • Do explore cultural considerations by reading relevant research and by consulting with experienced clinicians. Be aware of culturally prescribed “idioms of distress” (e.g., somatization and under- or overreporting of symptoms), as well as your own cultural bias and how it could impact the therapeutic process. • Do use structured interviews, standardized assessments, self-report measurements, and evidence-based treatments throughout therapy. Scientifically supported assessments and therapies have shown high rates of success (Norcross & Wampold, 2011). A description of evidence-based therapies for DSM-5 disorders can be found on the American Psychological Association’s Division 12 (Society of Clinical Psychology) website. • Do inquire about past and present substance use as research shows very high comorbidity between PTSD and substance abuse. When inquiring about substance use, it is useful to learn about the type, frequency, amount, and duration of substance(s) used. • Do always inquire about past and present suicidal or homicidal ideation as research shows a significant positive correlation between PTSD symptoms and suicide (Boscarino, 2008; Prigerson et al., 2002; Sareen et al., 2007). Should the client endorse suicidal ideation, proceed by exploring whether such ideation is passive (e.g., wishing to disappear) or active (e.g., “I want to kill myself”). If active ideation is present, ask if there is a specific plan in place (e.g., use of a gun, medication overdose), and the seriousness and lethality of the intention (e.g., highly unlikely to highly likely). As appropriate, collaboratively develop a plan for the client to remain safe (i.e., suicide safety plan). Consult with an experienced colleague regarding your assessment of risk and the adequacy of the safety plan. If needed, discuss hospitalization. 206 O. Lupesko-Persky and L. M. Brown

• Don’t rush the client into revealing the details of their trauma during the initial stages of therapy. While a diagnosis of PTSD or ASD requires that specific factors pertaining to a traumatic event are established for meeting Criterion A, consider discussing the traumatic event but be attuned to the dynamics in the room. Does the client independently and voluntarily share any of the details about their traumatic event? If not, it may be preferable to obtain necessary details once treatment commences, when the therapeutic alliance is better established. • Don’t avoid making a comorbid diagnosis when warranted. Because of the high prevalence of PTSD with mood disorders, it is important to ascertain if the client has symptoms of a mood disorder. If yes, it is important to identify the severity of the symptoms using appropriately normed, evidence-based assessments. The diagnosis would inform case conceptualization and could influence the type of psychotherapy selected. • Don’t follow pseudoscience or use non-substantiated techniques when treating PTSD. Use a well-established evidence-based treatment such as Prolonged Exposure Therapy (PET), Cognitive Processing Therapy (CPT), or Eye Movement Desensitization and Reprocessing (EMDR). Read about each modality and use the one that is best for your client.

Summary

Moving trauma and stress-related disorders into a chapter of their own in the DSM-5 was a significant step indicating that the etiology of these disorders was stress, rather than mood. The pain and suffering resulting from PTSD reflect a way of processing the trauma, albeit in a dysfunctional way. Trauma and stress-related disorders are complex, multi-faceted, and often more challenging to diagnose than depression or anxiety. Different people can endorse completely different symptoms (e.g., hyperarousal vs. avoidance, anger vs. shame), and different comorbid disorders (e.g., depression vs. substance use), and still meet DSM-5 criteria for a PTSD diagnosis. In the past two decades, we have witnessed a growing body of research on scientifically supported psychotherapies for PTSD such as EMDR, PET, and CPT. These psychotherapies are now considered first-line treatments for PTSD. The diagnosis and treatment of such disorders require well-trained and skilled mental health clinicians who possess working knowledge about trauma disorders and use evidence-based practices.

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Leilani Feliciano, Amber M. Gum, and Katherine A. Johanson

Mood disorders are among the most commonly seen psychiatric disorders, occurring in about 20.8% of the general population (lifetime prevalence rate) (Kessler et al., 2005) and up to 37.4% in late life populations (Luppa et al., 2012). They are found among adult, child, and older adult populations and cut across racial, ethnic, and socioeconomic groups. Mood disorders are costly not only to the individual in terms of emotional suffering and physical distress but also to families (e.g., disrupted household routine and economic burden) and society. In fact, in 2017, the World Health Organization reported that depression is now considered to be the most disabling condition in the world, representing the leading cause of disability. Depression is noted to account for 7.5% of all years lived with a disability (WHO, 2017b). In addition, of all mental health disorders, mood disorders are responsible for the highest suicide risk in more developed countries (Nock et al., 2008).

Description of the Disorders

Depressive disorders, as described by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013), share symptoms that affect mood (e.g., feelings of sadness), cognition (e.g., difficulty concentrating), and physical being (e.g., psychomotor agitation) and that are severe enough to cause distress or disrupt daily functioning. Previously, the DSM-IV-TR

L. Feliciano (*) · K. A. Johanson University of Colorado, Colorado Springs, CO, USA e-mail: [email protected] A. M. Gum Louis de la Parte Florida Mental Health Institute University of South Florida, Tampa, FL, USA

(APA, 2000) grouped depressive disorders with bipolar and related disorders, which have since been separated in the DSM-5 to reflect a desire “for clustering of disorders based on known pathomechanisms” (Sachdev, Mohan, Taylor, & Jeste, 2015: p. 4). The new category of depressive disorders includes the following specific disorders: disruptive mood dysregulation disorder, major depressive disorder (including major depressive episode), persistent depressive disorder, premenstrual dysphoric disorder, substance/medication-induced depressive disorder, depressive disorder due to another medical condition, other specified depressive disorder, and unspecified depressive disorder (APA, 2013). Each is discussed next.

Disruptive Mood Dysregulation Disorder

Disruptive mood dysregulation disorder (DMDD) was developed for and included in the DSM-5 (APA, 2013) as a means of reducing diagnoses of bipolar disorder in children, as these symptoms usually evolve into depressive or anxiety disorders with increasing age, whereas they typically do not evolve into bipolar disorder. DMDD is marked by chronic and severe irritability as evidenced by persistent anger and irritable mood interspersed with frequent outbursts. Symptom criteria include repeated verbal or physical outbursts, occurring approximately three times per week, which represent behaviors above and beyond what is merited by a given situation. Further, the outbursts must occur outside of typical levels of development. Associated moods are otherwise consistently irritable day-to-day and readily evident to others (APA, 2013). Symptoms must occur for at least 12 months without gaps larger than 3 months in symptom presence (APA, 2013). Moreover, the symptoms must occur in multiple (a minimum of two) settings with at least one setting in which symptoms are severe. The onset of symptoms must occur before age 10, and initial diagnosis must be made between the ages of 7 and 18 years. Importantly, there must be no evidence of manic or hypomanic episodes, which is used to differentiate symptoms of DMDD from symptoms of bipolar I disorder. As with other DSM-5 disorders, other diagnoses, including major depressive disorder, must not better account for the outbursts and irritable mood, and neither substance use nor physical conditions may be responsible for the behaviors associated with DMDD. Oppositional defiant disorder, another pediatric psychiatric disorder, is highly comorbid with DMDD (APA, 2013). Upward of 5% of children from clinical samples display the primary DMDD feature of persistent irritability, and the estimated 3-month prevalence rate of DMDD in a community sample ranged from 0.8% to 3.3%, with 1% meeting full criteria (APA, 2013; Copeland, Angold, Costello, & Egger, 2013). DMDD is most frequently diagnosed in early childhood and affects preschoolers the most (Copeland et al., 2013). Grau et al. (2018) estimated the German population prevalence rate at 0.50% among adults, supporting the finding that DMDD decreases in prevalence with age. Lastly, greater rates of DMDD are predicted in boys (vs. girls) and younger children (vs. adolescents) (APA, 2013). 9 Depressive Disorders 215

Major Depressive Disorder

Given its wide prevalence and clinical severity, major depressive disorder (MDD) is the prototype of depressive disorders and is marked by a major depressive episode (MDE), a distinct period of change in emotional and/or physical functioning lasting a minimum of 2 weeks (APA, 2013). In addition to low mood (sadness) or decreased pleasure or interest in usual activities (anhedonia), at least four other symptoms related to changes in weight, sleep, physical movement, energy level, feelings of worthlessness or guilt, ability to concentrate, and/or thoughts about death or suicide (either thoughts or attempts) must be present to fulfill criteria for an MDE (see Table 9.1). These symptoms must result in personal distress or otherwise substantially affect one’s ability to perform important activities, such as work. Lastly, the symptoms may not be caused by a substance or physical/medical problem. Additional criteria for MDD include that the disorder cannot be better accounted for by other disorders (e.g., schizophrenia or psychotic disorders) or evidence of manic or hypomanic episodes (which are more characteristic of a bipolar disorder) (APA, 2013).

Table 9.1 DSM-5 symptoms of depressive disorders for differential diagnosis Persistent depressive Major depressive disorder disorder (dysthymia) Premenstrual dysphoric disorder At least five symptoms Depressed mood must be Mood changes must begin 1 week must be present and last a present and last a majority of pre-menses and improve by 1 week majority of the day for the day for most days for at post-menses and be present for most most days for at least least 2 years, AND at least menstrual cycles within the past year. 2 weeks: two symptoms must be A minimum of five symptoms must 1. Depressed mood present: be present, including at least one 2. Anhedonia 1. Appetite change from A and one from B: 3. Substantial weight or (overeating or reduced A. Mood symptoms appetite change appetite) 1. Labile affect 4. Changes in sleep 2. Changes in sleep (e.g., 2. Anger or irritability (e.g., insomnia or insomnia or 3. Depressed mood or hypersomnia) hypersomnia) hopelessness 5. Observable agitation 3. Changes in energy level 4. Anxiety or tension or retardation of (e.g., fatigue) B. Additional symptoms motor movements 4. Lowered self-esteem 1. Reduced interest in activities 6. Changes in energy 5. Difficulty concentrating 2. Problems concentrating level (e.g., fatigue) or making decisions 3. Low energy 7. Experience of 6. Experience of 4. Appetite change or food worthlessness or hopelessness cravings feelings of guilt Major depressive disorder 5. Changes in sleep (e.g., 8. Difficulty criteria may also be met insomnia or hypersomnia) concentrating or throughout the course of 6. Feeling lack of control or making decisions PDD being overwhelmed 9. Thoughts of death or 7. Physical changes (e.g., suicide (ideation or bloated) attempt) Note: Adapted from the DSM-5 (APA, 2013) 216 L. Feliciano et al.

MDD must be differentiated from normal feelings of bereavement or grief in response to losing a significant other, losing physical ability following a medical condition, etc. Symptoms associated with MDD may certainly overlap with those of grief and bereavement (e.g., changes in appetite or weight), yet MDD can only be diagnosed if an MDE is /has been established. Given the prevalence of bereavement in late life, clinicians and researchers should take care not to misdiagnose intense grief reactions as MDD in older adults (Wakefield & First,2012 ). Thus, it is essential to approach diagnosis holistically and in consideration of personal history and relevant cultural factors (APA, 2013). MDD can be classified based on severity, recurrence, presence of psychosis, and level of remission (APA, 2013). Mild, moderate, or severe specifiers are assigned based on the number of symptoms present and the degree to which they impair functioning. For example, mild MDD is present if the minimum number of criteria is met, functional ability is not significantly disrupted, and impairment is small but controllable. Moderate and severe MDD are present when more symptoms are endorsed, symptoms are increasingly distressing, and impairment is significant. Recurrent episodes of MDD may be present if criteria are met for subsequent episodes occurring at least 2 months apart. MDD with psychosis can also occur in which someone experiences hallucinations and/or delusions in addition to symptoms of MDD. Psychosis during MDD is usually a sign of severity of the presentation. Remission status is based on the number of criteria present following diagnosis of MDD; specifically, one is in partial remission if symptoms have decreased or been absent for less than 2 months and in full remission in the event of a 2-month period of symptom absence. Lastly, MDD can further be associated with mixed, melancholic, or atypical features; anxious distress; catatonia or peripartum occurrence; mood-congruent or incongruent features; or seasonal onset (APA, 2013). These specifiers allow for recognition of symptoms occurring on a continuum and allow for more detailed assessment of the additional symptoms (e.g., with anxious distress can lead to further assessment of anxiety symptoms; Sachdev et al., 2015). According to the American Psychiatric Association (APA, 2013), the yearly prevalence of MDD is 7% and is highest among young adults and women, as typical onset occurs during puberty or adolescence. Using a population-based sample of Swiss adults, Vandeleur et al. (2017) estimated a lifetime prevalence rate of 28.2% for MDD and also demonstrated higher rates of depressive disorders (including MDD) among women than men. In addition to gender, the prevalence of MDD also varies by ethnicity, such that African Americans and Whites are equally likely to experience MDD whereas Asian Americans are less likely to report MDEs. With regard to the Hispanic or Latina/Latino population, immigrants are less likely to experience depression than American-born Hispanics or Latina/Lantinos (Jackson- Triche et al., 2000). MDD differentially affects those within different settings. For example, relative to the general population, people living in nursing home or long-term care settings, patients in medical settings (especially those with chronic illness), and palliative care recipients are more likely to meet criteria for MDD (Feliciano, Renn, & Segal, 2018; Seitz, Purandare, & Conn, 2010). Lastly, according to the World Health 9 Depressive Disorders 217

Organization (2017a), MDD is the primary source of disability worldwide in countries of middle income and high income, which poignantly describes the pervasive impact of this disorder on functioning and well-being.

Persistent Depressive Disorder (Dysthymia)

Persistent depressive disorder (PDD), otherwise known as dysthymia, reflects the combination of previous edition DSM disorders, including dysthymic disorder and chronic major depressive episode (APA, 2013). PDD symptom criteria require at least a 2-year duration of consistently low mood as well as two additional symptoms related to changes in appetite, sleep, self-esteem, ability to concentrate, energy level, or the experience of hopelessness (see Table 9.1). These symptoms cannot be absent for longer than 2 months throughout the depressive span, reflecting the chronicity of PDD. Further, during the period in which PDD occurs, it is possible for one to also meet criteria for MDD (with persistent major depressive episode) (APA, 2013; Sachdev et al., 2015). Like other mental disorders, the constellation of symptoms for PDD may not be the result of substances or physical or medical problems or be attributable to symptom profiles of other mental disorders (e.g., schizoaffective disorder), nor may there be evidence of manic or hypomanic episodes. The client must never have met symptom criteria for cyclothymic disorder, in which depressive and hypomanic episodes are present within a 2-year period. Lastly, symptoms of PDD must cause personal distress or significantly affect one’s ability to function in important life arenas. Similar to MDD, PDD can be qualified with specifiers, severity ratings, remission level, age of onset, and degree of presence of MDEs (e.g., persistent, intermittent; APA, 2013). According to the APA (2013), the annual prevalence rate of PDD is low, estimated at 0.5% in the United States. Vandeleur et al. (2017) demonstrated a lifetime prevalence rate of PDD at 18%, with higher rates among women (22.9%) than men (12.5%) in a population-based study. With regard to specifiers, the lifetime prevalence was estimated at 15.2% for PDD with persistent MDE, 0.4% for PDD with intermittent MDE, and 2.5% for PDD with pure dysthymia.

Premenstrual Dysphoric Disorder

Premenstrual dysphoric disorder (PMDD) became classified as an official depressive disorder with the publication of the DSM-5 (APA, 2013; Zachar & Kendler, 2014). PMDD (previously named late luteal phase dysphoric disorder) has a conten- tious history and was previously classified as a depressive disorder not otherwise specified given its need for more research; see Zachar and Kendler 2014( ) for a brief history and overview. 218 L. Feliciano et al.

The core feature of PMDD involves changes in mood, ranging from sadness to anxiety to irritability, which begins the week before menses and gradually remits by the week following menses (APA, 2013). These changes must accompany a majority of menstrual cycles within the past year. At minimum, five total symptoms must be present during this time, including at least one of the following symptoms: labile affect, depressed mood or the experience of hopelessness, angry or irritable mood, or feeling anxious or tense. Further, the client must endorse at least one additional symptom related to reduced engagement in life areas (e.g., socializing or working), ability to concentrate, changes in sleep or appetite, physical changes (e.g., feeling bloated), changes in energy level, or the experience of losing control or feeling overwhelmed (APA, 2013). See Table 9.1 for symptom criteria. These symptoms must result in personal distress or otherwise significantly affect the ability to complete important activities. They must not be caused by substance use or physical/medical problems or be the result of the worsening of another disorder (e.g., MDD). Lastly, the pattern of changing mood pre-menses and remittance post-menses must be documented through at least two menstrual cycles, although provisional PMDD can be diagnosed if all other criteria are met (APA, 2013). PMDD must be differentiated from a common experience by menstruating women known as premenstrual syndrome, or PMS. Although both occur pre- menses, PMS is more commonly associated with behavioral and physical changes but not the affective symptoms required by PMDD. Moreover, symptoms of PMDD tend to be more severe than PMS (APA, 2013). Prevalence rates of PMDD vary depending on study methodology (e.g., retrospective vs. prospective ratings), yet average rates, inclusive of multiple countries, are estimated at approximately 5% (Epperson et al., 2012). The incidence rate of PMDD in the United States is estimated at 2.5% (spanning 40 months), and annual prevalence rates range from 1.8% to 5.8% with higher reports from menstruating women who are nearing menopause (APA, 2013). Lastly, PMDD prevalence rates are estimated at 1.2–6.4% in Asian countries (Banerjee, Roy, & Takkar, 2000).

Substance/Medication-Induced Depressive Disorder

Substance/medication-induced depressive disorder is diagnosed if depressive symptoms develop during or within 1 month of exposure to substances or medications that caused intoxication and/or withdrawal and that are known to confer similar symptoms as depressive disorders (e.g., anhedonia, depressed mood). Further, symptoms must continue past the typical end point of the effects (e.g., withdrawal) of the substance (APA, 2013). Clinicians should include a specifier regarding symptom onset (e.g., during intoxication or withdrawal) and use the diagnostic code associated with the corresponding substance and the degree of substance use disorder (e.g., mild, moderate, severe, or absent). 9 Depressive Disorders 219

Depressive Disorder Due to Another Medical Condition

Depressive disorder due to another medical condition is diagnosed in the event that a physical condition (e.g., Parkinson’s disease, hypothyroidism) is directly responsible for depressive symptoms. This diagnosis should be qualified with specifiers (e.g., whether or not MDE is present) and accompanied by the name of the physiological condition present (APA, 2013).

Other Specified Depressive Disorder and Unspecified Depressive Disorder

In earlier versions of the DSM, the depressive disorder not otherwise specified diagnosis was given when clinicians wanted to capture depressive conditions that did not meet the full criteria for any other depressive disorder or were provisional based on limited assessment information. In the DSM-5, this category has been eliminated and replaced by two options: other specified depressive disorder, and unspecified depressive disorder. The diagnoses of other specified depressive disorder and unspecified depressive disorder may be assigned when a client presents with depressive symptoms that are subclinical, that is, the symptoms substantially affect functioning, but full criteria for a depressive disorder are not present. The DSM-5 describes three examples of conditions that would fit under this category including recurrent brief depression, short-duration depressive episode, and depressive episode with insufficient symptoms. Recurrent brief depression would refer to the presence of depressed mood and at least four of the eight additional depressive symptoms that are brief in nature (e.g., last 2–13 days) but recur over at least 1 year (i.e., 12 consecutive months). The person must experience distress or impairment in function. Short-duration depressive episode also refers to a condition in which there is depressed mood and at least four additional symptoms; however, the symptoms and associated distress or impaired functioning only last for 4–13 days. Depressive episode with insufficient symptoms refers to a situation in which a depressed mood is present and at least one additional depressive symptom with concomitant distress or impaired function for at least 14 days. In these examples, the person would not meet criteria for any other depressive, bipolar, or psychotic disorder during the specified timeframes. Unspecified depressive disorder is assigned if the clinician opts not to include information for why the depressive symptoms and associated distress or impairment do not meet threshold for another more specific depressive disorder. This may occur in settings in which additional information necessary to make a more specific diagnosis is lacking as in the case of an emergency room (APA, 2013) or within a co-visit with a medical provider in an integrated care setting. 220 L. Feliciano et al.

Procedures for Gathering Information

There are numerous ways in which clinicians and researchers can begin the process of gathering information for assessment. These strategies include both informal and formal assessment methods. Despite the presence of some excellent structured and semi-structured clinical interviews, informal assessment remains the most commonly practiced strategy for information gathering. Typically, the clinician or mental health practitioner will meet with the client in a face-to-face interview and ask a number of questions regarding his or her current mood, the length of time that the person has felt this way, and specific symptoms. An assessment of family history, medical history, and previous psychiatric history is usually also undertaken. The flow of questions in such an interview is typically unstructured and open-ended and depends on the person’s response to the questions. Unfortunately, relying solely on this strategy may be less reliable and lead to the possibility of misdiagnosis or failure to recognize (and assess for) comorbid conditions that present with similar symptomatology. For this reason, many mental health organizations prefer to use a mix of formal and informal methods of gathering data to serve as a guideline to ensure that all pertinent questions are asked. To approach assessment from an evidence-based perspective, the purpose of assessment should determine the type of assessment strategies utilized. The purpose of assessment typically reflects clinician/researcher needs for: screening, diagnosis, and treatment planning; thus, the type of assessment chosen should reflect these needs. Standardized screening measures are excellent choices if the goal of the assessment is to identify those who may be at risk of developing a depressive mood disorder. These measures can help identify those people who may need further assessment with a structured or semi-structured diagnostic interview. The primary benefits of using a screening measure include the brief amount of time required to administer them and a decreased need for extensive training in their usage, making them ideal for use in primary care and other general health and social service settings. The most common screening measures are self-report measures. Typically, the person is asked to indicate the severity of a specific symptom that he or she may be experiencing over an identified time period (e.g., over the last 2 weeks). The inventory is then scored by the clinician. The person’s score on the instrument reflects the severity of the disorder. Commonly used self-report measures of depressive symptoms include the Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996), the Center for Epidemiological Studies-Depression Scale (CES-D; Radloff, 1977), the World Health Organization Five-Item Well-Being Index (WHO-5, Version 1; Bech, 1996), the Montgomery-Asberg Depression Rating Scale-Short form (MADRS-S; Montgomery & Asberg, 1979) and the Profile of Mood States (POMS; Plutchik, Platman, & Fieve,1968 ). Of all the self- report inventories available, the BDI-II is the most popular instrument used. The BDI-II is a 21-item self-report inventory that addresses depressive symptoms and has been validated for use with community-dwelling adults, older adults, and inpatient samples. The BDI-II takes approximately 20 minutes to administer and has 9 Depressive Disorders 221 good evidence for internal consistency and concurrent validity (Segal, Coolidge, Cahill, & O’Riley, 2008; Steer, Rissmiller, & Beck, 2000). Other self-report measures have been designed for use with specific populations, such as the Geriatric Depression Scale (GDS; Yesavage et al., 1982), the Nine-Item Patient Health Questionnaire (PHQ-9; Spitzer, Williams, Kroenke, Hornyak, & McMurray, 2000) and the shorter two-item version of the Patient Health Questionnaire (PHQ-2; Arroll et al., 2010), and the Beck Depression Inventory— Primary Care (BDI-PC; Beck, Guth, Steer, & Ball, 1997). These inventories are thought to be more valid for use with older adults and medical patients, respectively, due to a decreased emphasis on items related to somatic symptoms which tend to be more frequently endorsed in these populations. Clinician-administered screening measures are also quite common, perhaps more in research settings than in clinical settings due to time restrictions. These instruments include the Hamilton Rating Scale for Depression (HRSD; Hamilton, 1967), the Montgomery-Asberg Depression Rating Scale (MADRS; Montgomery & Asberg, 1979), and the Inventory of Depressive Symptomatology—Clinician- rated. The HRSD is a commonly used clinician-rated measure of depression severity and has been considered by many to be the “gold standard.” Although there are several versions of the HRSD available, the 21-item inventory is the most commonly used. This inventory typically takes approximately 20–30 minutes to administer. The HRSD has been well validated and has good internal consistency (Cronbach’s alpha = 0.81 and 0.88) (Carmody et al., 2006). The MADRS is a 10-item rating scale for depression that takes approximately 20 minutes to administer. The MADRS is an excellent alternative to the HRSD as it is reported to be more sensitive to tracking clinical change in symptoms, is unifactorial, and has higher internal consistency ratings and inter-rater reliability (>0.90; Montgomery & Asberg, 1979). There are also screening measures that are designed for use with special populations such as individuals with cognitive impairment. This is important as depression is more prevalent in early stages of cognitive impairment, typically when the individual still maintains insight or awareness of his/her cognitive decline and symptoms (e.g., forgetting, losing track of conversations). However, depression may still be present in later stages, although it is often more difficult to detect. Thus, the Cornell Scale for Depression in Dementia (CSDD; Alexopoulos, Abrams, Young, & Shamoian, 1988) is completed by the clinician in conjunction with another person with sufficient knowledge of the identified patient (e.g., administered directly to a caregiver or significant other). Depressive symptoms are evaluated on a 3-point rating scale (0 = “absent,” 1=“mild or intermittent,” and 2 = “severe”) with higher scores being indicative of higher severity of depression. The CSDD has adequate inter-rater reliability (kappa = 0.67), good internal consistency (0.84), and concurrent validity with the HRSD. Self-report screening measures tend to differ on how frequently the measure should be administered, the symptoms covered, the number of and format of the questions, and the amount of time necessary to administer (see Table 9.2 for examples). The main drawback to the use of screening measures is their inability to fully assess the degree of impairment and nuances of the depressive symptoms. 222 L. Feliciano et al.

Table 9.2 Comparison of self-report screening measures Time to Measure Frequency Symptoms covered Format of questions administer 1. BDI-II Every Less core symptoms Scaled questions with a “0” 10–20 minutes 2 weeks indicating absence of the symptom and a “3” indicating the most severe expression of that symptom 2. BDI-PC Every Less core symptoms 4-point scale <10 minutes 2 weeks 3. CES-D Weekly Emphasis on 5 minutes affective symptoms 4. GDS Weekly Depressive “Yes/no” format 10–20 minutes (long symptoms form) 5. GDS Does not assess for 5–7 minutes (short suicidality form) 6. PHQ-9 Every Maps onto the major 4-point scale with “0” 5–10 minutes 2 weeks criteria of the indicating not at all and “3” DSM-IV, MDD indicating nearly every day diagnostic criteria Includes item on suicidal ideation 7. WHO-5 Last few Less core symptoms 4-point scale with “0” <5 minutes weeks Does not assess for indicating at no time and “3” suicidality indicating all of the time 8. SDS Past several Scaled questions with “1” days indicating a little of the time and “4” indicating most of the time

Screening measures tend to be more inclusive (i.e., more sensitive than specific) to capture as many possible persons at risk and therefore tend to result in more false positives. For these reasons, screening measures should never be used in place of a thorough diagnostic workup in making a definitive diagnosis. For diagnostic purposes, semi-structured and structured interviews are excellent tools to assist in confirming the presence of a disorder. These interviews are reliable and valid tools that assist in conducting a more thorough evaluation and diagnosis of disorders compared to unstructured interviews. With semi-structured interviews, the interviewer has a list of specific questions to be covered and flexibility to ask follow-up questions to seek clarification and details necessary for diagnosis. Structured interviews contain a set number of questions to be asked in a set order. Because of their format, these types of interview tools provide a standardized process for gathering information, which can improve consistency in service delivery and reliability in diagnosis, and provide a means for tracking clinical outcomes/change indicators (Segal & Williams, 2014; APA, 2015). In addition, 9 Depressive Disorders 223 structured and semi-structured interviews decrease the need for extensive training of interviewers. However, some of these interviews are time-consuming, and while they can be used for tracking change, they are not practical for this purpose. Once a diagnosis is confirmed, a clinician-administered measure such as the Hamilton Rating Scale for Depression (HRSD; Hamilton, 1967) may be more useful for tracking outcomes (Joiner, Walker, Pettit, Perez, & Cukrowicz, 2005). The other disadvantage to fully structured interviews is that there is no flexibility in questioning. If a question is not fully answered or explicated well, the interviewer is not allowed to deviate from the prescribed set of questions. To deviate from the standardized process would lead to a decrease in reliability and validity of the norms. For this reason, semi-structured interviews are more commonly used than structured interviews, as they combine the benefits of standardization and flexibility (e.g., the clinician can supplement the standard questions with additional questions). The most commonly used structured and semi-structured interviews are discussed in more detail in Chap. 2 in this volume. Finally, if the goal of assessment is tracking outcomes or clinical change over time, clinicians can use a severity measure or have the client use a data sheet to self- monitor depressive symptoms (e.g., daily mood log) or engagement in pleasurable events (e.g., weekly activity log). Because self-report is subjective, can be biased, or otherwise inaccurate (relies on memory and adequate perceptions of events), direct observation of the client may also be useful in tracking outcomes. These observations can occur within session by the clinician (e.g., observation of person’s grooming, hygiene, psychomotor agitation or slowing) or out of session by a significant other (e.g., collateral data). Regardless of the method chosen, tracking outcomes can provide evidence as to accurate diagnosis of the condition, provide information for treatment planning, and allow for evaluation of treatment effectiveness.

Recommendations for Formal Assessment

In their evidence-based review of depression and its assessment, Joiner and colleagues (2005) recommended that a structured clinical interview is the best start for assessing depression. In addition, these researchers recommended that the interview should be supported with well-validated and reliable self-report instruments to provide a measure of symptom severity. In this manner, both clinician ratings and client reports are adequately considered. We heartily agree with these recommendations. However, in certain settings in which a full clinical interview is not possible (e.g., primary care), we add that it is often more expedient to use a valid and sensitive screening measure first, followed by a more thorough assessment for those individuals who screen positive. The American Psychiatric Association (APA) recently released the third edition of guidelines on psychiatric evaluation in adults. These guidelines support the use of such quantitative assessment tools. They note that while the field has yet to come to a complete consensus on adoption, these 224 L. Feliciano et al. tools may help clinicians conduct reliable and thorough assessment of patients’ symptoms, which may then prevent potentially relevant symptoms from being overlooked (APA, 2015).

Case Illustrations

We present two cases to illustrate the assessment of depressive disorders. The first case represents a thorough, formal assessment of mood, medical, cognitive, and psychosocial history. This type of assessment is ideal, conducted in specialty behavioral health settings. The second case illustrates the dramatic shift toward brief collaborative care interventions delivered in primary care and other health and social service settings (Crowley & Kirschner, 2015). In these settings, the emphasis is on rapid assessment of mood symptoms, collaborative treatment planning, and ongoing symptom monitoring and response.

Case I: Minority Older Adult with Major Depressive Disorder

The client was a 71-year-old, divorced, Hispanic-American woman who presented with complaints of lifetime depression. The intake assessment included a thorough assessment of her current and past history of psychiatric symptoms, alcohol and substance use, suicidality, and medical and treatment history using the Structured Clinical Interview for DSM-5. The SCID was supplemented with a depression severity measure (HRSD) and a mental status exam. Because the client also endorsed some memory complaints, the intake assessment also included a brief neuropsychological battery. At intake, careful attention was given to developing rapport and explaining the reason for assessment and for questions that were asked about her psychiatric and family history. The client reported symptoms consistent with a diagnosis of MDD, including depressed mood all day nearly every day, fatigue, and disrupted and restless sleep (occasional difficulties falling asleep but waking frequently and sometimes taking 1–3 hours to fall back to sleep). She stated that she cried frequently, was lonely, and had few social supports. She reported being self-critical (about her weight and cleanliness/clutter of her home), feeling worthless and guilty over things that she had done or not done. She believed that she has brought the depression on herself and wondered why she didn’t take better care of herself. She also reported a loss of interest and pleasure in things that she used to enjoy and felt that she had to push herself to do anything, reporting “having nothing to look forward to.” She also reported feeling discouraged and pessimistic about the future (e.g., saw her future as “bleak”). When asked how she thinks things will work out, she stated that she will “probably be alone the rest of my life.” A review of her psychiatric history revealed that she had struggled with depression on and off for most of her life. Her 9 Depressive Disorders 225 medical history was notable only for a total hip replacement several years prior, and her family history was unremarkable for psychiatric disorders. In addition to depressive symptoms, the client reported several psychosocial stressors including worry about finances, problems at work (conflict with supervisor), and worry about physical health. However, these did not appear to be excessive given her current financial situation (i.e., low income) and history of medical problems. She denied current suicidal ideation, hallucinations, and delusions. She denied suicidal or homicidal ideation. Her mental status exam was notable for psychomotor retardation, somewhat blunted affect, and negative thought. She described her mood as “sad” and was preoccupied with worry over cognitive complaints including difficulties concentrating at work, making decisions, and difficulty remembering medications and dates. She reported concerns about her finances and health. On exam, she also met criteria for mild cognitive impairment. At the conclusion of the assessment, this client was diagnosed with major depressive disorder, recurrent, moderate. In addition to depressive symptoms, she reported psychosocial stressors including worry about finances, problems at work (conflict with supervisor), and worry about physical health. Despite this report, her symptoms did not indicate a diagnosis of a comorbid anxiety disorder or anxious distress specifier, as her worry seemed commensurate to her situation, and she denied that the worry was causing distress or impairment in social or occupational functioning. Given her test results, the client also received a diagnosis of mild cognitive impairment. The treatment plan focused on depressive symptoms and utilized problem- solving therapy techniques, which has empirical evidence for its value with older adults experiencing depressive symptoms and cognitive impairment (Kiosses & Alexopoulos, 2014). The case is illustrative of some of the issues related to working with a minority older adult. For example, careful attention was given to the development of rapport and reducing stigma associated with reporting mental health symptoms. The interviewer was attentive to the client’s biopsychosocial concerns and took care to use the client’s preferred language for discussing depressive symptoms, in attempts to create an atmosphere of caring and comfort to assist the client with the assessment process.

Case II: Primary Care Patient with Depressive Symptoms

The patient was a 56-year-old Caucasian female who was screened as part of the primary care clinic’s routine screening procedures, while she was visiting the clinic for medical complaints. Screening included the Patient Health Questionnaire-9 items (PHQ-9) and the Generalized Anxiety Disorder-7 items (GAD-7). Her scores indicated moderately-severe depression and moderate anxiety symptoms. She denied suicidal ideation based on the last item of the PHQ-9. There was no lengthy, formal psychosocial or cognitive assessment, although she reported significant 226 L. Feliciano et al. distress due to caring for her mother with Alzheimer’s disease and helping other family members (adult child, grandchildren), all of whom lived with her. The intervention was guided by a brief version of behavioral activation for depression (Gum, Schonfeld, Tyler, Fishleder, & Guerra, 2016), with a flexible number of sessions and follow-up telephone calls based on how well she engaged in behavioral goals she set and her PHQ-9 scores. To assess treatment response, the PHQ-9 was administered during each encounter and discussed with her. She initially had difficulty completing behavioral goals she set for herself, but with attention to barriers and problem- solving efforts, she gradually began to complete more goals between encounters, and the PHQ-9 improved to the non-depressed range by the last encounter. This case is an example of using brief screening tools to identify patients in distress, develop collaborative treatment plans with the patient, and monitor treatment response over time. There was less attention given to formal diagnosis. If the patient had not improved, then referral to a specialty behavioral health setting would have been warranted, where more thorough formal assessment and interventions would have been provided.

Impact of Gender, Race, Culture, Age, and Other Aspects of Diversity

Multiple dimensions of diversity can impact the assessment of mood disorders, including race and ethnicity, socioeconomic status, and age, to name a few. A thorough review of diagnostic considerations for each diverse group is beyond the scope of this chapter; rather, the focus is on general considerations and strategies. Moreover, there are significant individual differences within groups that require a flexible, individualized approach to diagnostic interviewing. The individual’s background likely impacts the assessment process from the first encounter, as the clinician strives to build trust and rapport and socialize the individual to the assessment process. As the assessment progresses, the client’s background may influence how symptoms are presented and conceptualized, for which the clinician needs to consider the validity of standardized assessment tools being used and additional cultural factors to assess. Finally, individuals do not experience mood symptoms in a vacuum; rather these symptoms occur in the context of other biopsychosocial considerations, which inform the clinician’s case conceptualization and treatment planning.

Rapport Building and Education About the Assessment Process

The next section primarily focuses on rapport building in the clinical interviewing and testing process. The following relates to both older adults and minority populations. Older adults enter assessment situations with a wide range of perceptions about themselves, their environments, the presenting problems, and their providers 9 Depressive Disorders 227 and health-care settings. Compared to younger adults, older adults tend to have lower “mental health literacy,” a phrase used to indicate individuals’ ability to identify mental health problems and treatments according to the dominant conceptualizations (Farrer, Leach, Griffiths, Christensen, & Jorm, 2008). Older adults may have concerns about institutionalization, being labeled “crazy,” or other forms of stigma. Concerns about stigma are common in older adults in general, although they may be more pronounced for minority older adults, including African-Americans (Conner et al., 2010). This poor mental health literacy and stigma may impact the assessment in multiple ways, including rapport building and symptom reporting (i.e., whether symptoms are reported and how they are described). Two strategies during the initial rapport-building phase may mitigate these concerns and maximize information gathering with older adults and minority groups: (1) carefully informing the client of the purpose of the assessment and what to expect during the assessment process and (2) reducing stigma through empathetic responses that recognize that distress is common and understandable. First, it is important to ascertain the client’s understanding of why she or he is seeing the clinician and to provide him or her with all relevant information about the purpose of the assessment. Similarly, the interviewer should inform the client about what to expect, such as length of the assessment, types of information that will be sought, rationale for the information being asked of the client, from whom information will be sought (including gathering appropriate permissions), and how the assessment results will be used and reported back to the client. Some clients may be concerned about the outcomes of assessment (e.g., hospitalization, competency, or legal issues) or concerned about protection of their confidentiality, so the clinician needs to carefully discuss the potential outcomes of the assessment and what information will be shared with whom. Stigma concerns may be reduced by empathizing with the client’s symptoms or situation, expecting distress as common or understandable in some difficult situations. For example, while assessing mood symptoms with an older caregiver who had recently placed her partner in a long-term care facility, the clinician noted that caregivers often feel guilty, worrying that they “didn’t do enough,” and then asked if the client was experiencing any feelings of guilt. At this point, she began to open up more about her guilt as well as other depressive symptoms.

Use of Standardized Assessment

Standardized diagnostic and screening tools that have been validated for diverse populations are a critical component of diagnostic interviewing. Although it is beyond the scope of this chapter to provide a comprehensive review of all potential measures, it is critical to examine the evidence of validity with diverse populations prior to selecting measures. Some tools have become well-established with diverse populations. For example, the Patient Health Questionnaire-9 (PHQ-9; Kroenke, Spitzer, & Williams, 2001) is a brief, nine-item screening tool for depression that 228 L. Feliciano et al. was created to assess DSM-IV criteria for major depression (APA, 2000). It has shown very good validity in relation to expert clinician interview, with 88% sensitivity and 88% specificity for diagnosis of major depressive disorder at scores of 10 or higher. It can also be used to assess severity of depressive symptoms. This scale has been used with a wide range of samples, including primary care and other medical patients, individuals from various cultural backgrounds (e.g., diverse populations within the United States, including Latino and African-American; Nigerian; Thai; Korean; Chinese) (Diez-Quevedo, Rangil, Sanchez-Planell, Kroenke, & Spitzer, 2001; Huang, Chung, Kroenke, Delucchi, & Spitzer, 2006; Lotrakul et al., 2008), and older adults (e.g., Kroenke, Spitzer, Williams, & Lowe, 2010; Phelan et al., 2010).

Supplementing Standardized Assessment with a Cultural Formulation

Despite the value of standardized tools, the individual’s cultural context must be considered while formulating a diagnosis and treatment plan. A DSM-IV workgroup developed a cultural formulation (for review, see Lewis-Fernandez & Diaz, 2002), which has since been further refined and expanded, with case examples available. The DSM-IV workgroup identified four domains to assess: (1) cultural identity of the individual (e.g., reference group, acculturation across host and origin cultures, language); (2) cultural explanations of illness (e.g., idioms and symptom presentation, meaning of illness in relation to cultural norms, perceived explanatory models); (3) cultural factors related to psychosocial environment and levels of functioning (e.g., interpretations of stressors, social networks); and (4) cultural elements of the client-clinician relationship combined to create an overall formulation. These domains are important to assess, given that clients’ culture impacts all aspects of their help-seeking, including their perceptions of their problems, causes, and potential solutions and their relationships with providers. Regarding cultural identity, it is important that clinicians recognize that clients’ degree of identity with their culture of origin and the majority culture are not necessarily related. Instead of assuming a “zero-sum model” in which the person is viewed as high on one dimension of identify and low on the other, a client may have a low or high sense of identity on each dimension. Immigration status is an important part of cultural identity and background that may impact distress and stressors. Using nationally representative data, Jimenez and colleagues (2010) found higher rates of DSM-IV diagnoses of lifetime and 12-month dysthymia for Latino immigrant older adults, compared to older Latinos born in the United States. Cultural factors influence how individuals conceptualize and report their mood symptoms. For example, Hispanic-American adults tend to emphasize somatic symptoms more so than emotional or mood-related symptoms and also are less likely to distinguish between mood and somatic symptoms (for review, see Lewis- Fernandez et al., 2005). A similar pattern has been found with older adults, who 9 Depressive Disorders 229 may present with more somatic symptoms, including a focus on physical health conditions, agitation, or gastrointestinal symptoms, as well as more anhedonia and fewer depressed or mood-focused symptoms, including guilt (Gallo & Rabins, 1999; Hegeman, Kok, van der Mast, & Giltay, 2012). Thus, the clinician will gather better information for diagnosing a mood disorder by utilizing a biopsychosocial conceptualization, validating the individual’s somatic symptoms and becoming familiar with specific cultural idioms. Spanish terms often used for distress or depression include “nervios” or “desanimado” (discouraged) (Lewis-Fernandez et al., 2005; Noguera et al., 2009), but Spanish-speaking patients may use a variety of other terms as well (Camacho, Estrada, Lagomasino, Aranda, & Green, 2017). African-American older adults have discussed difficulties recognizing when they were depressed, racial discrimination and other life stressors that contribute to feeling depressed, and stigma from clinicians as well as family members and friends that can keep them from recognizing, reporting, and seeking professional assistance for depression (Conner et al., 2010). These types of observations underscore the importance of assessing the domains put forth in the DSM-IV workgroup’s cultural formulation outline, including perceptions of symptoms and problems, cultural identity and environment, and relationships with providers. To guide clinicians in this assessment, for DSM-5, the workgroup developed a Cultural Formulation Interview (CFI), based on literature review and new field trials in the United States, Canada, India, Kenya, the Netherlands, and Peru (Lewis- Fernández et al., 2014). The CFI includes 16 core questions to systematically assess the four dimensions from the original cultural formulation, with patient and informant versions. It also contains 12 supplemental modules that can be used to gather more information; the modules for older adults, immigrants and refugees, and caregivers might be particularly relevant for assessment with diverse older adults and their families. The questions are open-ended, and the authors conceptualize the CFI as a person-centered, ethnographic approach that allows patients to describe their problems, explanations, and experiences in their own words. The CFI begins by asking about the patient’s (or informant’s) perspective regarding the presenting problem, its causes, supports that help, and stressors that make the problem worse. The next set of questions ask about the patient’s cultural identity and how it relates to his or her problems. Subsequent questions ask about coping strategies the patient has tried and how the patient has sought help (formal or informal) from others. The final questions ask about preferences for future assistance and any concerns or observations the patient has about his or her relationship with the clinician. The questions are written in plain language, with instructions that there is no “right” answer and definitions for some terms. Thus, adding the CFI or other questions to assess cultural considerations is a valuable supplement to the standard diagnostic assessment tools, even those that have been validated with diverse populations. In addition, assessing patients’ multidimensional needs, such as housing, environment, physical, and social needs, also helps to understand their full scope of problems and how other needs may relate to mood symptoms. 230 L. Feliciano et al.

Biopsychosocial Assessment

Individuals from underserved populations, particularly those from lower socioeconomic status or older adults, frequently have complex, multidimensional problems associated with their depressive disorder. Such problems may include physical illness and limitations, limited income, poor social support networks, and unsafe or unstable housing situations. These individuals also may view their mood symptoms in relation to these other problems, complicating identification of symptoms. For example, an unemployed, low-income client may primarily discuss their concerns related to job-seeking, rather than their mood symptoms. Or an older adult may talk about his or her loneliness rather than depression (Barg et al., 2006). Thus, to fully explore mood symptoms and develop a comprehensive treatment plan, the clinician needs to conduct an assessment of the clients’ multidimensional needs. Some formal assessment tools exist for this purpose. For example, the Camberwell Assessment of Need for the Elderly (CANE; Reynolds et al., 2000) is a validated tool that guides an interviewer to assess for needs across multiple life domains (e.g., accommodation, food, self-care, transportation), based on information from clients, informants, and clinicians. Versions exist for adults, older adults, individuals with learning disabilities, individuals in forensic settings, and mothers. Advantages of this type of assessment include rapport-building, case conceptualization (i.e., gaining a comprehensive understanding of factors contributing to and affected by the mood symptoms), and treatment planning with regard to case management needs. Older adults with depression have been found to experience significantly more unmet needs on the CANE compared to older adults without depression, across all domains of need (environmental, physical, psychological, social) (Stein et al., 2016), underscoring the importance of supplementing mood evaluations with an assessment of other needs. In fact, regarding implications for treatment planning, addressing multidimensional needs for low-income depressed older adults with thorough case management may be sufficient for alleviating depressive symptoms, without psychotherapy or other interventions for depression (Areán et al., 2015).

Adjusting Assessment Procedures

In addition to assessing a client’s multidimensional needs, the interviewer may need to adjust the assessment process to accommodate these multidimensional needs. For example, the clinician may need to be flexible regarding time of day and location for meeting, such as if the client has other responsibilities such as work or caregiving, depends on others for transportation, or has physical limitations that limit ability to travel to certain clinical settings. For a client with communication difficulties, the clinician may want to consider multimodal communication strategies, such as written cues or oral administration of paper-and-pencil questionnaires. For a client with 9 Depressive Disorders 231 physical limitations, the clinician should inquire about the client’s best time of day and may need to schedule breaks or assessments across multiple time periods. Nonetheless, it has been our experience that physically frail clients can endure lengthy assessments as long as the clinician develops good rapport, orients the client to the length of the assessment, remains alert for signs of fatigue, and offers breaks or rescheduling.

Information Critical to Making a Diagnosis

Several considerations are important when making a diagnosis, including several areas already discussed, such as the nature of the symptoms, functional impairment or distress, cultural diversity, socioeconomic status, and health status. Additional considerations include differentiating among possible diagnoses and the use of specifiers.

Differential Diagnosis of a Depressive Disorder Versus Other Psychiatric Conditions

The importance of differential diagnosis cannot be understated. Accurate diagnosis impacts the clinician’s ability to prescribe and deliver appropriate treatments and to predict clinical outcomes. Whereas the presence of manic or hypomanic episodes may appear to easily differentiate unipolar and bipolar disorders, the distinction may not always be so readily apparent when assessing an individual. One challenge relates to the issue of self-reported mood. It can be difficult to differentiate between a “normal good mood” that may occur during remission of MDD or PDD versus an “unusually high or elevated mood” that occurs during a manic or hypomanic episode in bipolar disorder. For example, with chronic MDD or PDD, the person may have felt unusually down or depressed for such a long period of time that any increase in mood may seem unusually high. In this case, the person would respond positively to questions designed to capture mania (e.g., person required less sleep than usual because their “usual” during the chronic depression was 10 or more hours of sleep). A second difficulty in differentiation has to do with determining the difference between the self-reported atypical or irritable symptoms in MDD and the irritable mood that occurs with the bipolar disorders, which may be qualitatively different but unclear to the person who has never experienced both. Fortunately, these symptoms are not the sole criteria upon which to base a diagnosis. Careful questioning and eliciting examples can provide necessary detail to assist in determining if the self-reported description of “elevated” or “irritable” mood meets criteria for abnormal functioning. 232 L. Feliciano et al.

In addition, a number of additional symptoms should be considered before a definitive diagnosis is made. For example, people with MDD tend to desire more or better sleep, whereas individuals with bipolar disorders report less of a desire or need for sleep and are often doing some activity during normal sleeping hours (Joiner et al., 2005). Other factors that suggest the possibility of bipolar instead of unipolar depression include worse cognitive functioning (Gildengers et al., 2012), family history of bipolarity, and a higher number of past mood episodes (Angst et al., 2011). Another difficulty in differentiation has to do with overlapping symptoms. For example, individuals with anxiety disorders commonly report feelings of sadness and hopelessness (Hopko et al., 2000), which are hallmark symptoms of depressive disorders in adults. The difficulty in differentiating these two disorders is long- standing with empirical and theoretical literature discussing this issue going back to the 1980s. The DSM-5 (APA, 2013) allows for recognition of these anxious symptoms in terms of using a specifier, with anxious distress to denote the expression of at least two of the five anxiety symptoms (e.g., difficulty concentrating, fear of something bad happening) occurring during most days of either an MDE or PDD. However, the presence of both depressive and anxiety symptoms compli- cates the diagnostic picture in terms of which symptoms appeared first or are primary. What is clear is that when these symptoms are comorbid, the prognosis is poor (e.g., longer duration of symptoms, more suicidal ideation, poorer treatment response) (APA, 2013).

Use of Specifiers

The DSM-5 (APA, 2013) utilizes a number of standard specifiers to describe the clinical status of the most recent mood episode and the course of the disorder. The first type of specifiers describes symptom features of the mood episode: with anxious distress, with mixed features, with melancholic features, with atypical features, with psychotic features (mood-congruent or mood-incongruent), with catatonia, with peripartum onset, and with seasonal pattern (recurrent episode only). With anxious distress was added in DSM-5 in recognition of the common co-occurrence of anxious symptoms with depressive or manic/hypomanic episodes. With mixed features is used when the person meets criteria for one type of mood episode (depressive or manic/hypomanic) and displays at least three symptoms of the other types of episode, without meeting full criteria. Melancholic features refer to a person who is unresponsive to pleasant or pleasurable stimuli, who tends to experience the depression as being worse in the morning and who reports excessive feelings of guilt. Atypical features of depression include what is referred to as “mood reactivity,” which is temporary lightening of mood in response to positive events, and the presence of at least two of the following: increased appetite or weight gain, hypersomnia (greater than 10 hours of sleep per day), feeling as if the arms or legs are weighed down (leaden paralysis), and an extreme sensitivity to 9 Depressive Disorders 233 rejection in relationships. Psychotic features involve hallucinations or delusions and may be mood-congruent or mood-incongruent. With catatonia includes not responding, talking, or moving or repetitive speech or movement. With peripartum onset involves onset during pregnancy or within 4 weeks of giving birth. With seasonal pattern refers to a pattern of recurrent episodes that occur only during specific times of year. Based on a review (Sachdev et al., 2015), three changes to the specifiers may have particular utility with older adults. Many older adults with depression also experience symptoms of anxiety, so with anxious distress may better characterize these older adults. Similarly, older adults may be more stable in their moods, so mixed features may signify some kind of deterioration in the mood disorder or other possible medical condition. Third, depressed older adults are more likely to experience psychotic symptoms than younger ages, so it may be useful to use the psychotic features specifier, which is no longer dependent on the severity of the depressive episode (Sachdev et al., 2015). Another type of specifiers is severity specifiers. These specifiers include mild, moderate, or severe. The severity specifiers are discussed in more detail in the specific disorders section. Also, recovery can be characterized asfull remission such that the person is symptom free between the recurrent episodes or partial remission of symptoms during the interepisode period. Empirical research regarding the epidemiology and predictive value of the symptom specifiers appears to be limited for older adults. Characterizing the severity and course of the mood disorders, however, has important implications for treatment. Older adults with more severe depressive symptoms and younger age of onset are more likely to experience a chronic course (Comijs et al., 2015).

Dos and Don’ts

To provide the best assessment and treatment for those with depressive disorders, certain steps should be followed to ensure an accurate and informative diagnostic process: Do: • Use validated, standardized interview tools, supplemented by self-report scales and individualized assessment. • When a brief screening tool is used and results in a positive screen, conduct a thorough evaluation to rule out false positives and avoid overdiagnosis. • Use a cultural formulation assessment process. • Assess the client’s biopsychosocial needs. • Be flexible with assessment scheduling, location, and procedures with clients who have complex medical or social needs. • Educate the client about the assessment process, including its purpose, procedures, and how the results will be used. Elicit the client’s questions and concerns. • Involve the family as appropriate and preferred by the client. 234 L. Feliciano et al.

Don’ts: • Make assumptions about a client based on group status (e.g., race, ethnicity, age). • Assume a “zero-sum model of acculturation” (p. 281, Lewis-Fernandez & Diaz, 2002); clients’ levels of acculturation within their origin and majority cultures are not necessarily dependent on one another. • Overpathologize what is considered normative within a given culture or dismiss what is abnormal within a culture (Lewis-Fernandez & Diaz, 2002). • Assume that depression is a natural part of aging. • Attend primarily to family members, ignoring the client who may be more challenging to communicate with due to language or cognitive barriers.

Summary

Depressive disorders are common and some of the most widely studied of all disorders. They are costly to the individual, families, and society. The causes of depressive disorders are numerous and complex, including any number of biopsychosocial factors. Assessments of depression vary in the degree to which they account for these biopsychosocial factors in the type of items utilized and the thoroughness of the clinical interview. Depression may present differently across individuals and settings, varying from brief episodes and subclinical presentations to more severe episodes and chronic symptomatology. Unfortunately, many people with depressive disorders are either untreated or poorly treated. Early identification through good clinical interviewing and assessment can help to identify people who could benefit from treatment and assist in delivering appropriate treatment. At the same time, it is important to follow brief screening with more thorough assessment before forming an official diagnosis. Ideally, assessment includes mood symptoms and functioning, as well as biopsychosocial needs assessment and a cultural formulation. Because of the multifaceted nature of the depressive disorders, further research is necessary to aid in the ability to improve screening, diagnosis and treatment, to better address these disorders and alleviate the distress and disability that accompany them.

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Samantha L. Connolly and Christopher J. Miller

Description of the Disorders

Bipolar and related disorders are complex, chronic conditions characterized by periods of significantly depressed and elevated mood. Individuals with bipolar disorder experience marked impairments in occupational and interpersonal functioning, and these difficulties have been shown to persist despite clinical remission in approximately half of the diagnosed population (Sanchez-Moreno et al., 2009). Indeed, bipolar disorder ranks as the ninth leading cause of disability worldwide (World Health Organization, 2001). The majority of patients with bipolar disorder will have at least one other comorbid psychiatric diagnosis; substance use and anxiety disorders are particularly prevalent and can contribute to poorer illness outcomes (American Psychiatric Association, 2013; Bauer et al., 2005). Rates of completed suicide among individuals with bipolar disorder are between 15 and 60 times that of the general population, and 25–50% of those with the diagnosis will attempt suicide within their lifetime (Baldessarini, Pompili, & Tondo, 2006; Jamison, 2000). Bipolar disorder has a strong genetic component (McGuffin et al., 2003), but environmental influences such as stress or trauma may impact illness onset and severity (Aldinger & Schulze, 2017). Some research has suggested that psychological factors including temperamental differences or cognitive dysfunction may also serve as vulnerabilities for the development of the disorder (McKinnon, Cusi, & MacQueen, 2013). Accurate diagnosis is crucial to ensure the effective treatment and management of this often debilitating condition.

S. L. Connolly (*) · C. J. Miller VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), Boston, MA, USA Harvard Medical School, Department of Psychiatry, Boston, MA, USA e-mail: [email protected]

The DSM-5 includes the following seven diagnoses under the category of Bipolar and Related Disorders: bipolar I disorder, bipolar II disorder, cyclothymic disorder, substance/medication-induced bipolar and related disorder, bipolar and related disorder due to another medical condition, other specified bipolar and related disorder, and unspecified bipolar and related disorder (American Psychiatric Association, 2013).

Bipolar I Disorder

To receive a DSM-5 diagnosis of bipolar I disorder, the patient must meet criteria for a manic episode, which is a distinct period of elevated, expansive, or irritable mood that must also be accompanied by persistently increased activity or energy. Manic irritability can be differentiated from depressive irritability in that it may involve feelings that others are moving too slowly to keep up with the patient’s fast- paced thoughts or are serving as obstacles in the way of the patient’s plans. This period must last for at least 1 week, although all episodes involving hospitalization meet criteria for mania regardless of length, presumably due to their severity. Manic episodes must also include at least three additional symptoms, such as increased grandiosity, decreased need for sleep, and racing thoughts (see Table 10.1); four symptoms are required if the patient presents with irritable mood only. Patients experiencing mania act in ways that are uncharacteristic of their typical behavior, such as taking on an unrealistic number of work tasks or creative ventures, engaging in risky sexual behavior, or impulsively spending large amounts of money. Manic episodes must also cause marked impairment in social or occupational functioning or involve psychotic features or hospitalization. Psychosis during mania may involve religious or grandiose delusions, such as that the individual is invincible or has special powers. Importantly, while bipolar I disorder is often characterized by a history of both manic and major depressive episodes, the experience of depressive episodes is not required to receive a bipolar I diagnosis. That being said, mania-only bipolar disorder is relatively rare, accounting for between 5% and 28% of bipolar diagnoses based on various estimates (Perugi, Passino, Toni, Maremmani, & Angst, 2007). The lifetime prevalence rate for bipolar I disorder worldwide has been estimated at approximately 0.6%, and rates of the disorder are equivalent between men and women (American Psychiatric Association, 2013; Merikangas et al., 2011). Mean age of onset reported in the literature ranges from 18 to 25 years old with a smaller subset of the population being diagnosed in midlife (American Psychiatric Association, 2013; Sherazi, McKeon, McDonough, Daly, & Kennedy, 2006). Differences have been identified between these two subgroups, such that earlier age of onset is associated with greater illness severity, family history of bipolar disorder, and increased risk of suicide attempts compared to those in the older-onset group (Sherazi et al., 2006). 10 Bipolar Disorders 241

Table 10.1 Diagnostic features for manic and hypomanic episodes Manic episode Hypomanic episode A. A period of unusually and persistently high, A. A period of unusually and persistently expansive, or irritable mood and unusually and high, expansive, or irritable mood and persistently increased activity or energy level unusually and persistently increased activity lasting a minimum of 1 week (or any length if or energy level lasting a minimum of four requiring hospitalization). consecutive days. B. Accompanied by at least three of the following B. Accompanied by at least three of the symptoms (four if the mood is only irritable): following symptoms (four if the mood is 1. Increased self-esteem or grandiosity only irritable): 2. Decreased need for sleep 1. Increased self-esteem or grandiosity 3. Increased talkativeness or pressured speech 2. Decreased need for sleep 4. Report of racing thoughts or flight of ideas 3. Increased talkativeness or pressured 5. Easily distractible by nonsignificant details/ speech stimuli 4. Report of racing thoughts or flight of 6. Psychomotor agitation or an increase in ideas goal-directed activities 5. Easily distractible by nonsignificant 7. Excessive involvement in high risk activities details/stimuli C. This period has caused marked impairment in 6. Psychomotor agitation or an increase social or occupational functioning, or in goal-directed activities necessitates hospitalization, or there are 7. Excessive involvement in high-risk psychotic features. activities D. The episode is not attributed to the C. The episode involves a marked change in physiological effects of a substance. functioning that is uncharacteristic of the individual when not experiencing symptoms. D. Alterations in mood and functioning are observable by others. E. The episode is not severe enough to cause marked impairment or necessitate hospitalization. F. The episode is not attributed to the physiological effects of a substance. Note. Adapted from the DSM-5

Bipolar II Disorder

Bipolar II disorder is characterized by the presence of both hypomanic episodes and major depressive episodes. Hypomanic episodes differ from manic episodes in their length and severity. They are characterized by at least four consecutive days of elevated, expansive, or irritable mood along with increased activity or energy and three additional symptoms (see Table 10.1) or four symptoms if presenting with irritable mood only. Hypomanic episodes involve an unequivocal, uncharacteristic, and observable change in functioning in the patient, but not to the point of causing marked impairment or necessitating hospitalization. However, individuals with bipolar II disorder must have a history of at least one major depressive episode. Individuals with bipolar II disorder are more likely to present to treatment during a depressive episode versus a period of hypomania; given the lack of impairment associated with hypomania, they often do not find fault with these symptoms. It is 242 S. L. Connolly and C. J. Miller important to note that bipolar II disorder is not a milder version of bipolar I disorder. While individuals with bipolar II disorder do not experience the impairment of mania, they often experience longer and more frequent depressive episodes as compared to bipolar I, which significantly impacts functioning (American Psychiatric Association, 2013). Indeed, the functional impairment observed in bipolar disorder has largely been attributed to the experience of depressive symptoms versus manic or hypomanic symptoms (Bauer, Kirk, Gavin, & Williford, 2001). The lifetime prevalence of bipolar II disorder is 0.4% (Merikangas et al., 2011). Average age of onset is during the mid-20s and is somewhat later than that observed in bipolar I disorder; similar to bipolar I disorder, no clear gender differences have been reported. Major depressive episodes typically precede hypomania in those ultimately diagnosed with bipolar II disorder (American Psychiatric Association, 2013). If an individual initially had a diagnosis of major depressive disorder, the diagnosis would convert to bipolar II disorder upon the experience of a hypomanic episode. Similarly, a diagnosis of bipolar II disorder would convert to bipolar I if a manic episode were to occur.

Cyclothymic Disorder

Cyclothymic disorder is characterized by its chronicity and subthreshold hypomanic and depressive symptoms. This disorder requires at least a 2-year period in which the individual has experienced numerous periods of hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods of depressive symptoms that do not constitute a major depressive episode. The time length is shortened to at least 1 year of such patterning among children and adolescents. The individual cannot be symptom-free for more than two consecutive months and symptoms must cause clinically significant distress or impairment. If an individual subsequently meets criteria for major depressive disorder, bipolar II disorder, or bipolar I disorder, the cyclothymic disorder diagnosis is removed. The lifetime prevalence rate of cyclothymic disorder ranges from 0.4% to 1% and is equally common among men and women. The disorder is thought to typically emerge in adolescence and early adulthood and has a 15–50% likelihood of subsequently converting to bipolar I or II (American Psychiatric Association, 2013).

Substance/Medication-Induced Bipolar and Related Disorder

Individuals who develop mood disturbances as a result of substance or medication use can receive a diagnosis of substance/medication-induced bipolar and related disorder. This condition is characterized by a prominent and persistent shift in affect that may be elevated, expansive, or irritable; the presence of depressed mood or anhedonia is not required to receive this diagnosis. It must be determined that the 10 Bipolar Disorders 243 substance in question is capable of causing such mood effects and that the symptoms only emerged subsequent to the substance use. Substances that may lead to such effects include stimulants, steroids, and phencyclidine (PCP). Symptoms should not be better accounted for by a non-substance-related bipolar disorder and must cause clinically significant distress or impairment. Importantly, this diagnosis does not refer to hypomanic or manic symptoms resulting from the use of an antidepressant medication or electroconvulsive therapy. In a shift from DSM-IV-TR (Text Revision; American Psychiatric Association, 2000) to DSM-5, the emergence of hypomania and mania that persists at a fully syndromal level beyond the physiological effects of these treatments is considered to represent “true” bipolar disorder and does not fall under the category of being substance- or medication-induced. This change is consistent with research indicating that antidepressant-induced mania or hypomania is a highly specific indicator of subsequent spontaneous manic or hypomanic episodes, and therefore a conversion to a bipolar diagnosis, among those being treated for depression (Akiskal et al., 1983; Ghaemi, Ko, & Goodwin, 2002).

Bipolar and Related Disorder Due to another Medical Condition

The diagnosis of bipolar and related disorder due to another medical condition is given when the individual displays a persistent period of elevated, expansive, or irritable mood accompanied by increased activity or energy that is the direct physiological consequence of another medical condition. Possible medical conditions that may result in this presentation include Cushing’s disease, multiple sclerosis, stroke, and traumatic brain injuries. Symptoms occurring exclusively during periods of delirium do not qualify, nor do symptoms that predated the development of the medical condition in question.

Other Specified Bipolar and Related Disorder

A diagnosis of other specified bipolar and related disorder may be used when the full criteria for any of the abovementioned disorders have not been met but the individual is experiencing clinically significant impairment or distress. Examples of circumstances in which this diagnosis is appropriate include the presence of (1) major depressive episodes and hypomanic episodes of less than 4 days, (2) major depressive episodes and hypomanic episodes with less than three symptoms, (3) hypomanic episodes and no history of major depressive episodes, or (4) symptoms of cyclothymic disorder for less than 2 years in adults or less than 1 year in children or adolescents. 244 S. L. Connolly and C. J. Miller

Unspecified Bipolar and Related Disorder

The unspecified bipolar and related disorder diagnosis may be used in circumstances in which the individual displays symptoms of a bipolar or related disorder causing clinically significant distress or impairment but does not meet full criteria for any of the disorders discussed above. This diagnosis is often used when the clinician does not have enough information to make a more definitive diagnosis, such as after conducting a brief diagnostic screen under time constraints.

Specifiers

A variety of specifiers may be added to a diagnosis to provide further detail regarding the patient’s presentation. The “with anxious distress” specifier can be used to characterize patients with at least two symptoms of anxiety occurring during a manic, hypomanic, or depressive episode. Co-occurring anxiety is associated with greater illness severity among individuals with bipolar disorders (Simon et al., 2004). An indication of a manic or hypomanic episode “with mixed features” refers to the presence of at least three co-occurring depressive symptoms during the episode; a depressive episode with mixed features indicates the presence of at least three concurrent hypomanic or manic symptoms. The “with rapid cycling” specifier refers to the presence of at least four episodes of hypomania, mania, or major depression occurring within the past year. Rapid cycling may be more common in women and is associated with greater illness severity (Schneck et al., 2004). The “with melancholic features” specifier captures depressive episodes marked by a near-total loss of pleasurable feelings, while “with atypical features” refers to depressive episodes characterized by responsiveness to positive stimuli and increased appetite and sleep, among other symptoms. The “with psychotic features” specifier can be applied when delusions or hallucinations are present within an episode, and “with catatonia” can be specified when psychomotor immobility and lack of responsiveness to external stimuli are observed. The “with peripartum onset” specifier is applied when the mood episode occurs either during pregnancy or in the first 4 weeks after delivery. The postpartum period is particularly high risk among women with bipolar disorders; they are 23 times more likely to have a psychiatric admission in the 30 days following birth compared to non-childbearing periods (Munk-Olsen, Laursen, Pedersen, Mors, & Mortensen, 2006; Sharma, Doobay, & Baczynski, 2017). Peripartum mood episodes with psychotic features occur in between 0.1% and 0.2% of deliveries and are more likely among women with histories of prior peripartum mood episodes or prior mood disorder diagnoses (American Psychiatric Association, 2013). The “with seasonal pattern” specifier can be applied if at least one type of episode tends to occur during a particular time of year for at least 2 years. The prototypical example of this specifier involves an onset of depression in the fall or winter that remits in the spring, although 10 Bipolar Disorders 245 hypomania and mania may show seasonal patterns as well. The “in partial remission” specifier is utilized if symptoms of an episode still remain but no longer meet full criteria for the episode or if there have been no significant symptoms for a period of less than 2 months. The “in full remission specifier” is employed when there have been no significant symptoms of an episode for at least 2 months. Mild, moderate, and severe specifiers can indicate the number and severity of symptoms as well as the degree of impairment.

Procedures for Gathering Information

The procedures for gathering information to determine a potential bipolar disorder diagnosis may vary considerably based on context, resources, time constraints, and the availability of additional informants such as family members or other providers. Ideally, this process will involve an in-person diagnostic interview conducted by a trained clinician who assesses for symptoms of bipolar or related disorders as per the DSM-5 (see the Recommendations for Formal Assessment section later for examples of diagnostic interview protocols). While the degree of structure within the interview may vary from an informal assessment to the use of a standardized protocol, it is always important to ask questions and respond to patients’ answers in an open, nonjudgmental, and easy-to-understand fashion. Providing opportunities for patients to describe their symptoms and concerns in their own words will allow for a better understanding of the diagnostic presentation, reinforcing that the patient’s personal experience is an invaluable component of the decision-making process. However, the interviewer should also anticipate that patients may lack insight into the full extent of their symptoms and that more focused, close-ended questions are often necessary to gather the information needed to reach a diagnosis. This is particularly true when assessing for bipolar disorder, given that individuals with this diagnosis spend the majority of time in depressive episodes versus hypomanic or manic episodes and may be less likely to find their elevated mood states to be impairing (Akiskal & Benazzi, 2005; American Psychiatric Association, 2013). Therefore, it is crucial to specifically screen for a history of hypomanic or manic symptoms regardless of the patient’s presenting concerns. An individual not assessed for these symptoms may receive an incorrect diagnosis of depression and initiate antidepressant medication; as noted above, antidepressants can trigger hypomanic or manic episodes among those with bipolar disorder, further underscoring the importance of thorough diagnostic assessment to prevent potentially harmful treatment recommendations. The interview should thoroughly assess for current and past suicidality given the elevated risk of attempted and completed suicide within this population (Baldessarini et al., 2006; Jamison, 2000). Possible comorbid conditions such as anxiety and substance use disorders should also be assessed, as they frequently accompany bipolar disorder and may be causing additional impairment (Bauer et al., 2005). It is 246 S. L. Connolly and C. J. Miller

important to consider additional factors that may influence the diagnostic impression, including recent stressors, prescription and recreational drug use, past history of psychotherapy or hospitalizations, and co-occurring medical conditions. Furthermore, the interviewer should be attuned to behavioral cues that may inform the diagnostic picture, including the patient’s affect, rate of speech, quality of eye contact, psychomotor functioning, and personal hygiene. Slowed speech and movement, poor hygiene, and restricted eye contact may be indicators of a possible depressive episode, whereas pressured speech and psychomotor agitation may be signs of hypomania or mania. Important information can be gained from additional informants, such as the patient’s significant other, family members, or medical providers including primary care doctors or emergency department staff. The assessor should verify whether informed consent is needed by the patient to discuss their functioning with an additional party. As individuals with bipolar disorders may be less likely to report impairment associated with hypomania or mania, observations of outside informants can be particularly helpful in identifying periods of distinct mood changes or unusual, erratic behaviors that may ultimately qualify as hypomanic or manic episodes (Akiskal & Benazzi, 2005). Ideally, the provider will be able to gather information from multiple sources (e.g., the patient and his or her significant other or spouse) and through various formats (e.g., interview, behavioral observation, and self-report questionnaires) to provide the most comprehensive assessment of the patient and his or her presenting concerns. However, time constraints or situational factors may preclude a thorough in-person interview. In such circumstances, it may be indicated to complete a brief structured screening measure, either administered by the provider or as a self-report questionnaire (see Recommendations for Formal Assessment section for examples), followed by a more comprehensive assessment interview if the patient screens positive. Regardless of the measures used, efforts should be made to inform the patient of the purpose and goals of the assessment. The patient should be encouraged to ask questions and voice any concerns he or she may have in completing this process. Taking a collaborative stance and establishing good rapport are important to both ensure a successful assessment process and to create a strong foundation for future clinical work. Even if the assessor will not be providing subsequent clinical care to the patient, they serve as a representation of their field and can have a major influence on the patient’s willingness to engage in treatment.

Recommendations for Formal Assessment

The use of formalized assessment tools ensures that the provider assesses symptoms in a structured, standardized, and comprehensive manner; providers who forgo formal assessment procedures for more unstructured approaches may be less likely to detect the presence of co-occurring disorders (Zimmerman & Mattia, 1999). The standardized format of these tools provides reliability in the diagnostic process 10 Bipolar Disorders 247 across patients, in addition to allowing the provider to track changes in an individual patient’s symptoms over time. Formal assessment measures reviewed in this section include semi-structured interviews, structured interviews, and screening tools (see Table 10.2).

Semi-Structured Interviews

The administration of a semi-structured interview by a trained mental health professional is considered the gold standard of diagnostic assessment. Semi-structured interviews, as their name suggests, include a standardized, structured set of questions assessing the symptoms of psychological disorders but provide flexibility such that the interviewer can “stray from the script” and ask clarifying questions or request examples as needed in order to determine whether diagnostic criteria is fully met. The structure of these interviews is designed to streamline the assessment process while also ensuring that all relevant information is gathered. For instance, if a patient denies any history of low mood, the interviewer may be able to “skip out” of the more comprehensive depression module; if a patient endorses manic symptoms, the interviewer may be prompted to ask more detailed questions regarding the extent of impairment and the duration of recent episodes. The semi-structured interviews discussed in this chapter include the Schedule for Affective Disorders and Schizophrenia (SADS) and the Structured Clinical Interview for DSM-5 (SCID).

Table 10.2 Formal assessment measures for bipolar disorders Semi-structured Interviews Structured Interviews Screening Tools Pros Standardized, structured Fully standardized interview Quick to complete set of questions Can be administered with Standardized questions Allows for flexibility in relatively little training and Can be administered administration and the does not require clinical without training or can use of clinical judgment judgment be completed by the in assessment patient Cons Can be time consuming to Can be time consuming to Requires a follow-up administer administer diagnostic interview to Interviewer needs May not accurately capture confirm findings significant training symptoms among patients May not accurately with poor insight capture symptoms among patients with poor insight Examples Schedule for Affective Composite International CIDI screening scale for Disorders and Diagnostic Interview Version bipolar disorder Schizophrenia (SADS) 3.0 (CIDI) (CIDI-SC, BPD) Structured Clinical Mini International Mood Disorder Interview for DSM-5 Neuropsychiatric Interview Questionnaire (MDQ) (SCID) (MINI) Hypomania Checklist (HCL-32) 248 S. L. Connolly and C. J. Miller

The SADS (Endicott & Spitzer, 1978) was designed to assess for the presence of psychiatric disorders based on the Research Diagnostic Criteria (RDC), a standardized diagnostic system with clear inclusion and exclusion criteria that predated DSM-III (Rogers, Jackson, & Cashel, 2004; Spitzer, Endicott, & Robins, 1978). The SADS is available in three versions—its standard form assesses for current and lifetime symptoms in separate sections, while the SADS-L (lifetime) probes for current and lifetime symptoms concurrently, and the SADS-C (change) assesses for change in patient functioning since the previous assessment (Endicott & Spitzer, 1978). The SADS is divided into disorder-specific modules that assess for the presence, severity, and duration of symptoms necessary to reach a diagnosis, in addition to modules that gather medical, social, and treatment histories. Test-retest reliability between experienced psychiatrists using the SADS-L was 0.83 for manic episodes, 0.72 for hypomanic episodes, and 1.0 for major depressive episodes (Simpson et al., 2002). The SADS has demonstrated strong reliability and validity in a review of 21 studies and is particularly sensitive in identifying mood disorder diagnoses (Rogers et al., 2004). The SCID was initially developed as a standardized tool to diagnose mental disorders based on DSM-III criteria (Spitzer, Williams, Gibbon, & First, 1992). It therefore has undergone multiple iterations as new versions of the DSM have been released and is currently updated to reflect the criteria of DSM-5. The SCID for DSM-5 is available in both a researcher and clinician version (First, Williams, Karg, & Spitzer, 2015a, 2015b); the researcher version provides the most comprehensive assessment of disorders and specifiers, while the clinician version is abbreviated to focus on the most common diagnoses encountered in clinical settings. The SCID also offers an electronic version, NetSCID-5, that can be accessed through any Internet-connected device and allows for data to be stored in HIPAA-compliant databases and downloaded to statistical software programs. A validation study demonstrated that using this computerized version decreased the number of errors in interview administration as compared to those completing the paper version of the SCID (Brodey et al., 2016). The interview is divided into disorder-specific modules that utilize a decision-tree format to determine if the patient meets DSM criteria for a given condition. In addition to assessing the range of mental disorders, the SCID gathers information regarding medical, social, and treatment history. Depending on the version used, diagnostic complexity, and the patient’s reporting style, the SCID is estimated to take between 30 and 180 minutes to administer. Although reliability and validity data are not yet available for the revised SCID for DSM-5, previous iterations have shown strong psychometric properties (Rogers, 2001). Average test-retest reliability of the SCID for DSM-III-R in determining a bipolar disorder diagnosis across multiple clinical sites was 0.84, indicating high levels of agreement between interviewers; however, reliability data is hard to obtain within community samples given the low base rate of bipolar disorder in the general population (Williams et al., 1992). It is important to note that diagnostic reliability is higher when the patient’s presentation is more severe, such as mania with psychotic features, as opposed to more subtle hypomanic symptoms (Akiskal & Benazzi, 2005; Dunner & Tay, 1993; First & Gibbon, 2004). SCID reliability was 10 Bipolar Disorders 249 not found to vary based on the clinical training of the interviewer (e.g., psychiatrist versus social worker; First & Gibbon, 2004).

Structured Interviews

Structured interviews comprise a fully standardized set of close-ended questions that do not require the clinical judgment of the interviewer to determine whether additional probes or examples are necessary. They can be administered by non- specialists and allow for direct comparisons across patients. While often used in large epidemiological research studies, these tools can also have value within clinical settings by providing relatively straightforward, comprehensive, and standardized diagnostic assessments. The Composite International Diagnostic Interview Version 3.0 (CIDI; Kessler & Ustun, 2004) is a fully structured interview developed by the World Health Organization (WHO) to determine psychiatric diagnoses based on DSM-IV-TR and International Classification of Diseases criteria (ICD-10; World Health Organization, 1993). Individuals from clinical and nonclinical backgrounds alike can be trained in administering the CIDI through computerized or in-person trainings (Kessler & Ustun, 2004). The CIDI contains 41 sections assessing a range of psychiatric disorders as well as physical comorbidities, suicidality, overall functioning and distress, and sociodemographic information. The interview is available in paper and computerized formats, takes approximately 2 hours to complete, and utilizes algorithms to determine diagnoses. An earlier review of the test-retest reliability of the CIDI demonstrated relatively low agreement rates (bipolar I; 0.61, bipolar II, 0.59; Wittchen, 1994), but a more recent examination found that the concordance of bipolar I diagnoses obtained by the CIDI as compared to the SCID was relatively high (0.88; Kessler et al., 2006). Differentiating between bipolar II and subthreshold bipolar disorder proved more problematic due to inconsistencies in disorder criteria between measures, but reliability was high when lumping these outcomes together (0.88; Kessler et al., 2006). The Mini International Neuropsychiatric Interview (MINI; Hergueta, Baker, & Dunbar, 1998; Lecrubier et al., 1997), as its name suggests, was developed as a shorter alternative to existing structured diagnostic interviews. The MINI bears many similarities to the CIDI in its use of screening questions, decision trees, and algorithms to determine diagnoses. It was intended to be a brief, inexpensive measure with high sensitivity and specificity that can be easily administered by clinicians or non-clinicians after 2–3 hours of training. The MINI assesses for current diagnoses of 18 disorders as well as suicidality and takes approximately 15 minutes to complete. The measure has shown fair concordance in diagnosing manic episodes with both the CIDI (0.65) and the SCID (0.67), and rates are notably higher in detecting major depressive episodes (CIDI:0.73, SCID:0.84; Lecrubier et al., 1997; Sheehan et al., 1997). 250 S. L. Connolly and C. J. Miller

Screening Measures

In time-constrained situations, it may be indicated to utilize a screening measure, a very brief assessment of symptoms administered by the clinician or completed by the patient in questionnaire format. These tools are convenient—for instance, the patient could complete a screening questionnaire while in the waiting room prior to their appointment—and can detect whether more thorough assessment is needed. Screening measures can help to prevent inappropriate depression diagnoses and subsequent antidepressant prescriptions among those who may in reality meet criteria for a bipolar disorder (Phelps & Ghaemi, 2006). It must be emphasized that screening tools are never intended to determine diagnoses in the absence of additional assessment. The creators of the CIDI have developed a brief, interviewer-administered screening for bipolar disorders made up of 12 questions derived from the larger interview (CIDI screening scale for bipolar disorder, CIDI-SC, BPD; Kessler et al., 2006; Kessler et al., 2013). This screening tool was found to have high sensitivity, identifying between 67% and 96% of true cases of bipolar disorder, and high positive predictive validity, such that 31–52% of those who screened positive met criteria for bipolar disorder (Kessler et al., 2006). Similarly strong results were replicated in a subsequent follow-up study, demonstrating excellent concordance between the CIDI screener and SCID in determining bipolar diagnoses (Kessler et al., 2013). The Mood Disorder Questionnaire (MDQ; Hirschfeld et al., 2000) is a self-report screening tool for bipolar disorders. It contains 13 items assessing for DSM-IV manic and hypomanic episodes, followed by additional items assessing for co- occurrence of symptoms as well as level of impairment. The MDQ takes approximately 5 minutes to complete and has demonstrated acceptable test-retest reliability (Hirschfeld et al., 2000). The sensitivity of the MDQ has demonstrated large variability, ranging from detecting 28% of cases in a community sample to 90% of those with bipolar I in a clinical sample. Indeed, the measure has generally proven stronger in detecting bipolar I disorder as compared to bipolar II and performs better in clinical as opposed to community samples (Hirschfeld et al., 2003; Miller, Klugman, Berv, Rosenquist, & Ghaemi, 2004; Rouget et al., 2005). The Hypomania Checklist (HCL-32; Angst et al., 2005) was developed as a tool to better screen for bipolar II disorder, particularly among those with major depression, given previous research demonstrating the difficulty of detecting hypomanic symptoms during diagnostic assessment. The primary 32 items assess behaviors, emotions, and thoughts implicated in hypomania; the scale also collects information regarding the duration of symptoms and others’ reactions to the patient’s behaviors. The psychometric properties of the HCL-32 have been evaluated in over 20 international studies, and the measure has demonstrated high sensitivity in detecting bipolar diagnoses (estimated at 80%), particularly among those with preexisting diagnoses of major depression (Meyer, Schrader, Ridley, & Lex, 2014). The measure has also shown good internal consistency and comparability across cultures, 10 Bipolar Disorders 251 although test-retest reliability rates have demonstrated discrepancies between studies (Meyer et al., 2014). Multiple other screening measures exist, including the General Behavior Inventory (GBI; Depue et al., 1981) and the Bipolar Spectrum Diagnostic Scale (BSDS; Ghaemi et al., 2005), as well as a variety of tools intended to measure the severity of bipolar symptoms (see Miller, Johnson, & Eisner, 2009). It is important to ensure that the measure being used has strong psychometric properties, including internal consistency and test-retest reliability, as well as good sensitivity in identifying individuals with the disorder and specificity in detecting those who do not have the disorder. The low overall base rates of bipolar disorder within the population are thought to contribute to the variable effectiveness of screening tools in accurately identifying those who do, and do not, meet diagnostic criteria; as such, these tools may be more accurate when employed within clinical versus community samples. These weaknesses again emphasize that screening tools for bipolar disorder are not considered robust enough to be used in isolation when forming a diagnosis (Mitchell, 2012). The use of fully structured interviews and/or screening measures has pros and cons. Benefits of these tools include their entirely standardized procedure, the ability for non-clinicians to be trained in administration and scoring, and often their shorter administration times. However, they rely entirely on the patient’s self-report in determining diagnoses which can negatively impact validity, particularly among patients with poorer insight into their functioning. In the case of screening measures, additional assessment will be needed if it is indicated that a patient may meet diagnostic criteria. It is important to consider these trade-offs when determining the proper assessment measure, or combination of measures, to use within a given context.

Case Illustrations

Andy. Andy is a 40-year-old Caucasian man presenting to an outpatient mental health clinic along with his wife Jane. Jane asked to join for the initial portion of the diagnostic assessment and Andy agreed. Andy presented as slightly disheveled, in wrin- kled clothes with messy hair. He was noticeably fidgety, repetitively tapping his feet on the floor, and shifting in his seat. When asked what brought him into the clinic, Andy spoke quickly and irritably, stating that he is “feeling good” and is frustrated to be “wasting time” at this appointment, but agreed to come in for an assessment given his wife’s insistence. Jane shared that she is concerned that Andy’s mood is “too up,” that he is not getting enough sleep, and that some of his ideas do not make sense. She reported that he has had multiple periods like this in the past and that he had been seeing a psychologist and psychiatrist before they moved 6 months ago for Andy to start a new job as a graphic designer. Since moving, Andy stated that he did not need to continue treatment as he was feeling happy and motivated by his new position. 252 S. L. Connolly and C. J. Miller

Jane expressed being worried that Andy’s behaviors may end up costing him his job; she shared that he was placed on disciplinary probation for not submitting work on time and will be fired if his performance does not improve. The clinician thanked Jane for her input and then completed the SCID for DSM-5 with Andy alone. Andy endorsed a history of major depressive episodes beginning at age 20. He described having his “first real high” at 25 upon finishing a graduate program. He had trouble recalling the length of this period but described feeling highly creative, having a decreased need for sleep without feeling fatigued, and having unprotected sex with several strangers which he described as highly unusual for him, particularly as he was in a monogamous relationship at the time. He noted that this subsequently led to his relationship dissolving, which motivated him to see a psychiatrist. He reported being prescribed a mood stabilizer and noted having taken his medication regularly for the past four years. However, he chose to not refill his prescription upon moving, given improvements in his mood and his dislike of the medication’s side effects. With regard to his current functioning, Andy reported feeling “super up, but also edgy at the same time” for approximately the past 3 weeks. He endorsed decreased need for sleep (4 hours per night versus his typical 8) and increased energy which he has been trying to “burn up” by biking several hours per day, when he previously had not used his bike in over a year. He described an increase in creativity, particularly with regard to his work, and noted pulling multiple all-nighters draft- ing out plans to revamp the company’s overall vision and mission. He stated feeling “unstoppable…my ideas are flowing so much faster” and reported with confidence that he will be promoted to head of the design department within the next month as he has “the most valuable mind in the company by far.” The clinician noted that he became tangential in his thinking several times during the interview and needed to be redirected. He denied any current recreational or prescription drug use and did not report having any medical conditions. The clinician assessed for risk, and Andy denied suicidal or homicidal ideation. Given the duration of Andy’s abnormally elevated and irritable mood, in combination with his heightened energy, grandiosity, decreased need for sleep, flight of ideas, and increased goal-directed activity, as well as the significant impairment these behaviors have had on his work functioning, Andy meets criteria for a current manic episode and, therefore, bipolar I disorder.

Lisa Lisa is a 25-year-old Hispanic female who reported experiencing depressed mood on a health history intake form administered at her initial primary care appointment at a community health center. She presented as withdrawn, with poor eye contact and slowed, quiet speech. Her primary care doctor recommended that she be evaluated by the center’s behavioral health clinic and Lisa agreed. She met with a prescribing clinician who completed a brief unstructured diagnostic interview confirming that Lisa met criteria for major depressive disorder. Lisa described a history of experiencing periods of persistent low mood in which she had decreased appetite, difficulty sleeping, fatigue, trouble concentrating, and anhedonia. These 10 Bipolar Disorders 253 episodes typically lasted about 1 month and began in her teenage years. She described herself as always being a “moody person” but noted that the periods have gotten worse in the past several years; she was having trouble getting out of bed, was skipping more of her college courses, and was often late to her part-time job. These difficulties were further exacerbated by symptoms of anxiety, particularly in social situations. While she noted always being introverted and having a small circle of friends, she reported becoming increasingly withdrawn from others and turning down social plans. Lisa declined psychotherapy services, explaining that her busy schedule made it too difficult to commit to sessions, but was amenable to initiating an SSRI to treat her symptoms of depression and anxiety. Several months later, Lisa returned to the clinic for a follow-up appointment to monitor her response to the medication. Lisa’s affect was noticeably brighter, and she met the clinician with a smile. When the clinician noted this change, Lisa agreed that she had been feeling “really bubbly” for the past several weeks. She described striking up conversations with classmates she had never talked to before and reported joining five clubs on campus, spanning a wide range of activities that she had no prior experience in. She reported that waking up, going to school, and working at her part-time job felt easy and that she was no longer tired at the end of the day; she also noted sleeping 2 hour less than usual and feeling even more rested upon waking. Lisa spoke very quickly and was noticeably talkative; when the clinician mentioned this, Lisa agreed, stating that her mother had made the same comment and that her thoughts felt “fast and hard to keep track of.” She went on to say that she and her mother got in a small fight last weekend over a lewd joke Lisa made at a family dinner that Lisa’s mother found to be inappropriate and uncharacteristic of her. Lisa denied any current substance use. The clinician had Lisa complete the Hypomania Checklist (HCL-32), and she screened positive for hypomania. The clinician then administered the bipolar disorder module of the SCID for DSM-5. This interview confirmed that she met criteria for a hypomanic episode given her persistently elevated mood, talkativeness, racing thoughts, increased goal-directed activity, and decreased need for sleep, all of which was uncharacteristic of her and noticeable by others but was not causing marked impairment. These symptoms were deemed to extend beyond the physiological effects of her antidepressant medication. Lisa endorsed having experienced several similar periods of lesser intensity about 1 year ago that lasted at most 2 days. She agreed that this was the longest and most intense period of elevated mood she has experienced. Given her history of major depressive episodes and current hypomanic episode, Lisa therefore meets criteria for bipolar II disorder. While Lisa was hesitant to discontinue her antidepressant medication at first, explaining that she had never felt better, she ultimately agreed with her clinician that her behaviors were negatively affecting her relationships with others and her ability to focus on her schoolwork. They subsequently explored alternative treatment options. 254 S. L. Connolly and C. J. Miller

Impact of Gender, Race, Culture, Age, and Other Aspects of Diversity

Rates of bipolar disorder are roughly equivalent between men and women, and similar rates of diagnosis are found around the world (American Psychiatric Association, 2013; Weissman et al., 1996). Age of onset is typically late adolescence to early adulthood although a smaller subset may develop bipolar disorders in midlife (American Psychiatric Association, 2013). Race may influence the appropriate diagnosis of bipolar disorders. A collection of research has demonstrated that Black patients with bipolar disorder are more likely to receive an incorrect diagnosis of schizophrenia as compared to other racial groups (Chen, Swann, & Johnson, 1998; Jones & Gray, 1986; Mukherjee, Shukla, Woodle, Rosen, & Olarte, 1983; Neighbors, Trierweiler, Ford, & Muroff, 2003); this effect was found to hold regardless of the race of the clinician (Neighbors et al., 2003). Multiple factors may contribute to this phenomenon. Black patients may be more likely to (1) demonstrate psychotic symptoms during manic episodes that are subsequently misconstrued as schizophrenia, (2) display paranoia-like symptoms that may in fact be realistic concerns regarding racist behaviors directed toward them, and (3) show blunted affect, a symptom of schizophrenia, due to cultural differences in the display of emotions or a sense of guardedness when interacting with a nonmi- nority provider (Jones & Gray, 1986; Kennedy, Boydell, van Os, & Murray, 2004; Neighbors et al., 2003). Regardless of the reasoning behind this phenomenon, it is important for the clinician to be cognizant of this reality when assessing for bipolar disorder versus attempting to be “color blind” and ignore any potential impacts of race and culture on a patient’s presentation and on a provider’s clinical judgment (Neighbors et al., 2003). Minority patients with bipolar disorders may have higher rates of comorbid substance abuse, homelessness, and involuntary hospitalizations (Kilbourne et al., 2005). It has also been posited that structural and cultural barriers experienced by minority patients, including poor access to healthcare and stigma, may lead them to present to care in more severe states of impairment as they may wait longer to seek help (Hwang et al., 2010). Patients from differing cultures may tend to report distress in terms of somatic versus psychological symptoms, as has often been observed among Asian patients (Lin & Cheung, 1999); this is important for the assessor to keep in mind when evaluating whether a patient meets diagnostic criteria for bipolar disorder. The interviewer should take care when considering a patient’s religious beliefs and practices as they may or may not relate to a diagnosis of bipolar disorder. Religiosity and spirituality have been found to be protective factors that can provide effective coping strategies among those with a mental disorder (De Fazio et al., 2015). However, religious themes often emerge in the context of hypomanic and manic episodes and therefore certain behaviors and beliefs may represent bipolar symptomatology. It is important for the assessor to differentiate between normative 10 Bipolar Disorders 255 aspects of one’s religious beliefs and marked shifts in their thoughts and behaviors. For instance, the interviewer can ask questions to determine whether the amount of time an individual reports praying or reading religious texts is markedly greater than at other times in the past, whether the patient’s self-described feelings of transcen- dence or connection with God are significantly stronger or more intense than usually experienced, and whether these shifts occurred in conjunction with the emergence of additional hypomanic or manic symptoms (Michalak, Yatham, Kolesar, & Lam, 2006). Religious content can also be observed in the context of psychosis, including auditory hallucinations of God or spirits, beliefs of possession by the devil, or grandiose delusions of being a savior or God figure (Brewerton, 1994). As seeing or hearing God or spirits is normative within certain belief systems, contextual factors must be strongly considered when determining the nature of a patient’s reported experiences.

Information Critical to Making a Diagnosis

As discussed elsewhere, it is helpful to gather information from key informants when determining a bipolar diagnosis, such as family members or other healthcare providers involved in their care. This is particularly relevant when diagnosing bipolar disorders as patients may lack insight into the extent of impairment or change in behavior they are experiencing during manic or hypomanic episodes. Indeed, a diagnosis of hypomania requires that others have observed changes in mood and functioning. Given the lack of marked impairment seen in bipolar II disorder and patients’ tendency to present in a depressive episode, it can be particularly difficult to identify a history of hypomanic episodes (Angst et al., 2005). However, this information is critical to determining an accurate diagnosis. Therefore, assessors should be sure to always assess for a history of hypomanic or manic symptoms when a patient presents with depression. Utilizing scales specific to the diagnosis of hypomania, such as the HCL-32, can be helpful in identifying more nuanced behaviors that may be indicative of bipolar II disorder, such as being more social or traveling more than usual. As detailed in the diagnostic criteria section, symptoms of mania and hypomania can be induced by certain recreational and prescription drugs as well as by certain medical conditions; therefore, it is very important to obtain a thorough medical history of the patient including any recent diagnoses or medication changes. Finally, given that bipolar disorder has a strong genetic component, it is helpful to gather a family history of psychiatric disorders that may inform the diagnostic process. 256 S. L. Connolly and C. J. Miller

Dos and Don’ts

The clinician should keep the following recommendations in mind when assessing for bipolar disorders:

Dos: Don’ts: Inform the patient about the nature and Administer an assessment measure that you have not purpose of the assessment process and been properly trained in allow them to ask questions Obtain information from additional sources without Use validated, standardized assessment verifying whether you need the patient’s informed tools such as semi-structured or structured consent interviews Rely exclusively on screening measures to make Follow-up on a positive bipolar disorder diagnostic decisions result from a screening measure with a Provide a diagnosis of depression without more thorough assessment interview confirming that the patient has no history of manic Incorporate feedback from additional or hypomanic symptoms sources such as the patient’s family or Assume that a patient has not experienced other providers when available hypomania or mania just because they do not Screen for comorbid disorders, such as describe their symptoms as being problematic anxiety and substance use disorders Overpathologize behaviors and beliefs that may be Conduct a thorough risk assessment to normative within a patient’s culture or assess for suicidality mischaracterize symptoms based on cultural Screen for hypomania and mania among differences in the manifestation of psychopathology individuals presenting with depressive symptoms, even if they don’t initially mention any periods of elevated mood Consider the patient’s social and cultural background as it may relate to the manifestation of their symptoms and the ways they describe their illness

Summary

Bipolar disorders are impairing and chronic conditions that require accurate diagnosis to ensure appropriate treatment and management. The assessor has the option of utilizing semi-structured interviews, structured assessments, or screening measures to aid in determining a bipolar diagnosis, and each method has unique pros and cons to consider depending on the patient, available resources, timing, and context. The input of key informants can also be crucial in arriving at an accurate diagnostic decision. Among the many considerations the assessor should keep in mind, it is always important to adequately explain the assessment procedure to the patient, allow opportunities for questions, and remain cognizant of cultural and contextual factors that may influence a patient’s presentation and diagnosis. A successful assessment procedure can both direct a patient to the appropriate avenues for treatment and 10 Bipolar Disorders 257 serve as a positive introduction to the mental healthcare delivery system. Completing the diagnostic process in an informed, thoughtful, and thorough fashion is necessary to ensure the best level of care for patients with bipolar disorders.

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Jason E. Peer and Zachary B. Millman

Schizophrenia is a complex, heterogeneous disorder for which an accurate diagnosis is critical to the provision of appropriate information and treatment recommendations to individuals and their family members. Unlike most disorders in medicine, the symptoms of schizophrenia cannot be linked to a specific pathophysi- ological mechanism, and must be assessed solely on the basis of observations, verbal reports, and inferences. Thus, patient self-report is central to making a diagnosis. However, for various reasons, individuals with schizophrenia may have difficulty describing their experiences. This difficulty may be due to the direct effects of symptoms but can also be compounded by poor insight and cognitive impairment. Additionally, high rates of substance use, mood symptoms, and traumatic experiences in this population can complicate self-reporting and the differentiation of schizophrenia symptoms from these other factors. In this chapter, we will describe these challenges in detail and offer strategies to address them in the context of clinical and diagnostic interviews. We outline procedures for gathering information, present case illustrations, discuss the impact of race, culture, diversity, and age on assessment and diagnosis, summarize the information critical for making a diagnosis, and conclude by presenting suggestions for the “dos and don’ts” of conducting diagnostic interviews with individuals who are believed to have schizophrenia.

J. E. Peer (*) VA Maryland Health Care System, Baltimore, MD, USA e-mail: [email protected] Z. B. Millman Department of Psychology, University of Maryland Baltimore County, Baltimore, MD, USA

Description of the Disorder

Over the past 100 years, there has been a growing recognition of schizophrenia as a syndrome with a distinct constellation of symptoms, a variable course, and a range of other associated features. While there is general consensus about some aspects of this disorder, there is still a great deal to be learned about schizophrenia, particularly in the realms of etiology, pathophysiology, and successful treatments. In this section, we will provide a brief background of what is currently known about the prevalence, course, etiology, characteristic symptoms, associated features, treatments, and outcomes of schizophrenia.

Prevalence, Etiology, and Course

Schizophrenia is among the top ten leading causes of disability worldwide (World Health Organization, 2008). It is estimated to affect 1% of the population, although there is significant variability in incidence across studies (Jablensky, 2000; Messias, Chen, & Eaton, 2007; McGrath, Saha, Chant, & Welham, 2008). There is a slightly higher incidence among males than females (Aleman, Kahn, & Selten, 2003), with males also tending to have an earlier age of onset (Cowans, Weber, Fisher, Bedno, & Niebur, 2011) and a generally less favorable course. The typical age of onset is during adolescence or early adulthood. Genetic factors play a strong role in the etiology of schizophrenia, and a number of different genes are implicated in risk for the disorder (e.g., Cannon, Kaprio, Lonnqvist, Huttunen, & Koskenvuo, 1998; Coelewij & Curtis, 2018; International Schizophrenia Consortium, 2009). However, no single genetic factor has consistently been identified, suggesting that multiple genes may combine or interact to give rise to this complex disorder. In addition, several environmental factors are associated with slight but reliable increases in risk for schizophrenia. These include prenatal infection (Mednick, Machon, Huttunen, & Bonett, 1988), obstetric and perinatal complications (Cannon, Jones, & Murray, 2002), social stress and trauma (Bentall & Fernyhough, 2008; Pruessner, Cullen, Aas, & Walker, 2017), winter/spring season of birth (McGrath & Welham, 1999), older paternal age (Wohl & Gorwood, 2007), and cannabis abuse (Kraan et al., 2016; Marconi, Di Forti, Lewis, Murray, & Vassos, 2016). Historically, schizophrenia was considered to be a progressive disorder with a poor and deteriorating course (McGlashan, 1998). However, several studies of long- term outcome in schizophrenia have found that most individuals with schizophrenia experience a stable or fluctuating course, about a third show a worsening over time, and other individuals experience lasting improvements, in some cases no longer requiring antipsychotic treatment (Carpenter & Strauss, 1991; Ciompi, 1980; Harding, 1988; Harrow, Jobe, & Faull, 2012). A review of several long-term follow- up studies found 40–76% of patients demonstrate an “undulating” course pattern characterized by variations in the severity of symptoms over time (Harding, 1988). Although symptoms may be quite variable over time, the cognitive and functional 11 Schizophrenia 263 deficits associated with schizophrenia frequently both predate the onset of psychotic symptoms and persist even during periods of symptom remission (Jones, Rodgers, Murray, & Marmot, 1994; Keshavan, Diwadkar, Montrose, Rajarethinam, & Sweeney, 2005).

Characteristic Symptoms and Associated Features

Conceptualizations of schizophrenia and its diagnostic criteria have fluctuated over the past century and have been influenced by historical, cultural, and social factors as well as the state of our scientific knowledge. However, hallucinations and delusions (i.e., positive symptoms) and negative symptoms have been noted as features that distinguish schizophrenia from other disorders dating back to Kraeplin’s writings on dementia praecox (1904) as well as Bleuler’s work (1972). The current Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association [APA], 2013) diagnostic criteria for schizophrenia are summarized in Table 11.1. The core symptoms of schizophrenia generally have been divided into two categories: positive symptoms (i.e., the presence of experiences that do not typically occur in the absence of schizophrenia) and negative symptoms (i.e., representing a reduction or loss of normal function). Factor analytic studies of

Table 11.1 Summary of DSM-5 diagnostic features for schizophrenia Criterion Description A. Characteristic Symptoms Two or more of the following: delusions, hallucinations, (active phase) negative symptoms, disorganized speech or behaviora Time frame: At least 1 month (or less if successfully treated). B. Social/Occupational One or more areas of functioning (e.g., work, interpersonal, Dysfunction self-care) are impaired. Time frame: significant portion of time since the onset of disorder C. Duration Some sign of disturbance or impairment (can be less severe or fewer symptoms) precede or persist after active phase (Criterion A) for at least 6 months. Exclusion Criterion D. Schizoaffective and Mood Active-phase symptoms (criterion A) do not occur concurrent Disorder exclusion with mood episode, or if mood episode is present, it is brief E. Substance use and general Symptoms or disturbance are not due to drug use or medical condition exclusion withdrawal, medication, or a medical condition F. Relationship to Pervasive If there is a history of autism or PDD, a diagnosis of Developmental Disorder (PDD) schizophrenia is only given if there is an active phase consisting of prominent hallucinations or delusions. Adapted from DSM-5 (APA, 2013) aNote: only one symptom is necessary to fulfill this criterion if delusions are bizarre, or auditory hallucinations include two or more voices conversing with each other or a voice commenting on the individual’s behavior or thoughts 264 J. E. Peer and Z. B. Millman symptoms suggest that a three-factor distinction may be more representative of clinical data (Kay & Sevy, 1990; Liddle, 1987). Specifically, symptoms of disorganized speech and behavior appear to cluster together somewhat independently of hallucinations/delusions or negative symptoms.

Positive Symptoms

Hallucinations are the most frequent type of positive symptoms and may occur in any sensory modality but are most commonly auditory. Auditory hallucinations generally occur when the individual hears a voice or voices that are not their own and cannot be heard by others. The voices sometimes tell the person what to do (i.e., command hallucinations), sometimes comment on the person’s thoughts or actions, may consist of more than one voice having a conversation with each other, or may consist only of sounds rather than voices. Hallucinations are distinct from the person’s own thoughts and need also to be distinguished from the isolated experience of hearing one’s name called out or the experience of voices heard either right at the time of descent into sleep (i.e., hypnagogic hallucinations) or right at the time of waking (i.e., hypnopompic hallucinations), which are commonly experienced in the absence of schizophrenia. Delusions are defined as “fixed beliefs that are not amenable to change in light of conflicting evidence” (DSM-5, p. 87). The content of delusions can be quite variable but generally fall into one of several categories: grandiose delusions, persecutory delusions, delusions of reference, or delusions of having one’s thoughts or actions controlled by an outside entity. Delusions are considered to be bizarre if they are clearly implausible and disconnected from typical life experiences or the cultural context of the individual’s experience, for example, the belief that one’s brain has been replaced with another’s would be considered bizarre. In contrast, a non- bizarre delusion represents a false belief but one that could actually occur, for example, the belief that the government is spying on a person. Severe disorganization of thoughts or behavior is a subset of positive symptoms that have been shown to be relatively distinct from hallucinations and delusions. These refer to abnormalities in the process, structure, and form of thoughts or behaviors. In the context of a diagnostic interview, disorganization of thought can most readily be identified by observations of the person’s speech patterns (e.g., loose associations, tangentiality, or incoherent speech) during the interaction. Disorganization of behavior often manifests as unusual motor behaviors such as pacing, rocking, or other odd or erratic movements. Severe disorganized behavior can result in the inability to appropriately maintain activities of daily living such as personal hygiene, grooming, and dressing. For example, an individual presenting in an interview with poor hygiene and grooming or wearing clothing inconsistent with the season (e.g., winter coat and hat during the summer) may be experiencing symptoms of disorganized behavior. Catatonia (i.e., absence of movement or waxy flexibility) can also occur in schizophrenia but is less common than the other positive symptoms. 11 Schizophrenia 265

Negative Symptoms

Negative symptoms represent a diminution or absence of emotions, thoughts, or behaviors that are typically present in individuals who do not have schizophrenia. Five domains of negative symptoms were identified during the National Institute of Mental Health Consensus Development Conference on Negative Symptoms: asociality, avolition, anhedonia, blunted affect, and alogia (Kirkpatrick, Fenton, Carpenter, & Marder, 2006). Avolition refers to an absence or reduction in the ability to initiate or sustain goal-directed behaviors. Anhedonia refers to the reduced ability to experience pleasure. Asociality specifically refers to lack of interest or engagement with other people. Alogia, or poverty of speech, is characterized by a diminished ability to carry out meaningful conversation, whereas blunted affect refers to diminished emotional expression (facial, voice tone, etc.). Factor analytic studies of negative symptom assessment measures generally identify two factors representing expressivity (blunted affect and alogia) and pleasure/motivation (avolition, anhedonia, and asociality; Carpenter, Blanchard, & Kirkpatrick, 2016).

Associated Features

In addition to positive and negative symptoms, schizophrenia is associated with a range of problems in multiple domains. Poor social, educational, and vocational functioning are quite common, as are cognitive deficits such as impairments in verbal memory, concentration, and abstract reasoning. Depressed mood, anxiety, and irritability or anger can also be present. Risk of suicide is higher among persons with schizophrenia than in the general population and subjective quality of life is frequently poor.

Treatments and Outcomes

Many individuals with schizophrenia are prescribed antipsychotic medications, both for acute exacerbations of positive symptoms and for preventing symptom relapses. However, some individuals with schizophrenia experience a suboptimal medication response even when adherence to medication regimens is good (Bruijnzeel, Suryadevara, & Tandon, 2014). In addition, current medications have little, if any, benefit for negative symptoms, social disability, and cognitive deficits. Effective psychosocial interventions have been developed to ameliorate residual positive symptoms (e.g., cognitive-behavior therapy), interpersonal deficits (e.g., social skills training), functional difficulties (e.g., supported employment), and cognitive deficits (e.g., cognitive remediation). Optimal treatment for schizophrenia includes both medication and specific psychosocial interventions tailored to each individual’s stage of disorder, current clinical status, personal goals, and social needs. 266 J. E. Peer and Z. B. Millman

Procedures for Gathering Information

The information needed for making a diagnosis of schizophrenia involves the interviewee’s self-report, behavioral observation and, if possible, collateral information. The clinical interview is the primary vehicle for gathering a description of symptoms and functioning. As such, it is critical to create a comfortable interview experience conducive to obtaining the most accurate information. In large part, this can be accomplished through use of standard clinical skills involved in developing rapport and by adopting a matter of fact approach to the interview. It is also helpful to provide a careful description of the purpose of the interview and its duration. If feasible, offering the interviewee the opportunity to take a brief break if he or she chooses can also enhance rapport and participation in the interview. We have found that the Structured Clinical Interview for DSM-5, Clinician Version (SCID-5, CV; First, Williams, Karg, & Spitzer, 2015) is a useful way to organize the diagnostic interview. It has a standardized semi-structured format that is comprehensive yet is flexible enough to allow clinicians to pursue additional follow-up questions or clarifications as they determine if diagnostic criteria are fulfilled. It can be tailored for the individual’s clinical presentation and is well suited for diagnosis of schizophrenia. The SCID-5 is divided into modules that correspond to DSM-5 disorders and includes standard questions for eliciting symptoms for each specific diagnostic criterion as well as appropriate rule-outs for each disorder. Each symptom is rated as “absent (or subthreshold)” or “present.” Two SCID-5 modules, the Psychotic and Associated Symptoms Module and the Differential Diagnosis of Psychotic Disorders Module, provide most of the information needed to make (or rule out) a diagnosis of schizophrenia. The Psychotic and Associated Symptoms Module addresses specific symptoms associated with schizophrenia. The Differential Diagnosis of Psychotic Disorders Module provides a series of questions to determine how to best classify the identified psychotic symptoms (e.g., a psychotic mood disorder vs. schizophrenia). The interview is intended to be supplemented with all available information when making a diagnosis (First et al., 2015). In clinical settings, this information can often include the medical record (e.g., an inpatient admission or discharge note), referral information, and observations from family members and other clinicians. The SCID-5 begins with an overview that includes a series of questions designed to gather background information on demographics, work history, mental health treatment history, current mental health problem, and substance use history. This overview serves several purposes. It allows the interviewer to develop rapport with the interviewee by gathering more general information with questions that tend to be nonthreatening. It provides the opportunity to obtain general information about mental health history, the nature of the onset of illness, and mental health treatment, all from the interviewee’s perspective. This information can inform the interviewer’s initial hypotheses about diagnosis and which symptom domains to follow up on in greater detail later in the interview. The overview is also an excellent chance to observe how the person behaves in the interview situation and how he or she 11 Schizophrenia 267 responds to questions. These observations can be critical in diagnostic interviews for schizophrenia. For example, what is the quantity of information contained in responses? Is there a paucity or overabundance of information (i.e., circumstantiality)? How coherent are responses? Are they logical and straightforward or tangential (i.e., responses include information only loosely related to the questions)? What is the quality of information provided? Does the interviewee minimize or deny symptoms? Does the interviewee provide vague or detailed descriptions? On the basis of these observations, the interviewer may need to tailor the remainder of the interview to maximize the quality of information as well as the efficiency with which it is obtained.

Recommendations for Formal Assessment

In addition to the SCID-5 (described above) and standardized symptom interviews for psychotic symptoms (described below), additional assessments may be helpful in gaining a full understanding of the clinical presentation of an individual believed to have schizophrenia. For example, we have noted the prevalence of cognitive and functional impairment among individuals with schizophrenia. A thorough clinical evaluation would likely include some neuropsychological testing and assessment of social and occupational functioning. There are several reliable self-report and family/clinician administered psychosocial functioning assessment measures available (see Mausbach, Moore, Bowie, Cardenas, & Patterson, 2009 for a review). Assessments of substance use, trauma history, and mood symptoms can also be critical to making (or ruling out) a diagnosis of schizophrenia and can inform treatment not just of psychosis but of the range of problems that commonly co-occur with schizophrenia.

Standardized Interview Formats

Determining a diagnosis of schizophrenia is based on the presence or absence of given symptoms. As discussed above, the SCID-5 is one of the most commonly used instruments. Several other structured and semi-structured interviews are also available. Use of symptom rating scales can also be helpful in describing and qualifying the severity of symptoms. There are several symptom rating scales that are widely used in clinical and research settings. Familiarity with one or more of these scales can aid the newer interviewer with understanding and recognizing some of the characteristic symptoms of schizophrenia, particularly negative symptoms which are generally more difficult to assess. These measures were specifically designed to enhance the reliability with which these symptoms could be rated. They include training protocols or manuals and provide comprehensive behavioral descriptors for each symptom. Nevertheless, their 268 J. E. Peer and Z. B. Millman administration also requires clinical sensitivity and judgment. We briefly describe some of the most commonly used scales. The Brief Psychiatric Rating Scale (BPRS; Overall & Gorham, 1962) is one of the oldest and most established clinician-rated scales. It contains 18 items that cover a range of psychiatric symptoms typically observed in hospitalized patients, each of which is rated on a 7-point scale ranging from “not present” to “extremely severe.” The symptoms covered by this scale not only correspond with positive and negative domains of schizophrenia but also include coverage of anxiety and depressive symptoms. The UCLA Clinical Research Center for Schizophrenia and Psychiatric Rehabilitation has developed an expanded 24-item BPRS that is manualized and includes additional items to evaluate additional psychiatric symptoms (e.g., suicidal ideation, mania), more detailed behavioral anchors, and additional probe questions to elicit symptom reporting (Lukoff, Liberman, & Nuechterlein, 1986; Ventura, Green, Shaner, & Lieberman, 1993). The BPRS has consistently demonstrated good psychometric properties, is widely used, and considered a “gold standard” in treatment research for schizophrenia. The Positive and Negative Syndrome Scale (PANSS; Kay, Fiszbein, & Opler, 1987) was developed to be a relatively brief yet comprehensive assessment of symptoms of schizophrenia. It consists of 30 items that are adapted from the BPRS and other psychopathology measures. Each item is carefully defined and includes detailed behavioral anchors relevant to the symptom in question. Items can be summed to represent positive, negative, and general psychopathology scales. An accompanying structured clinical interview is available to facilitate reliable assessment and rating of symptoms (Opler, Kay, Lindenmayer, & Fiszbein, 1992). Negative symptoms can be challenging to assess and distinguish from depressed mood, secondary effects of positive symptoms (e.g., social isolation due to paranoid delusions), medication side effects, cognitive impairment, and medical disorders with similar presentations. Two recent negative symptom assessment measures have greatly improved the reliability with which these symptoms can be evaluated and both measures include training manuals and/or videos that can assist the newer interviewer with evaluating these symptoms. The Clinical Assessment Interview for Negative Symptoms (CAINS; Kring, Gur, Blanchard, Horan, & Reise, 2013) is a 13-item scale with two subscales tapping impairment in emotional expression (4 items) and motivation/pleasure (9 items). Each item is rated on a 0–4-point scale with higher scores reflecting greater impairments. Items include additional interview probes and comprehensive behavioral anchors. The CAINS has excellent reliability and has been well validated in both tightly controlled research studies (Kring et al., 2013) as well as in general clinical use in the field (Blanchard et al.,2017 ). An interview guide and online training videos are also available from the authors. The Brief Negative Symptoms Scale (BNSS; Kirkpatrick et al., 2011) contains 13 items that share a similar factor structure as the CAINS tapping deficits in emotional expression, motivation, and pleasure. Each BNSS item is rated on 0 (absent)–6 (severe)-point scale and includes semi-structured interview prompts and behavioral anchors. The BNSS has good reliability and strong evidence for validity 11 Schizophrenia 269

(concurrent, predictive, and convergent/discriminant). Training materials include a manual, interview guide, and training videos and are available from the authors.

Case Illustrations

Here we briefly describe some clinical vignettes that illustrate some of the characteristic symptoms that are commonly encountered in interviews. These vignettes are not from a single case but instead represent an amalgamation of several clinical interviews that were selected to illustrate relevant symptoms. Table 11.2 also includes descriptions of these symptoms as well as behavioral symptoms (e.g., negative and disorganized symptoms) associated with schizophrenia.

Hallucinations and Delusions

This vignette includes description of positive symptoms leading to a recent psychiatric hospitalization. Note that delusional symptoms include delusions of reference and grandiose delusions, and the auditory hallucinations are consistent in content with the grandiose delusions. Also note that the active symptoms were present for several months, gradually becoming more severe. Interviewee (I): I was hearing voices. That was when it was getting really bad. I was confused. I couldn’t tell if the voices were real or not. Clinician (C): Can you give me an example of this? I: I was doing pretty well for myself. I had a job, an apartment, and a car and in the middle of everything I left to go to New York City. I saw a television show about Wall Street and I thought it was about me. I was getting messages from commercials, movies, from other people. When I interacted with people I got hidden messages from them. I believed that important financial people wanted me to go to New York City and that I would become rich if I went there. C: How long had this been going on? I: It had been going on for a while, like a couple of months, but it wasn’t until I saw this particular television show that I was convinced that I was supernatural. C: How did you become convinced you were supernatural? I: I heard voices telling me. C: Tell me a little bit more about the voices. Did you hear more than one voice? I: Yes, lots of voices at a time. They talked to each other, it was like they were worshipping me. Table 11.2 Descriptions of characteristic symptoms of schizophrenia from symptom rating scales Characteristic Symptom Item description with sample anchors Delusionsa Unusual, odd, strange, or bizarre thought content. Include thought insertion, withdrawal, and broadcasting. Include grandiose, somatic, and persecutory delusions. Very mild ideas of reference (people stare/laugh at him/her). Ideas of persecution (people mistreat him/her). Unusual beliefs in psychic powers, spirits, UFOs. Not strongly held. Some doubt Moderate delusion present but not strongly held (functioning not disrupted); or encapsulated delusion with full conviction (functioning not disrupted) Severe full delusion(s) present with much preoccupation or many areas of functioning disrupted by delusional thinking Hallucinationsa Reports of perceptual experiences in the absence of external stimuli. When rating degree to which functioning is disrupted by hallucinations, do not include preoccupation with the content of the hallucinations. Consider only disruption due to the hallucinatory experiences. Very mild while resting or going to sleep, sees visions, and hears voices, sounds, or whispers in absence of external stimulation but no impairment in functioning Moderate occasional verbal (auditory), visual, olfactory, tactile, or gustatory hallucinations 1–3 times but no impairment in functioning or frequent nonverbal (e.g., sounds or whispers) hallucinations Severe several times a day or many areas of functioning are disrupted by hallucinations Disorganized Disorganized process of thinking characterized by disruption of goal-directed speechb sequencing (e.g., circumstantiality, tangentiality, loose associations, (thought non sequiturs, gross illogicality, or thought blocking) disorder) Mild thinking is circumstantial, tangential, or paralogical. There is some difficulty in directing thoughts toward a goal, and some loosening of associations may be evidenced under pressure Moderate able to focus thoughts when communications are brief and structured but becomes loose or irrelevant when dealing with more complex communications or when under minimal pressure Severe thinking is seriously derailed and internally inconsistent, resulting in gross irrelevancies and disruptions of thought processes which occur almost constantly Disorganized Unusual and bizarre behavior, stylized movements or acts, or any postures behaviora,b which are clearly uncomfortable or inappropriate Mild eccentric or odd mannerisms or activity that ordinary persons would have difficulty explaining, e.g., grimacing, picking. Observed once for a brief period Moderate mannerisms or posturing maintained for 5 s or more that could make the patient stand out in a crowd Severe posturing, intense rocking, and strange rituals that dominate patient’s attention and behavior Reports of behaviors that are odd or unusual. Not limited to interview period Mild peculiar behavior (e.g., talking loudly in public, fails to make appropriate eye contact when talking with others) Moderately severe highly unusual (e.g., wandering streets aimlessly, eating nonfoods, fixated staring in a socially disruptive way) Severe unusual petty crimes (e.g., directing traffic, public nudity, contacting authorities about imaginary crimes) (continued) 11 Schizophrenia 271

Table 11.2 (continued) Characteristic Symptom Item description with sample anchors Negative Diminished emotional responsiveness as characterized by a reduction in facial symptomsb expression, modulation of feelings, and communicative gestures (blunted affect) Mild changes in facial expression and communicative gestures seem stilted, forced, artificial, or lacking in modulation Moderately severe affect generally appears “flat,” with few changes in facial expression and a paucity of communicative gestures Extreme changes in facial expression and evidence of communicative gestures are virtually absent. Patient seems to constantly show a barren or “wooden” expression Note: mild-level symptoms may not always meet the threshold of diagnostic criteria but are listed here to provide the range of symptom presentation aAdapted from BPRS (Lukoff et al., 1986) bAdapted from PANSS (Kay et al., 1987)

C: How were they were worshipping you? I: They were saying things like: He is brilliant. We’ve never seen someone with so much genius. He finished high school at age 15. He is a magician with numbers. The following is an example of an exchange in which an interviewee describes paranoid delusions about being monitored by the government: Clinician (C): Has there ever been a time when you thought people were going out of their way to try to hurt you? Interviewee (I): Well, they would come in my room at night and go through my things. C: Can you tell me a little bit more about that? I: They came in when I was sleeping and also when I wasn’t there. C: Who did you think was going through your things? I: The government. C: What did you think they were looking for? I: The CIA is keeping an eye on me. They follow me when I’m outside too. C: Why would the CIA be keeping an eye on you? I: My therapist might work for them too. But I’m not sure about that. She has other things to worry about that are more important than me. C: You said before that the CIA is keeping an eye on you. Why would they do that? I: They want to find a way to lock me up. So I won’t tell anyone the things I know. But I keep my eye out for them. When I see they’ve been there I know I need to be careful. C: Can you tell me a little bit more about this? 272 J. E. Peer and Z. B. Millman

I: Well, they leave little clues. They want me to know they are watching me. Like when they come in my room, I can tell. C: How can you tell? I: I can feel it. I can just tell. Sometimes my lamp shade is tilted a certain way and that is usually a sign they have been there.

Disorganized Speech

This brief exchange from an interview represents an extreme example of disorganized speech, that of derailment where an interviewee’s response is largely unrelated to the original question. Furthermore, the response is largely incomprehensible, indicating a relatively severe form of thought disorder. C: What are some of the difficulties you had at work? I: Well solving a mathematical problem for one thing. For solving the radius of the circle you divide the circle by quadrant upside and down, you take the hypotenuse of the quadrant and depending on the circumference of the circle divide it by the diameter of the quadrant. In the case of an interviewee with significant disorganization symptoms, the clinician should adopt a much more structured approach shifting to more close-ended questions. In some cases, the interview may need to be limited and the clinician rely on other informants to obtain needed information to inform diagnosis such as the duration of active symptoms or other types of behaviors that have been observed.

Impact of Gender, Race, Culture, Age, and Other Aspects of Diversity

As with any diagnostic interview or clinical encounter, the impact of race, ethnicity, age, and other individual differences must be taken into consideration when conducting an interview with an individual who may have schizophrenia. It is incumbent on the interviewer to be knowledgeable about common experiences, as well as the cultural and social contexts, of the patients they see. There are some diversity considerations specific to diagnosing schizophrenia that are worth noting. Delusional beliefs frequently contain spiritual or religious themes. The content of positive symptoms among people with schizophrenia varies by religious and cultural affiliation. Interestingly, members of non-Western cultures appear to experience hallucinations as less distressing than members of Western societies which, given the diagnostic criterion of functional impairment in schizophrenia, has implications for clinical assessment (Luhrmann, Padmavati, Tharoor, & Osei, 2015). Related, many religious and cultural communities attribute voice-hearing and/or a 11 Schizophrenia 273 perceived connection with higher powers not to mental illness at all, but to spiritual sources (Larøi et al., 2014). Different cultures and religious traditions have widely divergent beliefs about communication with God, communication with deceased individuals, and the role of God (or gods) in determining one’s path or fate in life. Clinicians should keep in mind the ways in which culture may impact perceptual experiences. Indeed, thoughts that are considered unusual in Western cultures may be neither indicative of schizophrenia nor inherently pathological in non-Western cultures. Thus, before concluding that a belief is delusional it is important to gain an understanding of the individual’s spiritual experiences as well as the normative religious beliefs in their family, culture, or community. There are several identified culturally specific concepts of emotional distress that can also impact the expression of mental health conditions and in some cases lead to misdiagnosis. Here we note a few syndromes described in DSM-5 that may, in some cases, share some overlap in clinical presentation with schizophrenia or be misconstrued as psychotic symptoms (APA, 2013). For example, dhat syndrome occurs in South Asia and is a cultural explanation for a range of emotional and somatic complaints whereby young men report a white discharge noted in urine or feces and attribute their symptoms to semen loss. Maladi moun is a Haitian cultural explanation for physical and mental health conditions. In this conceptualization, illness is attributed to others’ envy or hatred usually in response to an individual’s perceived success or attractiveness. Finally, taijin kyofusho is a primarily Japanese cultural syndrome (although it has been described in other cultures) whereby an individual experiences anxiety over interpersonal situations due to the conviction that ones’ appearance or actions will be offensive. This can include distorted perceptions of ones’ body or the belief that one has offensive body odor. In some cases the conviction with which these beliefs are held may have a delusional quality. Without cultural context, these cultural expressions could be misconstrued as symptoms of schizophrenia, as they could be perceived as unusual in the majority culture and/or expressed with a high degree of conviction. Thus, familiarity with these syndromes is recommended. With regard to race more broadly, clinicians should be wary of potential racial bias in clinical diagnosis. Specifically, African American individuals are much more likely diagnosed with schizophrenia than White individuals in the United States (Coleman et al., 2016; Gara et al., 2012, Hampton, 2007). Multiple hypotheses have been put forth to explain this disparity, including inadequate cultural sensitivity of diagnostic instruments (Schwartz & Blankenship, 2014), clinician bias (Gara et al., 2012), cultural influences on symptom expression during assessment (e.g., Peltier, Cosgrove, Ohayagha, Crapanzano, & Jones, 2017) and “healthy paranoia” secondary to exposure to racial discrimination and/or safety concerns associated with some low-income environments (Combs et al., 2006). Although the veracity of these hypotheses is still a subject of debate, these diagnostic trends are complicated further by the fact that African American individuals are also truly at greater risk for psychotic disorder, likely by virtue of the greater likelihood for exposure to risk factors for psychosis, including urban upbringing, low socioeconomic position, social exclusion, and trauma exposure (Selten, van der Ven, Rutten, & Cantor-Graae, 274 J. E. Peer and Z. B. Millman

2013; van Os, Kenis, & Rutten, 2010). Clinicians are therefore encouraged to develop cultural awareness in their assessment skills, carefully assess the range of psychiatric symptoms in patients, and entertain multiple hypotheses about the etiology of symptoms. Based on recent research, we provide a few suggestions to consider in interviewing. In a carefully designed study, Gara et al. (2012) used clinical interview transcripts that were redacted to remove any linguistic, syntax, phrasing, or situations that could cue a clinician to patient ethnicity and compared these diagnosis to original diagnoses made with unredacted transcripts. They found that when African American interviewees described hallucinations or delusions they were more likely to be given a diagnosis of schizophrenia when compared to diagnoses made based on ethnically blinded transcript. The authors conclude that clinicians failed to complete a thorough assessment of mood symptoms and tended to preemptively give a diagnosis of schizophrenia to African American patients. When considering the intersection of race and culture, Peltier (2017) found that over 60% of African American patients in a public health clinic in southeastern USA who endorsed experiencing auditory or visual hallucinations attributed these to spiritual or supernatural cultural beliefs. The odds ratios of a schizophrenia spectrum diagnosis dropped dramatically when hallucinations were considered attributable to religious or cultural influences. As such, clinicians are encouraged to inquire about the religious and cultural context surrounding reported beliefs or perceptions. The onset of schizophrenia occurs most often in late adolescence or early adulthood with a slightly older average age of onset for women than for men. Positive symptoms are often most severe during the first few years of the disorder, after which most people experience a stabilization or reduction in symptom levels as they age (Lehman et al., 2004). Negative symptoms and cognitive impairments do not appear to decline with age or duration of illness. Thus, clinical presentation may vary over time, and the interviewees age and age of illness onset are important considerations. With the realization that earlier intervention leads to better outcomes, there has been an increased focus on screening for psychosis among young people, and we provide a few comments on how the clinical presentation of schizophrenia varies at a younger age of onset. Children and adolescents with schizophrenia often present with a more severe clinical picture than individuals whose onsets were in young adulthood, the typical age of onset. Youth are more likely to have serious thought disorder and bizarre symptom content than later-onset patients (Bo & Haahr, 2016), and these symptoms may involve childlike themes (e.g., delusions involving fantas- tical characters such as vampires placing a computer chip in one’s brain; visual hallucinations of monsters). Children with schizophrenia also often present with more significant neurodevelopmental abnormalities relative to adults, including language, motor, and general cognitive functioning deficits (Jones et al., 1994). Those whose disorder takes hold during childhood or adolescence frequently respond poorly to antipsychotic treatment (Millman et al., in press) and are likely to experience a more chronic and disabling course (Fleischhaker, Schulz, Teper, Hennighausen, & Remschmidt, 2005). 11 Schizophrenia 275

Despite these age-related trends in symptom presentation, several issues complicate the assessment of schizophrenia in children and adolescents. First, psychotic symptoms for most youth presenting for evaluation are only just emerging. A longer-term history of symptom course is therefore typically unavailable to inform the diagnosis. Second, magical thinking, thoughts of being the focus of others’ attention, and other psychosis-like experiences are often part of normative development for children and adolescents (Carol & Mittal, 2015). Interviewees may therefore endorse experiences that on their surface appear to implicate a psychotic disorder but after detailed probing are revealed to lack the pathological nature inher- ent to schizophrenia. For these reasons, parental input is often especially valuable when assessing for schizophrenia among youth. It is important to note that the earliest clinical manifestations of psychosis often involve positive symptoms that are not severe enough to be considered formally psychotic. As symptoms first begin to develop, insight into the nature of the experience often remains intact (e.g., the individual has begun to hear a voice but recognizes that it is not real) and/or the symptom is not yet seriously impairing. Given their association with a subsequent onset of schizophrenia, the emergence of attenuated positive symptoms among adolescents and young adults (i.e., the peak age of onset for schizophrenia) itself often warrants clinical attention (Nieman & McGorry, 2015). Notably, however, most individuals with attenuated psychosis do not go on to develop the full disorder (Fusar-Poli et al., 2015; van Os, Linscott, Myin-Germeys, Delespaul, & Krabbendam, 2009). Clinicians are therefore challenged to carefully assess the degree of conviction and impairment stemming from putative psychotic symptoms in young people, maintaining attention to the possibility that they may suggest an emerging disorder, while at the same time not assuming the diagnosis is or ever will be schizophrenia. In the vignette below, the clinician interviews a 16-year-old male who was referred by his psychiatrist for an evaluation due to concerns of possible schizophrenia. The vignette demonstrates the importance of querying the degree of conviction held by the patient in distinguishing between a formal psychotic symptom and an attenuated psychotic symptom. Clinician: Have you had the feeling that people were out to get you? Interviewee: Actually, I have. C: Tell me about that. I: I think people are watching me. When I go out, they stare at me. Sometimes they hide in the shadows where I can’t see them. It’s like there’s some sort of evil plan. C: Why would they do this? I: I don’t know. They just are. At this point in the interview, the clinician is concerned that the patient may be experiencing paranoid symptoms of schizophrenia. The content of the experience is moderately developed (e.g., the attribution of an evil plan) and is compelling to the patient. However, the clinician queries the degree of conviction held by the patient 276 J. E. Peer and Z. B. Millman to determine whether this may qualify as a symptom of schizophrenia, an attenuated psychotic symptom, or perhaps something unrelated. C: Are you sure people are watching you? I: Well, not really. It definitely feels like they are, but it’s possible I’m just going crazy or something. C: Tell me what it’s like in the moments when you’re out and you have this feeling. I: I’ll be walking in the mall and watching people go by. And I start to think that they’re all planning something against me. Then I start arguing with myself about whether that even makes sense. Then after a few minutes I convince myself that they probably aren’t, and I carry on. The patient described self-inducing doubt as to the reality of the symptom. As a result, although concerning, the symptom is not of psychotic intensity and would not in itself fulfill criterion A1 (delusions) for schizophrenia. Probing the degree of conviction, both in the moment (i.e., while the experience is happening) and during the interview revealed important information to inform the diagnosis. The vignette below depicts an 11-year-old female who was referred for assessment by her school counselor. Children and early adolescents often have concrete (i.e., black and white) mental representations of abstract concepts such as those related to psychosis. Thus, it is common for youth to endorse experiences resem- bling psychosis that, upon further inquiry, are found to lack one or more central features of schizophrenia-related psychotic symptoms. Clinician: Have you had the feeling that somebody could read your mind? Interviewee: Yes. C: How so? I: Kids at school read my mind all the time. I’ll be thinking something, and then they say it. It’s so weird. Here, the patient has endorsed an experience that could be related to first-rank symptoms of schizophrenia. Substantially more contextual information, however, is needed for the assessment. C: What kind of thoughts of yours do they read? I: Just things like whether it’s time for lunch yet or whether something another kid said was funny. C: What else? I: That’s pretty much it. C: Okay, who specifically reads your mind? I: Just my best friend Ally. Sometimes Shirah. C: How is it possible that they are reading your mind? I: We’re just best friends and that’s what best friends do. C: Do other kids do this with each other too? I: I don’t know, probably. C: Is this scary when it happens? 11 Schizophrenia 277

I: No it’s funny! C: Does it make you do anything differently? I: No, we just laugh about it. The experience described by the patient clearly lacks the pathological quality of a positive symptom. It is a normative experience that is restricted to one or two of her closest friends and to very specific thought content that can be explained by the environmental context (e.g., a peer making a joke). Further, there is no distress or behavior change related to the experience. Detailed follow-up on interview questions related to positive symptoms of psychosis for children can often reveal a picture that does not conform to the essence of the construct about which the interviewer intends to query.

Information Critical to Make a Diagnosis

According to DSM-5, a diagnosis of schizophrenia is based on fulfilling three basic criteria reflecting the presence of characteristic symptoms, social/occupational dysfunction, and the duration of illness as well as by ruling out other conditions that can account for psychotic symptoms (APA, 2013).

Criterion A: Characteristic Symptoms

Two or more of the following five symptoms must be present: delusions, hallucinations, disorganized speech, disorganized behavior, and negative symptoms. Examples of characteristic positive symptoms are included in the case illustrations above. Disorganized speech and behavior and negative symptoms are evaluated based on behavioral observation. Table 11.2 shows some sample descriptions of these symptoms taken from select items of the rating scales described above. In addition to determining the presence of these symptoms, the interviewer must also determine that symptoms must have been present for the majority of time for at least a month. In the case that symptoms remit with appropriate treatment within a month, this criterion can still be met if it is judged that symptoms would persist without treatment.

Criterion B: Social/Occupational Dysfunction

There also must be evidence of a marked decrease in functioning for a substantial portion of time since the onset of disorder. Individuals with schizophrenia often experience high rates of unemployment and significant impairments in occupational 278 J. E. Peer and Z. B. Millman functioning (Cook & Razzano, 2000; Marwaha & Johnson, 2004) and can experience substantial limitations in social and instrumental functional activities (Bellack, Morrison, Wixted, & Mueser, 1990; Patterson, Goldman, McKibbin, Hughs, & Jeste, 2001). Evaluating these impairments in an interview setting can be difficult. Often this information can be gathered in an overview section where educational and work history is typically covered. The interviewer should be listening for any difficulties the interviewee had with schooling, maintaining a job, or periods of unemployment. For individuals who are employed, it is useful to identify if there is a discrepancy between educational attainment or training and current occupation. For example, an individual who is originally trained as a computer programmer but is currently only working 20 hours per week in an unskilled labor position is likely “underemployed.” In this case, further inquiry may reveal that after the onset of symptoms, full-time employment in a demanding technical field became too stressful and unmanageable. Functioning in other domains such as social, self-care, and related activities of daily living should also be assessed to determine if this criterion is fulfilled. Although some of this information may be gathered through interview, obtaining information through observation and from additional sources (family members, medical record) can also be very helpful. Comparing the person’s educational or occupational attainment with his parents or unaffected siblings can also be informative in determining if there is a decline in functioning (APA, 2013). The decline in functioning must be presumed to be a consequence of schizophrenia symptoms to satisfy the impairment criterion. Therefore, two caveats are warranted related to evaluating this criterion. First, in the case of social and occupational functioning, it is important to differentiate between limited opportunities for socializing and work and actual impairment. In certain settings, other socioeconomic factors such as poverty, high unemployment, or crime may limit the access to work and social activities, and this should be taken into account when determining whether an individual meets the criterion for functional disability. Second, when evaluating younger individuals it is useful to consider whether there has been a failure to achieve expected levels of functioning in these domains (e.g., was the individual unable to complete school) and these should be considered when evaluating this criterion.

Criterion C: Duration

There must be evidence that some form of impairment or disturbance has persisted for 6 months with at least 1 month of active-phase symptoms (i.e., Criterion A). The DSM-5 does not specify a sequence to the duration of symptoms. That is, individuals can experience difficulties for several months leading up to the emergence of active-phase symptoms or alternatively, experience an acute episode followed by residual symptoms over the course of several months. Obtaining collateral information from family members can be particularly helpful when evaluating this criterion, particularly for individuals presenting for mental health treatment for the first time. 11 Schizophrenia 279

Rule Outs and Differential Diagnosis

Psychotic symptoms are not exclusive to schizophrenia and therefore one must rule out other conditions that might account for these symptoms. The most common conditions include: mood disorders with psychotic features, schizoaffective disorder, substance-related disorders, post-traumatic stress disorder (PTSD), and general medical conditions. Depressive and Bipolar Related Disorders. To make a diagnosis of schizophrenia, the active-phase symptoms must not be accompanied by a mood episode (manic or depressive), or if a mood episode is present, it can only have minimal duration relative to active-phase psychotic symptoms. This determination can be diagnostically challenging for several reasons. First, behavioral symptoms associated with depression can resemble the negative symptoms of schizophrenia. Second, the psychomotor agitation and flight of ideas associated with mania can in some cases be mistaken for thought disorder or behavioral disorganization. Third, epidemiological data indicated that 14–19% of those diagnosed with a major depressive episode seem to have also experienced some degree of psychotic or psychotic-like symptoms (Johnson, Herwath, & Weissman, 1991; Ohayon & Schatzberg, 2002). In the case where the interviewee endorses both mood and psychotic symptoms, the interviewer must determine a time course for these symptoms. In the interview, it is often helpful to focus on a specific episode and/or psychiatric admission. This approach allows the interviewer to anchor questions to a specific time frame and thus increase the accuracy and reliability of responses. In some cases, it may be clear that the person only experienced delusional symptoms, for example, when clearly in a manic episode, or experienced auditory hallucinations only during a depressive episode. In these cases, a mood disorder with psychotic features diagnosis would be given. The following vignette demonstrates an example of how an interviewer might differentiate between a mood disorder with psychotic features and schizophrenia in an individual who has endorsed symptoms of depression: Clinician: Have you ever heard voices that other people could not hear? Interviewee: Yes. C: Tell me a little bit more about that. I: Well, when I’m depressed, I hear this voice, it sounds a little bit like my father but I know it’s not him. It says things like “You’re no good anyway.” “You’ve never been any good.” “You should die.” When I hear it I just don’t even want to get out of bed. C: Is it always just one voice? I: Yes, just one. C: Have you ever heard it at a time when you were not feeling depressed? I: No. C: So, let me make sure I have this straight, you sometimes hear a voice criticizing you when you are depressed and you only hear it when you are depressed. You never hear it when your mood is okay. Is that right? I: That’s right. 280 J. E. Peer and Z. B. Millman

Schizoaffective disorder For individuals where both psychotic symptoms and mood symptoms are prominent, a diagnosis of schizoaffective disorder may be warranted. The DSM-5 criteria for schizoaffective disorder specify that both mood episode (depressed, manic, or mixed) and active-phase psychotic symptoms must occur concurrently and that mood symptoms must be present for a predominant portion of the duration of disorder, but there must also be at least a 2-week period where hallucinations or delusions occur in the absence of a mood episode (APA, 2013). Schizoaffective disorder is less common than schizophrenia (Perälä et al., 2007), and determining the time course and sequence of these symptoms is challenging within a single interview session. Gathering historical clinical data from mental health providers, the medical record, or family members can help in this determination. Often people may need to be followed over time to fully clarify their diagnoses. Indeed, a 2-year longitudinal study of stability of DSM-IV diagnosis in first-episode psychotic patients found that when a diagnosis was changed at a follow-up interview, the most common new diagnosis given was schizoaffective disorder, suggesting that a longer time period is needed to determine the presence of affective symptoms (Salvatore et al., 2009).

Substance-related disorders There is a high prevalence of substance use disorders (SUDs) among people with schizophrenia (Blanchard, Brown, Horan, & Sherwood, 2000; Regier et al., 1990), and SUDs have a profoundly negative impact on course of illness, outcomes, and other quality of life indicators (Bennett, Peer, & Muralidharan, 2018; Dixon, 1999). Substance use and withdrawal can also induce psychotic experiences. Therefore, in making a diagnosis of schizophrenia, it is critical to determine that the reported symptoms are not accounted for by substance use or withdrawal. In the case that the interviewee has an identified substance use problem, there are several techniques the interviewer can use to differentiate psychotic symptoms associated with schizophrenia as opposed to substance use. A first approach is to identify a period of time when the interviewee was not using drugs and assess if psychotic symptoms were present. This may be an extended period of sobriety or a period when he or she may have been in a restricted environment such as an inpatient psychiatric unit without access to illicit substances. When such a period is not present, cases of extended substance use overlapping with psychotic symptoms will require the interviewer to make some clinical judgments. A qualitative evaluation of psychotic symptoms may be informative. For example, are the symptoms characteristic of the drug of abuse (e.g., paranoia during excessive cocaine use, hallucinations during alcohol withdrawal), or are they notably bizarre or unusual (APA, 2013)? Another approach is to evaluate the longitudinal course of psychotic symptoms and substance use. Did psychotic symptoms precede the initiation of substance use? Do psychotic symptoms wax and wane with substance use or seem to follow an independent trajectory? Conversely, are there periods of increased psychotic symptoms in the absence of substantial increase or decrease in substance use? 11 Schizophrenia 281

General medical conditions Ideally, a diagnostic interview should be preceded by a careful physical examination and laboratory tests to rule out medical conditions that may account for psychotic symptoms, such as endocrine, metabolic, and autoimmune disorders left untreated, or temporal lobe epilepsy (APA, 2013). This is particularly relevant when a patient is presenting with psychotic symptoms for the first time.

Post-traumatic stress disorder (PTSD) Although not a specific exclusion criterion for schizophrenia, interviewers should be aware that the symptoms and behavioral concomitants of PTSD and schizophrenia can overlap (see Chap. 8 of this volume for additional information about diagnostic interviewing for PTSD). For example, trauma-related flashbacks associated with PTSD may be experienced and described as hallucinations and must be carefully assessed. Behaviorally, individuals with either diagnosis may be described as paranoid and isolate themselves from others. Whether this represents an avoidance symptom of PTSD or “true” paranoia can usually be ascertained through careful interview. Complicating this further, many individuals with schizophrenia have experienced traumatic life events and may in fact meet diagnostic criteria for both disorders (e.g., Mueser et al., 1998), or they may have delusional beliefs about traumatic events that did not actually occur. The following vignette illustrates and interviewer’s attempt to determine whether a voice heard by the interviewee is related to PTSD or schizophrenia.

Clinician: When you hear the voice, what kinds of things does it say? Interviewee: He says I’m rotten and damaged and no good to anybody. And he says he’s going to hurt me. C: Is it the voice of someone you know? I: I don’t think so. It reminds me of when my uncle abused me as a child. He used to say things like that to me. C: Is it your uncle’s voice that you are hearing? I: No. It’s definitely not his voice. I would know his voice anywhere. It’s someone else’s voice. I don’t know who. C: Sometimes when people have memories of bad things that happened in the past, they can see it or hear it, almost like it’s happening again. Like a flashback. Is that when you hear this voice, when you have memories about the abuse that happened when you were younger? I: Sometimes I hear it when I have those memories, but I hear it other times too. C: When are some other times that you hear it? I: Anytime I get stressed out. Even if I’m not thinking about what happened. In this case, the voice does not appear to be solely related to flashbacks of childhood abuse but is more likely related to a psychotic process that may be associated with schizophrenia and would lead the interviewer to explore whether other symptoms of schizophrenia are present. 282 J. E. Peer and Z. B. Millman

Barriers to Gathering Information Critical to Make a Diagnosis

We have found that some symptoms and features specific to schizophrenia can, in some cases, complicate and impede the interview process. Here we briefly discuss some common roadblocks to gathering diagnostic information that we have observed in clinical interviews with individuals with schizophrenia and some sample strategies for overcoming them. These factors often overlap and many of the strategies can be used interchangeably.

Poor insight Individuals with schizophrenia may lack insight into their mental disorder, which can limit the accuracy of self-report. Although insight is a broad construct with several definitions, current conceptualizations of insight in schizophrenia include the following dimensions: awareness of illness and symptoms, acknowl- edgement of and compliance with treatment, and ability to make accurate attributions for psychotic experiences (Amador, Strauss, Yale, & Gorman, 1991; David, 1990; McEvoy et al., 1989). Lack of insight has been associated with several variables in schizophrenia populations most notably treatment compliance and outcome (e.g., Lysaker, Bell, Milstein, Bryson, & Beam-Goulet, 1994). It should be noted that insight can fluctuate over time and as such may impact the clinical presentation (i.e., wavering conviction in the veracity of a delusional belief). The interviewer should attempt to gage the level of conviction in psychotic symptoms as this can be informative for treatment purposes (see Table 11.3 for example questions). Individuals with poor insight may minimize or deny the presence of symptoms and more notably deny the existence of any functional impairment, particularly when presented with close-ended (i.e., yes or no) questions. With some strategic more open-ended questions the interviewer can often gather some of this information indirectly. Example 1 Clinician: You told me you were hospitalized on a psychiatric unit 2 months ago. While you were there, what did the doctors tell you was wrong? Interviewee: They said I had schizophrenia. C: What did they tell you about schizophrenia? I: That I wasn’t thinking right and that I needed to take medication for it. C: Has the medication been helpful? I: Yeah. It makes me calmer and my thoughts don’t get so jumbled up. C: Not so jumbled up, How so? I: Well before I had all these ideas and things were just really noisy in my brain. I would hear a song on the radio and hear these extra messages like I could hear all these different frequencies. 11 Schizophrenia 283

Example 2 C: So you said your family was worried about you and took you to the hospital. What kinds of things were they concerned about? I: They told me I wasn’t coming out of my room and that they could hear me yelling when no one was around and acting weird. C: Acting weird… in what way?

Table 11.3 Considerations and tips for diagnosing psychotic symptoms Considerations Tips and sample questions Can psychotic symptoms be accounted for by What do others say when you talk about this? normative cultural or religious experiences? Do your friends, family, or community members have this experience? If the content of the unusual experience is religious or spiritual in nature, ask: How do you explain this experience? How would other members of your faith/spiritual practice explain this experience? What is the degree of conviction and distress How certain are you that [insert symptom here] associated with psychotic symptom? is actually happening? (particularly pertinent to adolescents and Could there be another explanation for what young adults and individuals assessed for an you are describing? initial episode of psychosis) Why do you think you’re having this experience? How has this experience changed your behavior/life? Are you still able to do things the way you used to? Can psychotic symptoms be accounted for by Ensure that comprehensive evaluation of mood disorder? psychiatric symptoms is completed prior to providing a diagnosis of schizophrenia Consider the relation of psychotic symptoms to mood disorder in terms of time course, content, and co-occurring symptoms Be particularly vigilant to concerns of overdiagnosis of schizophrenia among African Americans presenting with psychotic symptoms Are psychotic symptoms being underreported Use all available information (medical record, due to cognitive impairment, limited insight, other providers) and/or heightened suspiciousness? Where possible, include additional informants in interview Adopt a non-challenging stance and utilize existing information to probe about symptoms (e.g., recent hospitalization, difficulties at school or work) 284 J. E. Peer and Z. B. Millman

Cognitive impairment Many individuals with schizophrenia experience some degree of impairment across multiple cognitive domains including attention, memory, problem-solving, and processing speed (Heinrichs & Zakzanis, 1998). More generally, these impairments are manifested in a reduction in the efficiency with which individuals process information (Dickinson, Ramsey, & Gold, 2007). Distractibility and inattention may be more pronounced in acute phases of the disorder particularly if individuals are experiencing auditory hallucinations. However, cognitive impairments are relatively stable across the course of schizophrenia and often persist even after an acute episode of psychosis resolves (Hill, Schuepbach, Herbener, Keshavan, & Sweeney, 2004). For some individuals, the interview may need to be tailored to accommodate these cognitive impairments. To accommodate memory difficulties, particularly when gathering information about lifetime episodes, it is helpful to reference questions to a time frame around a specific inci- dent. For example: Clinician: You said you were first hospitalized when you were 19, shortly after you were discharged from the army. You said this was in Georgia. Is that correct? I want to ask you some specific questions about how you were feeling right before you went into the hospital. Attentional difficulties also may make it necessary to take frequent breaks or divide the interview into several brief meetings rather than attempt to complete it in one sitting.

Negative symptoms For individuals with prominent negative symptoms, there is a general diminution in drive or motivation, social affiliation, and impoverished thinking, all of which can substantially limit the amount of information garnered in the interview. Notably, these symptoms manifest themselves as limited engagement in the interview and poverty of speech (brief unelaborated responses to questions). While in and of themselves these negative symptoms are informative for the diagnosis of schizophrenia, they can substantially limit obtaining other necessary diagnostic information. When evaluating Criterion B with someone with prominent negative symptoms (or marked cognitive impairment), it is helpful to use specific and concrete questions. For example, ask the interviewee to describe a typical day for herself, what time does she get out of bed and how does she spend her time (e.g., watching TV, working, participating in a day program). This is a concrete line of questioning that can generate necessary information to determine level of functional impairment.

Guarded and suspicious presentation This is perhaps one of the most challenging barriers to a diagnostic interview. The interviewer will likely notice this presentation early in the interview and can adjust his or her approach accordingly. The obvious challenge is to build the rapport necessary for the interviewee to engage in the interview and share the needed information. There are several reasons why an interviewee may be guarded. In addition to suspiciousness, he or she may be reluctant to discuss symptoms because of embarrassment, a history of negative interactions with treatment providers, or fear of being hospitalized. Making sure there is a careful 11 Schizophrenia 285 description of the purpose of the interview and taking some extra time during the overview section may facilitate rapport. Emphasizing the importance of the interviewee’s perspective and the value of his information to the treatment process can help with engagement. The other strategy is to be attentive for symptom information throughout the interview. One will not always obtain all the necessary information during the psychotic module of the SCID-5. Often, even if an interviewee denies all psychotic symptoms, he or she may provide information during other parts of the interview that, if followed up upon, can reveal additional symptoms. In general, with a person who is guarded or suspicious, such follow-up can be accomplished by asking more open-ended questions and gently probing for more information where possible, with questions such as: “Why might that be?” “Has this ever been a problem for you?” The task is to encourage the interviewee to explain his experience.

Clinician: Has it ever seemed like people were going out of their way to give you a hard time or trying to hurt you? Interviewee: No C: How about at your job? You mentioned earlier you had had troubles with your boss and coworkers. I: Well yeah….everyone had an agenda against me and they were deceitful and corrupt. C: Why do you think they singled you out? In the case of an interviewee denying all symptoms, it may be diagnostically informative to gently challenge her with other collateral information gathered from the medical record, other clinician, or family member. For example: Clinician: So I’ve asked you about a lot of different symptoms that people sometimes have and it sounds like none of these have been a problem for you. I understand you were hospitalized last month and are now getting treatment here at the clinic. I’m interested in hearing your take on what’s been going on. Interviewee: Well I was locked up by the police and then forced to go to the hospital then the judge said I have to take medication. C: What was going on before you were locked up? [patient goes on to describe paranoid delusion about being electronically monitored by FBI with surveillance cameras mounted in her home and surrounding community]. As a final caveat, it should not be assumed that one will always encounter these barriers with individuals with schizophrenia. For many individuals, particularly among stable outpatients, rapport can be established relatively quickly and the necessary information for making a diagnosis can be obtained during the interview. Often individuals appreciate the opportunity to explain or discuss their experience with mental disorder. 286 J. E. Peer and Z. B. Millman

Dos and Don’ts

Do maintain an empathic and patient approach to the interview. Individuals with schizophrenia often have experienced failure and rejection in many domains of their lives. This may result in a more guarded, reticent, or withdrawn presentation in the interview. The interviewer may need to work a bit harder to establish rapport and set the patient at ease. Experiencing positive symptoms of schizophrenia may be distressing and frightening to the patient, and a warm empathic approach can ease this distress and enhance the information gained during the interview. Where possible, avoid using jargon, and instead use the interviewee’s own words to refer to psychotic episodes (e.g., nervous breakdown). Some associated symptoms and cognitive impairment may result in longer latencies and less coherence to an interviewee’s responses. A good diagnostic interviewer will tailor the interview to accommodate the interviewee’s limitations. A patient and gentle interview style can facilitate engagement in the interview process while helping the interviewer obtain the most accurate information possible. Lastly, depending on the clinical context, a diagnostic interview may represent one of the interviewee’s first contacts with the mental health system. Thus, the interviewer should attempt to maximize the engagement in treatment by making the interview experience as person-centered and positive as possible. But, don’t turn the interview into a therapy session. While an empathic stance to a diagnostic interview is recommended, it is also important to remember the purpose of the interview. Many novice interviewers have a tendency to respond therapeutically to any sign of distress. This type of response is not always necessary and can make the interview process much lengthier and inefficient, resulting in a dis- service to both interviewee and interviewer. The purpose of the interview is to determine a diagnosis, often to inform a course of treatment. Therefore, throughout the interview, an interviewer should be asking herself: how is this statement or question relevant to determining a diagnosis? Of course, there may be occasions where an interviewee is too distressed to participate in a diagnostic interview. An interviewer will need to use clinical judgment as to how and when to respond to distress and ultimately if it is necessary to terminate the interview and reschedule. Don’t apologize for questions. Novice interviewers may have a tendency to apologize for questions or qualify questions (e.g., “this next question may be difficult for you to answer”). There also may be a tendency to avoid questions based on the perception that the interviewee will become upset or will not be able to answer. Instead, a matter of fact and direct approach is recommended. Interviewees are often quite open to sharing their experiences, and individuals with schizophrenia are no exception. One should not automatically assume that they will not want to answer or can’t handle certain questions. Simultaneously, one should avoid becoming overly fascinated by psychotic phenomena to the detriment of the interview. Again, the purpose of the interview is to obtain information necessary to make a diagnosis. Do avoid arguing with interviewees about the veracity of their psychotic experience. It is unlikely that an interviewer would openly argue with an interviewee 11 Schizophrenia 287 about her delusional beliefs. However, the interviewer should be prepared with a response in the event that he is asked whether or not they agree with an interviewee’s beliefs or experiences. Often the interviewer can deflect such questions by making a matter of fact and nonjudgmental statement like: “I haven’t had any experiences like that. I’m really just interested in hearing more about what your experiences have been with [psychotic symptom].” The reader is referred to other clinical approaches based on motivational interviewing that have been developed to help engage patients with limited insight into treatment and avoid confrontation/argu- ment (Amador, 2012). Don’t assume a diagnosis of schizophrenia based on one or two symptoms. There is no single symptom that is pathognomonic to schizophrenia. Auditory hallucinations and delusions can occur in many other disorders or as a result of multiple forms of substance use and withdrawal. Therefore, it is critical to do a thorough assessment to make a fully informed diagnosis. As a strategy, the diagnostic interview can be approached as a series of hypotheses that are refined as the interview progresses. The interviewer should be flexible and seek out information that will either confirm or disprove the hypotheses. Indeed, research has indicated that clinicians may show a tendency to preemptively give a diagnosis of schizophrenia to African American patients who describe psychotic symptoms, without a thorough evaluation of mood symptoms. Table 11.3 provides some considerations and tips for differentiating psychotic symptoms associated with other factors or diagnoses from schizophrenia. Do anchor questions to specific time periods or events. Many diagnostic criteria are somewhat dependent on an interviewee’s ability as a historian. Therefore, wherever possible, questions about symptoms should be anchored around a specific time frame or event. It may require a bit more time up front to determine such a time frame, but it is worthwhile if it can assist the interviewee in accurately recounting symptoms retrospectively. As discussed above, the time course of symptoms is critical to determining a diagnosis of schizophrenia and making a differential diagnosis regarding mood episodes, PTSD, and possible substance-related symptoms. Do obtain training with interviewers who have clinical expertise in schizophrenia. Many of the symptoms of schizophrenia are determined based on behavioral observation. Observing an experienced interviewer complete a diagnostic interview and/or watching videotaped interviews can greatly enhance the novice interviewer’s understanding of symptoms of schizophrenia. Additionally, participation in video- tape supervision (often the norm for clinical training programs) can substantially improve interviewing skills with this population.

Summary

In this chapter, we have provided a description of schizophrenia psychopathology, a summary of diagnostic criteria and several interviewing strategies for this sometimes challenging diagnosis. Although schizophrenia is a complex disorder with a 288 J. E. Peer and Z. B. Millman variable clinical presentation, we hope that this information can provide a roadmap to the diagnostic interviewing process and highlight potential pitfalls to be avoided. Structured clinical interviews such as the SCID-5 are the gold standard for establishing a diagnosis of schizophrenia. Interview-based symptom assessments such as the BPRS, PANSS, CAINS, and BNSS can also be very useful for helping the interviewer determine whether Criterion A (active-phase) symptoms of schizophrenia are present. Information from collateral sources as well as standardized assessment of psychosocial functioning can assist in determining if Criterion B (social/occupational dysfunction) is met. A thorough diagnostic interview will also include an assessment of mood symptoms, substance use, medical history, and trauma to differentiate between schizophrenia and other disorders that may include psychotic or psychotic-like symptoms. Our aspiration has been to provide the reader with informative clinical descriptions and tips to enhance the interviewing process. We encourage clinicians to seek out additional training resources and continue to hone interviewing skills and strategies specific for this important population.

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Paternal ages below or above 55 years old are associated with a different risk of schizophrenia in the offspring. European Psychiatry, 22, 22–26. World Health Organization. (2008). The global burden of disease: 2004 update. Geneva: World Health Organization. Chapter 12 Personality Disorders

Neil Bockian

Description of the Disorders

According to the DSM-5, “A personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment” (American Psychiatric Association, 2013, p. 645, emphasis in the original). The definition has some important elements. Personality disorders (PDs) persist over time, often for decades, sometimes for a lifetime. To determine whether or not an individual has a personality disorder, the characteristics must be considered to deviate markedly from the individual’s culture or subculture. It must be pervasive, characterizing the individual, rather than a quirk or an isolated symptom. Signs of the disorder must also be present reasonably early in life. Given that personality traits have a fairly strong genetic basis (Bockian, 2006), and experiences that put one at risk for a personality disorder rather frequently occur early in life, there are children who have developed personality disorders (Kernberg, Weiner, & Bardenstein, 2000); there are no age restrictions on the diagnosis. Inflexibility is also a key aspect of a personality disorder; behaviors that are appropriate in some circumstances are broadly overapplied. A metaphor is useful here. It is appropriate to wear formal attire to a wedding, jeans on a hike, and a bathing suit to the beach, but, if all one has is a bathing suit, one will be inappropriately attired most of the time. Similarly, as adults, relying on others is appropriate in some circumstances, but excessively relying on others most of the time for most things (a characteristic of dependent personality disorder) is maladaptive. There is arguably no clear line between a personality disorder and a normal personality. At the extremes, the differences are easy to discern; someone who has a

N. Bockian (*) Department of Psychology, Adler University, Chicago, IL, USA e-mail: [email protected]

© Springer International Publishing AG 2019 293 D. L. Segal (ed.), Diagnostic Interviewing, https://doi.org/10.1007/978-1-4939-9127-3_12 294 N. Bockian clear case of paranoid personality disorder is quite different from someone who has “normal” levels of trust. However, differentiating someone with a “mild case” of paranoid PD from someone who is (subclinically) extremely guarded is not so easy. Likewise, differentiating someone who is “too” guarded from someone who is healthfully suspicious is also a rather fuzzy boundary. For that reason, various dimensional systems have arisen in recent years. An alternative model for personality disorders is included in an appendix of the DSM-5; it is heavily influenced by the five-factor model (Widiger & Gore, 2013). For our purposes, however, rather than focusing on an alternative system, I will include some allusions to the spectrum notion of personality disorders (Millon, 2011) that uses already familiar categories. Similar to the idea of the autistic spectrum, one can consider each personality disorder to be part of a spectrum in its own right, with a range of degrees of severity. However, with personality, we can go beyond the constraints of a psychopathological conceptualization; there are personality strengths that have a spectrum relationship with the disorders. So, for example, the guardedness that is on a spectrum relationship with outright paranoid PD can be an asset among people who are involved in law enforcement professions such as detectives and FBI agents. Similarly, the over-the-top drama and craving for attention of histrionic PD is on a spectrum relationship with the friendliness and “life of the party” vivaciousness of the healthy sociable individual (Millon, 2011; Oldham & Morris, 1995). Although the primary purpose of this chapter is to equip clinicians with the tools necessary to accurately diagnose personality disorders, noting the associated healthy characteristics will alert clinicians to possible strengths of the individual, and to set goals for treatment in alignment with the person’s potential. Personality disorders are often under-recognized in the clinical interview, especially an initial intake. Personality disorders can be rather subtle. Often, the presence of a personality disorder is detected indirectly. With depression, clients often tell us quite directly about feelings of sadness, lack of motivation, lack of pleasure, and suicidal ideation. In anxiety, clients can often readily describe their worries and fears, even when that anxiety is “free floating” and not clearly or consciously anchored to any thoughts. Conversely, almost by definition, personality disorders are ego-syntonic. They are experienced by the person as being “who they are,” not a troubling and unusual state of affairs. Due to this ego-syntonic perspective, people with personality disorders are often puzzled by the difficulties they are having in their interpersonal relationships, in their places of employment, and in school settings. People with some personality disorders tend to blame others for their difficulties; this is most notable in the paranoid, narcissistic, and antisocial personality disorders. Others blame themselves so strongly that they seem to approach delusional intensity; this occurs most strongly in the avoidant and masochistic personality disorders. The proper assessment of personality disorders in the clinical interview, more than in other disorders, is a blend of art and science, of intuition and empiricism. To assess individuals with personality disorders accurately in a first interview, a variety of skills and perspectives will be necessary. I believe that most, if not all of these skills are well-known to the clinician, but their application in this context may be 12 Personality Disorders 295 rather novel. Part of the task, of course, is to be thoroughly familiar with the diagnostic criteria for each disorder. Beyond that, however, empathy is important in this context. The clinician must be able to radically see the world through the eyes of the individual with the disorder. In addition, I will argue that in order to optimize the proper initial assessment of the individual with a personality disorder, the clinician will be in touch with his or her intuitive self, and take a systematic approach to nurturing and encourage the growth of that intuition. Finally, it is important for the clinician to have a firm grounding in theory. My own grounding in theory is primarily from the perspective of Theodore Millon (2011), who provided novel insights, and, equally if not more importantly, integrated the perspectives of the current major schools of thought. Cognitive, behavioral, psychodynamic, humanistic, systems, sociological, and other theories have a seat at his broadly inclusive table. As previously noted, one idea that I will highlight is the spectrum notion of personality disorders, considering each personality disorder as part of a spectrum that ranges from healthy to normal, and then includes the mild, moderate, and severe psychopathology range. In this chapter, I hope to capture the essence of this theoretically inclusive path, with the aim of facilitating the practice of both the novice and the expert in diagnostic interviewing. This chapter includes the aggressive–sadistic and self-defeating/masochistic PDs (from the appendix of DSM-III-R; American Psychiatric Association, 1987) as well as passive-aggressive/negativistic PD (DSM-III-R main text and DSM-IV appendix; American Psychiatric Association, 1994) and the depressive PD (from Appendix B of DSM-IV-TR; American Psychiatric Association, 2000). I have seen individuals with these disorders, and they must be treated. It is incumbent on mental health fields to address the social conditions, such as abuse, bullying, unstable social environments, problematic parenting, and so on, which have contributed to their development. The sadistic and masochistic personality disorders, especially, are the messengers from those dark places, and their voices must be heard. A brief review of Millon’s theory will be helpful in guiding the reader to a theory- driven and deeper understanding of personality disorders, and to the approach taken in this chapter. Millon’s theory and observations are comprehensively captured in his 1100+ page magnum opus, completed in 2011, Disorders of Personality. The following summary of the key elements is, by necessity, a substantial simplification. That said, there are two elements that are most fundamental to Millon’s approach for our present purposes, namely, the dimensions that underlie the derivation of each of the personality disorders, and the system of eight domains that integrate multiple perspectives into an understanding of the individual. According to Millon, there are four dimensions that underlie psychic life, which tie into evolutionary adaptation. The healthiest state is one of balance; extremes in any of the polarities tend to be problematic. These four dimensions are labeled (Aims of) Existence, (Modes of) Adaptation, (Strategies of) Replication, and (Processes of) Abstraction. The derivation of the personality disorders is summarized in Table 12.1, and described below. The first dimension is labeled “Existence” and has Life Enhancement (pleasure) and Life-Preservation (pain) at the opposing poles. Thinking in evolutionary terms, 296 N. Bockian

Table 12.1 Polarity Model and its personality style and disorder derivatives. The Schizoid is low on both pleasure and pain; the Depressive is high on pain and low on pleasure. (Adapted from Millon, Grossman, Millon, Meagher, & Ramnath, 2004, p. 63) Existential AimReplication Strategy Life Life Reproductive Reproductive Enhancement Preservation Propagation Nurturance Polarity Pleasure–Pain Self–Other

Deficiency, Pleasure (low) Pleasure–Pain Self (low) Self (high) Self–Other Imbalance or Pain (low or (Reversal) Other Other (Reversal) Conflict high) (high) (low)

Adaptation DSM Personality Disorders Mode Passive: Schizoid, Masochistic Dependent Narcissistic Compulsive Accommodation Depressive* Active: AvoidantSadistic HistrionicAntisocialNegativistic Modification Structural SchizotypalBorderline, BorderlineParanoidBorderline, Pathology Paranoid Paranoid pain warns us of threats to our existence, while pleasure (e.g., eating tasty foods) tends to guide us toward living longer. In the broader sense, pleasures such as healthy relationships, love, and physical contact with others are life-enhancing but entail risk (e.g., rejection or even physical harm). Pain avoidance (e.g., staying home) is safe, but leads to other problems (such as isolation). With problems associated with risky pleasure-seeking behavior (Maclean, 2008) and loneliness (Leigh- Hunt et al., 2017) both causing problems on a large scale, the need to balance enhancement and preservation is amply illustrated. Imbalances with an excessive focus on pain are seen in the depressive and avoidant personality disorders, whereas insufficiencies in pain focus are seen in the emotionally flat schizoid (who is also low on the pleasure dimension), and insufficient pain focus paired with average levels of pleasure focus characterizes the antisocial PD. The second dimension, Adaptation, has at its poles Ecologic Adaptation (passive) and Ecologic Modification (active). This refers to the tendency of the individual to yield and adapt to surrounding circumstances (adaptation/passive), as opposed to actively making efforts to change the current environment or circumstances (modification/active). People with dependent and schizoid personality disorders are classically passive, while the active types are illustrated by the aggressive–sadistic, antisocial, and histrionic personalities. The third dimension, Replication, has Reproductive Individuation (self-oriented) and Reproductive Nurturance (other-oriented) as its two polar extremes. The individuation or “self” strategy is the investment of one’s energy in self-actualization, to fulfilling one’s own potential. Conversely, the nurturance or “other” strategy is to invest one’s energy in encouraging others to fulfilltheir potential. The prototype of the “self” strategy is the narcissistic, antisocial, aggressive–sadistic, and paranoid spectrum. People on the dependent and histrionic spectra typify the nurturing “other” strategy. 12 Personality Disorders 297

Notably, Millon describes individuals who are intrapsychically conflicted, a dimension that is given little attention in cognitive-behavioral approaches, although examined in psychodynamic therapies as well as the Motivational Interviewing approach (Miller & Rollnick, 2013). Millon describes two types, active and passive, who are ambivalent with regard to the individuation–nurturance polarity. The most notable example is the passive–aggressive/negativistic PD (Millon’s “active- ambivalent” category). Millon (2011) notes: Those persons whom the evolutionary theory refers to as “ambivalent” are oriented toward both self and others, but there is an intense conflict between the two. A number of these patients, originally represented in the DSM as the passive-aggressive personality, vacillate between giving primacy one time to others and then to self the next, behaving obediently one time, and reacting defiantly the next. Unable to resolve their ambivalence they weave an actively erratic course. (p. 526, emphasis in the original) The reader likely notices a similarity to the borderline personality disorder, which is also conflicted on the self–other polarity; as we shall see, people with borderline PD are conflicted in other ways as well. The passive–ambivalent type is far subtler, and manifests as, perhaps surprisingly, the obsessive-compulsive personality spectrum. Millon (2011) states: The … compliant-compulsive personality spectrum displays a picture of distinct other- directedness, a consistency in social compliance and interpersonal respect: their histories usually indicate having been subjected to constraint and discipline, parental strictures and high expectations. Beneath an overtly passive veneer they experience intense desires to rebel and assert underlying oppositional feelings, a covert self-oriented desire and impulse. Trapped in their ambivalence they are often unable to make decisions or act (p. 479, emphasis in the original). Two other intrapsychically conflicted types have the pain–pleasure polarities reversed, according to Millon’s theory. The active variant is the aggressive–sadistic spectrum, in which inflicting pain (e.g., cruelty) is “the preferred mode of relating actively to others” (Millon, 2011, p. 616). The passive variant is the self-defeating/ masochistic spectrum, in which receiving or experiencing pain has become, in some ways, preferred to pleasure, and is passively accepted, and perhaps even encouraged. In deriving the personality disorders, one might think that Millon would cross this 2×2×2 matrix into eight personality types. This was not done originally, in part because he did not consider pleasure to be pathological. Instead, the self–other dimension is divided into four parts: detached, dependent, independent, and ambivalent, and a fifth part, discordant, is a subversion of the pain–pleasure dimension. Each of these five dimensions was crossed with the active–passive polarity to create 10 basic personality types. Three additional types, the structurally defective/ more severe disorders, were derived as decompensations from the more basic types. The schizotypal (severely detached) was considered a deterioration of the schizoid and/or avoidant PDs, while the paranoid, a deterioration of the independent dimension (narcissistic and antisocial PDs). Borderline PD is a bit more complex, representing internal conflicts on all three dimensions (active–passive, pain–pleasure, self–other). Typically, admixtures of the histrionic and dependent 298 N. Bockian

PDs (dependent dimension) as well as negativistic PD (ambivalent dimension) can be seen, and often, in the more acting out types, antisocial PD; any or all of these disorders can be in a severe form. I once had a student diagnose a person with antisocial and dependent personality disorders, and, indeed, the individual met criteria. The correct diagnosis, however, was borderline PD. In this quixotic personality disorder, criteria for the near-opposite antisocial and dependent PDs can coexist in the same person. The other critical piece of Millon’s approach that we will review here is the functional/structural trait domains (see Table 12.2). There are four basic categories of domains: Behavioral, Phenomenological, Intrapsychic, and Biophysical. The Behavioral category has two domains: Expressive Emotion and Interpersonal Conduct. The Intrapsychic category is broken down into three functional domains: Intrapsychic Dynamics, Intrapsychic Contents, and Intrapsychic Architecture. The final category, Biophysical, includes the Mood/Temperament domain. These are further broken down into Functional and Structural domains. Functional domains, as the name implies, refer to how the person copes with and interacts with the environment, that is, how the person functions. The Structural domains refer to deeper, more enduring features of the person—how the person is put together, so to speak. The structural aspects of the person provide templates or platforms for the functional areas. The meaning of most of the domains is rather self-evident from their labels. The Expressive Emotions domain refers to how the person’s feelings manifest in their words and behaviors; the Interpersonal domain refers to relationships with others, and the Cognitive domain refers to the thoughts, beliefs, and schemas of the person. The Mood/Temperament domain refers to the biological realm; this refers to the heritability and other biological factors that influence personality. The Self-Image domain is also rather intuitive—our image of ourselves—and generally this refers to our comparison of ourselves (similar to or different from) others, as well as the person’s general “sense of self.” The other domains require a bit more explanation. The Intrapsychic Dynamics domain refers to the ego defense mechanisms, such as projection, rationalization, and reaction-formation, as described by Anna Freud (1936). Intrapsychic content is derived primarily from the object-relations school of

Table 12.2 Functional and structural domains of personality. (Adapted from Millon, 2011; see also https://www.millonpersonality.com/theory/functional-structural-domains/) Functional Domains Structural Domains Behavioral Level Expressive Emotion Interpersonal Conduct Phenomenological Level Cognitive StyleSelf-image Intrapsychic Level Intrapsychic Dynamics Intrapsychic Contents Intrapsychic Architecture Biophysical Level Mood/temperament 12 Personality Disorders 299 thought. The way I believe is most concise to explain it is like this. I have a mother. She is a real person, out there in the world. Inside my head, there is a representation of my mother. Believe me, those two are not the same. The Intrapsychic Content refers to the latter—the symbolic internalized representations of important people in our lives inside of our minds, conscious and unconscious. Often, these internal representations are merged from experiences with several individuals, especially those experiences that occur early in life, and are evidenced simply as our expectations of others. Finally, Intrapsychic Architecture is the overall organization of the psyche, which gives it cohesion and fortitude. A metaphor is useful here. There are many architectural structures in the world—single-family homes, barns, skyscrapers, and so on. Further, each of these external structures bears within it an internal structure—division into rooms, closets, and so on. In addition, any particular structure can be solid, flimsy, or somewhere in between. The type of structure and the interior design correspond to the type of personality; the strength of the structure would refer to the resilience of the psyche. So, for example, a pathological narcissistic personality disorder might be akin to a skyscraper, glitzy on the outside, but hollow within; the overall structure is flimsy, and at risk of collapse; a healthy obsessive– compulsive spectrum individual might resemble a modest home, solidly structured, with an efficient internal layout, and with neat and well-organized material within. One can readily see how the domains help to integrate various disparate theories into a more unified whole. The Expressive Emotions, Interpersonal, and Cognitive domains are emphasized in cognitive-behavioral therapy; the Intrapsychic domains are prominent in psychodynamic, object relations, and self-psychology approaches; humanistic/person-centered approaches tend to emphasize the Phenomenological domains, and, of course, the Interpersonal school is associated with the Interpersonal domains. Adlerian psychotherapy (Individual Psychology) is holistic and integrative, and brings in Intrapsychic, Cognitive, Expressive Emotions, and other elements. As our knowledge of biology grows, the relevance of factors such as heredity, exposure to toxins, nutrition, as well as brain structure, neural activity, and neurochemistry are becoming increasingly clear in all forms of therapy. With the theoretical considerations above, as well as an eye to the DSM-5, below is a description of each of the personality disorders. I have organized them alphabetically by cluster (Clusters A, B, and C from the DSM-5) followed by the disorders that are no longer in the manual but have appeared in the appendices of previous DSMs.

Paranoid Personality Disorder (Cluster A)

Paranoid PD is characterized by suspiciousness, mistrust, and reading malicious intentions into others’ behaviors. The main difficulty in evaluating individuals with paranoid PD is the profound difficulty maintaining rapport, and the extreme difficulty obtaining useful information from the client. Metaphorically, I find paranoid PD to be like the HIV virus. Just as HIV attacks the immune system, which is the pathway to recovering from the disease, paranoid PD attacks the therapeutic 300 N. Bockian relationship, also the pathway to recovery. Paranoid PD tends to overlap most often with narcissistic, antisocial, avoidant, and sadistic personality disorders. Individuals with healthy personalities on the paranoid spectrum are vigilant, and are able to detect subtle deceptions from others. They naturally fill roles such as law enforcement, security, watchdogs and crusaders for justice.

Schizoid Personality Disorder (Cluster A)

People with schizoid PD are emotionally muted or flat, and generally prefer to engage in solitary activities rather than spend time with other people. Schizoid PD is relatively rare, and, due to the general lack of strong feelings, motivation to engage in therapy is generally weak. People with schizoid PD seek treatment, typically, for mild to moderate anxiety associated with being in social situations, difficulties at work (related to social or motivational problems), and/or difficulties in a relationship (e.g., feeling pressured to be more emotional with a significant other). They can also become lonely; it can be difficult to obtain meaningful contact with others on an intermittent basis without becoming completely isolated. Schizoid PD tends to overlap with avoidant, dependent, and obsessive–compulsive personality disorders. Healthy variants of this type are stoic, unflappable, calm, and grounded.

Schizotypal Personality Disorder (Cluster A)

People with schizotypal PD are odd and eccentric. Genetic studies have shown that schizotypal PD has a spectrum relationship with schizophrenia (Siever, 1992). It overlaps with schizoid, avoidant, and paranoid PDs. On the other end of the spectrum, individuals with normal and healthy variants of schizotypy are creative and offbeat, and are comfortable being unconventional.

Antisocial Personality Disorder (Cluster B)

Colloquial usage of the word “antisocial” can mean someone who avoids social contact, but in the technical sense, it would be better construed as anti-society, or unsocialized. Individuals with this disorder, according to DSM-5, evidence “a pattern of disregard for, and violation of, the rights of others” (American Psychiatric Association, 2013, p. 645). Individuals with antisocial PD generally come across as harsh and unempathic; however, con artists (who can use empathy-like qualities to sense vulnerabilities) are also included in the group. By definition, the person is generally self-serving, with little regard for the harm their behaviors may do to others. Healthy variants of this disorder are bold, adventurous, and free spirited. 12 Personality Disorders 301

Borderline Personality Disorder (Cluster B)

Of all the personality disorders, borderline PD has received the most scholarly and public consideration (Bockian, Porr, & Villagran, 2002). Characterized by substantial emotional dysregulation, impulsivity, and an unstable identity, individuals with borderline PD command the attention of those around them. A number of studies indicate that the risk of death by suicide hovers at approximately 8–10% (Zanarini, Frankenburg, Hennen, Bradford Reich, & Silk, 2005) with suicidal ideation and attempts being extremely common. Naturally, clinicians, family members, and loved ones become greatly concerned. Healthy variants of this disorder are emotionally intense; regarding the “Mercurial” style, Oldham and Morris note, “No other style…is so ardent in its desire to connect with life and with other people. And no other style is quite so capable of enduring the changes in emotional weather that such a fervidly lived life will bring” (1995, p. 293).

Histrionic Personality Disorder (Cluster B)

As the name suggests, individuals with histrionic PD are dramatic in their presentation, and crave being the center of attention. Other features include having a shallow, vapid internal world, fickleness, and seductiveness. Histrionic PD tends to overlap with dependent, antisocial, and narcissistic PD; perhaps ironically, mixtures of obsessive–compulsive and histrionic PDs are not uncommon (e.g., the perfec- tionistic actor). On the healthy end of the spectrum are individuals who are sociable, energetic, vivacious, and fun-loving.

Narcissistic Personality Disorder (Cluster B)

The definition of narcissistic PD includes traits such as arrogance, grandiosity, lack of empathy, and self-centeredness. There are two important subtypes that must be addressed in order to have a basic understanding of narcissistic PD. The psychodynamic view (e.g., Kernberg, 1970; Kohut, 1971) sees narcissism as a defense against underlying feelings of inadequacy or inferiority. The typical experiential background of such an individual is humiliation by others. The child asserts, essentially, that not only is he or she not inferior to those who put him or her down, but is superior to them. Deep down, however, underlying feelings of shame and inferiority remain. Other theorists (e.g., Benjamin, 2003; Millon, 2011) have seen narcissism as more authentic, with the grandiosity and unrealistic expectations of reward being fostered through simple learning. Lorna Benjamin (2003) colorfully labels the phenomenon “His majesty, the baby” in her classic text (p. 141). To review briefly, imagine a child is extremely overvalued by his parents, for example, and praised for 302 N. Bockian even the most ordinary achievement. Often such children are very cute, handsome, or pretty, and receive a great deal of attention for that alone. I like to imagine a prince, raised to royalty, expecting to become king of the entire land simply for existing, and being informed that he is special from the moment of his birth; some (but by no means all) such individuals have a benign, passive arrogance. The child’s “grandiosity” is in alignment with his experience. Which one is “really” narcissism? Such questions do not concern us for our present purposes. Both types exist in the real world, and such disagreements are semantic battles for the meaning of the word “narcissism.” The insecure/defensive type has been labeled the “compensatory narcissist” (Bockian, 1987; Bockian, Smith, & Jongsma, 2016; Millon, 2011) and the insecure narcissist (Millon, 2011). The latter type has been previously referred as a “secure narcissist” (Bockian, 2006; Millon, 2011). Narcissistic PD tends to overlap with antisocial, histrionic, aggressive–sadistic, schizoid, and obsessive–compulsive personality disorders. The healthy variant of this type is the genuinely self-confident individual, a trait associated with career and interpersonal success.

Avoidant Personality Disorder (Cluster C)

People with avoidant personality disorder actively avoid social contact due to fears of being ridiculed, rejected, or humiliated. Unlike the person with schizoid PD, who are socially isolated due mainly to apathy, individuals with avoidant PD long for social contact, crave it, even, but hesitate out of intense fear. Thus, they usually come across as deeply conflicted, wanting to reach out but afraid to do so. A key underlying belief is, “if someone gets to know me, that person will reject me.” The avoidant individual tries to walk a tightrope of having the relationship be close enough to maintain it, but distant enough that the other person will not discover how “terrible” they are and reject them. It is among the most emotionally painful of the personality disorders. I suspect that avoidant PD is under-recognized and undertreated, as such individuals tend to be quiet, to avoid causing trouble, and, most importantly, view the therapeutic relationship, with the expectation of sharing a good deal of personal information, to be threatening. Avoidant PD tends to overlap with schizoid, dependent, and paranoid personality disorders. Healthy variants include individuals who are deeply sensitive, introspective, and deep thinkers; they are often creative, which may find expression in poetry or other artistic works.

Dependent Personality Disorder (Cluster C)

People with dependent PD have, according to the DSM-5, “A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation” (p. 675). Such individuals tend to have poor self-esteem. Their actual competence tends to be impaired, at least in part due to a self-fulfilling prophecy in 12 Personality Disorders 303 which they engage since childhood: believing that they are incapable, they spend their energy finding ways to persuade others to do things for them, rather than developing skills; naturally, their skill development proceeds at a lower rate. Dependent PD often overlaps with schizoid, avoidant, histrionic, and obsessive–compulsive PDs. Healthy variants of this type tend to be warm, affectionate, supportive, inter- connected, and devoted (Bornstein, 2005).

Obsessive–Compulsive Personality Disorder (Cluster C)

Individuals with obsessive–compulsive PD are rule-bound, constricted, and overly stringent about matters of morality. Their relationships are characterized by coolness and formality, which can slip into coldness and aloofness in more extreme cases. A telling characteristic is that they often become so invested in details that they lose sight of the overall situation, or even the goal they are trying to achieve. For example, a person with OCPD can become so invested in the timing of activities during vacation that the entire situation becomes very stressful—thereby losing the point of a vacation, which is to enjoy oneself. Typical reasons for coming to therapy, then, are difficulties in close relationships, in which a partner desires more affection, and difficulties at work, in which their productivity suffers due to excessive attention to detail and indecisiveness. Ironically, people with the healthy variant of this type are among the most productive on the planet. Organized, efficient, knowledgeable, and hardworking, they are often the “right hand” of the CEO of an organization. In relationships, their loyalty, conscientiousness, and attentiveness often make them excellent partners in long-term relationships. Obsessive–compulsive personality disorder frequently overlaps with schizoid, dependent, and narcissistic personality disorders. The following are descriptions of PDs that have been included in prior editions of the DSM.

Passive–Aggressive (Negativistic) Personality Disorder

Passive–aggressive personality disorder was in the DSM-III-R as part of the official nomenclature (not an appendix). It is described as, “A pervasive pattern of passive resistance to demands for adequate social and occupational performance…” (American Psychiatric Association, 1987, p. 356). Examples of such behavior (from the criteria) include procrastination, doing poorly on a task the person does not want to do, and so on. Problems with authority figures marked this personality type. It was thought to be too narrow a construct, as it consisted, essentially, entirely of passive–aggressive behavior, with nearly all of the criteria being examples of such behavior. It was reformulated as passive–aggressive (negativistic) personality disorder in Appendix B of the DSM-IV and DSM-IV-TR; for ease of reference, I will 304 N. Bockian refer to it as “negativistic” going forward. The idea of “negativistic attitudes” was added to the resistance to demands concept of its predecessor; they are characterized as sullen, moody, and irritable. Millon’s (2011) formulation is that negativistic individuals are the “active ambivalent” type. Such individuals, then, tend to have mixed feelings, especially in relationships; they swing back and forth between being self-oriented (such as the narcissistic type) and other-oriented (such as the dependent type). It creates a confusing and often frustrating picture for individuals in relationships with them…including therapists. Oppositional-defiant disorder shares many characteristics with passive–aggressive/negativistic PD formulations, but is diagnosed in children and adolescents. Passive–aggressive PD overlaps with borderline, paranoid, avoidant, antisocial, and histrionic PDs. Although passive– aggressive behavior is generally problematic, it is noteworthy that such behavior formed the backbone of the civil rights movements in India under Gandhi, and in the United States under Martin Luther King, Jr. Healthy personalities on the negativistic spectrum have traits that are consistent with “type ‘B’” personalities—they tend to value personal and leisure time, to not be overly ambitious or pressured about time, and hold to the right to resist inappropriate or excessive efforts to control them.

Sadistic Personality Disorder

Not to be confused with sexual sadism, sadistic personality disorder is a pattern characterized by “cruel, demeaning, and aggressive behavior” (American Psychiatric Association, 1987, p. 371). It appeared in Appendix A of DSM-III-R. Aggressive– sadistic individuals take pleasure in seeing others suffer, and use violence and psychological intimidation to get others to bend to their will. The disorder is well-illustrated by novels and films, with world-class villain’s nearly always having this character type; examples include Voldemort in the “Harry Potter” series, Sauron in “Lord of the Rings,” and Hannibal Lecter in “The Silence of the Lambs.” Sadistic PD overlaps primarily with paranoid, antisocial, and narcissistic personality disorders. Healthy variants of the disorder are characterized by their commanding style, leadership abilities, competitive spirit, and action orientation.

Self-Defeating Personality Disorder

Introduced in Appendix A of the DSM-III-R (American Psychiatric Association, 1987), and drawn from nonsexual conceptualizations of masochism (e.g., moral masochism), self-defeating personality disorder is characterized by self-sacrifice, rejecting help from others, and being drawn to relationships in which he or she will suffer. Importantly, the DSM notes, as exclusion criteria, that these behaviors occur when other, more positive alternatives exist, and does not occur “exclusively in 12 Personality Disorders 305 response to, or in anticipation of, being physically, sexually, or psychologically abused” (American Psychiatric Association, 1987, p. 374). An excellent metaphor for the psychopathology exhibited by this group is a capacity to “snatch defeat from the jaws of victory.” Self-defeating PD overlaps primarily with dependent, passive– aggressive, and depressive personality disorders. Healthy variations of this personality type are giving, generous, nonjudgmental, tolerant, humble, and responsible. It includes the type of person who is beloved for their long-standing support of a cause or an organization, putting needs of others first with little if any personal gain, who smiles shyly and cannot wait to get out of the spotlight when recognized at award ceremonies.

Depressive Personality Disorder

Individuals with depressive personality are characterized by a pervasively gloomy mood, feelings of guilt, as well as beliefs of inadequacy and worthlessness. They tend to be self-critical, self-derogatory, and pessimistic. There may also be a negativistic, critical, and judgmental attitude toward others. Beck’s (Beck, Rush, Shaw, & Emery, 1987) “Cognitive Triad” of negative beliefs about the self, the world, and the future, would fit most such individuals. Depressive personality disorder has a somewhat complex history. Dysthymic disorder was derived from depressive personality disorder formulations, and thus the distinction between them can be difficult to establish. Indeed, in the DSM-III, under “Age at Onset” for Dysthymic Disorder, states, “This disorder usually begins in childhood, adolescence, or early adult life, and for this reason has often been referred to as Depressive Personality.” As noted by Widiger and Gore (2013) “There is no meaningful distinction between early-onset dysthymia, an officially recognized mood disorder diagnosis, and depressive personality disorder” (p. 7). The distinction, such as it is, emphasizes cognitive aspects of depressive PD (e.g., beliefs of worthlessness) as well as the early onset and pervasive nature of depressive PD. I would side with those who would argue that early-onset, chronic, pervasive depres- siveness would be better conceptualized within the personality disorder realm. Depressive PD overlaps most notably with negativistic PD, as well as avoidant, dependent, and obsessive–compulsive PDs. While at first glance it may be difficult to conceive of a healthy version of depres- siveness, Oldham and Morris’ (1995) “Serious” type connotes the adaptive qualities of such a style. “Serious” individuals are realists, who eschew modern pressures to put on rose-colored glasses and “spin” negative situations into positive ones. Note Oldham and Morris (1995): What they sacrifice in silver linings, they gain in ability to carry on in even the worst of circumstances. No other personality style is quite so able to endure when a harsh climate seems to descend on the planet. This is a no-frills, no-nonsense, just-do-it personality style, whose strength in hard times can help everyone to survive (p. 366) 306 N. Bockian

Procedures for Gathering Information

Unlike many other mental disorders, gathering information regarding individuals with personality disorders presents some special challenges. As noted above, insight is often poor, inaccurate, or distorted. It is therefore necessary, in formulating the questions one asks of individuals with personality disorders, to radically empathize with the client, and see the world from their perspective. To illustrate the distinction, let us compare, for a moment, assessing for Major Depressive Disorder and Narcissistic Personality Disorder. Criterion A1 from Major Depressive disorder states, “Depressed mood most of the day, nearly every day, as indicated by subjective report (e.g., feels sad, empty, hopeless) or observations made by others (e.g., appears tearful)” (American Psychiatric Association, 2013, p. 160). It would be quite reasonable to ask, “Do you feel sad often these days? Would you say you are sad most of the day, on most days? Do you find yourself feeling hopeless?” Most depressed clients could answer those questions readily. Criterion A1 from Narcissistic PD, states, “Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).” Now imagine asking, “Do you have an exaggerated sense of self-importance? Do you exaggerate your achievements? Do you expect to be recognized as superior, beyond what your achievements would warrant?” Clearly, this approach is problematic. Radically empathizing with the client would entail seeing it through their eyes. So, rather than asking the questions in the aforementioned manner, one might say, “it appears that you find that others do not fully appreciate your ideas and your potential.” Notice the careful wording—by inserting “you find that,” the clinician can emphasize the subjectivity of the client’s impressions. The use of our own subjectivity—our countertransference—can further refine our ability to tune into our clients, and provide appropriate responses. Intake interviews are much more effective when we are able to validate the valid (Linehan, 1993), and finding the validity in the statements of our clients can be challenging when their views are somewhat distorted. For example, I have had exchanges with clients that are similar to the following: Therapist: And what did you say when your partner started to cry? Client: She does that a lot. She cries all the time. Therapist: What do you make of that? Client: She’s just a crier, that’s all. Therapist: Did you ask her what was going on? Client: Not really. We have a lot of money, a big house, and a nice car. There’s nothing to cry about, really. I could feel the muscles in my shoulders tightening up. Paying attention to the sensations, I can usually experience the connected emotions: anger bubbles up, along with anxiety. Tracing the trail further, I notice the associated thoughts in my mind. The statements the client is making are contrary to some of my most deeply 12 Personality Disorders 307 held values, that people “should” try to understand one another, that the feelings of others are to be treasured, that kindness should prevail, and that the sharing of feelings should be encouraged, especially in committed relationships. It is from these beliefs that the anger has emerged. The anxiety—also connected to the tightened muscles—is connected with concerns regarding my role. A first session is too early to be confrontational; my role here is to provide support and validation, and to gather appropriate information to make an accurate diagnosis. Hiding my feelings—not being genuine—is contrary to some of my most important values regarding not only the therapeutic relationship, but relationships in general. Awareness of this complex of physical sensations, thoughts, and emotions allows me to take the next step: radical empathy. What is it like to be him? He sees his partner crying, and probably he is unresponsive. I let go of my own thoughts and associations, let go of my compassion for his partner, and return to his needs and feelings. She is crying. No empathic arousal is stirred in him; that is currently beyond him. Her crying does not move him, but it’s a safe bet that she is hoping for an emotionally supportive response, one he is currently, likely, unable to give. It’s just pressure. What he probably feels is annoyed. Therapist: Do you feel annoyed when she does that? Client: Exactly! Man, she can be so annoying… So, for diagnostic purposes, what I have done over the years is to recognize patterns of reactions that I have, and how they are associated with various traits. I have observed that the responses are quite reliable. So, at this point, when I feel a particular type of tightening in my neck and shoulders, my alarm bells go off. I no longer need to tie the sensations and emotions to particular cognitions. I have connected with my intuition, or my intuitive self, in order to “feel” that I may be dealing with narcissistic personality disorder. Suspecting that there is narcissistic PD, I can begin to ask questions specific to the disorder to confirm or disconfirm my hunch. Although there is preliminary evidence that there are “normal” countertransference reactions (Colli & Ferri, 2015; Rossberg, Karterud, Pedersen, & Friis, 2008), my approach here is more idiographic, and challenges each of us to be aware of our own reactions, rather than to list common responses to any given disorder. While my “gut” is usually pretty accurate, there is room in the above snippet to imagine that the person has antisocial or aggressive–sadistic PD. Further interaction, involving asking questions that are aligned with the criteria for each relevant disorder, as well as a further back and forth between my intuitions and the selection of such questions, continues to move the interviewing process forward. A few words are in order here about the meaning of countertransference. The concept of countertransference has evolved substantially over the course of many decades, and now involves many conceptually nuanced meanings; I will describe two. Among my students, and I would guess among most professionals in the field, the word countertransference is associated with a therapist’s unconscious reaction to a client, generally regarding issues that are unresolved areas of conflict for the therapist (Gelso & Hayes, 2007). It is the exact parallel of transference—a client’s unconscious reaction to the therapist—but in the opposite direction. As it dates back 308 N. Bockian to Freud and the emergence of the concept, this is described as the “classical” approach to countertransference. Because it is unconscious and involves the therapist’s unresolved issues, classical countertransference is, by this definition, highly problematic to the therapy, and it is essential that therapists be able to recognize and address their problematic reactions as they arise. However, another definition of countertransference is Kernberg’s 1965( ) “totalist” approach, which involves the total emotional response of the therapist to the client, conscious and unconscious, healthy and unhealthy. My approach to countertransference in this chapter is within the totalist camp. I would say that during a session I am able to reach conscious and preconscious thoughts as indicated above, although getting to deeper levels requires time outside of the session. It can arise, of course—for example, if there is a client to whom I have a strong negative reaction but do not know why. There are behavioral indicators of classical countertransference, such as dreading sessions with the person, procrastinating on returning phone calls, over-involvement, rescuing, and so on. In such situations, reflection and/or consultation is important, in order to maintain a healthy relationship. Conscious awareness, of course, is crucial to distinguishing between classical countertransference and basic emotional responses. If I know why I am having a negative emotional reaction to a client, which happens, for example, rather regularly when a client reports being callously and remorselessly cruel to another person, it is not countertransference in the classical sense; it is an emotional response, understandable within the totalist framework. While there are a variety of pathways to self-understanding, I have found mindfulness to be particularly useful in maintaining awareness during a session. It is commonly defined as “…paying attention in a particular way: on purpose, in the present moment, and non-judgmentally” (Kabat-Zinn, 1994, p. 4). Consistent with my experience, preliminary research is very promising in this regard, some of which will be described presently. Bruce and his associates (Bruce, Manber, Shapiro, & Constantino, 2010) developed a model of how therapists can improve their work through mindfulness. … we propose that mindfulness practice may be a means for training psychotherapists to better relate to their patients. We posit that mindfulness is a means of self-attunement that increases one’s ability to attune to others (in this case, patients) and that this interpersonal attunement ultimately helps patients achieve greater self-attunement that, in turn, fosters decreased symptom severity, greater well-being, and better interpersonal relationships. (p. 83) Notably, a double-blind study showed that therapists trained in mindfulness meditation had better outcomes with their clients, as shown by greater improvement on a wide variety of symptoms (Grepmair et al., 2007). Applying this model to the process of assessment, I would posit that the attunement process can increase both the accuracy of assessment, and the ability to maintain rapport with the client. Self-awareness combined with empathic attunement can lead to an uncannily accurate and rapid understanding of a client. Tansey and Burke (1989) describe an interaction with a consultant, who has come in, received some basic demographics, and listened to a few minutes of a tape-recorded session between a resident and a client. 12 Personality Disorders 309

Turning to face the presenting resident, he proceeds to deliver a series of well-articulated formulations about the nature of the current therapeutic interaction, its relationship to the genetic history, and some feelings with which the therapist might be struggling that had not yet been mentioned. The presenter nods vigorously on all counts, and the consultant…goes so far as to predict a shift in the direction of the material that might be coming within the very session under examination. The recording is turned back on, to the wide-eyed anticipation of all, and—voila!—the predicted shift irrefutably occurs. (p. 2) The authors attribute the process by which the consultant reached his conclusion to be based primarily on empathy, which they understood in the context of countertransference theory. In other words, our understanding of others at a deep level is related to our unflinching examination of ourselves, and ourselves in relation to that person. The value of having a rapid “feel” for the diagnostic category into which our client falls cannot be underestimated. Knowing the personality style and possible personality disorder of an individual is extremely helpful in the establishment of rapport. For example, a client with a dependent personality style or disorder will attach rapidly, especially when the messages such as “we will work through this difficult time together” and “our team is here to support you” are sprinkled throughout the interview by the clinician. Conversely, such messages to individuals who view themselves as autonomous (e.g., the narcissistic, antisocial, and aggressive– sadistic types), a nurturing approach is often received negatively, especially early on in the relationship. Although later on in therapy, often more than a year into it, the person with one of these “independent” (Millon, 1999, 2011) personalities may be able to receive badly needed and restorative nurturance from the therapist, such is not the case in the first interview. A better approach is to emphasize the consulting role of the therapist, and emphasize the power that the client has. With the exception of forensic settings, generally a client is free to leave therapy, thereby having control over the therapy’s duration. While generally we therapists are highly empowered, it is a reality that most of our clients can “fire” us at any time. Thus, for the independent types, phrasing such as, “should you choose to engage in this treatment, then…” and “what is it that you hope to gain from this treatment?” followed by a straightforward discussion of the potential benefits and limitations of the treatment is, perhaps somewhat ironically, more inviting. With radical empathy in mind, we have a framework within which to word questions so that people with personality disorders will resonate, and thus respond accurately to the intent of the question. Samples of such wordings are listed in Table 12.3. As will be noted below, there are many examples of such wordings in the carefully constructed semi-structured interviews presented below. In sum, then, the model presented in this chapter is that, ideally, a person involved in the diagnosis of personality disorders should (1) know the diagnostic criteria, both for PDs in general and for each personality disorder in particular; (2) be able to radically empathize with the client, so as to be able to translate the criteria into a form that is meaningful for the client; (3) be highly self-aware in order to facilitate that empathy, with mindfulness being recommended as a pathway through which that self-awareness can be fostered. 310 N. Bockian

Table 12.3 Select translations of DSM-5 criteria into useful assessment questions Personality Disorder Assessment question(s)/statement(s) Cluster A: Paranoid You keep your radars up to make sure others are being straight and honest with you. {Depending on rapport} Have others hurt or betrayed you in the past? Schizoid Do you prefer to engage in solitary activities, such as going for a walk by yourself, or even just sitting home alone, rather than going to events with other people? Schizotypal Are you an “outside the box” thinker? Are you open to ideas that are outside of the mainstream, such as telepathy and ESP? Do you believe you have ESP or are able to sense others’ thoughts directly? Cluster B Antisocial Hey, it’s a dog-eat-dog world out there, right? Given a choice of being the winner or the loser, you’ll take being the winner. Borderline You are a sensitive person, and you find that being rejected hurts so badly that it makes you feel completely blown away. Does it ever get so bad that you want to end your life? Histrionic Do you find that there seems to be one drama after the other in your life? Narcissistic Do you find that others have difficulty appreciating or understanding many of your more advanced ideas? Cluster C Avoidant Would you say that you fear rejection more than most people do? Are you afraid that if someone gets to know you pretty well, he or she will reject you and hurt you? Has that been your experience? Dependent Do you find that you need help with everyday decisions? Do you like for (your significant other) to help you pick out what to wear, and things like that? Obsessive– Staying organized is really important to you. Do you like to keep a pretty Compulsive strict routine, so that you can be as efficient as possible? Appendices from prior DSMs Depressive When you look back, how long would you say you have been at least somewhat depressed and negative? {Looking for answers such as “since childhood” or “always.”} Aggressive– Would you say you are highly competitive? Do you get annoyed when other Sadistic people whine or complain? Do you feel a need to “put them in their place” if they do? Masochistic When something good happens, do you feel like you don’t deserve it? Does (Self-Defeating) that make you uncomfortable? {Depending on rapport:} Do you think that you should be punished for being bad, or for bad things you have done? Negativistic Do you find that other people are annoyed or angry with you a lot, for no (Passive– apparent reason? Do you wish you could get out from under the thumb of Aggressive) people who are in authority over you? 12 Personality Disorders 311

Recommendations for Formal Assessment

There are several strategies for formal assessment that can be useful for personality disorders. As this chapter is dedicated to diagnostic interviewing, I will keep this section brief, and limited to two self-report instruments (MCMI-IV; MMPI-2-RF) and two semi-structured interviews (SIDP-IV; SCID-5-PD) as well as some comments on the use of informants. The interested reader is directed to more comprehensive reviews (Clark et al., 2018; Miller, Few, & Widiger, 2012). Structured and semi-structured interviews are considered the best available methods for accurately diagnosing personality disorders (Rogers, 2003). They have the advantage of being systematic and comprehensive. They can also be outstanding tools for sharpening the clinician’s ability to provide assessments. The SIDP-IV (Pfohl, Blum, & Zimmerman, 1997) and the SCID-5-PD (First, Williams, Benjamin, & Spitzer, 2016) are both worded in ways consistent with the guidelines I provided above—that is, the diagnostic questions are generally worded in a way that would be palatable to the person being interviewed. For example, on the SIDP-IV, the criterion for negativistic, “Passively resists fulfilling routine social and occupational tasks,” is worded “When some people get tired of doing their daily chores at work or at home, they might try to get out of them by inventing excuses, pretending to forget, or deliberately not working very hard. How often do you do things like this?” As noted above, such framings are crucial in order to conduct a valid diagnostic interview for this population. The SIDP-IV takes about 60–90 minutes to administer. It has scales for Negativistic (Passive–Aggressive), Self-Defeating (Masochistic), and Depressive personality disorders, in addition to the 10 personality disorders currently in the DSM-5. Although an alternate form is available, in which it is organized by personality disorder, in its standard format it is organized by topic: A. Interests and Activities, B. Work Style, C. Close Relationships, D. Social Relationships, E. Emotions, F. Observational Criteria (i.e., the examiner’s observations); this layout provides a natural feel to the interview. The inter-rater reliability has been shown to be good, with kappa values generally above 0.70 (Jane, Pagan, Turkheimer, Fiedler, & Oltmanns, 2006). A corresponding self-rating form and an informant form are available. Although the SIDP-IV has not been updated for DSM-5, it is also true that the diagnostic criteria for personality disorders have not changed with the most recent revision of the manual. The Structured Clinical Interview for DSM-5 Personality Disorders (SCID- 5-PD) is a semi-structured interview that assesses the 10 personality disorders from the DSM-5. It takes approximately 30–120 minutes to administer, depending on how much follow-up is needed to determine the diagnosis. It is organized by personality disorder. A corresponding self-rating form and an informant form are available. The SCID instruments are widely used in both clinical and research practice, and are considered to be valid and reliable. Self-report inventories can also be very helpful in assessing individuals with personality disorders. Originally designed primarily for personality disorders, the 312 N. Bockian

Millon Clinical Multiaxial Inventory (currently in its 4th edition) provides clinicians with a good deal of useful information (Millon, Grossman, & Millon 2015). It includes scales for the 10 DSM-5 personality disorders, as well as scales for disorders previously from the appendices of prior DSMs (depressive, aggressive–sadistic, masochistic/self-defeating, passive–aggressive/negativistic) and a new designation, the “turbulent” personality (an active–pleasure-oriented personality, associated with hypomania). Each of the personality disorders are now on a spectrum that includes normal personality (style), a personality “type” (intermedi- ate), and a personality disorder. Each personality disorder scale also has three “facet scales” that provide more precise meaning to the scale elevations. For example, the Borderline scale has the facets “Uncertain Self-Image, Split Architecture, and Temperamentally Labile.” There are three modifying indices (disclosure, desirabil- ity, and debasement) that describe test-taking style, and two scales (validity and consistency) that control for random responding, inability to understand the questions, and other issues that could render the profile invalid. There are 10 clinical syndrome scales (generalized anxiety, somatic symptoms, persistent depression, alcohol use, drug use, posttraumatic stress, schizophrenia, major depression, and delusional disorder). Internal consistency values are very strong, ranging from 0.67 (obsessive–compulsive) to 0.91 (borderline) on the primary scales, and 0.63–0.87 on the Grossman Facet Scales; nearly all of the scales exceed the 0.70 cutoff for good internal consistency. Test–retest reliabilities (at 1 week) were also strong, with the majority of the correlations exceeding 0.80. External validity studies with similar instruments (the MMPI-2-RF, BSI, and MCMI-III) indicated good continuity with the prior version of the test, and appropriate correlations with related instruments. The MCMI-IV has 195 items, and takes about 25–30 minutes to administer. The Minnesota Multiphasic Personality Inventory (MMPI) is extremely well- known, and I will thus only (briefly) review the personality disorder scales on the latest version, the MMPI-2 RF (MMPI-second edition, Restructured Form). A recent study demonstrated that specially developed personality disorder scales are reliable and valid (Sellbom, Waugh, & Hopwood, 2018). The study, which included a normative community sample, a university sample, a mental health sample, and a prison sample generated 10 personality disorder scales corresponding to the 10 personality disorders of the DSM-5. Internal consistency estimates ranged from 0.60 to 0.88, with the median score being above 0.70 in all four samples. Test–retest reliability (1 week) was also solid, ranging from 0.78 to 0.91, with a median of 0.86. With regard to convergent validity, correlations were measured between the MMPI-2- RF-PD scales and the SCID-II-PQ (a self-report inventory designed to accompany the SCID-II, the semi-structured interview that is the predecessor to the current SCID-5-PD). The correlations ranged from 0.28 to 0.70, with large correlations (>0.5) for the paranoid, schizotypal, borderline, histrionic, avoidant, and dependent PDs; moderate correlations (>0.3) for antisocial, narcissistic, and obsessive–compulsive PDs; and a weak correlation (<0.3) for schizoid (r = 0.28). The MMPI-2-RF has 338 items, and takes about 35–50 minutes to administer. In general, the MMPI-2-RF Personality Disorder scales performed well enough to be useful in clinical practice, although stronger convergent validity for a few of the scales would be desirable. 12 Personality Disorders 313

Informants can be extremely helpful in diagnosing a personality disorder. Given the ego-syntonic nature of personality disorders, significant others not infrequently have a clearer awareness of the individual’s problems. There is a risk that a person with antisocial PD, for example, will be dishonest in an interview, that the person with histrionic PD will have only a vague sense of their historical information from childhood, that a person with borderline personality disorder will misconstrue the intentions of others, and that someone with paranoid PD will be fearful of revealing personal information. Parents, spouses, siblings, children, and close friends can be invaluable sources of information. I usually try to interview informants in the presence of the client. This helps to avoid foreseeable problems with trust. However, informants are not a panacea; they can have their own biases and agendas, and their input must be considered part of a larger overall strategy.

Impact of Gender, Race, Culture, Age, and Other Aspects of Diversity

In my experience as a clinician, knowing about diversity factors in a person’s life is as important as knowing their diagnosis—and sometimes more so. Training in diversity issues is prominent in accredited training programs, so at this point many clinicians are aware of the impact of the variables summarized usefully by Pamela Hayes’ “ADDRESSING” acronym: Age, Developmental and acquired Disability, Religion, Ethnicity, Socioeconomic status, Sexual orientation, Indigenous heritage, National origin, and Gender (Hayes, 2008). To address each of these for each personality disorder would be a book in its own right, so I will address some issues that I believe are relatively central and more common. The most general, global issue is to determine, in alignment with DSM principles, the degree to which any particular behavior is normative within a particular cultural context. Further, there is a fine balance between discussing cultural norms and stereotyping. I draw heavily on McGoldrick et al.’s (2005) classic, Ethnicity and Family Therapy in order to navigate these waters. The distinction between acknowledging norms and stereotyping lies in thinking in terms of likelihoods, rather than absolutes. So, for example, it is well-known that Chinese families, influenced byConfucianism , tend to be relatively hierarchically structured (compared to American families) with special authority given to the male head of household. An ethos of working hard is also common in this culture. Expectations are that children follow a moral code of obligations and duty, including filial piety (Lee & Mock, 2005). Of course, any specific case can vary tremendously from that pattern, with degree of acculturation being one important variable (e.g., if that family is fourth-generation American, they may fit more closely with American norms than Chinese ones) as well as simple individual difference (e.g., even a first-generation Chinese man could be very low in dominance, for a variety of psychological reasons). The question incumbent upon us for present purposes is whether an 314 N. Bockian individual should be diagnosed with a personality disorder, given a certain set of characteristics, within a particular subculture. So, in the example above, does this Chinese father fit criteria for obsessive–compulsive PD? The personality disorder has criteria such as rigidity, strict adherence to a moral code, and authoritarian behavior toward subordinates. The proper analysis, diagnostically, is to ask whether these traits are excessive relative to the norms in the Chinese community at a similar level of acculturation. If the behavior is not unusual or only modestly deviant from norms in his community, then these behaviors would not be considered meeting criteria. Similarly, regarding paranoid personality disorder, members of minority groups, immigrants, and refugees, for example, who have experienced discrimination may respond with guardedness to members of mainstream culture. This should not be interpreted as paranoia. One of the more difficult issues in the diagnosis of antisocial personality disorder is to appropriately assess antisocial behaviors when societal forces make such behaviors adaptive. Individuals in high-crime/high-violence neighborhoods often adapt by becoming tough and harsh. Individuals may join gangs for self-defense, but the price of being in the gang is illegal activity and violence. It is also fair to say, however, that individuals exposed to such a background are at greater risk for developing the disorder. There is no completely satisfactory resolution to the problem. However, the key approach is to fully understand what is meant by antisocial personality disorder, apart from its behavioral manifestations. Antisocial personality disorder, according to Millon (2011) is the “active independent” personality type. Individuals who are “followers” do not belong in this category. There are some in gangs, for example, who are for the most part following a leader or the group. Such individuals are more likely to have issues with dependency than hyper-independence. In addition, antisocial PD is generally characterized by impulsivity. Planning and reasoning can be useful differentiators. Individuals who engage in solitary antisocial behavior, who have an “eat or be eaten” attitude, who chafe at any kind of authority, who are cold, callous, or cruel (e.g., meets the criterion related to torturing animals) are likely to have the disorder. None of these are generally characteristic of people from even the most dangerous neighborhoods and impoverished circumstances; the average low-SES person is a law-abiding citizen, trying to make the best of extremely trying circumstances. However, underdiagnosis is just as big a problem as overdiagnosis, and we must carefully check our biases. Are we excusing behavior that should not be excused, due to the person’s difficult circumstances? Are we diagnosing as if their circumstances made no difference? Either one is an inappropriate bias. Lack of a diagnosis leads to under-treatment; overdiagnosis leads to inappropriate treatment and, unfortunately, possible stigma in our society, in which stigma against individuals with mental illness still is prevalent. An important differential diagnosis is between antisocial PD and borderline PD, particularly in men. Don Dutton’s groundbreaking work in domestic violence is truly eye-opening in this regard. Superficially, domestic violence against women by men would seem to indicate antisocial personality disorder—the anger, the violence, the seeming callousness, and so on. However, upon closer inspection, the 12 Personality Disorders 315 pattern does not fit well. The well-known pattern of the abuser being contrite and feeling guilty and begging for forgiveness and for the person not to leave is one clue; the fact that the risk of violence is highest when the partner leaves or threatens to leave is another. Dutton notes that attachment insecurity fits the pattern more closely, and traits of borderline PD—impulsivity and anger (shared between the two disorders) but also feelings swinging from loving to hating the other person (and back again) as well as feelings of guilt, worthlessness, anxiety, and other traits, indicate that borderline PD is the far superior conceptualization (Dutton, 2007). Surely, a person committing domestic violence may very well have antisocial or sadistic PD; however, we must be very mindful of gender bias in this regard. It is particularly important in this area, because the treatments for antisocial and borderline PD are generally very different. People with antisocial PD are by definition, callous (literally, thick-skinned, emotionally) while Linehan describes people with borderline PD as having extreme emotional hypersensitivity, as if they had a bad burn on their psychological “skin” (Linehan, 1993, pp. 69–70). There are times when, with antisocial PD, I feel as if I need to “turn up the volume,” emotionally, in order to be heard. In contrast, such an approach would overwhelm the person with borderline PD. Evidence is growing that treating people who commit domestic violence with DBT is effective (Sonkin & Dutton, 2003). Millon’s analysis of social conditions that contribute to the recent dramatic increase in borderline personality disorder can act as a template for understanding social factors that foster mental disorders in general, and personality disorders in particular. Millon notes that borderline symptoms parallel various changes in society. The identity disturbance that plagues many individuals with borderline PD is correlated with a breakdown in institutions that once supported identity formation. Once anchors for individual identity, churches, synagogues, and other religious institutions have experienced declining membership and participation for many years. Television shows also model behaviors that are borderline in nature. Notes Millon (1987): …“life stories” must be composed to capture the attention and hold the fascination of their audiences—violence, danger, agonizing dilemmas, and unpredictability, each expressed and resolved in an hour or less—precisely those features of social behavior and emotionality that come to characterize the affective and interpersonal instabilities of the borderline. (p. 365) In addition, characters are often portrayed as being right or wrong in simplistic ways, supporting the “split” thinking characteristic of borderline PD. Marriages, too, are divided, with a majority ending in divorce; sadly, and all too often, parents carry on their feud, painting the other as all bad, and themselves as all good; the parallels to borderline thinking are obvious. Using mind-altering drugs can further erode emotional stability and clarity of thought. Finally, the dizzying pace of change in our society, including changes in social norms, rapid technological advance, and shifting moral values contribute to the difficulties in identity formation. These societal conditions are not necessarily problematic in and of themselves; however, they do complicate the task of identity formation, and in certain vulnerable individuals, lead to problematic outcomes. 316 N. Bockian

Case Illustrations

Case 1: “Jamie.” “Jamie” is a 32-year-old married Caucasian cis-gender heterosexual woman of Anglo Saxon and German origin. Describing herself as “spiritual but not religious,” Jamie was raised in a Mormon home. She had been in therapy, on and off, since childhood. Jamie came to therapy due to feelings of depression, fears of having a serious illness, rumination, and difficulties in relationships. She denied a history of physical or sexual abuse. Fearing that she had a serious illness despite substantial reassurance from physicians following numerous tests, Jamie would sometimes spend hours researching illnesses on the Internet, often going to work with just 2 hours of sleep. Although highly intelligent and possessing a graduate-level degree, she was significantly underemployed, working in the shipping department of a local department store. Perhaps most prominent were overwhelming feelings of guilt, which plagued her almost constantly. She did not believe that she deserved what she had. Her income was low, but financial support from her family of origin, her husband while she was married, and boyfriends, allowed her to live a middle-class lifestyle; for this, she felt overwhelmed by feelings of guilt and inadequacy. She reported that when she was growing up, according to her family, “nothing she ever did was good enough.” Praise was virtually never given, but harsh verbal reprimands were given if her work and behavior were less than perfect. She described her father as extremely competent and financially successful, but emotionally “clueless.” She often experienced feelings of despising herself; on a few occasions, she reached the point where she would slap herself in the face or punch herself in the stomach to express her self- loathing. She described her husband as a completely unemotional and emotionally unavailable man with a significant alcohol problem; although I never worked with him, if her description was accurate, he was on the schizoid spectrum, perhaps with full-blown schizoid personality disorder. They divorced because she felt completely neglected. Her dating relationships were characterized by fears of abandonment and several “preemptive strikes,” breaking up with a partner before he broke up with her, even though, by her reports, his verbal behaviors were consistently affectionate. There were several longer-lasting relationships in which her partner was dismissive, neglectful, or critical; these relationships felt more authentic to her. At times in her relationships, she would get angry and harshly critical of her partner, and then feel guilty and contrite. In many of her friendships, Jamie would listen to her friend’s problems and provide support, way past the point where she felt comfortable in terms of time and energy, though few if any of her friends were supportive during her times of trouble. Although she tutored students in writing, and helped her friends, Jamie had great difficulty completing her own papers, as her self-doubts and perfectionism interfered. When Jamie was growing up, her mother was ill much of the time; much of the household revolved around the efforts not to disturb her, and much of her father’s energy was consumed with caring for her. Diagnostically, then, Jamie is highly complex. With the self-injurious behavior, fears of abandonment, and mood problems, borderline personality disorder must be 12 Personality Disorders 317 considered. For symptom disorders, her fears regarding having a serious illness indicate Illness Anxiety Disorder, while her rumination and painful paralysis suggest possible Obsessive–Compulsive Disorder. Dominating the clinical picture, however, is Self-Defeating/Masochistic Personality Disorder. The criteria associated with the disorder—believing that she deserves to be punished, rejecting help, guilt following positive personal events, provoking rejection then feeling hurt, achieving for others but not for herself, rejecting opportunities for pleasure, losing interest in individuals who treat her well, and self-sacrifice—were virtually all met in this case. My emotional reactions were very helpful in guiding me in this case. When she described deserving to be punished, and not deserving anything good, I felt mostly perplexed and confused. Attempting to intervene to make her feel better, often resulting in intense guilt on her part, deepened my confusion, and left me feeling de-skilled. With cognitive–behavioral therapy as a base upon which I build a good deal of my therapeutic work, what was I to do with someone who reacted to what would ordinarily be considered positive reinforcers with waves of guilt, self- recrimination, and, at times, self-hatred? I often felt an incongruous wave of revul- sion (e.g., when she described hitting herself) or frustration (as I struggled to find a way to help her improve her mood and functioning without triggering her guilt and self-loathing) mixed with deep and sincere compassion (since she was in tremendous psychic pain). These feelings helped me to see the conflicted inner world she inhabited, and the distortion of pain and pleasure that she experienced. It is important to note that the idea that people with self-defeating personality disorder “enjoy suffering” is a substantial distortion. Although individuals with this disorder may believe that they deserve to suffer, with suffering providing some form of guilt reduction or sense of justice being served, they are still suffering…badly. Having experienced a taste of Jamie’s, and others’, internal world, I believe that self- defeating personality disorder is one of the more painful of the psychological conditions. Several diversity factors appeared to have played a role in Jamie’s developing self-defeating personality disorder. Self-defeating PD is disproportionately diagnosed in women, presumably primarily due to expectations of women within families and our society. Her upper-middle-class upbringing, contrasted with her relatively low earnings, fed her self-recriminations regarding being “undeserving.” Finally, her national origin (Anglo-Saxon/German) emphasizes productivity, wherein she believed that she fell short. Although in some cases, experiences with religious interpretations that emphasize guilt can increase the risk of feeling excessive guilt, that was not the situation in this case as her family was relatively nonpracticing. Although overapplied, Jamie had many of the strengths that are associated with this character type. Her characteristics included, per the characteristics listed for the healthy end of the self-defeating spectrum above, being generous, nonjudgmental, tolerant, humble, and responsible. While it is beyond the scope of the chapter to discuss her treatment, ultimately it was these characteristics that enabled her to connect meaningfully with others, and, in connection with a loving partner, overcome her self-doubts and negative beliefs. 318 N. Bockian

Case 2: “Juan” was a 42-year-old first-generation Hispanic cis-gender married heterosexual male. He worked as a physical therapist in a state hospital. Juan was referred for difficulties with his immediate supervisor, and for some difficulties with patients. Juan stated that his supervisor expressed frustration that he (Juan) was often late with paperwork. He never became licensed in PT, but was still able to work due to the particular rules in the state facility where he was employed. Juan noted that his boss was “too hard on him,” and “too critical,” and “did not understand him.” He was resentful of suggestions that his boss or others made to help him to improve his work. He would often argue with individuals on his treatment team about diagnoses, even those that were outside of his area of expertise. His mood came across as sad, irritable, and discontented. While at first I felt sympathetic toward Juan, I soon found myself feeling more and more frustrated. Any suggestion I would make was met with, “yes, but…” He seemed to get a strange sense of satisfaction from “defeating” any efforts I made to help him. I also found myself working harder than the client in trying to find solutions to his difficulties. In one notable interaction, after running through a list of possible solutions, when I could not think of any more, he smiled. My interpretation was that defeating me was more important than feeling better or getting well. Juan is a rather pure case of passive–aggressive (DSM-III-R) or negativistic personality disorder (DSM-IV-TR appendix). Other than some modest depression and anxiety (due to his difficulties with his supervisors and others) there were few symptoms other than his personality disorder (and even those could be considered largely secondary). The fundamental issue—his ambivalence over whether to be self-focused or other focused, in a hierarchically superior position, or an inferior one, played itself out in the therapeutic relationship, just as it did in his interpersonal relationships. My reaction—feeling frustrated over his active undermining of my efforts to help, and perplexed at his apparent lack of motivation to improve—have been reliable pointers to this personality type. Case 3: “Hope” is a 68-year-old divorced mother of six grown children. She grew up in an African nation, and has been residing in the United States for approximately 40 years. A number of months before I began to see her, Hope had had a stroke. This event led to her transition from community residence with her grand- daughter to living in a nursing home. Christian throughout her life, following the stroke she became a Baptist and was “reborn.” Since that time, according to her daughter, she has been extremely religious. Hope’s memory was somewhat impaired, thus some of the details in her history were rather sketchy. I had no difficulty connecting with Hope; she was interested in having a relationship with me and with her family members. I have often found that in nursing homes, due to the under-stimulating and often isolating environment, clients are very eager for a relationship, even those with relatively detached or independent personality styles. Simply providing an opportunity to talk about her concerns established a comfortable therapeutic rapport. Hope’s initial complaint to me was that she was seeing “devils,” shadowy spirits that would hide in corners or under her bed. She claimed that they were stealing her clothes and otherwise tormenting her. 12 Personality Disorders 319

Sadly, Hope’s clothing was disappearing, and needed to be replaced by the nursing home; staff believed that in fact the clothing was being stolen. Nonetheless, several diagnostic possibilities jumped to mind. Psychosis secondary to stroke and its atten- dant brain damage? Schizophrenia? Schizotypal PD? Atypical psychosis? Hope’s voice was sad and pleading as she reported her story, and I felt a distinct cry for help. Paying attention to my emotional reactions to her, I noticed that I felt sad, heavy, and helpless, and I experienced a strong urge to rescue her. This is a common gut-reaction I have noticed within myself when I encounter a client with depression, especially if the person has a tendency toward dependency. With clients who are more classically psychotic (e.g., schizophrenia) I often experience confusion and a struggle to create coherence. Hope, however, was more in the schizotypal range of functioning—she was having illusions (criterion 3), rather than frank hallucinations; she probably did see shadows, or vague movements on the ground, but interpreted them to be demons. Her behavior was odd and eccentric (criterion 7) most notably singing her prayers loudly in bed, and preaching to no one in particular. Her affect was often inappropriate, either overly excited or overly muted to the topic at hand (criterion 6). She was suspicious that others were talking about her negatively (criterion 5). Her speech was also odd, often being vague or circumstantial; I needed to redirect her speech fairly often in order to make progress in a conversation (criterion 4). I believed, then, that the best way to initially conceptualize the case was major depression with mood-congruent delusions, in the context of schizotypal personality disorder. Since the belief in spirits is common in Hope’s African culture of origin, the content of her thoughts was not particularly bizarre (Black, 1996), although the whole of the clinical picture was well outside the norms of her subculture (e.g., her daughter expressed concerns). Because of the behavior change after the stroke, one could consider it a personality change due to a medical condition; the personality to which she had changed, however, was best characterized as schizotypal PD. For further elaboration of this case, see Bockian (2006).

Information Critical to Making a Diagnosis

What is critical to making a diagnosis of personality disorder is to note how well the disorder under investigation fits the general guidelines for categorizing a PD, as noted above. It (1) must be an enduring pattern of inner experience and behavior; (2) deviate markedly from expectations of that individual’s culture; (3) is pervasive and inflexible; and (4) has onset in adolescence or early adulthood (although I would add that diagnosis prior to adolescence is a possibility). An excellent clue that the person has a personality disorder is that it is ego syntonic, that is, the person views the personality tendencies as a normal part of the self, and therefore sees the reactions of others as being what is problematic. Once the clinician determines that a personality disorder diagnosis is appropriate, then one should assess the specific criteria under each of the personality disorders. 320 N. Bockian

Dos and Don’ts

1. Do a comprehensive evaluation, including multiple sources of information, such as self-report inventories, clinical interviews, and, where practical, structured or semi-structured interviews, as well as informant interviews. 2. Do learn the diagnostic criteria well, and become familiar with major theories in the PD field so that you understand their meaning. 3. Do radically empathize with your client during the intake interview, seeing the world through their lens, even if that lens is distorted in some areas. Validate the valid in what they say. Be authentic. 4. Do learn to word questions in accordance with the radical empathy noted above, whether through attunement, through practice with semi-structured interviews, or, best of all, both. 5. Do attend to your emotional reactions, and learn what you typically experience in response to particular traits. Develop and hone your intuition. 6. Do use your ability to rapidly get a feel for the personality style of the individual to improve your rapport for the remainder of the interview. 7. Don’t become overwhelmed by the strong emotional reactions that occur due to personality disorders. 8. Don’t lose hope that the person can improve. 9. Don’t hesitate to seek supervision, peer consultation, or professional consultation as warranted. 10. Don’t reify—that is, think that the label indicates a real, tangible entity, which often leads to systematically ignoring information that does not fit our preconceptions. Personality disorder labels are there to provide guideposts to our understanding. The real person is always richer and more complex.

Summary

Diagnosing personality disorders is a blend of art and science, intuition and empiricism. In this chapter I have provided a model that includes relatively objective measures, such as semi-structured interviews and self-report tests, along with the most intimately subjective, namely, our emotional reactions to our clients. Radically empathizing with our clients helps us to connect with them more fully, and gain information that is more valid. Learning to hone your intuition is, to my mind, an essential ingredient in optimizing our ability to recognize personality disorders, and connect with the people who have them. While not the only pathway, I recommend mindfulness meditation as an excellent gateway, one which has preliminary scientific support in being used for such purposes. I recommend practicing with structured interviews, especially during training or early in one’s career, to gain an understanding of how to ask questions that will elicit meaningful responses. Working with people with personality disorders can be emotionally overwhelming, 12 Personality Disorders 321 even in early interviews, and accessing appropriate support—whether through supervision (during training), peer support, or professional consultation is healthy and at times an ethical imperative. Finally, there is no substitute for being highly familiar with the diagnostic criteria and relevant theory. Read, go to training sessions, and interact with fellow professionals about how to interact in a productive way with individuals with personality disorders.

References

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Siever, L. (1992). Schizophrenia spectrum personality disorders. American Psychiatric Press Review of Psychiatry, 11, 25–42. Sonkin, D., & Dutton, D. (2003). Treating assaultive men from an attachment perspective. In D. Dutton & D. Sonkin (Eds.), Intimate violence: Contemporary treatment innovations (pp. 105–134). New York, NY: Haworth Press. Tansey, M. J., & Burke, W. F. (1989). Understanding countertransference: From projective identification to empathy. Hillside, NJ: Analytic Press. Widiger, T. A., & Gore, W. L. (2013). Mental disorders as discrete clinical conditions: Dimensional versus categorical classification. In D. C. Beidel, B. C. Frueh, & M. Hersen (Eds.), Adult psychopathology and diagnosis (7th ed.). Hoboken, NJ: Wiley. Zanarini, M. C., Frankenburg, F. R., Hennen, J., Bradford Reich, B., & Silk, K. R. (2005). The McLean study of adult development: Overview and implications of the first six years of prospective follow-up. Journal of Personality Disorders, 19(5), 505–523. Chapter 13 Substance Use Disorders

Catherine E. Paquette, Jessica F. Magidson, Surabhi Swaminath, and Stacey B. Daughters

In this chapter, we present a framework for the assessment and diagnosis of substance use disorders (SUDs) with an emphasis on integrating a dimensional, multifaceted approach into the traditional categorical system that historically underlies most established diagnostic interviewing tools. Supplementing categorical diagnoses with dimensional tools allows for a more nuanced clinical picture than simply determining whether or not an individual meets criteria for an SUD. A dimensional approach may provide further information on the frequency and degree of use, associated impairment, and comorbid symptomatology. Using such information to supplement an SUD diagnosis can enable a more individualized treatment plan that targets the psychological underpinnings of substance use as well as the consequences of use. This chapter can be used as a clinical tool for the assessment of substance use at multiple stages (screening, diagnostic assessment and dimensional assessment), encompassing a broad scope beyond traditional methods of categorical diagnosis.

Description of the Disorder

Substance use problems are pervasive and costly. According to the 2016 United States National Survey on Drug Use and Health, 20.1 million people aged 12 and older met criteria for an SUD in the past year, of whom 15.1 million met criteria for Alcohol Use Disorder, and 7.4 million met criteria for an illicit drug use disorder (SAMHSA, 2017). There are serious public health and economic consequences

C. E. Paquette · S. Swaminath · S. B. Daughters (*) University of North Carolina at Chapel Hill, Chapel Hill, NC, USA e-mail: [email protected] J. F. Magidson University of Maryland, College Park, College Park, MD, USA

© Springer International Publishing AG 2019 325 D. L. Segal (ed.), Diagnostic Interviewing, https://doi.org/10.1007/978-1-4939-9127-3_13 326 C. E. Paquette et al. associated with substance use, including unemployment (Luck, Elifson, & Sterk, 2004), homelessness (Thompson, Wall, Greenstein, Grant, & Hasin, 2013), and violent crime (Friedman, Glassman, & Terras, 2001). Overdose is a particularly serious public health issue associated with substance use; in 2016, there were 63,632 drug overdose deaths in the United States, most of which involved opioids (Seth, Scholl, Rudd, & Bacon, 2018). Indeed, the opioid crisis was largely responsible for a 4.1-fold increase in the total number of overdose deaths between 2002 and 2017 (NIDA, 2018a). In the United States, an estimated $442 billion is spent each year on costs related to substance use, including healthcare expenditures, lost productivity, and crime, with $193 billion of these costs linked to illicit drug use (National Drug Intelligence Center, 2011) and $249 billion linked to alcohol use (Sacks, Gonzales, Bouchery, Tomedi, & Brewer, 2015). Substance use is associated with engagement in multiple health-compromising behaviors (e.g., condom nonuse, drug injection) resulting in numerous adverse consequences, such as increased rates of HIV/AIDS (Avants, Marcotte, Arnold, & Margolin, 2003). Evidence indicates that SUDs are highly comorbid with other mental health disorders. Epidemiological data suggest that among adults with SUDs, 43.3% have at least one other co-occurring psychiatric disorder (SAMHSA, 2017). Depressive and anxiety disorders are strongly associated with SUDs (Lai, Cleary, Sitharthan, & Hunt, 2015), as are psychotic disorders such as schizophrenia (Lev-Ran, Imtiaz, & Foll, 2012). SUDs also often co-occur with personality disorders such as borderline and antisocial personality disorders, with estimates of 22–36.4% and 3.1–30.3%, respectively (Colpaert, Vanderplasschen, Maeyer, Broekaert, & Fruyt, 2012). Of note, rates of comorbidity within psychiatric inpatient and residential substance use treatment facilities may be considerably higher than within the general community (Mowbray, Collins, Plum, Masterton, & Mulder, 1997). Comorbid psychiatric diagnoses often play an influential role in the course of an SUD, particularly increasing the likelihood of treatment dropout, relapse, and other negative consequences of substance use. For example, substance-induced depression is associated with a reduced likelihood of remission from SUDs, and depression during abstinence is associated with higher rates of relapse (Hasin et al., 2002). Substance use poses a significant public health concern particularly due to the difficulties in effectively treating individuals with SUDs. The rate of treatment dropout from substance use treatment programs is approximately 27% (SAMHSA, 2015b), which is notable given that length of time in treatment and treatment completion predict successful outcomes (Ghose, 2008). Even for clients who remain in treatment, relapse and eventual readmission is fairly common, particularly when SUDs are accompanied by comorbid psychiatric problems. Prospective research suggests that individuals who engage in substance use treatment typically require three to four treatment episodes over about 9 years before reaching a stable state of abstinence (Dennis, Scott, Funk, & Foss, 2005). Taken together, substance use is a significant public health concern due to the high costs of treatment combined with the associated individual risks and impairment. 13 Substance Use Disorders 327

Procedures for Gathering Information

There are a number of variables to consider when determining the best method of assessment for potential substance use problems. It is important to determine the goal of the assessment; specifically, whether assessment is aimed at identifying the presence of a substance use disorder, treatment referral, treatment planning, or treatment response. Variation in assessment environments (e.g., primary care, mental health or substance use treatment setting, harm reduction program, correctional facility) also impacts the most appropriate assessment approach. In this section, we highlight the important considerations for three types of assessment, namely, screening, diagnostic assessment, and dimensional assessment, and provide recommendations for approaching the unique demands of each type in different settings. Although the procedures in determining the appropriate treatment approach are beyond the scope of this chapter, the interested reader is referred to a review of the research foundations backing the American Society of Addiction Medicine’s client placement criteria (Gastfriend, 2004) and the current criteria text (Mee-Lee, 2013). Additionally, for assessment with clients who use opioids, the Substance Abuse and Mental Health Services Administration’s (SAMHSA) (2005) guide on medication- assisted treatment (MAT) provides useful information related to screening, assessment, and treatment matching into evidence-based opioid treatment programs that offer MAT (e.g., methadone and buprenorphine).

Screening

Screening for substance use and related problems is typically the initial stage of SUD assessment. Screening procedures necessarily vary across settings. The time- pressed nature of primary care settings necessitates the use of screening tools that are brief, clear, and easily administered. Substance use treatment centers typically utilize screening measures that gauge specific drug information, including different drug classes used and degree and frequency of use. Given the high rate of comorbidity between SUDs and other psychiatric disorders, clinicians in mental-health- specific settings may also utilize screening instruments to detect substance use. In these settings, it is useful to capture in-depth information regarding a client’s use, including level of impairment and frequency of use, to enable an understanding of the function of the substance use and determine the appropriate treatment approach.

Primary care In community settings that do not provide substance use treatment, such as primary care, assessment of substance use may need to be brief, focusing on identifying problematic use and determining appropriate referrals rather than conducting in-depth interviews. A primary care setting may utilize screening tools as a standard procedure to detect for the presence of substance use or an SUD if not already known. The Screening, Brief Intervention, and Referral to 328 C. E. Paquette et al.

Treatment (SBIRT) model is an evidence-based practice developed for primary care and other nontreatment settings that can help identify substance use problems and provide referrals to appropriate care (“SBIRT,” n.d.). The SBIRT model involves using standardized screening tools to assess for risky substance use, engaging the patient in a brief intervention (involving discussion and advice), and providing referrals to additional treatment as needed. More extensive information and resources related to the SBIRT model can be accessed on the Substance Abuse and Mental Health Services Administration’s (SAMHSA) website (www.integration.samhsa. gov/clinical-practice/sbirt). Note that while screening and brief intervention has been found to be efficacious in reducing alcohol consumption among patients in primary care settings (Bertholet, Daeppen, Wietlisbach, Fleming, & Burnand, 2005), brief interventions have not been effective in addressing alcohol use disorders or drug use, even when paired with passive referrals to treatment (Saitz, 2010; Saitz et al., 2014). Thus, further research is needed on effective screening and referral practices, which may include more involved “active” referral strategies for people who use drugs and people with SUDs.

Harm reduction Harm reduction programs for people who use drugs, including syringe exchange programs, typically conduct informal assessments to gather information about health risk behaviors (e.g., drug injection practices), desire/readiness for treatment, and need for other services such as medical care and case management. Even in these low-threshold settings, standardized screening tools may be administered when feasible to gauge clients’ interest in and need for more in-depth support. For example, a treatment readiness questionnaire such as the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES; Miller & Tonigan, 1996) or a briefer measure such as a contemplation ladder for alcohol or drug use (e.g., Hogue, Dauber, & Morgenstern, 2010) can help determine the client’s readiness to change their substance use and desire for treatment. However, the use of standardized screening measures is often deemed inappropriate in these settings due to client reading level, time constraints, and desire to minimize barriers to care (especially in outreach settings). A mixture of open-ended and close-ended questions can also be used effectively to guide client care decisions, and familiarity with standardized screening tools may help workers identify questions that are useful to ask.

Criminal justice Given the increasing numbers of drug-related crimes and people who use substances in the criminal justice system, it is also important to screen for SUDs in correctional facilities. SAMHSA’s Screening and Assessment of Co-occurring Disorders in the Justice System (2015a) is a useful resource that summarizes a range of evidence-based practices for screening and assessment of people in the justice system with comorbid substance use and mental health disorders. Despite increasing need, standardized and validated clinical screening and assessment tools specific to this setting are lacking (Knight, Simpson, & Hiller, 2002). Better methods to screen, assess, and subsequently match inmates to drug treatment programs are needed. 13 Substance Use Disorders 329

In sum, a wide range of self-report screening tools may be utilized based on type of setting and diagnostic purpose. For descriptions of widely used self-report screening tools for SUDs, the reader is referred to an updated chart of measures available on the National Institute on Drug Abuse website (NIDA, 2018b) as well as the chapter on instruments for screening and assessing co-occurring disorders in SAMHSA’s related guide (2015a).

Categorical Diagnosis

The traditional system for diagnostic assessment of SUDs, as with any mental disorder or medical disease, relies on a categorical system that identifies the presence or absence of a disorder. An SUD defined by theDiagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association [APA], 2013) is a maladaptive pattern of substance use leading to clinically significant impairment or distress across ten drug classes: alcohol; caffeine; cannabis; hallucinogens; inhalants; opioids; sedatives, hypnotics, and anxiolytics; stimulants; tobacco; and other (or unknown) substances. To receive an SUD diagnosis using DSM-5, an individual must endorse two or more of the following criteria in a 12-month period for a specific substance (e.g., cocaine use disorder) or for the combination of three or more substances (e.g., poly- substance use disorder): (1) taking the substance in larger amounts or over a longer period than intended; (2) a persistent desire or unsuccessful efforts to cut down or eliminate substance use; (3) spending a great deal of time in activities associated with substance use; (4) craving, or a strong desire to use the substance; (5) failure to fulfill major role obligations due to recurrent use; (6) continued use despite persistent interpersonal problems caused or exacerbated by the substance use; (7) reduction in important social, occupational, or recreational activities due to substance use; (8) recurrent use in situations in which it is physically hazardous; (9) continued use despite persistent psychological or physical problems caused by use; (10) tolerance; and (11) withdrawal. Standardized diagnostic interviews such as those described in Table 13.1 are useful tools for determining an SUD diagnosis based on DSM-5 criteria. Previous editions of the DSM differentiated between substance “abuse” (a maladaptive pattern of use thought to indicate a mild SUD) and substance “dependence” (a manifestation believed to be more severe, including tolerance and withdrawal symptoms). The DSM-5 eliminated these distinctions and instead uses a more dimensional approach, in which SUDs can be categorized by severity level depending on the number of symptoms. An SUD diagnosis can be specified as mild (two to three symptoms), moderate (four to five symptoms), or severe (six or more symptoms). Other changes in DSM-5 include the addition of drug craving as a symptom, and the elimination of problems with law enforcement as a symptom due to cultural considerations (APA, 2013). 330 C. E. Paquette et al.

Table 13.1 Standardized diagnostic interviews Psychiatric Research Semi-structured interview that distinguishes primary DSM-5 Interview for Substance diagnoses from substance-induced disorders. The PRISM was and Mental Disorders designed to address the poor reliability and validity found for (PRISM-5; Hasin et al., psychiatric diagnoses among people who use substances (Bryant, 1996) Rounsaville, Spitzer, & Williams, 1992; Kranzler, Kadden, Burleson, & Babor, 1995; Williams, Gibbon, First, & Spitzer, 1992), due partly to the fact that symptoms like depression, anxiety, and psychosis are also prevalent symptoms of withdrawal. Primary disorders are diagnosed when symptoms persist at least 4 weeks in the absence of heavy substance use or when symptoms precede the onset of heavy use. For a PRISM-5 substance-induced diagnosis, a primary episode must be ruled out and the symptoms must exceed the expected effects of intoxication or withdrawal. Structured Clinical Although time-consuming and rarely implemented in treatment Interview for DSM-5 settings, the SCID-5 provides a precise method for identifying SUDs (SCID-5; First, and psychiatric comorbidities and is among the most frequently used Williams, Karg, & instrument in clinical trials. The interview assesses current and past Spitzer, 2016) SUDs for alcohol as well as drug classes including sedatives- hypnotics-anxiolytics, cannabis, stimulants, opioids, hallucinogens, phencyclidine (PCP), and inhalants. Additionally, the SCID-V can be used to assess DSM-5 psychiatric comorbidities. It typically requires 20–30 min to administer the substance use module. Computer programs are available for data entry and scoring and training for clinicians typically requires 2–3 days. Mini International Brief structured interview that assesses for current (i.e., past 30 days) Neuropsychiatric and lifetime DSM-5 SUDs and comorbid psychiatric disorders. The Interview (MINI 7.0.2; MINI is widely used in research, and its short administration time Sheehan et al., 1998) makes it useful for clinical settings as well. It has demonstrated similar reliability and validity as the SCID, and takes approximately half as long to administer the same sections (Sheehan et al., 1997). The MINI can be administered by trained lay interviewers as well as clinicians. The Diagnostic Fully structured interview that assesses onset, recency, and lifetime Interview Schedule for history of DSM-5 SUDs, including for alcohol, amphetamines, DSM-5 (DIS-5; Robins, caffeine, cannabis, cocaine, club drugs, hallucinogens, inhalants, Helzer, Croughan, & opioids, PCP, sedatives, and tobacco. The DIS has demonstrated good Ratcliff 1981) reliability and validity and can be administered by a lay interviewer, which greatly reduces training and supervision costs. The interview itself takes 15–25 min. A computerized version is also available. The Composite Fully structured interview that provides lifetime diagnoses for past International Diagnostic and current SUDs. To supplement categorical diagnosis, the Interview (CIDI; Kessler CIDI-SAM also provides a quantitative score, which is created by & Ustun, 2004)- adding endorsed criteria within and across substances, thus Substance Abuse representing a tool that can be used categorically and dimensionally. Module (SAM) The CIDI can be administered by a lay interviewer in approximately 20–30 min. The CIDI-5, which relies on DSM-5 criteria, is currently in beta testing. 13 Substance Use Disorders 331

The International Classification of Diseases, Eleventh Revision (ICD-11; “ICD- 11,” 2018) also provides a classification for SUDs and is considered the international standard diagnostic classification for general epidemiological and health management purposes. The ICD-11 was recently published online (as of December 2018) for stakeholders to use in order to begin preparations for implementation, and is expected to go into effect in 2022 (https://www.who.int/classifications/icd/en/). SUDs in the ICD-11 draft are coded as a pattern of harmful use or substance dependence, similar to previous editions of the DSM.

Dimensional Assessment

Incorporation of a dimensional approach, which includes an evaluation of specific symptomatology and dimensions of functioning beyond the diagnosis of a given disorder, is useful in conjunction with diagnostic assessment and can serve as a basis for determining the appropriate treatment (Helzer, Kraemer, & Krueger, 2006). Studies have highlighted a number of dimensions related to substance use that help predict treatment outcomes, including specific SUD symptoms (e.g., craving), change self-efficacy, psychosocial functioning, and social support (see Tiffany, Friedman, Greenfield, Hasin, & Jackson,2012 ). Additionally, novel interventions have been developed that target specific SUD symptoms like craving, with promising results (Hone-Blanchet, Ciraulo, Pascual-Leone, & Fecteau, 2015). Thus, a dimensional approach to assessment is increasingly recognized as important for both substance use treatment and research. We highlight a few aspects of dimensional assessment, including assessing specific symptomatology, frequency/degree of use and associated impairment, and client treatment goals.

Substance use symptoms Assessing the specific symptoms a client may experience related to their substance use can enable a more in-depth understanding of the function of one’s use. Consider two clients who both meet DSM-5 criteria for a mild cannabis use disorder. One client endorses using cannabis over longer periods of time than intended and spending a great deal of time using cannabis, but no other SUD symptoms; she indicates that she uses cannabis because she has been bored since losing her job. The second client endorses craving cannabis, a persistent desire and unsuccessful efforts to control cannabis use, and continued use despite knowledge that cannabis exacerbates his anxiety. These different symptom presentations can help inform the determination of the client’s need for treatment as well as the specific treatment approach. For example, a brief motivational intervention may be most appropriate for the first client, while the second client may benefit from a more intensive cognitive-behavioral treatment. Assessing specific symptoms can serve to distinguish individuals who may meet criteria for the same diagnosis but have very different symptom presentations and underlying reasons for the substance use. 332 C. E. Paquette et al.

Frequency, degree of use, and impairment Beyond the categorical classification of an SUD, a clinician should assess the frequency and degree of a client’s substance use as well as associated impairment in emotional, social, and occupational functioning. Typically, the reduction of substance use or abstinence is the main outcome in substance use treatment programs. Accordingly, measures of frequency and degree of use such as those in Table 13.2 are often used to establish a treatment plan and can also be used to assess treatment response; such measures are generally more sensitive to treatment effects than dichotomous abstinence outcomes. Notably, however, problematic substance use typically affects multiple aspects of functioning and a thorough assessment of overall functioning (e.g., quality of life) as well as specific impairments (e.g., substance-related problems) is an important component of dimensional assessment. Self-report measures such as the Addiction Severity Index (ASI; McLellan et al., 1992) and the Short Inventory of Problems – Alcohol & Drugs (SIP-AD) (Hagman et al., 2009) can aid the clinician in assessing functioning across multiple domains; detailed descriptions of these measures are also included in Table 13.2.

Table 13.2 Examples of dimensional and symptom-based assessment tools Frequency, Degree of Use The Timeline Semi-structured clinical interview used to obtain self-report retrospective Followback (TLFB; estimates of substance use. The TLFB uses a calendar method and other Fals-Stewart, recall-enhancing techniques to assist individuals with their description of O’Farrell, Freitas, their daily substance use over a targeted time interval. The TLFB also McFarlin, & may be useful for assessing other events and mood over this time period Rutigliano, 2000) to assess the relationship between these variables and substance use. Form 90D Semi-structured interview with intake and follow-up versions that (Westerberg, assesses lifetime and past 90-day drug use of 12 drug categories. The Tonigan, & Miller, assessment instrument utilizes a calendar format, and for every drug 1998) class estimates age at first use, lifetime weeks of use, frequency of use in the current period, intensity of that use (by categorization), and relative use of various routes of administration. In addition, the Form 90D assesses history of psychosocial and environmental variables such as treatment services received, living experiences, incarceration, work, and education experiences. The interview takes approximately 40–60 min. Impairment Addiction Severity Most comprehensive and widely used measure to assess associated Index (ASI; impairment. The ASI can be administered either as a self-report McLellan et al., questionnaire or by a trained clinician in an hour long interview. The ASI 1992) assesses drug and alcohol use, medical status, employment status, family history, legal status, psychiatric status, and family and social relationships. Because it identifies problem areas in need of targeted intervention, it has been used extensively in clinical settings for treatment planning and outcome evaluation. Takes approximately 1 h to administer. Short Inventory of Ten-item self-report inventory of adverse consequences related to Problems – Alcohol alcohol and drug use across physical, social, intrapersonal, impulsive, & Drugs (SIP-AD) and interpersonal domains. (Hagman et al., 2009) 13 Substance Use Disorders 333

Treatment goals A dimensional assessment in the context of mental health and substance use treatment should also include consideration of the client’s goals for treatment. Consider an individual in treatment for a cannabis use disorder whose goal is to eliminate cannabis use but continue to drink alcohol in moderation after treatment. In light of this goal, a thorough assessment of the client’s alcohol use and related impairment (regardless of an Alcohol Use Disorder diagnosis) in addition to their cannabis use would aid in guiding treatment decisions. Consideration of a client’s treatment goals should also guide the outcomes assessment. Dichotomous indicators of abstinence may mischaracterize the effect of treatment among clients who aim to achieve abstinence from one substance but not another, or for those who aim to reduce substance use and related impairment but not to abstain entirely.

Recommendations for Formal Assessment

In this section, we provide more detailed recommendations related to a few important aspects of substance use assessment, including assessing substance use within specific drug classes, assessing comorbid symptomology, and the importance of stigma in the context of substance use assessment.

Assessing Use Within Specific Drug Classes

Psychoactive substances are categorized into specific classes (e.g., stimulants, depressants, hallucinogens) that differ in their physiological and behavioral effects as well as associated risks and consequences. For example, a stimulant (e.g., cocaine) versus an opioid analgesic (e.g., heroin) produces very different physiological and psychological effects. Cocaine use is often associated with feelings of euphoria, increased energy, alertness, and rapid speech, as well as physiological effects such as increased heart rate, temperature, and blood pressure. In contrast, heroin use tends to produce tranquility, sedation, and reduced anxiety; the physical effects may include fatal respiratory depression, nausea, and vomiting. The risks and consequences associated with each drug also differ. Cocaine is often linked with increases in sexual risk-taking behaviors and an increased likelihood of cocaine- induced psychosis, whereas heroin is associated with intense physical withdrawal symptoms and increased risk of fatal overdose. Given the differences in function and consequences, it is important to determine patterns of use within specific drug classes when conducting an assessment of substance use as well as when developing a treatment plan. For a review of drug class differences, we recommend Julien (2005), A Primer of Drug Action. Studies have generally found high agreement between validated self-report measures and biological measures of substance use (e.g., Hjorthoj, Hjorthoj, & Nordentoft, 2012); however, in certain settings (such as research and criminal 334 C. E. Paquette et al.

justice), a biological assessment of substance use within specific drug classes may be used to supplement self-report information. Biological methods include breatha- lyzer, urinalysis, blood, saliva, or hair samples. Urinalysis is the most widely used method, and is considered the most well-supported for use in clinical settings (Jarvis et al., 2017). However, the accuracy and clinical utility of each method differs based on a number of factors, most notably the window period during which substance use can be detected. For a description of the strengths and weaknesses of various biological methods, please refer to Dolan, Rouen, and Kimber (2004). A dimensional approach can even be taken with drug testing, given that some quantitative and semi-quantitative tests are sensitive to changes in the pattern, frequency, and amount of substance use (Preston, Silverman, Schuster, & Cone, 1997).

Assessing Comorbid Symptomology

The identification of an SUD is often only the first step in the diagnostic process. Given the implications and prevalence of psychiatric comorbidities with SUDs, including a psychiatric diagnostic assessment as part of the SUD assessment is important, particularly in understanding how the multiple disorders may overlap and fuel each other. The standardized diagnostic interviews in Table 13.1 can be used to diagnose a range of comorbid mental health disorders. However, note that a dimensional approach can also be beneficial when assessing for comorbid symptomology. A dimensional approach would consider the presence of specific symptoms and their function in relation to substance use regardless of whether the individual meets criteria for a comorbid diagnosis. Consider a client suffering from depressive symptoms; low mood or hopelessness may be a trigger for his substance use. Thus for this client, targeting these symptoms as part of treatment can also greatly improve substance use outcomes even if the client does not meet full DSM-5 criteria for major depressive disorder (MDD). Given the high rate of comorbidity of SUDs with depressive, anxiety, psychotic, and personality disorders, self-report scales assessing common symptoms and underlying psychological and behavioral constructs related to these comorbidities (e.g., emotion regulation, distress tolerance, impulsivity) can be useful. The reader is referred to the Science of Behavior Change Measures Repository (Science of Behavior Change, 2017) for relevant validated behavioral science measures in the domains of self-regulation, stress reactivity and stress resilience, and interpersonal and social processes. When assessing for comorbidity, it is first important to ensure that the intoxication or withdrawal effects of substance use are not accounting for the presence of symptomatology. This can be a significant challenge when diagnosing individuals with chronic substance use given the resemblance of intoxication states and withdrawal symptoms to certain psychological symptoms. The Psychiatric Research Interview for Substance and Mental Disorders (PRISM-5) is an example of a diagnostic tool developed to meet this need (Hasin et al., 1996, 2006; see Table 13.1). 13 Substance Use Disorders 335

It can be utilized to supplement DSM-5 guidelines when distinguishing between primary and substance-induced disorders. The substance use modules of the PRISM-5 precede other diagnostic modules so that the interviewer is able to place other disorders appropriately in the context of one’s substance use history to enable assessment of primary and substance-induced psychiatric disorders.

Addressing Stigma in Assessment

It is important to be cognizant of the stigma surrounding substance use when conducting assessments. Substance use problems are highly stigmatized, even more than other mental health problems (Barry, McGinty, Pescosolido, & Goldman, 2014), and this stigma can negatively impact the health of people who use substances. For example, people who use drugs report stigmatization when accessing medical care and drug treatment, which is related to reduced utilization of these services (Paquette, Syvertsen, & Pollini, 2018). In the context of screening and assessment, stigma may contribute to a reluctance to disclose substance use, and may lead individuals to minimize their substance-related problems. To maximize the validity of assessments, interviewers should emphasize building rapport, address substance use in a direct, nonjudgmental manner, and avoid use of potentially stigmatizing language (e.g., “addict,” “junkie,” “alcoholic”). In addition to avoiding slang and idioms, current recommendations for reducing inadvertent stigmatization include using person-first language (e.g., “person with an opioid use disorder”) and language that emphasizes the medical nature of substance use disorders (e.g., “substance use disorder” vs. “substance abuse”) (Broyles et al., 2014).

Case Illustration

Client 1: James

The first client (James) is a 47-year-old White male who was voluntarily attending 90 days of treatment at an intensive outpatient substance use treatment center for his opioid use. James enrolled in treatment the week after he had completed a 7-day inpatient detox. At the time of treatment entry, he reported that he was homeless. After dropping out of high school at age 16, James had worked in construction periodically, but had struggled to maintain employment due to his drug use. James indicated that he had been injecting heroin daily for over 15 years, with only brief periods of sobriety. In the month prior to entering treatment, James had experienced two near-fatal overdoses that had resulted in hospitalizations. James indicated that he believed he would die of an overdose if he continued to inject heroin, which ultimately prompted him to seek treatment. 336 C. E. Paquette et al.

The intake interview took place on James’ fourth day of treatment. At intake, the MINI was administered to assess for SUD and comorbid psychiatric diagnoses, and the Addiction Severity Index (ASI) was administered to determine substance use history and severity, as well as environmental strengths and stressors. Based on this assessment, he met criteria for a current severe Opioid Use Disorder (OUD). James indicated that his opioid use had caused numerous problems, including an inability to maintain employment and stable housing, broken relationships with family and loved ones, incarceration, and health problems including abscesses and hepatitis C. He noted that he had entered treatment twice previously, but both times had dropped out of treatment within the first month. The assessment of psychiatric symptoms using the MINI indicated the presence of depressive symptoms, which James indicated began after entering detox. James reported experiencing similar symptoms during periods of withdrawal in the past. In order to better assess whether James’ symptoms were indicative of primary or substance-induced depression, the PRISM depression module was added to the assessment battery. First, a primary depressive episode was ruled out. Although the majority of his symptoms started during withdrawal and many overlapped with common symptoms of opioid withdrawal, James’ symptoms exceeded the expected effects of opioid withdrawal. Thus, the PRISM clarified that James met criteria for a diagnosis of substance-induced depression. James indicated that the depressive symptoms he had experienced during past sobriety attempts had significantly contributed to his relapse to opioid use, noting that even after the physical symptoms of withdrawal had subsided, he could not “feel right” without opioids. Following review of his diagnostic assessment, a preliminary treatment plan was developed to treat James’ OUD. First, through a consultation with a psychiatrist, it was determined that James would be a good candidate for methadone maintenance treatment. The psychiatrist expected that methadone would alleviate James’ depressive symptoms, which were largely tied to withdrawal from opioids, as well as his drug cravings. Additionally, James’ treatment included 12 weeks of group-based intensive outpatient treatment and weekly individual appointments with a drug counselor until he produced negative urine drug screens for illicit opioids. Over the following year, James was stabilized on a methadone dose and came to the methadone clinic daily to receive his medication. As expected, James’ depressive symptoms reduced significantly after stabilization on methadone. A methadone drug counselor conducted monthly assessments of depressive symptoms, and by the end of the second month, James no longer met criteria for substance-induced MDD. Weekly urine drug screens typical in many methadone maintenance programs indicated that James continued to use heroin periodically; throughout the first year of methadone treatment, James produced 16 drug screens that were positive for heroin. However, the ASI administered again at 12 months posttreatment entry by a drug counselor indicated that James had experienced a notable decrease in drug- related problems related to legal status, employment, and housing. Specifically, James reported no arrests or incarceration during the 6 months, he had managed to obtain periodic employment as a day laborer, and he reported that he had been living for 2 months in a recovery community. 13 Substance Use Disorders 337

Client 2: Angel

The second client (Angel) is a 34-year-old Black female who was court mandated to attend 90 days of treatment at an intensive outpatient substance use treatment center for her opioid use. Prior to coming to treatment, Angel had been working part-time as a home health aide. Angel noted that things had been very difficult since her mother died 9 months prior. She reported feeling increasing depression and loss of motivation since her mother’s death, and she indicated that she started snorting heroin and smoking marijuana to “find relief” from her emotional pain. Angel was arrested after purchasing heroin, and was currently required to attend treatment as a condition of her probation. The intake interview took place on Angel’s third day of treatment. At intake, the MINI and the Addiction Severity Index (ASI) were administered. Angel met criteria for a mild OUD. She indicated that she had been snorting heroin two to three times per week for the past month, usually when it was given to her by a friend. Angel reported that the heroin helped her escape from her emotional distress, and she reported craving it. She also noted that when she obtained heroin, she would spend a great deal of time using it, and would use more than intended. She did not report any other impairment caused by opioids, with the exception of her arrest. Angel reported that she had been smoking marijuana daily, usually once in the evening, to help her sleep at night. She did not report any impairment due to marijuana use, and did not meet criteria for a cannabis use disorder. The assessment of psychiatric symptoms indicated the presence of recurrent MDD, including a current severe depressive episode that started after Angel’s mother died. Angel reported that she had experienced periods of depression in the past, but that this was her worst episode in memory. Angel reported that she began using heroin about 2 months prior in order to cope with her depressive symptoms. A treatment plan was developed to treat Angel’s depression and OUD. First, Angel met with a psychiatrist, who prescribed antidepressants. The treatment plan also included standard group substance use treatment sessions and attendance at a group focused on coping with depression and loss. Angel was referred to a community mental health center to receive individual psychotherapy targeting depression. Angel completed her 90-day contract and was reassessed at treatment completion. Her depressive symptoms were reduced significantly, though she still met criteria for a mild major depressive episode (MDE). Weekly urine drug screens throughout treatment had been negative for all substances. One year later, Angel no longer met criteria for MDD. She was again using marijuana daily; however, she indicated that she had not used heroin since leaving treatment.

Summary of Cases

These two case illustrations demonstrate the importance of individualized, dimensional assessments that distinguish between primary and substance-induced comorbidity. Although an assessment this thorough is not common in routine clinical 338 C. E. Paquette et al. practice, these vignettes are meant to illustrate the utility of a more thorough assessment approach. Both James and Angel met criteria for MDD and OUD. However, a dimensional assessment showed that James had a severe OUD and mild depression induced by withdrawal, while Angel had a mild OUD that was likely a result of her severe primary depression. These differences in diagnosis have important implications for treatment. James’ treatment needed to focus on his opioid use, and thus methadone was an appropriate treatment. As expected, James’ withdrawal-induced depressive symptoms remitted after methadone induction. In contrast, Angel’s treatment needed a more direct focus on depression in addition to substance use. The client’s depressive symptoms reduced after she was given antidepressants and psychosocial treatment, and she achieved long-term abstinence from opioids. By conducting a thorough, nuanced assessment that considered the relationship between the clients’ substance use and comorbidity, both clients were able to receive individualized care that targeted the cause of their dysfunction. Lastly, for both clients, assessing impairment and substance use outcomes beyond abstinence was important in order to understand the impact of the treatment. For example, James continued to use heroin periodically, but saw improvement in substance-related problems after being stabilized on methadone. Angel returned to regular marijuana use after treatment; however, she did not continue to use opioids, which had previously been problematic. An outcomes assessment focusing solely on abstinence would overlook the treatment’s success in resolving the primary disorders that were causing impairment, while assessing a range of outcomes related to the clients’ diagnoses allowed their progress to be more accurately captured.

Impact of Gender, Race, Culture, Age, and Other Aspects of Diversity

There has historically existed a striking absence of empirical attention to the distinct problems faced by underserved populations with SUDs. To address this issue, greater attention and funding has been allocated to research disparities among people who use substances. Individuals who use substances, like everyone, have intersectional identities and experiences, and the disparities they experience are likely influenced by a number of intersecting factors including comorbid mental disorders, injection drug use, and sexual minority status (to name only a few). In this section, we focus on a few aspects of diversity including gender, race/ethnicity, socioeconomic status (SES), and age. A growing body of research suggests that these identity factors (in addition to others not discussed here, such as sexual identity) are associated with unique needs and challenges relevant to substance use and SUDs. 13 Substance Use Disorders 339

Gender

Research has demonstrated that women differ significantly from men in terms of their pathways into SUDs. Research suggests that females use substances at a higher rate than males in early adolescence, but that males have a higher rate of change and as a result, higher rates of substance use in middle adolescence through early adulthood (Chen & Jacobson, 2012). Compared to women, adult males have greater rates of lifetime exposure to all categories of substances (Lev-Ran, Le Strat, Imtiaz, Rehm, & Le Foll, 2013). Even among adults with lifetime exposure, men have a higher prevalence of alcohol, sedative, cannabis, tranquilizer, opioid, hallucinogen, and cocaine use disorders. Although women are less likely than men to develop SUDs, women become dependent at a quicker rate, and experience more severe consequences of substance use over shorter periods of time (Hser, Huang, Teruya, & Anglin, 2004). Upon treatment entry, women’s substance use severity symptoms are equivalent to that of men, despite fewer years and quantities of use (Hernandez- Avila, Rounsaville, & Kranzler, 2004). Gender differences have also been documented when investigating substance use treatment. Women comprise a smaller proportion of the treatment population than men (SAMHSA, 2014), and may be less likely to enter treatment over the lifetime (Greenfield et al., 2007). Evidence suggests that gender is not a significant predictor of treatment retention or outcomes (Greenfield et al., 2007). However, certain factors that disproportionately affect women—such as co-occurring MDD and a history of sexual abuse—do predict treatment outcomes. Studies with substance use treatment samples have found higher rates of psychiatric comorbidity in women than in men (e.g., Chen et al., 2011). Compared to men, women suffering from SUDs report a higher rate of mood disorders (Miquel et al., 2013), Posttraumatic Stress Disorder and childhood trauma (Boughner & Frewen, 2016; Peirce, Brooner, King, & Kidorf, 2016), and borderline personality disorder (Chun et al., 2017). Several studies suggest that among women, trauma and its associated symptoms moderate treatment outcomes (Morrissey et al., 2005). Thus, assessment of comorbidity at the start of treatment may be a useful tool to identify women at high risk for treatment dropout and relapse.

Race and Ethnicity

Rates of substance use have been shown to be more prevalent in racial and ethnic minority populations (Center for Behavioral Health Statistics and Quality, 2017). Specifically, past-year illicit drug use disorder among persons aged 12 or older in 2016 was highest among persons reporting two or more races, followed by Native Americans and African Americans. For Alcohol Use Disorder, Native Americans had the highest rates, followed by persons reporting two or more races. 340 C. E. Paquette et al.

Studies of substance use treatment have identified racial and ethnic disparities in unmet need for treatment, treatment access and utilization, and rates of treatment completion. Epidemiological data indicate that Asian Americans with past-year SUDs have a higher likelihood of unmet need for treatment compared to Whites, even when controlling for a range of sociodemographic factors (Mulvaney-Day, DeAngelo, Chen, Cook, & Alegria, 2012). Research also suggests that different racial and ethnic groups enter different types of drug treatment; for example, Bluthenthal, Jacobson, and Robinson (2007) reported that Black and Latino alcohol users were significantly more likely to enroll in outpatient versus inpatient treatment compared to White alcohol users in Los Angeles County, and that the difference in treatment modality contributed to lower rates of treatment completion among Blacks and Latinos. Other research has also demonstrated that Whites have lower rates of treatment dropout compared to Blacks and Hispanics, even when controlling for sociodemographic variables including SES (Mennis & Stahler, 2016).

Socioeconomic Status

Socioeconomic status has been found to influence risk for substance use (in children and adults), as well as the development of SUDs and posttreatment outcomes. Research suggests that low childhood SES predicts later drug use (Daniel et al., 2009; Fothergill, Ensminger, Doherty, Juon, & Green, 2016). This may be due in part to lower engagement in substance-free pleasurable activities and greater engagement in activities paired with substance use among children with low SES (Lee et al., 2018). Multiple indicators of SES predict substance use and related problems among adults, including education and income (Elliott & Lowman, 2015), neighborhood disadvantage (Boardman, Finch, Ellison, Williams, & Jackson, 2001), unemployment (Lee et al., 2017), and subjective social status (Finch, Ramo, Delucchi, Liu, & Prochaska, 2013). One factor known to contribute to higher risk of substance use and SUDs among low-SES individuals is psychological distress. For example, unemployment has been found to increase psychological distress, which in turn is associated with increased drug use (Nagelhout et al., 2017). Psychological distress has also been found to predict relapse to substance use after treatment (Flynn, Walton, Curran, Blow, & Knutzen, 2004), which may partly explain why lower- income individuals are more likely to return to substance use after engagement in treatment (Walton, Blow, Bingham, & Chermack, 2003). These data highlight the importance of assessing psychological distress and related psychopathology in the context of substance use assessment, especially when working in low-SES communities. 13 Substance Use Disorders 341

Age

A great deal of literature has examined the relationship of age of substance use onset and later mental health. Retrospective and longitudinal studies have consistently demonstrated that early initiation of substance use (generally defined as prior to age 15) is related to a host of problems in adulthood, including a rapid escalation of substance-use-related problems (Fergusson & Horwood, 2002; Taylor, Malone, Iacono, & McGue, 2002), higher rates of psychiatric comorbidity (Tanaree, Assanangkornchai, & Kittirattanapaiboon, 2017), and unemployment and school dropout (Fergusson & Horwood, 2002). Underlying personality constructs may partly account for these associations. For example, the latent factor of behavioral disinhibition/undercontrol is predictive of early-onset substance use and misuse (Carlson, McLarnon, & Iacono, 2007). This analysis is supported by the high association between childhood disruptive disorders (e.g., attention-deficit hyperactive disorder; conduct disorder) and early age of onset of substance use (Brinkman, Epstein, Auinger, Tamm, & Froehlich, 2015). Assessing age of onset of substance use may thus provide some insight into problem severity and potential issues related to personality (e.g., impulsivity) and psychopathology, which may influence the likelihood of success after treatment.

Information Critical to Make a Diagnosis

Beyond obtaining the necessary information to make a categorical SUD diagnosis using DSM-5 or ICD-11 criteria, additional information is needed to develop a comprehensive, multidimensional diagnosis. For instance, a more detailed self-report assessment of one’s frequency and degree of use across specific drug classes and associated impairment can provide a more detailed clinical picture to supplement a categorical diagnosis, and this also facilitates the development of an individualized treatment plan. Further, the inclusion of comorbid psychopathology as part of an SUD diagnosis is crucial. This approach can be taken categorically or dimensionally based on the purpose of the assessment. Regardless, the understanding of psychological symptomatology that may be fueling one’s SUD is a necessary component of a drug-related diagnosis. Diagnostic work in comorbid substance using populations can be a challenge for numerous reasons, mainly due to the resemblance of intoxication states and withdrawal symptoms to certain psychological symptoms. An accurate diagnosis will be able to differentiate psychological symptoms that (a) are merely effects of intoxication or withdrawal; (b) occur exclusively in the context of active substance use; or (c) are independent from substance use (Hasin et al., 2006). In sum, including specific symptomatology related to substance use and psychological comorbidity is a necessary inclusion for SUD diagnosis given the prevalence of comorbid psychopathology among people who use substances. 342 C. E. Paquette et al.

Dos and Don’ts

Do: • Supplement a categorical diagnosis with a dimensional assessment that includes information on frequency and degree of substance use, use of specific drug classes, as well as degree of associated social, occupational, physical, and psychological impairment. • Incorporate an assessment of comorbid psychopathology into diagnostic assessment of SUD, both diagnostically as well as symptom-based. • Once specific symptoms are established, considerhow these symptoms may be fueling one’s SUD and how to develop an individualized treatment plan based on this information. • Elicit the client’s treatment goals as part of the assessment. Don’t: • Solely rely on a categorical diagnosis of substance use when attempting to develop an individualized treatment plan • Ignore psychological comorbidities that may seem secondary, but actually may be primary in one’s treatment for substance use • Take a uniform approach to diagnosis and fail to consider which tools may be most appropriate for a particular setting, client, or diagnostic purpose • Rely on a narrow range of measures to assess a given symptom or diagnosis

Summary

Diagnostic assessment of SUDs has different purposes depending on the setting and stage of treatment. At each stage of assessment, the inclusion of a more in-depth dimensional assessment is critical to informing treatment recommendations. Substance use research is increasingly emphasizing the etiological commonalities among psychiatric and SUDs. Understanding these shared pathways is crucial not only in improving our skills in diagnosing SUDs and related comorbidities, but also in advancing our field to move beyond clinical diagnoses toward “a more basic understanding of psychopathology” (Nunes & Rounsaville, 2006). In an effort to conduct the most comprehensive and clinically useful assessments, clinicians should stay informed on research related to SUDs and factors contributing to treatment response, and should incorporate these findings into an evidence-based assessment approach. 13 Substance Use Disorders 343

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Caroline F. Pukall, Tony Eccles, and Stéphanie Gauvin

This chapter will focus on three different categories of mental disorders related to sexuality and gender: sexual dysfunctions, gender dysphoria, and paraphilic disorders. In general, sexual dysfunctions are conditions that affect one’s ability to function sexually or to experience sexual pleasure; gender dysphoria is a condition in which distress is experienced due to an incongruence between one’s experienced gender (i.e., the internal, psychological experience of one’s gender) and one’s assigned gender (i.e., how one’s gender is perceived by others based on outward appearance); and paraphilic disorders are characterized by atypical, intense, and persistent sexual interests that cause distress or harm (or risk of harm). Typically, clinicians working in the area of sex therapy or sexual medicine will see clients with sexual dysfunctions and/or gender dysphoria, whereas clinicians who specialize in forensic psychology will see clients with paraphilic disorders, given that these disorders often entail legal consequences.

C. F. Pukall (*) Department of Psychology, Queen’s University, Kingston, ON, Canada e-mail: [email protected] T. Eccles Forensic Behavior Services, Kingston, ON, Canada S. Gauvin Sexual Health Research Laboratory, Department of Psychology, Queen’s University, Kingston, ON, Canada

Description of the Disorders

Sexual Dysfunctions

According to the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association [APA], 2013), sexual dysfunctions are characterized by disturbances in a person’s ability to respond sexually or to experience sexual pleasure. Sexual dysfunctions consist of clinically significant issues with desire, interest, and arousal (e.g., erection), orgasm (including ejaculation), and genitopelvic pain and penetration, and they may be diagnosed as being due to the use of medications and/or substances. When more than one sexual dysfunction is present, all should be recorded (APA, 2013). If the presence of sexual dysfunctions can be explained by comorbid nonsexual mental disorders, such as anxiety or mood disorders, only the nonsexual disorder diagnosis (e.g., generalized anxiety) should be made (APA, 2013). In addition, the diagnosis of a sexual dysfunction requires that issues that are better explained by the effects of a medical condition or by severe relationship distress, partner violence, or other stressors are ruled out (APA, 2013). There are seven sexual dysfunctions (Table 14.1; see the DSM-5 for three other designations [substance/medication-induced, other specified, and unspecified sexual dysfunctions]) that are diagnosable when the problem is associated with significant distress and has been present for a minimum of 6 months (APA, 2013). Subtypes are used to designate the onset, context, and distress severity. In terms of onset, “lifelong” refers to a sexual dysfunction that appears to have always been present, and “acquired” indicates that the sexual dysfunction developed after a period of non-problematic experiences. With respect to context, sexual dysfunctions may be restricted to certain types of stimulation, situations, or partners (“situational”), whereas “generalized” dysfunctions occur in all of these areas. Distress severity (i.e., mild, moderate, severe) should be documented for all sexual dysfunctions except for premature (early) ejaculation, in which the severity subtype corresponds to the client’s estimate of ejaculatory latency during penetrative sexual activity (i.e., mild, 30–60 seconds; moderate, 15–30 seconds; severe, prior to or at the start of sexual activity, or within 15 seconds) (APA, 2013).

Table 14.1 DSM-5 sexual dysfunctions according to biological sex Sexual response cycle phase affected Males Females Desire/interest Hypoactive sexual desire Sexual interest/arousal disorder disorder Excitement/arousal Erectile disorder Orgasm Delayed ejaculation Orgasmic disorder Premature (early) orgasm Genitopelvic pain/penetration disorder 14 Sexual Dysfunctions, Gender Dysphoria, and Paraphilic Disorders 351

Although not explicitly stated in the DSM-5 (but stated in previous versions), the sexual dysfunctions are based on the first three stages of the four-phase sexual response cycle (Masters & Johnson, 1966): (1) desire/interest, which consists of fantasies about and the wish to engage in sexual activity; (2) excitement/arousal, which manifests as subjective sexual pleasure and associated physiological changes (e.g., genital lubrication and engorgement); and (3) orgasm, which consists of the release of sexual tension and the rhythmic contractions of genitopelvic muscles and organs. A problem at any one stage of the sexual response cycle is likely to lead to difficulties with other stages; indeed, clinically, a high comorbidity among the sexual dysfunctions is observed. For example, a client presenting with orgasm difficulties may also experience problems with desire/interest. In addition, genitopelvic pain can potentially interfere with any or all aspects of sexual response. Although sound empirical data on comorbidities are lacking, a recent consensus statement concluded that comorbidity among the sexual dysfunctions was more common among women than in men (McCabe et al., 2016). Sexual desire and arousal disorders include hypoactive sexual desire disorder (HSDD) and erectile disorder (ED) for males and sexual interest/arousal disorder (SIAD) for females. The diagnosis of male HSDD is made when a client describes persistent or recurrent deficient (or absent) sexual/erotic thoughts or fantasies and desire for sexual activity (APA, 2013). Although the DSM-5 considers desire dysfunctions as distinct from arousal dysfunctions for males (i.e., there are separate diagnoses for HSDD and ED; see Table 14.1), this distinction is not made for females. Based on research indicating that women recognize a high degree of overlap in perceptions of sexual desire and arousal (Graham, Sanders, Milhausen, & McBride, 2004; note that emerging evidence also suggests the same for men), the DSM-5 includes the diagnosis of SIAD, which replaced the former diagnoses of female HSDD and female sexual arousal disorder (FSAD). SIAD is characterized by at least three of the following: absent/reduced (1) interest in sexual activity; (2) sexual/erotic thoughts or fantasies; (3) sexual excitement/pleasure during sexual activity in almost all or all (75–100%) sexual encounters; (4) sexual interest/arousal in response to any internal or external sexual/erotic cues; and (5) genital/non-genital sensations during sexual activity (75–100% of encounters); and no/reduced initiation of sexual activity and typically unreceptive to a partner’s attempts to initiate (APA, 2013). The prevalence of desire disorders in women is estimated to be between 15 and 55%—with rates of 40–50% in those aged 65 years and above— and between 15 and 25% in men (McCabe et al., 2016). A diagnosis of ED is made when at least one of the following three symptoms are experienced on all or almost all (75–100%) sexual encounters: marked difficulty inobtaining or maintaining an erection or a marked decrease in erectile rigidity (APA, 2013). A wide range of prevalence rates is reported for ED (i.e., 15–76%) as rates vary with age; overall, the prevalence rate of ED in the USA is 22% (McCabe et al., 2016). Orgasmic disorders consist of female orgasmic disorder (FOD) and, in males, delayed ejaculation (DE) and premature (early) ejaculation (PE). FOD is characterized by the presence of at least one of the following symptoms (experienced in 75–100% of sexual encounters): marked delay in, marked infrequency of, or absence 352 C. F. Pukall et al. of orgasm and markedly reduced intensity of orgasmic sensations (APA, 2013). FOD is estimated to affect between 16 and 25% of women (McCabe et al., 2016). The diagnostic criteria for DE consist of at least one of the following symptoms (experienced in 75–100% of sexual encounters), without desiring the delay: marked delay in ejaculation and marked infrequency or absence of ejaculation (APA, 2013). The prevalence of DE is 1–10% (McCabe et al., 2016). PE, which affects approximately 8–30% of men of all ages (McCabe et al., 2016), is diagnosed when a patient describes a persistent or recurrent pattern of ejaculation experienced in 75–100% of partnered sexual encounters within approximately 1 min following vaginal penetration and before the individual wishes it. Note that these criteria can also be applied to nonvaginal penetration activities; however, specific duration criteria have not yet been established for these activities (APA, 2013). Genitopelvic pain/penetration disorder (GPPPD) is a sexual dysfunction that is currently restricted to females; it affects between 14% and 27% of women (McCabe et al., 2016). The diagnosis of GPPPD involves persistent or recurrent difficulties with at least one of the following: (1) vaginal penetration during intercourse; (2) marked vulvovaginal/pelvic pain during vaginal intercourse or penetration attempts; (3) marked fear/anxiety about vulvovaginal/pelvic pain in anticipation of, during, or as a result of vaginal penetration; and (4) marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration (APA, 2013). The DSM-5 states that new research examining urologic pain in males suggests that a similar dysfunction may be diagnosable in the future (p. 439); its estimated prevalence is 16.8% (McCabe et al., 2016).

Gender Dysphoria

Gender dysphoria (GD) is characterized by an individual’s affective/cognitive dis- content (i.e., distress, dysphoria) that results from an incongruence between their experienced gender (i.e., the internal, psychological experience of their gender) and their assigned gender (i.e., how their gender is perceived by others based on their outward appearance) (APA, 2013). The diagnosis is made when the dysphoria is experienced for a minimum of 6 months and is associated with clinically significant distress or functional impairment. A diagnosis of GD is not solely based on gender role nonconformity (e.g., “tomboys”), and the following disorders need to be ruled out: transvestic disorder (i.e., the distressing or impairing behavior of cross-dressing for the purpose of sexual excitement), body dysmorphic disorder, schizophrenia or other psychotic disorders, or other clinical presentations (e.g., the desire to rid oneself of one’s penis for aesthetic reasons, which is rare) (APA, 2013). In addition, clinical guidelines have been developed in response to the high co-occurrence between GD and autism spectrum disorder in adolescents (Strang et al., 2018). As the expression of GD varies with age, the DSM-5 includes separate diagnostic criteria for children and adolescents/adults (see adapted criteria in Table 14.2). In children, the typical onset of cross-gender behaviors is between the ages of 2 and 14 Sexual Dysfunctions, Gender Dysphoria, and Paraphilic Disorders 353

Table 14.2 Diagnostic features for gender dysphoria in children and adolescents/adults Gender dysphoria in adolescents and Gender dysphoria in children adults At least six of the following (including the first one, At least two of the following: which is required for diagnosis): 1. A marked incongruence between one’s 1. A strong desire to be of the other gender or an experienced/expressed gender and insistence that one belongs to the other gender primary and/or secondary sex (or a different gender from one’s assigned characteristics (or in young adolescents, gender) the anticipated secondary sex 2. In boys (assigned gender), a strong preference characteristics) for cross-dressing or simulating female apparel; 2. A strong desire to be rid of one’s or in girls (assigned gender), a strong preference primary and/or secondary sex for wearing only typical masculine attire and a characteristics because of a marked strong resistance to the wearing of typical incongruence with one’s experienced/ feminine clothing expressed gender (or in young 3. A strong preference for cross-gender roles in adolescents, a desire to prevent the make-believe/fantasy play development of the anticipated 4. A strong preference for the toys, games, or secondary sex characteristics) activities stereotypically used or engaged in by 3. A strong desire for the primary and/or the other gender secondary sex characteristics of the 5. A strong preference for playmates of the other other gender gender 4. A strong desire to be of the other gender 6. In boys (assigned gender), a strong rejection of (or a different gender from one’s typically masculine toys, games, and activities assigned gender) and a strong avoidance of rough-and-tumble 5. A strong desire to be treated as the other play; or in girls (assigned gender), a strong gender (or a different gender from one’s rejection of typically feminine toys, games, and assigned gender) activities 6. A strong conviction that one has the 7. A strong dislike of one’s sexual anatomy typical feelings and reactions of the 8. A strong desire for the primary and/or secondary other gender (or a different gender from sex characteristics that match one’s experienced one’s assigned gender) gender Note: Adapted from the DSM-5

4 years, with more frequent expressions of anatomic dysphoria as one approaches puberty (APA, 2013). Based on recent studies, the overall prevalence of GD is estimated to be about 1% (Byne et al., 2018).

Paraphilic Disorders

The DSM-5 (APA, 2013) defines a paraphilia as an “intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners” (APA, 2013, p. 685). It distinguishes between a paraphilia (generally defined as an atypical, intense, and persistent sexual interest) and a paraphilic disorder (a paraphilia that causes distress or harm/risk of harm to others). There are eight specified paraphilic disorders (Table 14.3) and in each one, the specific focus of erotic interest 354 C. F. Pukall et al.

Table 14.3 The DSM-5 paraphilic disorders Paraphilic Criterion A (and other relevant Criterion B disorders information), as manifested by fantasies, urges, or behaviors. Recurrent and intense sexual arousal from… Voyeuristic …observing an unsuspecting The individual has acted on these disorder person (who is at least 18 years of sexual urges with a non-consenting age) who is naked, in the process person, or the sexual urges or fantasies of undressing, or engaging in cause clinically significant distress or sexual activity impairment in social, occupational, or Exhibitionistic …the exposure of one’s genitals other important areas of functioning disorder to an unsuspecting person Frotteuristic …touching or rubbing against a disorder non-consenting person Sexual sadism …the physical or psychological disorder suffering of another person Sexual masochism …the act of being humiliated, The fantasies, sexual urges, or disorder beaten, bound, or otherwise made behaviors cause clinically significant to suffer distress or impairment in social, Fetishistic …either the use of nonliving occupational, or other important areas disorder objects or a highly specific focus of functioning on non-genital body part(s) Transvestic …cross-dressing disorder Pedophilic Recurrent, intense sexually The individual has acted on these disorder arousing fantasies, sexual urges, sexual urges, or the sexual urges or or behaviors involving sexual fantasies cause marked distress or activity with a prepubescent child interpersonal difficulty or children (generally age 13 years or younger)a aThe individual must be at least 16 years old and at least 5 years older than the child/children; must not include an individual in late adolescence involved in an ongoing sexual relationship with a 12- or 13-year-olds

(minimum duration of 6 months) is characterized in Criterion A, and any distress, impairment, or harm that this interest causes is captured in Criterion B. Should an individual meet solely the requirements for Criterion A, then a paraphilia is identified. However, if the elements of Criterion B are also met, then a paraphilic disorder is diagnosed. This distinction reflects a line of thought in which an individual might harbor, for example, a sexual interest in children, in which case the presence of a paraphilia may be identified. However, it is only a paraphilic disorder if these feelings significantly impair the person’s ability to function or if these feelings are acted upon, causing harm (or the risk of harm). Note that it is possible for individuals to have multiple paraphilias/paraphilic disorders. In addition to specified paraphilias, the DSM-5 acknowledges a broad range of other paraphilias (e.g., necrophilic disorder), which are recorded as “other specified” paraphilias/paraphilic disorders 14 Sexual Dysfunctions, Gender Dysphoria, and Paraphilic Disorders 355 when the nature of the non-normative interest is clear and as “unspecified” paraphilias/ paraphilic disorders when it is not. In terms of the course specifiers, both the terms “in full remission” and “in a controlled environment” can generally be applied to the paraphilic disorders. An exception is that pedophilic disorders cannot be declared to be in remission, which has fostered some debate (e.g., Briken, Fedoroff, & Bradford, 2014). These specifiers were incorporated to reflect the potential for a person to greatly reduce the likelihood of acting on paraphilic interests, thereby countervailing distress, impairment, and the potential for harm. Under such conditions, the paraphilia remains, but the paraphilic disorder is deemed to be in remission. The specifier regarding the presence of a controlled environment was included because many individuals who have acted on paraphilic interests have restrictions on their liberty, thereby render- ing it difficult to assess their ongoing tendencies. With regard to the prevalence of paraphilic disorders, the DSM-5 cautions that there is considerable uncertainty. It is estimated that the percentage of males who have acted on such paraphilic impulses is (at most) 12% for voyeuristic disorder, 2–4% for exhibitionistic disorder, 10–14% for frotteuristic disorder, and around 3–5% for pedophilic disorder (APA, 2013). All rates are higher for males than females and sometimes substantially so. The reasons for this disparity are unclear, although sexual drive has been proposed as a mediator (Dawson, Bannerman, & Lalumière, 2016), and there is some suggestion that rates are somewhat higher for women than previously reported (Joyal & Carpentier, 2017).

Procedures for Gathering Information

Sexual Dysfunctions

The clinical interview is the main technique with which to assess and diagnose sexual dysfunctions. There is no widely used, validated, standardized interview as is the case for most other DSM-5 disorders. However, several authors have proposed clinical interview guidelines and recommendations about coverage of topics and process (e.g., Maurice, 1999 [available for free download at https://kinseyinstitute. org/collections/archival/sexual-medicine-in-primary-care.php]; Meana, Binik, & Thaler, 2008; Wincze & Carey, 2015). The clinical interview typically starts with the individual describing the nature of the problem and the reason for seeking treatment. Following an open-ended description of the problem, the clinician may ask more specific questions about when the problem started (onset), the conditions under which it occurs (context), and the extent of the problem and amount of distress experienced because of the issue (severity). Questions can then be asked about the various biological, psychological, and social problems that might be implicated (Meana et al., 2008). In terms of general biological factors, the clinician should assess and take into account age, 356 C. F. Pukall et al. general health status (e.g., body mass index), lifestyle factors (e.g., diet, cigarette smoking), hormone levels, chronic pain syndromes (e.g., chronic prostatitis syndrome, vulvodynia), and medical illnesses that affect vascular, sensory, and central nervous system functions. In addition, questions regarding past surgeries and injuries, especially those in the genital or pelvic region, and past and current medications should be posed (Meana et al., 2008). It is commonly understood that many medications, such as antidepressants, antipsychotics, and antihypertensives, can detrimentally affect sexual functioning. With respect to individual psychological factors, depression and anxiety are often comorbid with sexual dysfunction. If present and treatment does not target the associated mood disorders, treatment will likely not be successful. Substance abuse disorders may also have a major impact on sexual functioning. Certain maladaptive cognitive sets, unrealistic expectations, misinformation or lack of information, and negative emotional reactions can also impinge upon sexual function. Past sexual trauma and other negative experiences may set the foundation for sexual problems as well (Meana et al., 2008). Socially, family-of-origin attitudes regarding sexuality may be instilled early on and predispose the development of a sexual dysfunction. Assessing the quality of the individual’s current relationship is of utmost importance, as problems between the members of the couple may be a cause and/or a consequence of sexual problems. If so, these issues need to be appropriately addressed. Areas of inquiry related to the couple should include anger, distrust, discrepancies in sexual drive and preferences, communication, and physical attrac- tion (Meana et al., 2008). The comorbidity of partner sexual dysfunction is common and should be assessed and addressed if the partner is willing to be present in the sessions. In addition, ethnocultural and religious attitudes and beliefs are important as they can be implicated in the development and maintenance of sexual dysfunctions (Meana et al., 2008; Hall & Graham, 2012). Questionnaires can be used to formally assess the presence and/or comorbidity of sexual dysfunctions. In addition, information from the client’s treating physician with respect to results from laboratory tests (e.g., for hormone function, vascular integrity, nerve function) and physical examinations (e.g., gynecological) will provide useful information for diagnosis and treatment.

Gender Dysphoria

The most recent guideline for the standards of care for gender-diverse individuals— published by the World Professional Association for Transgender Health (WPATH) in 2011 and freely available at www.wpath.org/—outlines the process of assessment of individuals with GD. The role of mental health care providers on this team generally consists of a comprehensive psychosocial assessment of GD for the purpose of diagnosis. At a minimum, the following should be evaluated: gender identity and dysphoria, history and development of feelings of gender dysphoria, the impact of stigma related to any expression of gender nonconformity on mental health, and the 14 Sexual Dysfunctions, Gender Dysphoria, and Paraphilic Disorders 357 availability of social support (WPATH, 2011). If the individual meets the criteria for a diagnosis of GD, then information regarding options for gender identity and expression, as well as possible medical interventions (along with potential side effects and information about reversibility/permanence) and liaisons with relevant support groups, should be discussed and appropriate referrals made (WPATH, 2011). Given that individuals with GD may struggle with a range of mental health conditions (e.g., anxiety, self-harm, depression, personality disorders, autism spectrum disorder), mental health care providers should screen for these concerns and incorporate them into the overall treatment plan (e.g., providing or recommending therapy and/or psychotropic medications); addressing these issues can facilitate the process of transitioning (WPATH, 2011). Note that although a mental health assessment is needed for referral to hormonal/surgical treatments for GD, psychotherapy for the purpose of maximizing a person’s overall psychological well-being, quality of life, and self-fulfillment is recommended, but not required (WPATH, 2011). Should hormone therapy and/or surgery be a goal of the client, then the mental health care provider can assess whether the client is eligible and aware of the process (e.g., medical assessment to ensure there are no contraindications) as well as the benefits and effects of this treatment avenue (e.g., reproductive options, realistic expectations) in order to ensure that they are psychologically and practically prepared (WPATH, 2011). The type of information that should be documented in a referral letter for hormone therapy/surgery is summarized in Table 14.4. Note that additional letters from other health care providers may be necessary for medical intervention, and the number and type of letters depends on location.

Paraphilic Disorders

This section will focus on assessment procedures of adult males with paraphilic disorders. Very few females are identified with paraphilias, especially in forensic populations (for a review, see Cortoni, 2018); in addition, paraphilic disorders are

Table 14.4 Recommended content of referral letters for hormone therapy/surgery Recommended content 1. The client’s general identifying characteristics 2. Results of the client’s psychosocial assessment, including any diagnoses 3. The duration of the referring health care provider’s relationship with the client, including the type of evaluation and therapy or counseling to date 4. An explanation that the criteria for hormone therapy/surgery have been met and a brief description of the clinical rationale for supporting the client’s request for hormone therapy 5. A statement about the fact that informed consent has been obtained from the patient 6. A statement that the referring health care provider is available for coordination of care and welcomes a phone call to establish coordination 358 C. F. Pukall et al. generally not diagnosed in adolescence given that this period of sexual development is believed to be exploratory and fluid (Seto, Kingston, & Bourget, 2014). Certain paraphilias and their associated disorders are more likely to be encountered in a forensic setting (e.g., pedophilic disorder), and others are more common in traditional mental health settings (e.g., masochistic disorder). In either case, the approach to the assessment will be similar, although a forensic setting is likely to be more concerned with broader issues such as risk to the public. In addition, those undergoing court assessments may be less inclined to be forthright than those seeking an assessment of their own volition. Regardless, the assessment will be facilitated by a warm, respectful, empathic, genuine, and supportive demeanor on the part of the interviewer (Wilcox & Gray, 2017). The Association for the Treatment of Sexual Abusers (ATSA; http://www.atsa.com/) offers practice guidelines for psychosexual evaluations, and these guidelines stress the need to use multiple sources of information, especially when the assessment is involuntary. Interviews should promote engagement, incorporate the client’s perspective, and consider responsivity factors. Assessors are encouraged to gather information that includes, but is not limited to, the following: psychosexual development; the nature and frequency of sexual practices; paraphilic interests that may not be sexually abusive; the use of sexually oriented services or outlets (including pornography); abusive or offense- related sexual arousal, interests, and preferences; the history of sexually abusive behaviors; information about current and/or previous victim(s); contextual elements of sexually abusive behaviors; and the individual’s level of insight, self-disclosure, and denial (ATSA, 2014, pp. 18–21).

Recommendations for Formal Assessment

Sexual Dysfunctions

Measures exist for virtually every issue related to sexual function. Included in Table 14.5 are commonly used questionnaires for the assessment of sexual dysfunction; please refer to the Handbook of Sexuality-Related Measures (Milhausen, Sakaluk, Fisher, Davis, & Yarber, 2018, forthcoming) for additional measures.

Gender Dysphoria

Table 14.6 includes commonly used questionnaires for the assessment of gender identity/dysphoria. 14 Sexual Dysfunctions, Gender Dysphoria, and Paraphilic Disorders 359

Table 14.5 Questionnaires used for the assessment of sexual dysfunctions Questionnaire Description 1Female sexual Measures global sexual functioning, includes domain scores for functioning index (FSFI) desire, arousal, lubrication, orgasm, satisfaction, and pain; a modified version2 has been validated for women with same-sex partners 3Vulvar pain assessment Assesses vulvar pain characteristics, effects of vulvar pain on questionnaire (VPAQ) various aspects of life, coping strategies used, and romantic partner factors 4Sexual interest and Quantifies the severity of symptoms in women with sexual desire desire inventory for disorders females (SIDI-F) 5International index of Measures global sexual functioning, includes domain scores for sexual functioning (IIEF) erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction; a modified version2 has been validated for men with same-sex partners6 7Premature ejaculation Assesses ejaculatory control and frequency, amount of stimulation diagnostic tool (PEDT) needed for ejaculation, distress, and interpersonal difficulty 8Sexual distress scale Quantifies sexually related distress; validated for women and men9 (SDS) 10Dyadic adjustment scale Assesses dyadic cohesion, satisfaction, consensus, and affectional (DAS) expression 11Sexuality questionnaire A measure of gender identity and affectional and sexual orientation 1Rosen et al. (2000), 2Boehmer, Timm, Ozonoff, and Potter (2012), 3Dargie, Holden, and Pukall (2016), 4Sills et al. (2005), 5Rosen et al. (1997), 6Coyne et al. (2010), 7Symonds et al. (2007), 8Derogatis, Rosen, Leiblum, Burnett, and Heiman (2002), 9Santos-Iglesias, Mohamed, Danko, and Walker (2018), 10Spanier (1976), 11Alderson (2012)

Table 14.6 Questionnaires used for the assessment of gender identity/dysphoria Questionnaire Age group Description 1Gender identity Children This parent-report questionnaire has been questionnaire (GIQ) validated as a screening tool for children with potential problems in their gender identity development 2Gender identity/gender Adolescents and This self-report measure assesses an individual’s dysphoria questionnaire adults gender identity and gender dysphoria (GIGDQ) 3Sexuality questionnaire Adolescents and This self-report measure captures an adults individual’s gender identity and affectional and sexual orientation 1Johnson et al. (2004), 2Deogracias et al. (2007), 3Alderson (2012)

Paraphilic Disorders

In addition to the clinical interview for paraphilias/paraphilic disorders, questionnaires (see Table 14.7 for an overview), viewing time, and phallometry may be used. These measures can provide important information given that some clients may be reluctant to divulge information regarding their paraphilic propensities. 360 C. F. Pukall et al.

Table 14.7 An overview of commonly used questionnaires used in the assessment of paraphilic disorders Questionnaire Domain Multiphasic sex inventory (MSI) and the Characteristics of conventional and paraphilic sexual multiphasic sex inventory-II (MSI-II) behaviors The multidimensional inventory of Sexual attitudes, fantasies, and behaviors development, sex, and aggression (MIDSA) The Clarke sexual history questionnaire- Different aspects of conventional and paraphilic revised (SHQ-R) sexuality Paulhus deception scale (PDS) Impression management Psychopathy checklist-revised (PCL-R) Antisocial tendencies for forensic assessments The criminal sentiments scale (CSC) Attitudes toward the justice system and the degree to which an individual is tolerant of law violations and identifies with other criminals Abel and Becker cognitions scale The dysfunctional thinking styles believed to (ABCS) and the Bumby RAPE and facilitate sexual offenses MOLEST scales Stable-2007 Sexual and general self-regulation deficits The Static-99 and the sex offender risk Actuarial scale used for assessing sexual risk appraisal guide (SORAG) potential The violence risk appraisal guide Actuarial scale used for assessing risk of general (VRAG) violence in either sexual or nonsexual offenders The Minnesota sex offender screening Screening tool to prioritize sex offenders for tool (MnSOST) programs and level of community supervision

Questionnaires

The first and second editions of the Multiphasic Sex Inventory (MSI; Nichols & Molinder, 1984; MSI-II; Nichols & Molinder, 2000) measure a number of characteristics of conventional and paraphilic sexual behaviors. Moreover, both versions contain a treatment readiness scale that provides an index of an individual’s recep- tivity to treatment. While the MSI has good psychometric properties (Seto et al., 2014), there are fewer studies regarding the MSI-II and its psychometric properties are less clear (Akerman & Beech, 2012). The Multidimensional Inventory of Development, Sex, and Aggression (MIDSA, 2011) was developed to assess a range of sexual attitudes, fantasies, and behaviors. The developers have made available extensive development data (Akerman & Beech, 2012), and the scale has demonstrated acceptable psychometric properties (Seto et al., 2014). The Clarke Sexual History Questionnaire-Revised (SHQ-R; Langevin & Paitich, 2002) covers different aspects of conventional and paraphilic sexuality. While it is vulnerable to response bias, Laws, Hanson, Osborn, and Greenbaum (2000) note that such measures can assist a broader evaluation of sexual proclivities. Moreover, 14 Sexual Dysfunctions, Gender Dysphoria, and Paraphilic Disorders 361 employing a test of impression management such as the Paulhus Deception Scales (PDS; Paulhus, 1999) can be a useful adjunct in assessing impression management response bias and, in the case of the PDS, an individual’s level of personal insight.

Viewing Time and Choice Reaction Time

Viewing time (VT) and choice reaction time (CRT) measures (e.g., Abel Assessment of Sexual Interest; Abel, Huffman, Warberg, & Holland, 1998; PrefAssess; Gress, Brown, & Buttle, 2003) were developed to provide an objective but less intrusive assessment of sexual interests than phallometry (see below). These approaches employ measures of response delays induced by the preferred sexual content in stimuli to which the individuals are exposed. Typically, these response biases are quantified through differentials in VT or CRT. In reviewing two measures employing these indices, Gress, Anderson, and Laws (2013) found that adult sexual offenders had significantly longer average VT latencies than nonsexual offenders, but there was no effect for CRT. However, the VT measure in this study did not meet sensitivity or specificity criteria required to screen for the presence or absence of paraphilic propensities. Some believe the weak psychometric properties of these procedures render them better used as a clinical tool than a risk assessment measure (e.g., Akerman & Beech, 2012).

Phallometry

Phallometry involves the direct measurement of penile responses when individuals are exposed to auditory or visual sexual stimuli. These can vary on specific dimensions of interest (e.g., age, gender, and level of coercion). Phallometric responses are recorded as increases in either penile circumference or volume with indices reflecting differential responses to sex-typical and paraphilic themes. Phallometric measures have been well validated, although problems remain with a lack of standardization in terms of procedures and stimuli across evaluation centers. A recent meta-analysis (McPhail et al., 2017) supports the validity of phallometric testing for pedo-hebephilic propensities (i.e., sexual interests in prepubescent and pubescent children) especially if audio and slides are used; the use of video stimuli was not supported. While concerns about the faking of test responses are well grounded and counter measures are limited (Wilson & Miner, 2016), McPhail and colleagues stress that the validity of test results can be enhanced through the use of evidence- based practices and standardized procedures. It is recommended that users be trained in phallometry and familiar with its strengths and limitations, because the results often carry a lot of weight (e.g., regarding access to biological children) (ATSA, 2014). Furthermore, the results of such testing should never be used in isolation but rather be incorporated as part of a broader consideration of assessment information. 362 C. F. Pukall et al.

Assessing Antisocial Tendencies

Adherence to antisocial values is associated with increased rates of nonsexual recidivism for both sexual and nonsexual offenders (Witte, Di Placido, Gu, & Wong, 2006), and the assessment of such sentiments is generally included as part of a comprehensive evaluation of sexual abusers. In their most extreme form, antisocial tendencies are highly associated with criminal behavior and, in their extreme, they present as psychopathy, which led Hare (2003) to develop the Psychopathy Checklist-Revised (PCL-R) for forensic assessments. Psychopathy is characterized by a lack of empathy or conscience, manipulative behaviors, deceitfulness, along with impulsive and irresponsible behavior. The PCL-R has become widely used and accepted by forensic psychologists and the courts (Murrie, Boccaccini, Caperton, & Rufino, 2012). However, these authors demonstrated that the validity of PCL-R is eroded when users are not rigorously trained. Moreover, a subset of items measuring persistent and versatile criminality and aggression (Facet 4) fared better than all other PCL-R elements. Criminogenic values have also been linked to an increased risk to engage in antisocial behavior. The Criminal Sentiments Scale (CSC; Andrews & Wormith, 1984) measures attitudes toward the justice system and the degree to which an individual is tolerant of law violations and identifies with other criminals. A modified version (Simourd, 1997) has been shown to be a good predictor of future involvement in nonsexual criminal activity among sexual offenders (Witte et al., 2006).

Measuring Cognitions Related to Sexual Offending

Several scales have been developed to measure the dysfunctional thinking believed to facilitate sexual offenses. Examples include the Abel and Becker Cognitions Scale (ABCS; Abel, Becker, & Cunningham-Rathner, 1984) and the Bumby RAPE and MOLEST scales (Bumby, 1996). However, while these scales may have value in reflecting changes made in treatment, such changes may be unrelated to future sexual recidivism (Nunes, Pettersen, Hermann, Looman, & Spape, 2016). As such, they should probably not be regarded as reflecting differences associated with changes in sexual risk potential.

Examining Self-Regulation

Given that self-regulation deficits have been associated with sexual recidivism, the Stable-2007 (Hanson, Harris, Scott, & Helmus, 2007) incorporates six items pertaining to sexual and general self-regulation deficits. Hanson et al. note that higher scores on these items predicted risk for both sexual and nonsexual violence. 14 Sexual Dysfunctions, Gender Dysphoria, and Paraphilic Disorders 363

Risk Assessment

In employing risk scales, assessors must necessarily be mindful of the potential for the individuals being assessed to be deceitful in their efforts to obtain an evaluation that is favorable to them. As noted earlier, ATSA (2014) practice guidelines stress the need to include diverse and independent sources of information; doing so will greatly increase the validity of the scores obtained on risk assessment scales. If such information is lacking, a note to this effect should be made as a limitation of the assessment. The period since the mid-1990s has seen tremendous strides in the development of risk assessment scales for sexual offenders (Harris & Hanson, 2010). The Static-99 (Hanson & Thornton, 2000) is an actuarial scale that is in use globally for assessing sexual risk potential. It has been validated with many cultural groups and across several countries, but some caution needs to be exercised when using it (Phenix et al., 2016); Haag, Boyes, Cheng, MacNeil, and Wirove (2016) note that risk assessment tools can perform less well with certain cultural groups (e.g., indigenous offenders in Canada), so keeping their limitations in mind is recommended (Gutierrez, Helmus, & Hanson, 2016). The original Static-99 has undergone revisions in terms of structure and norms and is currently referred to as the Static-99R (Hanson, Thornton, Helmus, & Babchishin, 2016; Phenix et al., 2016). The obtained score on this actuarial scale is compared with a large database of offenders from several countries, and the sexual recidivism rates for those with a similar score over 5 years can be accessed. The Sex Offender Risk Appraisal Guide (SORAG; Quinsey, Harris, Rice, & Cormier, 2006) is also a widely used actuarial scale. The SORAG items include considerations of an individual’s offense history, school adjustment, alcohol use, and the presence of personality disorders and incorporate the PCL-R score among other factors. The obtained score is compared to actuarially derived recidivism rates for offenders with similar scores over 7 and 10 years. A related scale, the Violence Risk Appraisal Guide (VRAG; Harris, Rice, & Quinsey, 1993), may be employed to assess the risk of general violence in either sexual or nonsexual offenders. A revised version, the VRAG-R, may be used in place of both the VRAG and SORAG (Rice, Harris, & Lang, 2013). It is more efficient, incorporating just the Facet 4 items from the PCL-R. Since its introduction in the mid-1990s, the Minnesota Sex Offender Screening Tool (MnSOST; Epperson, Kaul, & Huot, 1995) and its most recent derivative (the MnSOST-3; Duwe & Freske, 2012) have been widely used in screening sex offenders to prioritize them for sex offender programs and the level of community supervision required (Duwe, 2017). While actuarial scales include the most robust risk predictors, these scales tend to be static and preclude the measurement of dynamic factors (e.g., the establishment of prosocial sources of support). To address this limitation, Hanson et al. (2007) developed the Stable-2007 that includes 13 dynamic risk factors associated with sexual recidivism (e.g., significant social influences, capacity for relationship 364 C. F. Pukall et al. stability, emotional identification with children). The tool can be used in conjunction with the Static-99R to determine risk, program priority, and treatment goals. The Violence Risk Scale: Sex Offender Version (VRS:SO; Olver, Wong, Nicholaichuk, & Gordon, 2007; Olver et al., 2018) contains 7 static and 17 dynamic risk factors designed to assess sexual risk, assist in treatment planning, and identify changes in risk as a result of treatment or other reasons. A recent trend is a growing emphasis on factors associated with a lowered probability of antisocial behavior rather than risk factors per se. For example, de Vries, de Vogel, Koster, and Bogaerts (2015) have developed the Structured Assessment of Protective Factors for violence risk (SAPROF), employing factors positively associated with desistance from sexual offending.

Case Illustrations

Case 1

Kelly (early 20s) was referred to sex therapy by her general practitioner for “painful sex.” Her spouse of 3 years (David, also in his 20s) attended the sex therapy sessions. Kelly and David had abstained from sexual intercourse until their wedding night in keeping with their religious beliefs. In David’s words, “the wedding night was a disaster.” Kelly appeared very nervous and when they tried to have intercourse; she winced and complained of pain when he attempted vaginal penetration. The couple continued their attempts over the next few months and, although penetration eventually became possible, it remained intensely painful for Kelly. She also reported discomfort with tampon insertion and internal pelvic examinations, although of lower intensity. They had settled into a pattern of sexual interactions characterized by David’s entreaties to have sex, Kelly’s increasingly anxious attempts to avoid it, and the occasional sexual interaction (about once per month) that was painful for Kelly and unsatisfying for both. They rarely discussed the problem. Kelly reported experiencing sexual desire and arousal during nonpainful sexual activities, but her desire/arousal plummeted when she anticipated or experienced the pain. In terms of their past, both reported supportive families and a generally happy childhood, with no history of physical or sexual abuse. They had no mental health concerns. David reported no sexual concerns, and they both reported a strong and satisfying nonsexual relationship. Areas targeted with psychometric measures were sexual dysfunction, pain- related experiences, and relationship adjustment. Consistent with the information obtained during the clinical interview, FSFI scores supported the diagnosis of GPPPD for Kelly, and the IIEF did not reveal evidence of sexual dysfunction in David. A pain scale revealed high pain intensity scores, and Kelly’s scores on measures of pain catastrophizing and anxiety were very high. The DAS confirmed their report of having a satisfying relationship outside of sexual activity. A referral was made to a gynecologist and a pelvic floor physical therapist with expertise in 14 Sexual Dysfunctions, Gender Dysphoria, and Paraphilic Disorders 365 genitopelvic pain; results were consistent with a diagnosis of provoked vestibulo- dynia (PVD), a common cause of genitopelvic pain, with considerable hypertonicity (tightness) of the pelvic floor musculature. The findings from this assessment were used to design a multidisciplinary treatment plan that simultaneously targeted all problem areas: genitopelvic pain; feelings of guilt related to, and communication about, sex; hypertonicity; and pain catastrophizing and anxiety.

Case 2

Sarah, a 28-year-old transwoman, was referred to sex therapy by her family doctor in order to obtain a letter for hormone therapy as this step was the next one in her physical transition to a feminine body. Sarah was designated male at birth, but since early childhood (3–4 years of age) recalled feeling distressed about “being a boy,” the stereotypical male toys that she was expected to play with, and the male clothing she was expected to wear. She identified as a girl since the age of 5. In her early school years, she avoided sports and all forms of rough-and-tumble play, played only with girls (and typically feminine toys), preferred to wear her hair long, and wore feminine clothing. When asked what she wanted to be “when she grew up,” Sarah would often respond, “a woman.” Although she was often bullied by other children (typically males), her parents, most other family members, and friends (girls) never questioned her choices. As Sarah approached puberty, she noted a sharp increase of distress (severe level) given the more obvious masculine changes that were occurring in her body, especially the growth of facial hair, the development of the typical male body contour, and the deepening of her voice. Sarah expressed sexual interest in females and dated several partners throughout high school and beyond, eventually marrying her current partner, Samantha, at the age of 25. Sarah was always open about her felt gender with her partners, and Samantha was described as supportive of any changes that Sarah opted for in terms of her journey as a woman. Sarah dressed femininely, wore make-up and nail polish, and was working with a voice coach in order to raise her pitch. She also wore a padded bra to feel and appear feminine. She was “out” in the trans community as well as with all close individuals in her social network, and she felt that she was ready to take the next step in terms of her physical transition (hormone therapy). Her distress level in terms of her physical body and being “misread” by others as male/man was moderate to high. She expressed realistic expectations in terms of the changes that hormone therapy entailed, she understood the risks and benefits of the treatment, and she recognized the reproductive implications of the treatment. She was not interested in surgery at this time. Upon examining her responses to the GIGDQ, Sarah’s gender identity was that of a woman, and her dysphoria was moderate to high. Her scores on anxiety and depression screening tools were in the moderate range. A letter detailing the diagnosis of GD and including the information required by WPATH (Table 14.4) was sent to a physician who was trained in hormone therapy for gender-diverse individuals 366 C. F. Pukall et al. in order to support Sarah’s request for hormone therapy. In addition, Sarah was given a referral to a trans-friendly mental health care provider to develop coping strategies for her depression and anxiety.

Case 3

John (age 56) was convicted of breaching a court order prohibiting contact with children. He babysat a six-year-old boy who disclosed he had been kissed on the mouth. John has ten prior sentencing dates over 30 years for a range of offenses; five of these were for sexual offenses. All involved boys aged 7–15. John was raised in an intact family by prosocial parents. However, he said his brother bullied him, which contributed to him acting out in school where his peers ostracized him. Behavioral problems emerged in elementary school, and many suspensions resulted. He was expelled in Grade 11, which ended his formal education. Throughout his adult years, John continued to struggle to make friends but enjoyed the support of his family. He spent most of his free time alone and at home, which he preferred. John reported having been sexually abused by an adult male neighbor when he was 7 years old. According to John, he did not see this experience as harmful. He had never been in a cohabiting relationship with an age-appropriate partner but expressed that he would like to be. He described being sexually attracted to adult males and acknowledged an interest in boys aged 14–16. John participated in a treatment program in 2006. The treatment report noted that few gains were made. He was described as being unreceptive to feedback and steadfast in asserting his victims “accepted and enjoyed” the abuse. He repeated this belief in the current assessment and stressed that he never pressured them and referred at times to having had a “relationship” with them. In regard to his current breach, John described it as “no big deal.” He denied kissing the boy and portrayed his contact with the youth as a benign attempt to help a neighbor who required childcare at short notice. He had no insight into his role in engineering these circumstances or others that gave him access to his victims, whom he portrayed as the initiators of the sexual activity. On the PDS, John’s scores revealed that his level of personal insight was poor. Scores on the MSI-II and Bumby MOLEST scales confirmed the presence of well- entrenched and enduring cognitive distortions; for example, he endorsed “strongly agree” in reference to the statements “Some sexual relations with children are a lot like adult sexual relationships” and “Society makes a much bigger deal out of sexual activity with children than it really is.” John underwent a phallometric evaluation of sexual preferences, revealing equivalent responses to both pubescent and prepubescent boys, a secondary but significant response to consenting adult males, and a negligible response to females of any age. The results of the interview and testing were consistent with pedophilic disorder. His PCL-R score was below the criterion for designation as a psychopath. John’s scores on the Static-99R and VRAG-R indicated a very strong risk of reoffending. On the Stable-2007, John’s results revealed 14 Sexual Dysfunctions, Gender Dysphoria, and Paraphilic Disorders 367 a combination of positive and negative ratings, reflecting a high level of stable dynamic needs. In aggregating the scores on the Static-99R, VRAG-R, and Stable-2007, John was appraised as representing a very high risk to reoffend sexually. A high-intensity sex offender program was recommended. Treatment targets included addressing the lack of positive social influences in his life, facilitating efforts to establish an age-appropriate relationship, cognitive distortions related to his offenses, improving sensitivity to victim impact issues, improving problem- solving skills, and providing him with strategies for coping with his paraphilic proclivities.

Impact of Gender, Race, Culture, and Other Aspects of Diversity

An extensive discussion of the impact of race, culture, diversity, and age for sexual dysfunctions, gender dysphoria, and paraphilic disorders is beyond the scope of this chapter (see Hall & Graham, 2012 for a book on this topic). In all therapies, an interconnectedness perspective can hold much explanatory and clinical potential. Among other recommendations, Hardy and Laszloffy (2002) encourage therapists to view all therapy as cross-cultural and to engage in a constant process of self- exploration. More practically, it is essential for therapists to work respectfully within clients’ religious and other beliefs and to recognize diversity in experiences, orientations, genders, and sociocultural circumstances.

Information Critical to Making a Diagnosis

Critical information needed for diagnosis includes the following: 1. A detailed description of the presenting issue. 2. Personal significance attached to the presenting issue. 3. Level of distress and areas of life affected. 4. Onset of the problem. 5. Frequency of the difficulty. 6. Patterns of the behavior. 7. What is the reason for seeking treatment at this time? 8. If partnered, how is the issue affecting the partner? 9. Information related to current/past partners/relationships and social support. 10. Sexual history, including information related to negative experiences (e.g., abuse). 11. Medical and psychiatric history, including past and present medications and surgeries. 12. Alcohol and drug use and abuse. 368 C. F. Pukall et al.

13. Sex/gender, gender identity, sexual orientation, and sexual identity. 14. Content and frequency of sexual fantasies. 15. Family of origin issues. 16. Client’s causal attributions for their difficulty. 17. Comorbid conditions. 18. Past or current convictions of problematic sexual behaviors. 19. Cultural and religious schemas.

Dos and Don’ts

Dos

1. Ask about sexual problems in a direct manner no matter what the presenting complaint. 2. Be open and nonjudgmental. 3. Recognize diversity in all aspects of sexual and gender identity. 4. Understand and respect the clients’ religious and cultural beliefs. 5. Provide normalizing statements and gently correct misinformation. 6. Ask about solitary sexual activities in addition to partnered activities. 7. Gaining information into fantasies may provide additional insight into the presenting complaints. 8. Ask questions about activities (e.g., anal sex) that are important for sexual health. 9. Ask about partner communication and the partner’s responses to the presenting complaint. 10. If working with a sex offender, gain information from as many sources as possible in order to obtain as comprehensive a history as possible. 11. Refer to a medical doctor for physical tests, laboratory investigations, and treatment. 12. If the individual is partnered, encourage the participation of both partners in assessment and treatment.

Don’ts

1. Don’t let lack of experience or discomfort with sexual issues prevent you from at least asking some screening questions about sexual dysfunctions; open the door for the client to discuss this topic and see if a referral may be needed if you do not feel competent. Most people will not spontaneously bring up a sexual problem. Direct questions must be asked. 14 Sexual Dysfunctions, Gender Dysphoria, and Paraphilic Disorders 369

2. Don’t assume that you know everything about the client and his/her fantasies, sexual orientation, relationship status, sexual experiences, gender identity, etc. 3. Don’t assume that sex and gender are binary concepts. 4. Don’t assume that older people, single people, disabled persons, people with intellectual issues, etc., are not sexual or sexually active. 5. In the case of sex offenders or individuals convicted of sexual crimes, don’t believe everything they tell you as they may want to mislead the clinician into thinking that they are functioning at higher or lower levels depending on the situation.

Summary

There are a number of disorders related to sexuality, gender, and paraphilias, and each must be carefully assessed and characterized. At a minimum, a single question about any sexual concern is necessary to potentially raise an issue that the patient may want to address but feels too embarrassed to spontaneously report.

References

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Brittany K. Bohrer, Danielle A. N. Chapa, Alexis Exum, Brianne Richson, Michaela M. Voss, and Kelsie T. Forbush

Description of the Disorder

The term “eating disorders” (EDs) broadly refers to psychiatric disorders marked by maladaptive eating patterns and attitudes about eating, body shape, and body weight. The four ED diagnoses described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) include anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), and “other specified feeding or eating disorder” (OSFED; American Psychiatric Association, 2013). Age of onset for the DSM-5 EDs varies by disorder, with age of onset for AN typically occurring in early-to-middle adolescence (Attia & Walsh, 2007) and age of onset for BN and BED occurring in the late teenage years to young adulthood (Kessler et al., 2013). Recent examination of prevalence rates for the DSM-5 EDs in adolescents estimates prevalence rates to be 5.7% in females and 1.2% in males (Smink, van Hoeken, Oldehinkel, & Hoek, 2014). Recent epidemiologic research conducted in Australia reported a three-month point prevalence rate of 16.3% for any DSM-5 ED, with the majority of ED cases accounted for by BED and OSFED, and rates of less than 1% each for AN and BN (Hay, Girosi, & Mond, 2015). Research in the United States found a combined ED prevalence of 13.1% by age 20 (Stice, Marti, & Rohde, 2013). Thus, in contrast to views of EDs as rare psychiatric disorders, they are relatively common in the general population.

B. K. Bohrer · D. A. N. Chapa · A. Exum · B. Richson · K. T. Forbush (*) University of Kansas, Department of Psychology, Lawrence, KS, USA e-mail: [email protected] M. M. Voss Children’s Mercy – Kansas City, Department of Adolescent Medicine, Kansas City, MO, USA

In the following section, the DSM-5 diagnostic criteria for EDs are described:

Anorexia Nervosa

AN is characterized by restriction of energy intake that results in a significantly low body weight, given a person’s age, sex, and other developmental and physical health factors (Criterion A). Persons with AN may display an intense fear of weight gain or engage in persistent behaviors to avoid weight gain (Criterion B). People with AN may report a distorted perception of their weight and body shape, deny the seriousness of their low body weight, or base their self-evaluation on their weight or shape (Criterion C). It is important to note that a person with AN may not report any concerns with body image or perceptual disturbance but may still meet criteria if there are persistent behaviors that are designed to prevent weight gain (e.g., excessive exercise, restricting food intake, etc.) and the person does not think that their low weight is a problem. Body weight is typically assessed in adults by calculating a person’s body mass index (BMI); for children and adolescents, additional information conveyed by BMI-for-age percentiles should be considered to account for growth trajectories. The DSM-5 does not provide a specific BMI cutoff for defining “significantly low body weight.” However, BMI cutoffs are included in the new DSM-5 severity categories for AN that define severity from mild to extreme based on BMI thresholds. The DSM-5 specifies two subtypes for AN: (1) restricting type, in which no binge eating or purging behaviors occur, and (2) binge eating/purging type, in which the person engages in binge eating and/or purging behaviors, such as self-induced vomiting and misuse of laxatives and/or diuretics.

Bulimia Nervosa

BN is characterized by repeated episodes of binge eating and inappropriate compensatory behavior at least once per week (on average) for a period of 3 months. The person must also report that their self-evaluation is unduly influenced by their shape and weight. An individual cannot simultaneously meet criteria for AN and BN. Thus, significantly low body weight is an exclusion criterion for BN and an inclusion criterion for AN. An objective binge eating episode refers to a discrete period of time (e.g., within 2 hours) in which an individual consumes an objectively large amount of food, in addition to experiencing a sense of loss-of-control (LOC). Although there are no caloric guidelines for what is considered large, the DSM-5 indicates that the amount eaten needs to be “definitely larger” than what most other people would eat under similar circumstances. Interviewers may also want to consider the person’s body size and height, gender, and physical activity patterns when making judgments of 15 Eating Disorders 377 whether or not the eating episodes are large. LOC may be expressed by individuals in terms that include, but are not limited to, feeling as though binge episodes were inevitable, like they could not stop eating once they started, or that they could not control what or how much was consumed. See the dialogue for an example of how to assess for binge eating episodes. Inappropriate compensatory behaviors (ICBs) are categorized into purging and non-purging methods. Purging ICBs refer to forced expelling of food from the body (through means such as self-induced vomiting, laxatives, diuretics) or misuse of certain substances (e.g., insulin omission in persons with type 1 diabetes or misuse of thyroid medicine to prevent weight gain or compensate for an eating episode). Non-purging ICBs refer to non-purging behaviors that are used to compensate for binge episodes by excessive exercise or restricting caloric intake.

Binge Eating Disorder

BED requires that an individual engage in recurrent episodes of binge eating (see above) in the absence of low body weight and ICBs. In addition, an individual must meet criteria for three out of five associated cognitive features for BED, such as (1) eating much more rapidly than normal; (2) eating until uncomfortably full; (3) eating large amounts of food when not physically hungry; (4) eating alone because of embarrassment associated with how much one is eating; and (5) feeling disgusted, depressed, or guilty after a binge has occurred. Finally, marked distress over binge eating is necessary for diagnosis.

Other Specified Feeding or Eating Disorder

The DSM-5 also includes a category called “OSFED” to encompass ED presentations that cause significant distress or impairment but do not meet diagnostic criteria for AN, BN, or BED. OSFED is the most common ED diagnosis (Keel, Brown, Holm-Denoma, & Bodell, 2011). OSFED does not necessarily imply that the person’s ED is less severe but rather encompasses the large proportion of serious ED presentations. A meta-analysis of mortality rates in the various ED diagnoses identified similar mortality rates in OSFED and full-threshold BN (Arcelus, Mitchell, Wales, & Nielsen, 2011). The DSM-5 provides five specific examples of presentations that fall within the OSFED category. For example, Atypical AN is an OSFED characterized by clinically significant, substantial weight loss (not better explained by a medical condition) that occurred rapidly in a person with a higher premorbid weight. Given that the person with atypical AN developed their illness at a higher baseline weight, this diagnosis is provided to intervene earlier in the illness course, rather than waiting until the person reaches a significantly low body weight. Purging disorder is an 378 B. K. Bohrer et al.

OSFED in which the person purges due to experiencing LOC after eating what most other people would consider a small or normal amount of food. Night eating syndrome is an OSFED characterized by recurrent consumption of food after waking up from sleep or the excessive consumption of food following an evening meal; the individual has full awareness and recollection of food consumption. Other OSFEDs include BN and BED of lower frequency or duration.

Avoidant/Restrictive Food Intake Disorder

Previously conceptualized in the DSM-IV (APA, 1994) as “feeding disorder of infancy or early childhood,” the DSM-5 reconceptualized this disorder as “avoidant and restrictive food intake disorder” (ARFID). It is important to note that ARFID is designated as a feeding disorder, not an ED. However, we included ARFID in this chapter because cases of ARFID are often seen in ED treatment settings. ARFID is characterized by limited interest in food, avoidance of food due to sensory characteristics, preoccupation with potentially undesirable consequences of food consumption (such as contracting an illness or disease from food, etc.) that is accompanied by substantial weight loss or nutritional deficiency or marked psychosocial impairment. Due to the consequences of nutritional deficiency in both AN and ARFID, there are considerable similarities in how these two disorders present clinically. It is important to note, however, that body image disturbances and persistent behaviors to prevent weight gain are not a component of the ARFID diagnosis in the DSM-5. For this reason, it can be difficult to differentiate cases of ARFID from cases of AN (Eddy et al., 2015), particularly in which symptoms of fat phobia are absent [non- fat-phobic AN; (Kennedy, Wick, & Keel, 2018)]. However, to make a definitive diagnosis of ARFID, the clinician must rule out AN and BN, and ARFID symptoms should not be attributable to cultural practices, a lack of food resources, or a concurrent medical condition that better explains low weight. For more information about other feeding disorders, interested readers are referred to Morris, Knight, Bruni, Sayers, and Drayton (2017).

Procedures for Gathering Information

EDs are complex psychiatric disorders that, if left untreated, result in substantial psychiatric and medical morbidity and high mortality rates (Arcelus et al., 2011). Given that EDs have the highest mortality rate of any mental disorder (Smink, Van Hoeken, & Hoek, 2012), proper assessment and early diagnosis are essential. Procedures for clinical interviewing should be given careful consideration, including identifying the problem area, establishing rapport, and providing appropriate clinical recommendations (see Table 15.1 for “dos and don’ts”). In addition to 15 Eating Disorders 379

Table 15.1 Dos and don’ts Do: Establish positive rapport. Many ED behaviors may be associated with embarrassment, guilt, shame, and/or secrecy. Moreover, treatment-seeking rates for individuals with EDs are low; thus, it is not uncommon for an ED assessment to be the first time an individual has discussed their ED thoughts and behaviors with someone. Do: Take a non-judgmental stance when assessing ED symptoms. Try to use language that normalizes disordered thoughts and behaviors. For example, when asking someone to describe what he or she ate during a binge eating episode, it may be helpful to ask, “what else?” (which assumes there is more food that was eaten), rather than “anything else?” (which subtly implies that there should not be more food that was eaten). It can be helpful to reassure the person being assessed that you would not know to ask these questions about their experience, if ED issues were not experienced by many people. Do: Work on your own internalized weight bias. Our society places value on thinness, and any internalized bias (even unconscious bias) that you may have toward people of higher body weights could be conveyed to your client, hindering your ability to do an effective interview. Do: Be mindful of your facial expressions and reactions during an interview. Sometimes binge eating episodes can be quite a bit larger than what most people would eat under similar circumstances (e.g., a full jar of peanut butter and a loaf of bread) or seem unpalatable (e.g., raw hot dogs). Keeping a neutral expression and familiarizing yourself with the full range of eating behaviors can help you to avoid passing judgment. Maintaining a non-judgmental stance, in turn, can help you get better quality information from your client, which will improve your ability to assess, diagnose, and create a strong treatment plan. Do: Assess associated impairment in addition to specific ED symptoms. Assessing clinical impairment (e.g., how symptoms impact one’s ability to engage in interpersonal relationships, at work or school, etc.) gives a more comprehensive description severity. Although the DSM-5 provides a categorical system through which AN, BN, and BED severities can be quantified, clinical impairment should also be considered. Measures such as the Clinical Impairment Assessment (CIA; Bohn et al., 2008) or the World Health Organization Disability Assessment Schedule (WHODAS 2.0) may be informative. Do: Establish a timeline to describe when symptoms began and for what duration they occurred. For ED diagnoses, the presence or absence of a single symptom for a period of time can influence diagnosis (e.g., the presence or absence of ICBs influences whether a diagnosis of BN or BED is appropriate). Do: Get specific details of an individual’s restricting and/or binge eating episodes. For instance, someone may be able to estimate how many cups or teaspoons of food they ate or they may able to provide the brand name of a food that can then be researched to provide additional information. Additionally, do not assume that binge eating episodes must feature “junk food.” Many persons who binge eat consume “healthy foods” during their binge eating episodes (e.g., eating an entire package of baby carrots). Consider the volume and amount of food relative to what most other people would eat in a similar situation when evaluating binge eating episodes. Finally, consider a person’s energy balance needs when evaluating binge eating and restricting episodes. A 6′4″ man who exercises for 2 hours per day will require more energy from food than a woman who does not exercise and is 5′0″ tall. Similarly, a woman of 5′4″ who weighs 400 pounds will require more energy to maintain her weight than a woman of 5′4″ who weighs 135 pounds. In other words, what constitutes a large amount of food will vary depending on the person’s specific energy input and output. (continued) 380 B. K. Bohrer et al.

Table 15.1 (continued) Do: Be sure to ask about the context of a person’s binge eating or restricting episodes. For example, persons who observe Ramadan practice fasting; yet, this does not preclude these periods of fasting to be considered inappropriate compensatory behavior (in addition to religious practices). Comprehensive questioning, such as clarifying if the individual is motivated to engage in this behavior in any part because of weight/shape impact, can help elucidate ED behaviors that may accompany other, day-to-day behaviors. An additional example of the importance of context might be an instance in which an individual reports binge eating on a holiday (such as thanksgiving) or at a particular restaurant where portions are typically quite large (such as the cheesecake factory); as it would not be unusual for a person to eat an objectively large amount under such circumstances, it can be helpful to consider what amount of food would be reasonable, given the setting. Do: Be patient! EDs can significantly impact a person’s insight and ability to describe his or her experience. Keep in mind that certain aspects of EDs, such as overvaluation of weight and shape, can be challenging to assess. Individuals may have limited insight into these symptoms or may not respond to a particular way of evaluating these concepts. For example, some individuals may not endorse loss-of-control during their binge eating episodes yet describe a sense of inevitability that they would consume a large amount of food; the latter fulfills the loss-of- control criterion for binge eating episodes and represents an alternative way to characterize loss-of-control over eating. Certain phrasing and descriptions of ED concepts may resonate with some individuals more so than others. Don’t: Do not make assumptions about a person’s ED based on his or her appearance (including body weight or shape). EDs occur in persons of all ethnicities, ages, genders, and body sizes. We simply cannot know whether a person has an ED based on their appearance. Don’t: Do not assume a person’s current ED presentation has been his or her primary lifetime ED presentation. For example, if a person currently meets criteria for bulimia nervosa and indicates that there was a time in which they were binge eating without engaging in ICBs, binge ED history should also be considered. Furthermore, if a person currently engages in non-purging ICBs (e.g., fasting), this does not preclude them from having a history of purging behaviors (e.g., laxative misuse). Don’t: Do not forget to consider important factors such as gender, cultural background, and other individual differences when formulating your case conceptualization. In special populations such as athletes, for example, the same amount of exercise that would be deemed “excessive” in an average person may not be considered excessive, given the demands of their sport training. utilizing well-validated self-report and interview-based tools to ensure proper diagnosis, it is important for clinicians to include the following additional components in their unstructured clinical interviews: (1) weight and dieting history; (2) current and past patterns of disordered eating behaviors and cognitions [including binge eating, ICBs, and body dissatisfaction (including desire for greater muscularity)]; (3) history of weight-based teasing or bullying; (4) social support and relationships; (5) suicidal ideation, self-harm, and suicide attempt histories; and (6) treatment history. We find it useful to collaboratively develop a timeline of the ED behaviors and cognitions that begins with the person’s first attempt to diet up until the present time. The interviewer should attempt to gather information on the temporal relationships between past dieting behaviors and weight fluctuations. For example, the interviewer will want to know how much weight was lost after the first attempt to 15 Eating Disorders 381 diet, over what period time the diet occurred, how much was consumed during that time, what other behaviors occurred during and after the diet ceased, and how the behaviors and thoughts affected their day-to-day functioning, their social relationships, and their self-image. The interviewer will also want to obtain the client’s lowest and highest body weights for their height (excluding pregnancy) and inquire about the eating behaviors, ICBs, and physical activity patterns the person was engaging in during that time. Obtaining a full weight history is important because people often “migrate” among ED diagnoses over time (e.g., from AN to BN) without recovering. Thus, obtaining information on weight history will enable the clinician to see the “full picture” with respect to the scope and severity of the ED. Throughout the diagnostic interviewing process, the interviewer should work to remain non-judgmental, supportive, and collaborative while also obtaining detailed information necessary to make an accurate diagnosis and develop an effective treatment plan. Given that lay definitions of various ED behaviors differ from clinical and diagnostic definitions, we encourage the clinician to err on the side of obtaining objective information and informant reports, when appropriate. Finally, it is important that clinicians are sensitive to the physical and cognitive needs of clients with EDs. Clinics that see people with EDs should be able to accommodate a full range of body shapes and sizes. For example, there should be sufficient seat padding or extra cushions to prevent people with low body weights from bruising and bariatric-sized chairs for people with higher body weights. Keep in mind how embarrassing it would feel if you were a client who was seeking help for your eating issues and you could not fit through the clinic front doors or you sat down and broke a clinic chair! You will also want to be mindful of the fact that clients who are malnourished may be slow to respond to questions or be forgetful. It is important to note that malnutrition is not perfectly aligned with body weight – many clients who are severely restricting their food intake (even clients living in larger bodies) may experience cognitive effects associated with inadequate caloric intake. Thus, depending on the client’s needs, the clinician may want to break up the intake session into a few shorter sessions.

Case Illustrations

Dialogue About Binge Eating Episodes

Therapist: You mentioned that there have been times when you felt as though your eating was out of control. What do you typically eat during these eating episodes? Sarah: Umm…I don’t know. [Long pause] …I guess a little of everything. Therapist: A little of everything; okay. What are some foods you typically eat? Sarah: Pizza, ice cream, candy…ugh, I feel so gross. Therapist: I’m here to support you and not pass judgment about your eating habits. I wouldn’t even know to ask about your eating habits if other 382 B. K. Bohrer et al.

people didn’t struggle with similar eating issues. I can imagine that it must be uncomfortable sharing this information with me, particularly because we don’t yet know each other well, and please know that it does not change my view of you in the slightest. Sarah: Thank you. I’ve never told anyone about these binges before, so it’s kind of hard for me to talk about. Therapist: I really appreciate your willingness to talk with me, especially because it’s something that you’ve held inside for so long. Do you mind if I ask more specific questions to try to get a better picture of your eating habits? That might help us work together to come up with a good plan to figure out how to address the food issues that you said you’d like to change. Sarah: Sure. That makes sense. The therapist used several strategies to support the client in opening up about her binge eating episodes. The therapist assured the patient that while it is uncomfortable to discuss binge eating episodes, the therapist would not judge her for the amount or types of foods she ate. The therapist also did not refer to the binge eating episodes as “binges” until the client had done so, which is helpful in the event that the client might not perceive their eating to be “binge eating.” Therapist: You said you eat pizza; what type of pizza do you typically eat? Sarah: My go-to is to order pizza for delivery. Therapist: What pizza place do you tend to order from? Sarah: I usually get Pizza Hut pizza. Therapist: What size and what type of toppings? Sarah: My usual order is a large, thin-crust with pepperoni and sausage, and an order of breadsticks. Therapist: How much will you typically eat? Sarah: The whole pizza and four or five breadsticks, usually. Therapist: Typically, more like four or more like five breadsticks? Sarah: Probably five. I’ll sometimes also have ice cream. Therapist: What kind? Sarah: Cookie dough. I usually get the generic brand. Therapist: How much of the ice cream will you have? Sarah: The whole container. Therapist: What size container? Sarah: Just the standard pint-size. Therapist: Okay, so Pizza Hut pizza and breadsticks, and cookie dough ice cream. What else? Sarah: Candy, sometimes. Usually Snickers, and I’ll eat one of those regular- sized bars. Therapist: What else? Sarah: That’s it. Therapist: And over what period of time do you eat these foods? Sarah: It’s usually on my lunch break, so an hour. 15 Eating Disorders 383

Therapist: Thank you for going through that with me. I would imagine it could be difficult to discuss the binges if you’ve never told anyone about them before. Just know I really appreciate you telling me because it helps me get a clear sense of your eating patterns so that we can later come up with a plan together to address them. The therapist used several more strategies to ask about the binge eating episodes. You can see the level of detail the therapist asked for in detailing the foods consumed. A useful guideline is to get enough detail that you could go to the store (or restaurant) and recreate the exact meal or snack. With some patients, using a portion or measurement guide may be helpful (i.e., helping them to describe their eating episodes with descriptors like cups, teaspoons, and ounces). The reason for obtaining such detailed information on eating episodes is because the size of the episode (small or typical meal or snack vs. an amount that is definitely large) determines whether the person should be diagnosed with purging disorder, BN, or BED. Another helpful strategy is to use the phrase “What else?” in asking about foods consumed in the binge eating episode. This phrasing tells the patient that you expect there to be more foods consumed, as opposed to the phrasing “Anything else?” which can suggest to the client that the amount of food he or she has described is already large enough. In this dialogue, the therapist asked, “What else?” until the patient reported being finished describing the eating episode. The therapist provided positive reinforcement (praise) to the patient for discussing the binge eating episodes and reiterated the rationale for why this information was sought.

Dialogue About Loss-of-Control over Eating

Therapist: You’ve described episodes of overeating when you’ll have five peanut butter sandwiches, which includes 10 slices of white bread and 15 ounces of peanut butter. Do you feel a sense of loss-of-control over your eating during these times? Will: Not really, no. Therapist: Do you feel like you could’ve stopped eating once you started? Will: Yeah, I planned to have a binge so I just let myself go on until I was full. Therapist: So, it sounds like this was a planned event. Did you feel it was inevitable you’d eat that amount of food? Will: I guess so, because I had planned it out. I’ve just been overeating like this for so long that I’m kind of numb to it now. It’s just something I plan to do. When it first started, it felt way more out-of-control. Now I just plan it into my week because I know it’s going to happen. The therapist asked about loss-of-control, and the patient denied having that experience during his recent binge eating episodes. The therapist then asked follow- up questions about loss-of-control in different ways that might resonate with the 384 B. K. Bohrer et al. patient (e.g., feeling like he couldn’t stop eating once he had started and feeling it was inevitable he would eat that amount of food). Each of these strategies was used to assess loss-of-control, which the patient eventually endorsed. In our experience, many times the sense of being out of control over binge eating episodes will lessen over the course of the ED illness. The sense of loss-of-control might go away or lessen because the person has experienced the episodes for a long period of time and/or because they plan to have a binge eating episode. This does not preclude them from experiencing a sense of loss-of-control over their eating, even if it is to a lesser degree than when he/she first started binge eating. The take-home message is that loss-of-control does not need to be severe to be considered present.

Dialogue About Exercise

Therapist: Do you ever exercise or participate in sports? Betsy: Of course, but I usually exercise to maintain a healthy heart… not necessarily to lose weight. Therapist: Being healthy is important to you. Tell me more about what a typical exercise session looks like for you. Betsy: I have a job as a fitness instructor, so I usually teach classes during the week. Therapist: Okay, what types of classes do you teach and how long do they last? Betsy: I teach a cardio aerobics class and sometimes yoga. Classes are typically 1 hour with a 5-minute warm-up and a 5-minute cool-down. Therapist: I’m familiar with some of those group classes. I also know that some instructors differ in how much they actually exercise in the class. Some instructors don’t do all the exercises or they use really light weights. They might walk around to give modifications and additional instructions to folks. Other instructors use class time to get their own work out in and do all of the exercises. How would you describe your teaching style? Betsy: Oh, I do all of the exercises, all of the time. I also tend to push myself pretty hard. My goal is to encourage my classes to test their physical limits and to get stronger. I have to model working hard for them. Therapist: You want everyone to get a great workout in. How many classes do you typically teach in a day? Betsy: On average, about two or three. Therapist: Alright, do you do any other types of physical activity in addition to teaching classes? Betsy: Oh yeah, I usually try to get my own workout in four times a week. Therapist: When do those fit in? On days when you teach classes or on your days off from teaching? Betsy: Typically, days that I teach classes because I’m already at the gym and dressed to workout. 15 Eating Disorders 385

Therapist: Okay, so it sounds like part of the reason you exercise is for the health benefits and because it is your job. I totally get that. I’m wondering if there is any added benefit that you might lose weight or change your body shape by working out. Betsy: Oh yeah, it is definitely an additional benefit. It also makes me feel less guilty about when I might overeat or drink too much alcohol over the weekend. Therapist: Okay, now that I have a better idea of your exercise patterns and the reasons why you exercise, I’m going to ask some more specific questions. Would that be alright? Betsy: Yeah, that’s fine. Therapist: How many days per week, on average, do you exercise for 2 or more hours? Betsy: Six days a week, typically. Therapist: Okay, and have you ever exercised when you were sick or injured? Betsy: I have to. I can’t miss work every time I’m sick or have an injury. Therapist: Okay, when you are sick or injured, do you still push yourself very hard or do you modify what you are doing? Betsy: I always push myself. It’s important to be an upbeat workout instructor. Therapist: Could you give me some examples of when you might have exercised when you were sick or injured? Betsy: I had a twisted ankle a few times. Therapist: Ouch, those can really hurt! I’m wondering if you ever went to a doctor for your twisted ankles? Betsy: A few times. They just tell me to rest my ankle. They don’t understand that I have a job to do and can’t afford to take time off. The therapist used several strategies to fully assess the patient’s exercise behaviors. The patient initially mentioned that her exercise was about health and that she exercised frequently for her job but not to influence body shape or weight. Because exercise can be a healthful behavior for many people, patients with EDs will sometimes frame their exercise in a positive manner. The therapist, however, should continue to ask about the patient’s exercise pattern in a non-judgmental manner to better understand how the ED and exercise might be related. The therapist in this case validated what the patient was saying and asked whether there was any added benefit that her shape and/or weight could be influenced by her exercise behaviors. The patient also framed her exercise as being necessary for work, so the therapist asked detailed questions about how much effort the patient put into exercise (e.g., more than other instructors) as well as the frequency of exercise (i.e., including additional workouts in addition to teaching exercise classes as part of her job). It is also important to inquire about days when exercise persisted despite an injury or illness or when against medical advice. Finally, the patient volunteered that she exercised to compensate for an overeating episode. If she had not volunteered this information, it would have been important for the clinician to ask if exercise was used to compensate for an eating episode. 386 B. K. Bohrer et al.

Recommendations for Formal Assessment

We highly recommend that clinicians include some type of formal assessment (in addition to unstructured clinical interviewing) as a part of their routine assessment practice for clients with an ED. Past research has shown that 30% of disorders can be missed by the interviewer if unstructured interviews are administered without any formal diagnostic interview (Zimmerman & Mattia, 1999). Moreover, other research indicates that (1) early response in the first month of treatment as defined by 2.88% weight gain (for persons with AN) or ≥70% reduction in binge eating or purging (for persons with BED or BN) is one of the only prognostic indicators for end-of-treatment response (Linardon, Brennan, & De la Piedad Garcia, 2016) and (2) clinicians who engage in routine assessment of cognitions and behaviors are able to treat clients faster and more effectively (Boswell, Kraus, Miller, & Lambert, 2015). Clinicians who routinely assess at intake and throughout treatment, therefore, have a better likelihood of seeing meaningful improvements in their clients. Below, we highlight some suggested diagnostic interviews for general psychiatric and ED-specific concerns. Given that many people with an ED have a comorbid mental health condition (Hudson, Hiripi, Pope Jr., & Kessler, 2007) and/or a lifetime history of suicidal ideation or suicide attempts (Forrest, Zuromski, Dodd, & Smith, 2017), we recommend assessing non-ED psychopathology (e.g., depression, anxiety, obsessive-compulsive disorder, substance misuse) in addition to ED-specific psychopathology. The selected measures (see below) do not represent an exhaustive list of assessments from which to choose. Clinicians should use their judgment of individual client’s needs and up-to-date information on the reliability and validity of a measure to make selections about which assessment to use for a particular client.

Self-Report and Screening Measures

The Eating Disorder Examination Questionnaire (EDE-Q; Fairburn & Beglin, 1994) is a 28-item self-report version of the Eating Disorder Examination (EDE) interview (see below). The EDE-Q measures constructs that are targeted in Enhanced Cognitive Behavior Therapy for EDs (CBT-E; Fairburn, Cooper, & Shafran, 2003). Thus, the EDE-Q is a valuable tool for clinicians interested in monitoring changes in relevant CBT-E constructs over the course of therapy. The EDE-Q performs similarly to the EDE interview (Fairburn & Beglin, 1994). Strengths of the EDE-Q include strong reliability and convergent validity. However, recent research has shown that the reliability of binge eating may be lower in men compared to women (Forbush, Hilderbrand, Bohrer, & Chapa, 2017). Another important limitation is that the factor structure of the EDE-Q has not replicated well across samples (Berg, Peterson, Frazier, & Crow, 2012). The EDE-Q is free for non-commercial research 15 Eating Disorders 387 or clinical use (https://www.rcpsych.ac.uk/pdf/EDE-Q.pdf). The EDE-Q is also available within the Recovery Record, Inc. mobile app (https://www.recoveryrecord.com/). The Eating Disorder Inventory 3 (EDI-3; Garner, 2004) is a 91-item self-report measure that is licensed by the Psychological Assessment Resources. The EDI-3 takes approximately 20 minutes to administer and 20 minutes to score (although interested clinicians can purchase an online scoring package). The EDI-3 is appropriate for use in persons aged 13 to 53 years. Three scales – Drive for Thinness, Body Dissatisfaction, and Bulimia – directly pertain to EDs, whereas the other nine scales assess correlated psychopathology (e.g., Maturity Fears, Perfectionism, and Emotion Dysregulation). The EDI-3 has good reliability and convergent validity (Cumella, 2006), although it has limited discriminant validity from depression (Anderson, Williamson, Duchmann, Gleaves, & Barbin, 1999). The EDI-3 has substantial normative data available and computerized scoring, and it provides useful supplementary materials (e.g., ED risk scores and ability to purchase an additional self-report diagnostic measure). The Eating Pathology Symptoms Inventory (EPSI; Forbush et al., 2013) is a 45-item self-report measure that assesses body dissatisfaction, binge eating, cognitive restraint, muscle building, purging, restricting, excessive exercise, and negative attitudes toward obesity. The EPSI is freely available for non-commercial research or clinical use [although any adaptations must be approved in writing from the copyright holder (Dr. Kelsie Forbush) prior to use]. The EPSI is also available within the Recovery Record, Inc. mobile app (https://www.recoveryrecord.com/). Strengths of the EPSI include strong psychometric properties in men and women and in persons with high and low body weights and a stable factor structure (Forbush et al., 2013). (Note, however, that Muscle Building tends to have lower reliability in women and generally should not be interpreted in women.) Although the EPSI is a new measure, it has a large, burgeoning support for its clinical utility, reliability, and validity. To download the EPSI, go to: https://psych.ku.edu/sites/psych.ku.edu/files/ docs/cv/EPSI.pdf. The SCOFF (Morgan, Reid, & Lacey, 2000) is a five-item self-report tool that is designed to screen for the possible presence of an ED. The content assessed in the SCOFF includes (1) making oneself “sick” (i.e., self-induced vomiting) due to eating large amounts of food, (2) losing control over eating, (3) losing more than one stone (i.e., 15 pounds) over a three-month period, (4) feeling one is “fat” when others disagree, and (5) endorsing the belief that food dominates one’s life. Individuals who provide affirmative answers to two or more questions on the SCOFF should be referred for a comprehensive ED assessment. Past research has shown that the SCOFF has high specificity (>0.90) and adequate sensitivity (>0.50) for screening EDs (Solmi, Hatch, Hotopf, Treasure, & Micali, 2015). A disadvantage of the SCOFF is the relatively high false-positive rate. 388 B. K. Bohrer et al.

Structured and Semi-structured Interviews

General Interviews

The Structured Clinical Interview for DSM-5 Disorders (SCID; First & Williams, 2016) is a semi-structured interview that assesses most of the common mental disorders. Although the SCID for DSM-5 disorders includes a module to assess feeding and EDs, it may be worthwhile for the clinician to administer an additional ED-specific interview, given that there are many aspects of ED psychopathology that are not measured in the SCID (e.g., internalized weight stigma, body checking, frequency of self-weighing) or that are not assessed comprehensively (e.g., excessive exercise). However, the SCID provides coverage of mood, anxiety, obsessive- compulsive, psychotic, and substance use disorders (and other disorders), providing important diagnostic breadth. A limitation of the SCID is that it can be challenging to learn to administer correctly, particularly if the clinician is not familiar with a broad range of psychopathological presentations. Thus, clinicians who wish to administer the SCID should receive appropriate training and supervision prior to use (see https://www.columbiapsychiatry.org/scid-5-training-media-0). The Mini-International Neuropsychiatric Interview (MINI; Hergueta, Baker, & Dunbar, 1998) is a structured diagnostic interview that provides coverage of 17 common psychiatric disorders and has been translated into 70 languages. The MINI takes approximately 15 minutes to administer, making it a widely used instrument in clinical settings and epidemiological research. The MINI includes AN, BN, and BED, but does not directly assess OSFEDs.

Eating Disorder-Specific Interviews

The Eating Disorder Examination (EDE; Cooper & Fairburn, 1987) is a semi- structured interview that assesses ED diagnostic criteria and other relevant constructs (e.g., reaction to prescribed weighing, which is not a diagnostic criterion for EDs but may give clinically relevant information). There are four EDE sub-scales: Eating Concern, Weight Concern, Shape Concern, and Restraint; the EDE also features behavioral items to assess specific ED behaviors (e.g., binge eating, purging, etc.). The EDE is a free, downloadable measure available from https://www.rcpsych. ac.uk/pdf/EDE_16.0.pdf. The EDE is an “investigator-based interview,” which means that the interviewer should have training in ED-relevant concepts and diagnostic criteria. There is evidence for test-retest reliability over periods of 1–2 weeks for EDE sub-scales and most behavioral items; there is also evidence for inter-rater reliability and internal consistency (Berg et al., 2012). The factor structure of the EDE has not been consistently replicated, and there is mixed evidence for the EDE’s construct validity (for a comprehensive review, see Berg et al., 2012). The Eating Pathology Symptoms Inventory—Clinician Rated Version (EPSI- CRV; Forbush, Wildes, Bohrer, Chapa, & Hagan, 2018) is a semi-structured interview that was created based on the EPSI self-report measure (Forbush et al., 2013). 15 Eating Disorders 389

The EPSI-CRV was designed to be used with less training than the EDE. The EPSI- CRV includes the eight dimensions of the self-reported version of the EPSI as well as additional modules that are used to formulate current (past 3-month) ED diagnoses. The EPSI-CRV enables diagnosis of multiple forms of EDs, including OSFED. To facilitate accurate recall, interviewees are provided with a food measurement guide, and the interviewer assists the interviewee in constructing a detailed calendar for the past 3 months. The EPSI-CRV has strong convergence with the self-reported version of the EPSI. The Eating Disorder Assessment for DSM-5 (EDA-5; Sysko et al., 2015) is a semi-structured interview for the assessment of DSM-5 feeding and EDs. The computerized version, available from https://eda5.org/, uses an algorithm to reduce the number of questions asked of interviewees (i.e., they are only asked relevant questions based on their answers); the paper-and-pencil and computerized versions had excellent diagnostic agreement with one another (kappa = 0.83). The EDA-5 demonstrated diagnostic agreement with the EDE (kappa = 0.74) and evidence for test- retest reliability over a 7–17-day period (kappa = 0.87; Sysko et al., 2015).

Medical Assessment

If psychological assessment suggests an ED, there are specific physical assessments that should be performed. Vital signs, including orthostatic blood pressure and heart rate, temperature, and last menstrual period (for females of childbearing age), should be assessed at each visit. Changes in orthostatic vital signs could indicate acute dehydration or chronic malnutrition. In the adolescent population, blood pressure changes are not often seen, but heart rate changes are common. Malnourishment may present with a low heart rate (bradycardia), low body temperature (hypother- mia), or prolonged missed periods (secondary amenorrhea). During history-taking, it is important to ask about symptoms that are related to a state of starvation. All organs can be affected during this state, but early and most common complaints include gastrointestinal (GI) complications such as constipa- tion, slowing of the stomach (gastroparesis), bloating, or reflux; cold or bluish col- oration of the skin (cyanotic extremities); dizziness or fainting; infrequent menstruation (oligomenorrhea); fatigue or difficulty concentrating. In adolescents, other common presentations to the pediatrician include a decrease in athletic ability or an unexpected drop in grades. The physical examination should include aspects that incorporate the above complaints, paying particular attention to the GI and cardiovascular systems. The integumentary system is also important to monitor, as lack of subcutaneous fat can result in frequent bruising or pressure ulcers, which usually have delayed healing time and are, therefore, at risk for infection. It is important to note that because bone marrow suppression can be seen during a state of malnutrition, patients may not present with typical signs and symptoms of an infection, so there should be a low threshold to treat. In adolescents who are premenarchal, it is essential to determine 390 B. K. Bohrer et al. pubertal progression so menarche can be accurately anticipated, as it can be delayed due to malnutrition. For those who use vomiting as a method of purging, additional signs on exam include calluses on the back of the hand (Russell’s sign), swollen salivary glands (parotiditis), and a swollen or red throat. The patient may also have fluid retention or marked diuresis, so utilizing weight gain as a marker of progress can be misleading. Monitoring physical health through laboratory and radiology findings is essential. Ongoing medical complications of EDs include electrolyte abnormalities that may reflect water loading, vomiting, laxative or diuretic use, arrhythmias, and osteopenia or osteoporosis due to chronic bone loss. Treatment should be focused on re-nourishment, using “food as your medicine.” Patients can be treated symp- tomatically to help alleviate discomfort during the refeeding process. Laxatives are not encouraged due to the high rate of abuse, but polyethylene glycol is a viable option. Patients need to be followed closely during their recovery, as acute complications and need for hospitalization are common. Thus, therapists should work closely with a physician who has experience treating patients who have EDs.

Impact of Gender, Race, Culture, Age, and Other Aspects of Diversity

Ethnicity and Culture

Research on ethnicity and culture is limited in the ED field. Asian and Pacific Islander populations are among the most understudied groups (Thomas, Lee, & Becker, 2016). The following section will focus on all ethnic minority populations and associated prevalence, risk factors, and considerations for assessment. Recent studies suggested that ED prevalence among African American, Latinx, Asian, Pacific Islander, and/or Native American ethnic minority groups are comparable to, or higher than, ED rates among non-Latinx European Americans (Marques et al., 2011). Despite the fact that members of ethnic-racial minorities are not protected from developing an ED, ethnic-racial minorities are less likely to receive a referral for ED assessment or treatment than European Americans (Franko, Becker, Thomas, & Herzog, 2007). Even when referred for treatment, ethnic and racial minorities are less likely to utilize mental health resources than their European American counterparts (Jimenez, Cook, Bartels, & Alegria, 2013). The lack of treatment referral and treatment receipt in ethnic minority groups is theorized to be the result of increased stigmatization of mental health services (Cheng, Kwan, & Sevig, 2013; Rao, Feinglass, & Corrigan, 2007). Ethnic-racial minority groups make up a significant proportion of low-income families and homes in the United States, when compared to European American peers. For this reason, considering financial barriers is important when making treatment recommendations. Another important consideration is the potential need to include the family in the assessment and treatment process (Griner & Smith, 2006). For example, excluding family members from 15 Eating Disorders 391 clinical services could violate the Latinx cultural value of familismo, which refers to a strong identification and attachment to the nuclear and extended families. Ethnic-racial minority patients who appear for services may be more likely to present with a higher level of psychiatric impairment (e.g., difficulties in work, social, and interpersonal functioning due to the ED) and/or disorder severity (e.g., high levels of dietary restraint, shape concerns, and frequent binge episodes; Grilo, Lozano, & Masheb, 2005; Lydecker & Grilo, 2016; Marques et al., 2011). Presentation with high severity may be due to cultural stigma, which suggests that ethnic-racial minorities may live with ED symptoms longer and wait to seek treatment until they are severely impaired (Becker, Hadley Arrindell, Perloe, Fay, & Striegel-Moore, 2010; Cheng et al., 2013). Despite having greater symptom severity upon initial treatment presentation, certain minority groups may simultaneously report lower body image concerns than their European American counterparts. For example, African American persons may present with a (relatively) lower desire to be thin, although the literature is mixed with some studies suggesting no differences in body image disturbance between African American and European American persons. Researchers suggested that potential differences in body image disturbance may be due to cultural preference for “curvier” body sizes among members of certain ethnic and racial groups (Gentles & Harrison, 2006; Gordon, Castro, Sitnikov, & Holm-Denoma, 2010; Sánchez- Johnsen et al., 2004). Asian individuals are likely to prioritize body image based on thinness, and culturally important features, such as eye shape and skin clarity (Brady et al., 2017). Finally, for first-generation ethnic-racial minorities, clinicians should evaluate the role of acculturation in the onset and maintenance of ED symptoms (for additional information and suggestions, see Wildes & Forbush, 2015).

Assessment Tip During assessment and treatment, it is important to consider the cultural practices of the population. While something may seem abnormal or maladaptive, it may be common practice in certain cultures. Cultural context is important in establishing and maintaining rapport with ethnic minority clients. Racism, discrimination, and sexism are also risk factors for maladaptive behaviors (including ED behaviors and cognitions), so maintaining cultural humility and working to the best of one’s ability to understand the client’s experience is important when working with minority patients.

Gender

Women have a higher prevalence of EDs compared to men (Hudson et al., 2007; Smink et al., 2012). It could be that ED behaviors are less likely to be identified in men (Robinson, Mountford, & Sperlinger, 2012), that men are less likely to seek treatment (Räisänen & Hunt, 2014), or that the current diagnostic system does not capture the experience of EDs in men. Compared to other EDs, men are most likely to be diagnosed with BED (Smink et al., 2012) and to report overeating (Striegel- Moore et al., 2009). 392 B. K. Bohrer et al.

Assessment Tip Clinicians may have difficulty assessing ED behaviors if they are unfamiliar with how EDs present in men. For example, restricting and binge eating in men may be different than in women because men typically have larger statures and higher caloric needs. Moreover, body dissatisfaction in men may be focused more on building muscle than losing weight or becoming thin. When the desire to build muscle is endorsed by a client, we recommend assessing for excessive protein intake and use of illicit substances to facilitate muscle gain (e.g., steroids). Gender plays a critical role in how EDs are experienced. Much of ED research, however, has been limited to a dichotomized definition of gender (i.e., man or woman). The experience of gender for many people is fluid and better defined as a continuous variable in which a person can identify anywhere along the continuum of “womanness” and “manness.” We define the term transgender broadly to be inclusive of any person whose gender identity does not match the gender that would correspond with their sex assigned at birth. It is estimated that approximately 1.4 million adults and 150,000 youth in the United States identify as transgender (Flores, Brown, & Herman, 2016), and this is important, given the association between EDs and transgender experiences. For example, levels of body dissatisfaction are high among transgender individuals who believe that their body is too feminine (i.e., perception of having too large breasts, hips, or proportion of body fat as compared to muscle) or too masculine (i.e., perception of having too much muscle mass and an undesired V-shaped torso) in comparison with their self-identified gender (Ålgars, Alanko, Santtila, & Sandnabba, 2012; I. Becker et al., 2016; Hepp & Milos, 2002; Surgenor & Fear, 1998). To influence their body weight or shape in a way that is more personally desirable, transgendered individuals may engage in disordered eating and unhealthy exercise (Ålgars, Santtila, & Sandnabba, 2010; Guss, Williams, Reisner, Austin, & Katz-Wise, 2017; Vocks, Stahn, Loenser, & Legenbauer, 2009) that could result in the development of an ED. The transgender community is susceptible to EDs; however, due to limited research, it is unclear what the prevalence of EDs is among individuals who identify as transgendered.

Assessment Tip When working with clients, it is critical to ask about their preferred pronouns and to use these pronouns in every subsequent interaction. Asking about pronouns should be done with every client (rather than assuming an individual’s preferred pronouns based on their outward physical appearance). Questions about pronouns and gender could be added to the intake process, on demographic paperwork, or during clinical interviews. Finally, careful assessment of body image may be helpful in working with persons who identify as transgendered.

Sexual Orientation

Although the literature on sexual minority populations is increasing, there is still a dearth of research on EDs among lesbian, gay, and bisexual (LGB) individuals. Recent studies have found the prevalence of EDs among gay or bisexual males is 15 Eating Disorders 393 higher than that of their heterosexual counterparts but comparable in gay or bisexual women (Feldman & Meyer, 2007; Shearer et al., 2015). LGB men and women are reported to experience greater overall ED symptom levels, in addition to increased risk factors, such as discrimination, prejudice, sexual violence (Kuna & Sobów, 2017), and displacement (Aichhorn et al., 2008). Overall, gay and bisexual men are more likely to report clinically significant ED symptoms and disordered eating behaviors when compared to heterosexual men (Matthews-Ewald, Zullig, & Ward, 2014). Sexual minority women are more likely to report binge eating, purging (Meneguzzo et al., 2018), and dieting behaviors to lose weight (Matthews-Ewald et al., 2014). To facilitate effective assessment and treatment, it is important for clinicians to assess social support and assist in the maintenance and development of strong social support systems. Strong social support, as well as engagement within the LGB community, are reported as protective factors for LGB individuals (Shearer et al., 2015). While social support can fluctuate during the “coming out” process, for LGB individuals “coming out” can positively influence ED symptom severity (Watson, Velez, Brownfield, & Flores,2016 ). Other social relationships, specifically decreased satisfaction within an LGB romantic relationship, can intensify the link between sexual minority status and increased bulimic symptoms, with exception to young adult men (Essayli, Murakami, & Latner, 2018).

Assessment Tip When assessing for EDs in a sexual minority population, it is important to consider social and environmental stressors and their impact on the client’s life experience and ED diagnosis.

Age

ED onset most typically occurs in adolescent and young adult populations (Hudson et al., 2007). However, recent research has shown that maladaptive eating behaviors and cognitions occur at significant rates among children and older adults (Campbell & Peebles, 2014; Lapid et al., 2010; Mitchison, Hay, Slewa-Younan, & Mond, 2014; Pinhas, Morris, Crosby, & Katzman, 2011). According to the Centers for Disease Control and Prevention (2018), about 42% of children and adolescents between grades 9 and 12 reported feeling too fat or wanting to be thinner, and about 81% reported being afraid of becoming fat as early as 10 years of age (CDC, 2018). Additionally, about 5% reported taking diet pills that were not prescribed by a doctor, vomiting or taking laxatives (4.4%), and/or not eating for 24 hours or more (13%; Hudson et al., 2007; CDC, 2018). Similarly, extreme dieting behaviors in older adults have been found to increase with age (Mangweth-Matzek, Kummer, & Pope, 2016; Mitchison et al., 2014). For men over the age of 45, the frequency of purging behaviors has increased, when compared to younger individuals (Mitchison et al., 2014). Although literature on older adults is limited, recent literature found increased body dissatisfaction among older adult women (Kilpela, Becker, Wesley, & Stewart, 2015; Mangweth-Matzek, Hoek, & Pope Jr., 2014). 394 B. K. Bohrer et al.

Assessment Tip When assessing both children and older adults, therapists should be specific and clear in their questions. For older adults, specifically, a thorough medical and ED history should be established to identify temporal relationships between life events and determine where medical causes can be ruled out. Social factors for children and adolescents are also important to consider. The American Academy of Pediatrics provides specific recommendations for ED cues in children (Campbell & Peebles, 2014). Clinicians should also assess body image in the context of normal shape and weight changes that occur during menopause or through the normal process of aging.

Athletes

Among athletes, the estimated prevalence of EDs is 13.5% to 32.8% in Norwegian samples (Sundgot-Borgen & Torstveit, 2004; Torstveit, Rosenvinge, & Sundgot- Borgen, 2008), although more epidemiological research is needed to better understand the rate of EDs in other cultures and parts of the world. Some research suggests that not all athletes are equally susceptible to developing an ED. Risk for an ED is higher in sports that emphasize anti-gravitation (e.g., ski jumping, jockeying) for men and esthetics (e.g., ballet/dancing) for women (Sundgot-Borgen & Torstveit, 2004). Athletes appear to have a higher rate of EDs compared to non-athletes (Smolak, Murnen, & Ruble, 2000). Athletes may be exposed to additional risk factors that non-athletes do not encounter; these additional risk factors include (1) the belief that sport performance is optimal at a lower weight, (2) revealing uniforms, and (3) reinforcement from judges and/or coaches for certain body types. Due to the serious health risks and medical complications associated with EDs for the general population (e.g., irregular heart rate, imbalanced electrolytes, bone deterioration; Mitchell & Crow, 2006), athletes who continue to participate in their sport with an ED are highly susceptible to physical injury, anemia, chronic fatigue, irregular menstruation (for women), and other serious medical problems [see Mountjoy et al., (2014) for a review]. To ameliorate medical complications and to keep athletes healthy and safe, it is critical to identify EDs as soon as possible, although the assessment of EDs in athletes may be tricky. Clinicians will want to fully understand if and how the athlete’s exercise patterns are contributing to their ED. Identifying unhealthy exercise behaviors in athletes might be challenging because (1) physical activity and sport participation are typically considered healthful behaviors and (2) athletes who exercise more than their coach recommends or when sick or injured may appear dedicated to their sport and/or team (and might even be rewarded). However, when patients engage in exercise past the point of their physical capacity, despite sickness or injury, against medical advice, or to compensate for an eating episode, it is unhealthful. Exercising more than recommended by coaches, 15 Eating Disorders 395 against medical (or sport trainer) advice, or when sick or injured may be suggestive of an underlying ED rather than indicative of sport commitment.

Assessment Tip For an example dialogue of exercise assessment, see the dialogue earlier in this chapter. When working with athletes, it is also recommended that you ask for collateral information from coaches, coaches’ assistants, and/or sports medicine staff.

Information Critical to Making a Diagnosis

ED diagnoses are nuanced. It is important to consider several critical pieces of information in order to accurately diagnose EDs. Please see Fig. 15.1 for information critical to making ED diagnoses.

General Anorexia nervosa Bulimia nervosa Binge ED considerations •Weight status • OBEs2 •Absence of ICBs • Loss-of-control • OBEs and/or •ICBs •Frequency of over eating purging •Frequency of behaviors • Size of binge- behaviors1 behaviors3 •Weight status5 eating episodes •Weight status4 •Size of restricting episodes6

Fig. 15.1 Information critical to make a diagnosis. Note: OBE = objective binge eating; ICB = inappropriate compensatory behavior. 1OBEs and/or purging behaviors are important to consider, as the presence of either OBEs or purging behaviors is necessary for the diagnosis of the binge eating/purging subtype of anorexia nervosa. 2The size of the binge eating episodes is crucial to diagnosis. The presence of subjective binge eating episodes (SBEs) in the absence of OBEs would indicate a diagnosis of purging disorder [or another “other specified feeding or ED” (OSFED)]. 3A diagnosis of bulimia nervosa requires the individual to engage in OBEs and ICBs at least once a week, on average, for a duration of 3 months (i.e., at least 12 OBEs and 12 ICBs in a 3-month period). A diagnosis of OSFED (bulimia nervosa of low frequency and/or limited duration) can be considered for persons who engage in OBEs and/or ICBs less frequently. 4A diagnosis of bulimia nervosa requires the individual to be at or above a normal body weight; a diagnosis of anorexia nervosa or OSFED should be considered for individuals who are at a low body weight. 5A diagnosis of binge ED requires the individual to be at or above a normal body weight. The diagnosis does not require the individual to be overweight or obese, although overweight and obesity can be associated with binge ED. 6It is important to consider the amount of food consumed during an episode of restricting. Some persons may report restricting yet consume an amount of food that would not be small enough to be considered restricting. It is also important to consider duration of the restricting episode, which should be considered alongside the amount of food consumed during the restricting episode (e.g., not eating anything for 8 hours vs. eating very small amounts of food throughout the day) 396 B. K. Bohrer et al.

Summary

EDs are complex psychiatric disorders that, if untreated, adversely affect social relationships, work productivity, and physical health and can lead to premature death. Despite common stereotypes, EDs have a prevalence that is similar to depression or anxiety. Moreover, EDs occur across the lifespan, in persons with food insecurity, in all genders, and in ethnic-racial minority groups. Having a rudimentary understanding of how to assess and diagnose EDs is, therefore, a requisite for mental health clinicians and physicians. This chapter provided information on the key signs and symptoms of EDs and how to assess these issues. We encourage the interested reader to refer to additional information and helpful resources provided by the National Eating Disorder Association (https://www.nationaleatingdisorders.org/) and Academy for Eating Disorders (https://www.aedweb.org/home) to learn more about the assessment, diagnosis, and treatment of EDs.

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Tyson D. Bailey, Stacey M. Boyer, and Bethany L. Brand

Description of the Disorders

Dissociative disorders (DDs) involve a disconnection from the present moment including one’s emotions, body, or surroundings, frequently in an effort to regulate internal states (e.g., emotions, overwhelming levels of physical arousal) during times of heightened stress. The development of a DD has most consistently been associated with antecedent trauma, particularly when exposure happens repeatedly in childhood (Dalenberg et al., 2012, 2014). To further understand DDs, we begin by presenting common symptoms, followed by a discussion of the current diagnostic criteria, prevalence, and difficulties with accurate diagnosis. Further, we discuss strategies for gathering information, including interviews, psychological measures (e.g., self-report and performance-based), and behavioral observations. We conclude with factors to consider when ruling out other diagnoses with similar presentations, such as schizophrenia or borderline personality disorder.

Dissociation Defined

Dissociation is frequently conceptualized as an adaptive behavior that is designed to assist us in managing intense distress when escape is not possible (e.g., Platt, Luoma, & Freyd, 2016). However, when we experience persistent heightened

T. D. Bailey (*) Private Practice, Lynnwood, WA, USA S. M. Boyer Christiana Care Health System, Newark, DE, USA B. L. Brand Towson University, Towson, MD, USA

© Springer International Publishing AG 2019 401 D. L. Segal (ed.), Diagnostic Interviewing, https://doi.org/10.1007/978-1-4939-9127-3_16 402 T. D. Bailey et al. emotion, particularly in early childhood, this effective coping strategy can be used so frequently that it becomes ubiquitous, out of the individual’s volition, and interferes with functioning (i.e., emotion and behavior regulation) (Putnam, 1997; Schore, 2009). Steinberg (1994, 2001) discussed five key dimensions of dissociation common within the DDs and other disorders: depersonalization, derealization, dissociative amnesia, identity confusion, and identity alteration (see Table 16.1 and below). The 4-D model (Frewen & Lanius, 2015) conceptualizes dissociation as existing on a continuum, with common, non-pathological experiences (e.g., flow, highway hypnosis) on one end and maladaptive experiences that may indicate the presence of a DD on the other. Research supports both ideas and has identified a core group of pathological dissociative experiences (Bernstein & Putnam, 1986; Waller, Putnam, & Carlson, 1996), as well as a continuum of less problematic shifts in consciousness. Specifically, studies have found the taxon differentiates between those who have a chronic or persistent dissociative pattern that interferes with functioning, whereas a dissociative continuum is applicable to those without a DD who experience fluctuations in consciousness (see Frewen & Lanius, 2015 for a review). Although dissociative symptoms are most commonly related to trauma, research suggests they occur in a variety of disorders such as somatic, substance use, and psychotic disorders. The most severe dissociation is found among individuals with trauma and attachment-related disorders (PTSD, borderline personality disorder)

Table 16.1 Steinberg’s (1994) dimensions of dissociation Symptom Examples Amnesia Forgetting important autobiographical events (“I don’t remember my wedding”) Gaps in memory beyond ordinary forgetfulness (“I don’t drink alcohol but found beer in my refrigerator that I must have bought”) Depersonalization Experiencing parts of body as strange, unreal, or disconnected “Watching” oneself from a distance “I’m not real” Derealization Familiar environments are experienced as strange/unreal “I didn’t recognize one of the friends I’ve known and seen for years” “Things don’t look real. They look far away” Identity confusion “I often experience a battle inside myself. No matter what type of decision I’m trying make, it seems like I have conflicting ideas about what I want” “I am always torn about how to dress and act. I sometimes want to look and act like a child, other times a teenager, and other times a conservative adult” Frequent conflicting opinion/thoughts about decisions Identity alteration Having self-states for specific roles (e.g., work, family) Referring to oneself by different names or in plural or third person pronouns Acting in a manner that is inconsistent with chronological age (“sometimes I suddenly find myself scared and literally hiding like a child and don’t know how to do simple things, while other times I feel smart and can give presentations at work”) 16 Dissociative Disorders 403 and particularly dissociative identity disorder (DID) (Lyssenko et al., 2018). Because chronic dissociation can interfere with information retention and treatment engagement (Lanius, Brand, Vermetten, Frewen, & Spiegel, 2012), it is important to assess these symptoms regardless of treatment setting or presenting problem.

Dissociative Disorders

According to the DSM-5, DDs involve a “…disruption and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior” (American Psychiatric Association, 2013: p. 291). There are five DDs within the current diagnostic structure: DID, dissociative amnesia, depersonalization/derealization disorder, other specified DD (OSDD), and unspecified DD. A dissociative subtype of posttraumatic stress disorder (DPTSD) is included in the DSM-5 to address patients with PTSD who also experience depersonalization/derealization (APA, 2013). Given that antecedent trauma is the most robust factor associated with the development of a DD and necessary for a diagnosis of DPTSD, assessing for dissociative symptoms is critical for all posttraumatic presentations (APA, 2013; Dalenberg et al., 2012, 2014). We will refer to complex dissociation as including individuals who have a diagnosis of DID or OSDD.

Prevalence

DDs are more common than many clinicians realize. According to a summary of epidemiological research, the prevalence in clinical settings is approximately 10% (inpatient range 4.3–40.8%, outpatient range 12–34.9%), with half of those individuals suffering from DID (reviewed in Sar, 2011). Although research has shown DDs are found cross-culturally, with prevalence rates of more than 5% in a number of countries (see Dorahy et al., 2014 for a review), differences in conceptualization and measurement are discussed as one factor that may affect the prevalence rates (Sar, 2011). Of note, much of the DD research has focused on DID because it causes the most significant disruptions in functioning. In community samples, the prevalence rate of DID is approximately 1–3% (Dorahy et al., 2014; ISSTD, 2011; Sar, 2011), indicating that this most severe form of DD is about as common as bipolar disorder and schizophrenia. Such high prevalence rates suggest that all individuals seeking psychological treatment should be routinely assessed for dissociative symptoms, particularly if there is a history of trauma. 404 T. D. Bailey et al.

Procedures for Gathering Diagnostic Information

Individuals who experience pathological dissociation, whether in the context of a DD or another disorder, typically present as highly complex and with shame-based desire to avoid discussing their dissociative symptoms or antecedent traumas (Briere, Dietrich, & Semple, 2016; Lyssenko et al., 2018). This presentation may lead to misdiagnosis because the individual feels comfortable discussing certain symptoms (e.g., mood fluctuations) but not others (e.g., amnesia). Therefore, accurate diagnostic assessment is best achieved through continual evaluation that includes a clinical interview and multi-measure/source corroboration (when possible). Routine assessment of dissociation begins with a thorough clinical interview. Semi-structured interviews provide clinicians with important information, while allowing for flexibility, and are important in gaining an understanding of the symptom profile for diagnostic clarity. Individuals who have a DD frequently utilize dissociative strategies when recalling distressing information, which may lead to an underreporting of experiences, particularly in the early stages of treatment. It is imperative that clinicians mindfully evaluate how deeply to delve into a client’s trauma history while in the beginning stages of forming a working relationship. This consideration is particularly important for those with a DD, who are likely to need more time to establish an alliance than other clinical groups (Cronin, Brand, & Mattanah, 2014). One cannot rule out dissociative symptoms or a DD presentation after a single diagnostic session. It can sometimes take years for clients to be willing to discuss their internal experiences in sufficient detail to effectively diagnose a DD, or for the client to become sufficiently aware of their symptoms to accurately report them. Behavioral indicators and the way in which individuals respond to certain questions may be an early indicator of dissociative symptoms (Loewenstein, 1991). Due to the complexities of dissociative presentations, it is helpful to have several sources of information when possible. These sources may include information gained from interviews, behavioral observations, self-report and performance-based measures, or collateral sources (e.g., parents, friends, partners). Records from other professionals (e.g., physician) or institutions (e.g., academic) may also be helpful in looking for patterns of behavior across settings. It is common for individuals who are eventually diagnosed with a DD to not have been given this diagnosis by previous clinicians because few have training in assessing dissociation. As such, it is important to do an independent assessment, rather than relying on past diagnoses.

Interviews for Dissociative Symptoms

Two formal semi-structured interviews exist for DDs: the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D; Steinberg, 1993) and the Dissociative Disorders Interview Schedule (DDIS; Ross, n.d.). Loewenstein (1991) 16 Dissociative Disorders 405 also offered a less formal clinical examination: the Office Mental Status Exam for Dissociation (OMSE). These interviews assess the following symptom domains: memory disruption, including blackouts, time loss, fragmentary recall of life history, disremembered behaviors, fugues, and discovery of unexplained possessions; depersonalization and derealization; usual bodily experiences, including somatoform symptoms, analgesia, and negative hallucinations (the ability to ignore or block out sensory information, such as taste or smell); identity confusion and alteration, including passive influence, hearing voices, changes in relationships, fluctuations in skills, habits or knowledge; and trauma and PTSD symptoms. The SCID-D is widely considered the “gold standard” for assessment and differential diagnosis of DDs (Steinberg, 1993). This 277-question interview assesses five symptom domains: amnesia, depersonalization, derealization, identity confusion, and identity alteration (see Table 16.1 for examples). The clinician may then select two additional clinical areas for further inquiry, including rapid mood changes, depersonalization, identity confusion, different names/person/childlike parts, internal dialogues, age regression and flashbacks, or feeling of possession. With each question, the client is asked to provide detailed examples of symptoms endorsed, as well as the frequency at which they experience these symptoms and any functional impairment. This interview requires training because it relies on clinical judgment to determine whether a response is consistent with dissociation. It provides a greater level of detail in comparison to the DDIS, which focuses solely on the client’s report of yes or no in regard to symptoms. The SCID-D-R has excellent interrater reliability (Steinberg et al., 1990) and test-retest reliability (Steinberg et al., 1990) and can distinguish DID from feigned dissociation and schizophrenia. Loewenstein’s (1991) OMSE for dissociation offers examples of common responses given by persons with DID. Table 16.2 lists essential questions. The clinician strives to be thoughtful about the order of questions. Generally, clients respond best when first asked about less evocative material, which facilitates rapport building. It is essential that clinicians solicit examples of symptoms endorsed and seek clarity about whether they occur exclusively in the presence of a medical condition or under the influences of substances.

Setting the Stage for the Interview When interviewing for dissociation, it is imperative to reinforce the client’s autonomy. Loewenstein (1991) recommends that the clinician explicitly remind clients they control their responses and may take breaks or discontinue the interview if needed. Until an alliance is formed, with triggers and coping strategies known, clinicians should assist clients in using containment and grounding strategies if they begin to dissociate, get overly detailed about trauma, or become distressed. Grounding focuses on bringing the client’s attention back to the present moment, with a focus on reducing dissociation. Examples include asking the individual to look around while describing five things in the room, using movement to help them feel their body such as pushing their feet into the ground, or orienting to the present moment (e.g., asking the city they are in or the current date). 406 T. D. Bailey et al.

Table 16.2 Office mental status interview for assessing dissociation Domain Example questions Blackout/time loss Do have difficulties remembering events in your life? Do you have blank spells when not under the influence of substances? Disremembered behavior Do you have moments where you are uncertain if you did something or if it was a dream? Do people talk about things you did that you have no memory of? Fugues Do you ever travel somewhere without remembering the journey or purpose of the trip? Unexplained possessions Do you find possessions (e.g., clothes, groceries, books) that you do not remember buying? Are any of these items unusual for you? Do you experience confusions about purchases on your bank statement? Do you find creations, such as writing or art, that you are certain you completed but you have no recollection of producing? Changes in relationships Do you notice people becoming angry or happy with you for reasons you cannot explain? Fluctuations in skill/habits/ Do you notice significant changes in your ability to complete knowledge tasks, without 1 day being easy and the next very difficult? Do your routines or preferences (e.g., food, music) seem to shift? Do you notice changes in what hand you use to do things or your writing style/penmanship? Fragmentary recall of life Do you have difficulty recalling certain periods of your life? history How much do you remember of your childhood? Is it difficulty to remember? Are there important events, such as the birth of a child or work promotion, that you do not remember? Intrusion/overlap/interference Do you notice thoughts or emotions that do not seem to be (passive influence) yours? Do you have difficulty controlling them when they are present? Do you have urges to engage in behaviors that are not usual for you? Do you hear conversations in your mind that seem as if it is two different people? Negative hallucinations Can you make aspects of your environment, such as people or objects disappear? Analgesia Can you dull or ignore physical pain with ease? Does this happen all the time or just sometimes? Depersonalization/ Do you ever see yourself engaging in behavior, but it’s like you derealization are watching from a distance or the ceiling Do you ever that parts of your body or thoughts are unreal? Do you notice the world is foggy or that locations you have been before appear strange? Do you ever experience confusions when looking in the mirror? Note: Selected examples adapted from Brand and Loewenstein (2010) 16 Dissociative Disorders 407

Although the therapeutic relationship is always important in assessment and treatment, building rapport and an alliance is even more critical among traumatized individuals who frequently have a history of being harmed by others (Herman, 1997; International Society for the Study of Dissociation et al., 2011). Clients often assume any interpersonal difficulty is their fault and is evidence of their bad/wrong/ brokenness, further reinforcing the shame cycle. It is critical to note that these experiences can be activated during the interview process and behavioral indicators of shame may be well controlled. The interactive complexities between shame and dissociation can be important diagnostically yet also create difficulties in obtaining an accurate picture of a client’s current symptoms.

Intra-interview Behaviors It is important the clinician carefully track both interview content and process for signs of possible dissociation. Clients with a DD often have moments of incoherent, non-cohesive, or even contradictory elements in their narrative (Putnam, 1989). There may be intra-interview dissociative phenomena including short memory lapses, trance states, and subtle or, more rarely, florid behavioral changes. For example, dissociative clients may lose their train of thought more than is typical, frequently ask the clinician to repeat questions, or have little or no memory of what was discussed during a prior or earlier part of a meeting. Subtle or significant behavioral changes may also be evident, including eye movements (e.g., unusual amounts of eye rolling, rapid blinking, eye closure, blurred/blinded vision), mannerisms such as repeatedly covering their eyes, and changes in posture (e.g. shifting from upright into a “collapsed” or even curled up, childlike position), facial expressions, voice, speech, and affect (Loewenstein, 1991; Putnam, 1989).

Memory Disturbance A hallmark of some DDs is memory disruption that cannot be explained by a medical condition or substance use. These disturbances include gaps in the autobiographical memory, time loss or blackouts, fugues, disremembered behaviors, and unexplained possessions. This fragmentary recall may be described as missing “chunks of time” or memories being “really fuzzy.” The individual may know of experiences that are normally remembered because others have told them stories or shown them photographs, but they do not actually remember participating in the event, including even important events (e.g., their wedding, the birth of their child), or a large gap such as their entire middle school years (Putnam, 1989). Such memory gaps usually occur in the remote past as well as in adulthood for complex dissociation. These blank spells extend beyond normal forgetfulness and are often distressing. Jennie, a woman living with DID, remarked, “I have such a bad memory. I look at the clock and see that two hours have passed and I have no idea what I’ve been doing! I think as hard as I can, trying to remember, but nothing is there – it is like a black hole.” Individuals with DDs may report discovering evidence they have engaged in an activity of which they have no memory. For example, the individual finds writings or drawings that they do not recall producing. Others may discover clothing they must have purchased or that possessions are gone and they have no recollection of getting rid of the items. Family and friends may also remark that they have said or 408 T. D. Bailey et al. done something for which they have no memory. Paul, a man living with DID, explained, “My wife and I often quarrel because she says I have promised to do something, but I really do not remember discussing it. Sometimes I even find things I must have written around the house, but I swear, I can’t remember writing it.” Others will describe marks or injuries on their body with no memory of how they obtained them. In some severe cases, the person may experience fugue states, finding himself or herself in a location with no memory of traveling or the purpose of the trip. These disremembered behaviors, discussions, and unexplained possessions are not a one-time occurrence but most often are part of a behavioral pattern that suggest the person suffers from a range of dissociative symptoms.

Depersonalization/Derealization Depersonalization and derealization are altered perceptual experiences, wherein the individual feels disconnected from himself or herself (“I’m not here”) or the world (“I’m not here”). Depersonalization and derealization often occur during or after trauma, yet for those with DDs, they frequently recur in times of stress. Derealization may be described as seeing through a “fog,” or living in a “daze” or “dream.” Depersonalization may be described as feeling “outside oneself” or “floating above” one’s body, watching things happen as if it were happening to another person, or feeling inhuman (e.g., “like a robot”). Lisa, a woman diagnosed with depersonalization disorder, stated, “I’m almost never in my body. I just kind of float out and hover above it, just watching everything happen like it is a movie. It is happening to me, but not happening to me.”

Unusual Bodily Experiences People with DDs often experience somatoform symptoms that cannot be medically explained, such as non-epileptic seizures, unexplained sensations or pains (e.g., pain in genitals), numbness, sudden paralysis, and shifting acuity in eye sight (Loewenstein, 1991). Some people report the ability to block out physical or emotional pain. Unlike those with borderline personality disorder, who tend to self-harm to stop numbness or depersonalization because they find it intolerable, individuals with DDs more frequently use self-harm toinvoke analgesia or depersonalization because they prefer to be dissociated than feel emotions or their bodies (Brand & Loewenstein, 2010). As such, an understanding of the functions of self-directed violence can be informative. Finally, it is not uncommon for people with DDs to report an aptitude for blocking out people, objects, or sounds in their environment.

Identity Confusion and Alteration Individuals with DDs frequently report a sense of confusion about their identity, likes and dislikes, and skills or abilities. Contrary to dramatic media portrayals of DDs, most people with DID seek to hide symptoms of identity confusion or alteration, and their shifts in identity tend to be subtly expressed (Brand & Loewenstein, 2010). Passive influence occurs in the presence of distinct self-states when one or more overlap to influence the person’s thoughts, feelings, or behaviors. Both individuals with DID and those with the similar form of OSDD, who experience fragmented self-states without amnesia between them, report passive influence phenomena. 16 Dissociative Disorders 409

This experience can be felt as a “war inside,” with conflicting opinions or demands about what to say, think, or do (e.g., arguing with one’s self for hours about what to wear or eat). Some people describe feeling like a “puppet,” with someone or something else inside them forcing them to be silent, to say things they do not wish to say, or to show emotions for no reason. As a result, it can appear as if the individual demonstrates rapid mood changes. Additionally, many people with DID report feeling suddenly much younger than their actual age (e.g., a middle-aged woman suddenly experiences herself as a very young child). Some people will look in the mirror and see someone other than themselves (e.g., of a different age, gender, or ethnicity). Others may call them by different names yet seem to know them. These experiences can be quite unsettling and frightening to admit or discuss. Fluctuations in skills, habits, or knowledge are common among more severe DDs. For example, they may produce skillful art or be able to operate a machine 1 day but have no ability to do so the next. Some clients will report suddenly not being able to drive. Others may describe baffling changes in handedness or preferences for food, music, or friends. Additionally, many people with severe DDs describe significant changes in handwriting that cannot be explained by fatigue (e.g., writing changes size, style, or developmental level). Finally, auditory hallucinations of voices or conversations are common among those with complex DDs, typically beginning in childhood. These voices may sound like people from the client’s past, or be childlike, harsh/denigrating, or protective and comforting. Dorahy et al. (2009) compared voice hearing among clients with DID and schizophrenia. Unlike those living with schizophrenia, clients with DID often report hearing multiple voices in conversation at the same time. Dorahy et al. (2009) also found that people with DID hear voices at a younger age, multiple voices that may comment on activities or converse, and child voices. Therefore, it is important not to assume a psychotic presentation when someone reports hearing voices and ask follow up questions to differentiate whether they are consistent with a DD.

Trauma and PTSD Symptoms Assessing trauma history is important regardless of presentation. The vast majority of individuals living with DDs are survivors of childhood maltreatment and meet the criteria for PTSD (Dalenberg et al., 2012, 2014). Intrusive images, flashbacks, nightmares, hypervigilance, and avoidance behaviors are common. Self-injurious behaviors are prevalent among those with complex DD, ranging from 24% to 77.5% (Coons & Milstein, 1990; Foote, Smolin, Neft, & Lipschitz, 2008).

Self-Report Measures

Self-report measures can be useful in screening symptoms for diagnostic clarification, as well as tracking progress in therapy. However, it is critical to note that highly dissociative individuals may under-endorse symptoms for a variety of reasons (see below). The following measures have solid evidence for reliability and validity. 410 T. D. Bailey et al.

Broad Trauma Measures Because trauma creates a variety of negative outcomes, including dissociation, measures that assess a breadth of symptoms can be helpful. Both the Trauma Symptom Inventory-2 (TSI-2) (Briere, 2011) and Detailed Assessment of Posttraumatic Stress (DAPS) (Briere, 2001) assess a variety of posttraumatic symptoms, including dissociation. Although scales on these measures may indicate the presence of dissociation, they do not provide detailed information about the specific symptoms experienced (e.g., amnesia), so are considered to be screens for dissociation, rather than diagnostic of DDs.

Screening Measures Several common dissociation measures primarily focus on a single score that is suggestive of the presence of dissociation. Similar to the broad trauma measures, the measures that yield a single score do not indicate which specific category of dissociative symptoms is present. However, these measures are valuable because they are quick to administer and score. High scores indicate the need for further exploration. The most common tool is the Dissociative Experiences Scale (DES) (Bernstein & Putnam, 1986). The DES-II is a 28-item measure that assesses the frequency of dissociative experiences through daily life. Scores over 30 are considered high in dissociation, with an average score of 48 for those diagnosed with DID. Other helpful screeners include the Somatoform Dissociation Questionnaire (SDQ) (Nijenhuis, Spinhoven, Van Dyck, Van Der Hart, & Vanderlinden, 1996) and the Cambridge Depersonalization Scale (CDS) (Sierra & Berrios, 2000).

Multiscale/Symptom Dissociation Measures When a dissociation score is found to be close to or higher than the cutoff on a screening or global trauma measure, further assessment for a DD is indicated, preferably with one of the following more detailed self-report measures as well as an interview for DDs. The Multiscale Dissociation Inventory (MDI) (Briere, 2002) is a self-report scale that assesses five different dissociative symptoms. The MDI does not have validity scales, so assessors must be aware that under- or over-reporting is not detected by the MDI. The Multidimensional Inventory of Dissociation (MID) (Dell, 2006b) is a 218-item self- report measure that provides a wealth of information about the types of severe dissociation. The MID has several validity scales and scales to assess for features of borderline personality disorder, but assessors are cautioned that the MID does not use a set time frame for experiencing symptoms. If concerning items are endorsed, it is important to determine if the symptoms are current and evaluate items related to exaggerating symptoms for attention. Finally, the DDIS (Ross, n.d.) has been expanded to include a self-report version.

Performance-Based Measures

Performance-based measures such as the Rorschach (Exner & Erdberg, 2005) and Thematic Apperception Test (TAT; Murray, 1943) can help identify DDs and differentiate them from other disorders by allowing the client to express important 16 Dissociative Disorders 411 internal experiences without discussing them directly (Brand, Armstrong, & Loewenstein, 2006). Statistically significant differences exist on the Rorschach between those with DDs and those without or those living with borderline personality disorder or schizophrenia (see Brand, Armstrong, Loewenstein, & McNary, 2009). Further, dissociative clients may respond with themes of disconnection, trauma, and interpersonal isolation, as well as have dissociative reactions when providing responses to the TAT (Pica, Beere, Lovinger, & Dush, 2001)

Case Illustrations

Chronically Traumatized Female

Emma1 is a middle-aged Caucasian female who entered therapy following a suicide attempt by overdose after being raped by her boyfriend. She reported physical, verbal, and sexual abuse by her alcoholic father, verbal abuse by her mentally ill mother, and sexual abuse by a neighbor during childhood. After being removed from her parents’ home, Emma was placed in foster care, where some caregivers were abusive. Due to “treatment-resistant” depression and repeated suicide attempts, she had been hospitalized over ten times. Emma demonstrated affective dysregulation with marked fluctuations in emotional states (e.g., anger giving way to tearful dysphoria, alternating with dissociative spells of looking “zoned out,” fear, and fleeting positive emotion). She was plagued with almost constant thoughts of suicide (with several life-threatening attempts) and occasional homicidal ideation toward her boyfriend. She had frequent nightmares that made her avoid sleep until the sun began to rise. Having been raped in bed as a child, she could sleep only on a couch. Emma distanced herself from emotions and memories of abuse through dissociation, avoidance behaviors, and focusing on her pressing health issues. She had few friends due to her conviction that others would “hate me if they knew me.” Emma also struggled with numerous medical problems including obesity, irritable bowel syndrome, fibromyalgia, lumbar disc disease, chronic fatigue syndrome, frequent headaches, and type II diabetes. Despite these daunting problems, Emma was likable and expressed a desire to “stay out of the hospital.” Eventually, a social worker who evaluated her recognized the complex trauma (CT) origin to Emma’s difficulties. Specifically, she noted identity confusion, amnestic episodes, and frequent depersonalization. She also noted an increase in these symptoms when asking Emma about her past. Emma was then referred to a therapist trained in treating CT-based problems. The therapist focused on psychoeducation, safety planning, and teaching Emma techniques for healthy emotion regulation. Emma gradually felt supported, enabling her to end the relationship with her abusive boyfriend. As her avoidance decreased and her engagement in the world

1 The case examples included in this chapter have been de-identified and altered to protect the clients’ confidentiality. 412 T. D. Bailey et al. increased, she began to experience more intrusive recollections of abuse. The therapist taught her grounding and containment strategies to manage these symptoms. After she was able to better control her PTSD symptoms, she began doing phase 2 trauma-processing work, starting with discussing the episodes of abuse about which she had the least shame. Her PTSD and dissociative symptoms tended to temporarily escalate, followed by stabilization, although she had several relapses of self-harm. Following several years of trauma processing, Emma’s depression began to show significant improvement that endured for longer periods and she felt increasingly self-confident. She earned an associate’s degree and obtained a better job. For the first time in her life, she became romantically involved with someone who was relatively stable and supportive. While she continued to struggle with obesity and diabetes, her health improved. During the last stage of treatment, she focused on the functions of overeating (e.g., reducing feelings of vulnerability), and she learned to tolerate physical and emotional intimacy.

African American Male

Marques was a 27-year-old male who presented for treatment because of concerns about his ability to manage his anger. Although he was hesitant to discuss his experiences at first, documents indicated a history of exposure to community violence, substance abuse (in utero exposure and early age of first use), and parents who were periodically incarcerated. As the oldest of four, Marques became responsible for taking care of his siblings when his caregivers were not present. Although there were often family members who would help out, they engaged in physical and emotional abuse of all the children, often targeting one child and forcing the others to watch to ensure “they learned their lessons.” Marques frequently attempted to protect his siblings, which resulted in more severe consequences for him, including a broken arm, concussion, and significant bruises throughout his adolescence. He learned early to use physical violence and verbal aggression to solve problems with peers, resulting in suspensions from school. He began smoking marijuana daily when he was 8 years old and drinking alcohol to the point of intoxication on a weekly basis by 10 years old, and he had tried nearly all other substances at least once prior to the age of 13. Upon entering treatment, he continued to smoke marijuana (>1/8 ounce a day) and drink on a daily basis (at least 13 oz. of hard liquor) and methamphetamines (binge consumption pattern). Treatment progressed slowly, with multiple missed sessions during the initial phase. Marques was charged with possession of drug-related paraphernalia, which resulted in him being ordered by the court to have weekly drug testing. One of his close friends overdosed, which motivated him to obtain treatment for his substance abuse. As he established sobriety for the first time in his adult life, the therapist noted his angry outburst arose after moments of sadness. As Marques learned to regulate his feelings, he began to describe himself as “fuzzy” or “watching myself 16 Dissociative Disorders 413 from far away” during aggressive episodes. He indicated that he occasionally heard his caregivers’ voices during these times, especially a particularly abusive uncle. At this point, the therapist administered the TSI-2 to assess a broad range of posttraumatic symptoms. Marques’ profile was notable for elevations on numerous scales, including the dissociation scale, so the clinician administered the MDI, which showed clinically significant elevations on depersonalization, derealization, and emotion constriction. As they further explored his experiences, Marques came to appreciate both the adaptive nature of dissociation during childhood but also began to recognize how dissociation was negatively impacting his current life, including numbing him from feeling positive feelings toward his girlfriend. He worked with his therapist to improve emotion regulation and reduce overreliance on dissociation using grounding techniques.

Impact of Race, Culture, Age, and Other Aspects of Diversity

Diversity, as it relates to development and expression of dissociative symptoms, has been under-researched (Dorahy et al., 2014). Although research often focuses on the interaction of a single diversity variable (e.g., culture), human identity is an interactive matrix that frequently shifts with context (Hays, 2016). Models such as Hays’ (2016) ADDRESSING framework provide a guide to assess each aspect of a person’s identity, evaluate whether they identify with a disempowered group within the context of a dominant culture, and understand the impact of identity dimensions on symptoms and presentation. Various identity aspects (e.g., young age, non- Caucasian), can increase the likelihood of experiencing trauma, and therefore, dissociative symptoms (see Brown, 2008 for a review). Cultural factors may also influence the development and expression of dissociative symptoms (APA,2013 ). For example, those in certain cultures may be more likely to describe passive influence phenomena as experiences of possession. Further, it is critical to consider how the clinician’s identity, particularly if they are of the dominant culture, may impact assessment, particularly when working with someone who has multiple target group identities (e.g., a Caucasian heterosexual male evaluating a lesbian African American Woman).

Intersubjectivity in Diagnostic Interviewing

It is imperative to consider the mutual influence of the client and clinician on the diagnostic process. Intersubjectivity is the product of interaction between the client and clinician’s identity dimensions. Through this interaction, certain dimensions may be notable, while others may be less obvious. Therefore, it is crucial not only 414 T. D. Bailey et al. to assess the client’s identity aspects but also the assessor’s own identity aspects and how they may impact what clients share or do not share during evaluation. Among those living with DDs, and particularly DID, intersubjectivity may be even more complex, with the individual potentially experiencing themselves as having multiple and varied self-states. These self-states may identify with varying ages, genders, sexual orientations, ethnicities, and so on. The client’s identity may shift in accordance with dissociative switching so that at one moment, they experience themselves as a cisgendered adult who is a married, heterosexual, Latina woman and the next they experience themselves as a gender queer Latino male child. In response, it is common for the clinician to experience a pull to shift his or her own behavior, although it is important to strive to remain as consistent as possible. For example, the clinician may feel a pull to speak in a more simplified manner or in a higher-pitched tones commonly used with children. Given the potentially complex and shifting identities of clinicians and DD clients, we recommend that the clinician track the following when interviewing dissociation, using the ADDRESSING framework: (1) how the client is experiencing himself or herself in this moment, (2) precipitants to felt identity shifts (e.g., sounds, topics of conversation, changes in the clinician), (3) and how the clinician is experiencing himself or herself in relation to the client. When a shift is felt, we invite the clinician to note the same, hold the space for curiosity, and promote exploration. In maintaining this frame throughout the interview, trauma-related triggers and dissociative phenomena can be more readily identified and understood (see Armstrong, 1992; and chapter 3 in Steele, Boon, & van der Hart, 2017 for further discussion).

Intersecting Identities and Trauma Vulnerability

Within the context of a dominant culture, there are target groups who are disempowered based on an identity variable. Some of those identities change over time, such as age, while others are static (e.g., ethnicity). Whether dynamic or static, certain aspects of identity increase the likelihood of experiencing a traumatic event(s) and developing dissociative symptoms. For example, gay and lesbian individuals are likely to experience attachment-related and other traumas throughout their lives because of their sexuality, particularly in countries where these aspects of their identity are considered criminal. However, it is also important to note that recent metanalytic results that suggest childhood maltreatment (e.g., physical, sexual, or emotional abuse), one of the most robust predictors of developing a DD, may be prevalent to a similar degree across the globe (Stoltenborgh, Bakermans-Kranenburg, Alink, & van Ijzendoorn, 2015). Research from around the world has demonstrated DDs are common across cultures, suggesting young age may be one of the more important risk variables to consider. 16 Dissociative Disorders 415

Information Critical to Making a Diagnosis

Regardless of whether criteria for a DD are met, comorbidity is typical when severe dissociative symptoms are present. Therefore, it is critical to understand what other diagnoses have a high frequency of dissociative symptoms, as well as how comorbidity can obscure the presence of a DD. For example, dissociation that did not rise to the level of a DD diagnosis is common in BPD, DPTSD, conversion disorders, complex PTSD, depressive symptoms, OCD, substance use disorders, and schizophrenia (e.g., Lyssenko et al., 2018).

Differential Diagnosis

Making the diagnosis of a DD can be challenging for many reasons. First, clients rarely volunteer information about their dissociative symptoms or trauma histories, so clinicians must inquire about both. Clients with DDs are typically aware that their symptoms sound “crazy” – creating shame, confusion, and/or fear that can reduce willingness to discuss them. It is common for them to report they are “losing their minds.” Second, many severely dissociative clients attempt to hide their poor memory, so clinicians need to directly ask about amnesia, as well as be attentive to brief moments of not recalling earlier aspects of the interview. For example, if a person shows a shift in affect, the assessor can ask them what was being discussed just before the change, especially if the mood shift(s) is accompanied by behavioral signs that may indicate dissociation. Third, most clinicians have received minimal training, if any, about trauma and dissociation, so they do not know what to ask or watch for, nor how to distinguish dissociative symptoms from similar seeming symptoms (Brand, 2016). Fourth, severely dissociative clients may be unable to accurately report some of their symptoms and elements of their life history due to amnestic gaps for childhood, adolescence, and/or adulthood. Furthermore, their ability to recall their daily activities and history can vary, sometimes even within a single assessment session, according to how dissociative they are in the moment. These individuals’ variable memory and amnestic gaps can be confounding for clinicians who are not familiar with DDs, who may mistake this for dementia, substance abuse, or malingering. These alternative hypotheses must also be considered. Assessors may need longer assessment periods before making a differential diagnosis. Fifth, dissociative symptoms can easily be mistaken for symptoms of other disorders. For example, hearing voices is often mistaken for a psychotic process such as that occurs in schizophrenia, although research indicates that traumatized non- psychotic people can experience auditory hallucinations (Brand & Loewenstein, 2014; Longden, Madill, & Waterman, 2012). The shifts from flat to depressed or irritable affect, or to agitation, are often mistaken for bipolar or borderline personality disorder. While these disorders can co-occur with DDs, they are not synonymous, and they can be due to an undetected DD. Sixth, skepticism about the 416 T. D. Bailey et al. existence and/or validity of DDs can contribute to misdiagnosis; this is an important topic worthy of further discussion. Skepticism and lack of training about dissociation often coexist. A survey of psychologists found that only 5% felt knowledgeable about DID, and 73% reported having received little or no training about DID (Mendez, Martinez-Taboas, & Pedrosa, 2000). Skepticism and lack of knowledge about the disorder were correlated, suggesting that more training about dissociation would be useful. Only 60.4% of US clinicians could correctly diagnose DID when presented with a vignette clearly depicting the condition (Perniciaro, 2015). The most frequent misdiagnoses were PTSD (14.3%), schizophrenia (9.9%), and major depression (6.6%). Accurate diagnoses were most often made by clinicians who had treated a DID patient and who accepted the validity of DID. Of concern, clinicians were confident in their diagnoses, regardless of their accuracy. Studies documenting a lack of training about dissociation and linking this knowledge gap with misdiagnosis of DDs have been conducted in the United States, Northern Ireland, and Australia, indicating a widespread lack of training about DDs (Dorahy, Lewis, & Mulholland, 2005; Leonard, Brann, & Tiller, 2005; Perniciaro, 2015). These individuals’ complexity can obscure a DD. DD clients typically have multiple comorbid psychological and medical disorders (International Society for the Study of Dissociation et al., 2011). Along with a mixture of dissociative symptoms, individuals with the complex DDs typically experience additional difficulties including PTSD, treatment-resistant depression, substance abuse, eating disorders, somatoform symptoms, self-destructive and suicidal behavior, and personality disorder traits (e.g., Dell, 2002). They report higher levels of first rank symptoms than do patients with schizophrenia, with the exception of audible thoughts and thought broadcasting (Kluft, 1987a; Ross et al., 1990). The individual may be partially conscious of some aspects of dissociation (e.g., hearing voices, thought insertion/withdrawal, “made” actions/impulses) as well as completely unaware of what they do in some states (e.g., time loss) (Dell, 2006a). Distinguishing characteristics are presented in Table 16.3 to clarify differential diagnosis. Self-report measures and dissociative interviews are useful in making differential diagnoses. Assessors are encouraged to routinely use one or more of the self-report measures, in addition to the semi-structured interviews for DDs listed above.

Exaggerated, Factitious, and Malingered Presentations

Individuals with developmental or prolonged trauma often show elevations on a wide range of clinical and validity scales due to the severity and breadth of symptoms associated with trauma (e.g., Wolf, Reinhard, Cozolino, Caldwell, & Asamen, 2009). Clinicians need to be knowledgeable and up to date about research that provides empirically based guidance for interpreting traumatized individuals’ performance on psychological tests and interviews, particularly in forensic and disability 16 Dissociative Disorders 417

Table 16.3 Features that typically distinguish DID/OSDD from borderline personality disorder, bipolar disorder, and schizophrenia Borderline Schizophrenia and Bipolar personality Feature DID/OSDD psychotic disorders disorder disorder Trauma Typically report CT less likely CT less likely CT is frequent and early onset, severe, often less severe chronic childhood than DID trauma (CT) Dissociative Typically endorse Endorse mildly high Lower Moderate symptoms high levels with symptoms with poor dissociation symptoms; intact reality RT scores expected significantly lower testing (RT) than DID with Often prefer to feel intact RT numb than to have Not significantly strong feelings. different from May self-harm to DID on DR and induce a state of DP, but dissociation significantly lower When dissociating, on AM, IC, IA may be involved in Distressed by elaborate inner feeling numb; world involving may self-harm to identities stop dissociating When dissociating, likely DR or DP. Do not have an inner world of complex identities Shifts in May admit to May admit to None May experience identity transformations in transformations in identity changes identity (e.g., “Part identity but with related to of me is a scared magical or polarized mood child and another delusional beliefs. changes (e.g., “I part is critical and (e.g., “I had to was the loving, yells like my become the prophet happy me when I abuser did.”) David and then had was dating my Endorse past and to fight myself when boyfriend but current amnesia for I became the devil.”) when he left, the many types of No current AM depressed, angry behaviors (except when me took over.”) recalling periods of Little if any florid psychosis) significant current AM outside of drug and alcohol use May have less detailed recall for behavior in mood states different from current one (continued) Table 16.3 (continued) Borderline Schizophrenia and Bipolar personality Feature DID/OSDD psychotic disorders disorder disorder Hallucinatory Voices express May endorse voices Experiences If experiences experiences conflicting without awareness hallucinations hallucinatory opinions and of hallucinatory only during experiences, they values quality episodes of are brief and Hearing “thoughts Voices are not psychotic distressing and that aren’t mine” involved in mania or occur during or “arguing elaborate, ongoing depression stress thoughts” discussions In psychotic If endorses voices, Multiple Voices are not depression, the they express conversations at typically related to voices are patient’s polarized the same time past abusers and/or typically solely thoughts, not May experience hurt children persecutory different values brief periods of Hallucinations are Voices not in and opinions “seeing” past due to psychotic conflict with traumas or process one another. “seeing” identities; RT otherwise intact. Auditory/visual hallucinations relate to high dissociation Affect Mood shifts are Flat and/or Less rapid Affect is often rapid and inappropriate affect mood shifts significantly less frequent that occur modulated than in due to internal or DID and shifts external events according to Typically avoid external affect precipitants Frequent emptiness and intense anger Ability to Perceptions are Perception is not Disturbed only Perception is perceive generally accurate significantly less during mood significantly less accurately and Thinking is usually accurate than in episodes accurate than in think logically logical and DID DID organized despite Thinking is Thinking is traumatic significantly less significantly less intrusions logical and logical and organized than DID organized than in DID Working Can develop a Less capable of Capable of Often less capable alliance working alliance developing a developing a of developing a although need working alliance working working alliance trauma-based alliance due to intense mistrust to be emotionality and repeatedly poor self- discussed and observation skills managed Adapted from Brand and Loewenstein (2010) Notes: CT childhood trauma, RT reality testing, DP depersonalization, DR derealization, AM amnesia, IC identity confusion, IA identity alteration, OSDD other specified dissociative disorder 16 Dissociative Disorders 419 assessments, where there may be motivation to exaggerate symptoms. Distinguishing exaggerated from factitious, malingered, and genuine DDs is further complicated because individuals may fully fabricate their symptoms, or they may have a genuine DD yet exaggerate some of their symptoms (Kluft, 1987b). Many validity scales that were developed to detect possible exaggeration or malingering included symptoms that are common among trauma survivors; when these individuals honestly report the wide range of symptoms they experience, their endorsement of items, which were thought to be rare, may elevate their scores such that they are misclassified as feigning. Research is developing that can assist clinicians in distinguishing feigned from genuine trauma presentations, although many tests have not yet been studied with traumatized, including highly dissociative, individuals. Space constraints limit this discussion to noting that individuals with genuine DDs are at risk for being misdiagnosed, and/or misclassified as feigning, by many validity tests and interviews. These include the Minnesota Multiphasic Personality Inventory-2 (Brand & Chasson, 2015; Brand et al., 2016; Butcher, Graham, Ben-Porath, Tellegen, & Dahlstrom, 2001); the PAI (Stadnik, Brand, & Savoca, 2013); the Structure Interview of Reported Symptoms (SIRS), although using the Trauma Index on the SIRS/ SIRS-2 greatly improves the utility of this test (Brand, Tursich, Tzall, & Loewenstein, 2014; Rogers, Sewell, & Gillard, 2010); and the TSI-2 (Briere, 2011; Palermo & Brand, 2018). The Test of Memory Malingering (TOMM; Tombaugh, 2002) is one of the only symptom validity tests that has been studied in DD individuals (Brand, Webermann, Snyder, & Kaliush, 2018). The TOMM shows promise because it does not over-classify DD individuals as feigners. It is notable that even clients diagnosed with DID in forensic evaluations pass the TOMM, providing support to the idea that the memory problems associated with this disorder are not typically exaggerated.

Dos and Don’ts

Dos • Routinely assess all clients for dissociation, regardless of presenting problem. Remembering that the most severe DD (DID) is about as common as schizophrenia and bipolar disorder. • Consider differences in culture and identity between the therapist and client, particularly when identity alteration happens. • It is critically important to assess traumatized clients for trauma-related difficulties, including dissociation. • Continually evaluate symptoms throughout treatment, utilizing interview, self- report, behavioral observation, and/or performance-based data. • Remember it is common for individuals to report more detailed dissociative experiences once rapport has been established, which may take months to years. 420 T. D. Bailey et al.

• Structure your interview to begin with less severe dissociative symptoms (e.g., depersonalization, derealization) and gradually moving toward more complex dissociative phenomena (e.g., amnesia, identity alteration). • If the client endorses milder forms of dissociation, either on a screening measure or during the interview, do ask about more severe forms (e.g., identity confusion and alteration). • If client reports having dissociative experiences that occur often, are disruptive to functioning, or cause distress, consider giving a screening measure, and if high, or there are signs of serious dissociative symptoms, do conduct a standardized interview for DDs. • When shifts in the client’s behavior and identity occur, strive to remain as consistent as possible without being rigid. • Know the latest dissociation literature, obtain specific training in recognizing dissociative symptoms, and consult regularly. Don’ts • Don’t avoid assessing for trauma exposure and dissociation due to concerns that it will be uncomfortable for the client or worry that inquiries may lead to the development of “false memories.” if questions are asked in a non-leading, respectful manner, with attention to client’s ability to tolerate the discussion, information that is crucial for diagnosis and treatment planning is generally attained. Simply asking about trauma exposure in a non-leading manner does not create false memories of trauma. • Don’t worry about “hurting” a dissociative client by asking about their symptomatic or traumatic experiences. If people learned to dissociate to survive trauma, they have survived worse things than discussing their symptoms. Of course, be mindful of clients’ ability to tolerate discussion if they seem overwhelmed. Go for the “headlines” of the story, rather than specifics. Take breaks, and use grounding and relaxation as needed. • Don’t be voyeuristic. When assessing for DID, be cautious about asking too many questions for the sake of curiosity. • Don’t consider a lack of elevation on a screening or broad trauma measure as evidence that dissociative symptoms are not present, particularly in the early stages of treatment.

Summary

Dissociative symptoms are conceptualized on a continuum, from those that are not considered pathological (e.g., highway hypnosis) to those that significantly impair functioning (e.g., identity fragmentation). Although generally thought of as rare, dissociative symptoms are common across many disorders, including PTSD and DDs. Given the potential impacts on treatment, it is imperative dissociation is routinely assessed for, particularly when there is a reported history of trauma. However, 16 Dissociative Disorders 421 individuals with DDs may be less likely to discuss these experiences at first because of concerns about how they will be perceived or whether the clinician can be trusted. As an alliance is formed, it is important to continue to evaluating whether or not dissociation is present, using multi-measure/source corroboration whenever possible. It is also important to obtain training, regardless of whether you are going to treat dissociation, as DDs are frequently misdiagnosed by those who have not learned how to effectively assess dissociative symptoms.

References

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Rebecca A. Grossman, Niza A. Tonarely, and Jill Ehrenreich-May

Description of the Population

A diagnostic interview is a useful first step in the assessment and treatment of a child exhibiting mental health concerns. There are a number of factors particular to youth that may impact the process of diagnostic interviewing. Similar to the diagnostic interviewing with other populations, it is of utmost importance to approach the process with children with genuine warmth and sensitivity in order to build and maintain rapport throughout the interview process. This chapter presents information relevant to the diagnostic interviewing process with children (and their caregivers), including the importance of considering development, guidelines for gathering information, a case study to illustrate the process, and considerations for diverse youth.

Differences Between Adults and Children

Children are in the midst of an intense cognitive and emotional development, which has implications for what is considered typical versus atypical behavior at any given time point. For example, there are behaviors that are common and adaptive at certain ages, such as separation distress during early childhood, which may be considered atypical or excessive at other ages. Similarly, development can vary between children, and the range of what is considered typical development is often broad. As

R. A. Grossman · N. A. Tonarely University of Miami, Coral Gables, FL, USA J. Ehrenreich-May (*) Department of Psychology, University of Miami, Coral Gables, FL, USA e-mail: [email protected]

© Springer International Publishing AG 2019 427 D. L. Segal (ed.), Diagnostic Interviewing, https://doi.org/10.1007/978-1-4939-9127-3_17 428 R. A. Grossman et al. such, awareness of developmental processes and expectations is of great importance when conducting diagnostic interviews with children. Additionally, symptoms of mental health disorders may be different in children compared to adults. While many symptom criteria in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) are often the same in children and adults, interviewers must be aware of slight differences within categories when considering a diagnosis. For example, many diagnoses have shorter time criteria for children than adults (e.g., a diagnosis of persistent depressive disorder in children requires the presence of symptoms for 1 year, compared to 2 years in adults). Similarly, symptom presentation may also be different in children from that in adults. As noted in the DSM-5, depressive disorders in children may be characterized more by irritability than sadness. Therefore, a firm grasp on DSM-5 criteria relevant to children is important for accurate diagnosis. In addition to differences in diagnostic criteria and symptom presentation, most children present with important contextual factors that are different from those of adults. First, many children do not come in for a diagnostic interview of their own volition. Instead, they are often brought to the clinic due to parent or teacher concerns. As such, many children may not understand why they are presenting for the interview nor recognize their problematic symptoms. Because of this, clinicians should always attempt to assess what the child knows about the process, why they think they have been brought to the clinic, and the clinician should be explicit about the interview process in a developmentally appropriate way. For example, children may be led to believe that they are going to see a doctor and may be nervous about receiving injections or receiving a physical exam. Therefore, clinicians should be aware of these common misconceptions and explain to the child what will and will not be occurring during the interview. This explanation can be aided by a review of an assent form or pre-interview handout for the child containing developmentally tailored information about the assessment process, in addition to the clinic’s standard consent process for the parent or legal guardian. Such information can even be provided on the clinic website for families to access prior to their visit. For an example of the type of information that may be provided to children, see Fig. 17.1. Explaining the interview process to the child and giving them the opportunity to provide their assent gives him or her a sense of autonomy, even for younger children where this may not be explicitly required by law. This can help increase rapport and trust in the clinician. Finally, there are important developmental considerations regarding the procedures for interviewing a child, including adjusting for children’s shorter attention spans, their typical fatigue and boredom during extended discussion, and resultant hyperactivity. When working with children, it is important to plan frequent breaks and to utilize methods to maintain the child’s attention, focus, and motivation. This may include creating a visual schedule that lists what will be covered during the interview or the schedule of the visit. To increase motivation, clinicians can employ the use of stickers or other reinforcers. For example, the clinician can explain that when a section is completed, the child can put a sticker on the visual schedule. 17 Children 429

Fig. 17.1 Pre-interview informational handout for children. Note: This example of a pre-interview informational handout might be provided to younger children to read independently or review with their parents or clinician during the intake appointment

These reinforcers can be used to earn rewards at the end of the interview, such as a small prize from a prize box or parent-provided incentive. Such strategies are especially helpful for children demonstrating inattention, hyperactivity, or oppositional behavior (which may be the presenting concerns). In such cases, utilizing a visual 430 R. A. Grossman et al. schedule and providing incentives for compliance may make the interview more pleasant for the child, and it will make the job of the clinician easier. To address oppositional behavior, interviewing clinicians may need to utilize a higher rate of reinforcement or complete the interview over multiple visits that are shorter in duration. In cases where children are particularly difficult or resistant to answering questions, it is of utmost importance for clinicians to establish strong rapport and maintain this rapport throughout. Such children may benefit from additional unstructured time with the clinician to build rapport and establish trust. Children should also be told explicitly that they may ask to use the restroom or take a break as necessary. For children who are more hyperactive, it can be helpful to allow them to stand and walk around the room while the clinician asks the child questions, as long as they are able to maintain their focus. For especially young children, or children who present with symptoms of separation anxiety, they may have trouble separating from their parents for the child portion interview. This can be a challenging situation, but a clinician may utilize rewards to increase compliance and encourage the child to separate. Alternatively, the clinician can allow the parent to remain in the room and fade out slowly while the clinician builds rapport with the child. If a child cannot separate from the caregiver without significant distress, it may be better to allow the parent/caregiver to remain in the room. However, it is important to note this behavioral observation when assigning a diagnosis.

Procedures for Gathering Information

Using the Referral Question

Prior to an initial evaluation or diagnostic interview with a child, a brief screen is often conducted to determine appropriateness of the referral for a given clinic or practice. This might include basic demographic information, referral source, and reason for referral (i.e., referral question). For children, this information is typically provided by a parent/caregiver who is seeking an evaluation for treatment or further assessment (i.e., psychoeducational or neuropsychological assessment). The referral question is critical to identifying appropriate assessment tools and formulating an initial set of hypotheses for the diagnostic evaluation process. The referral question is also important for determining whether the services requested can be provided in that particular setting.

Whom to Meet With

The referral question can provide valuable information about who to meet with to conduct the diagnostic interview and obtain relevant information. Depending on the purpose of the interview and the feasibility of communicating with other sources of 17 Children 431 information, the interviewer may wish to gather relevant data from others who observe the child in different contexts. This may include teachers, other caregivers or family members, or other service providers. In addition to interviewing the caregiver, child, and collateral informants, the order in which these individuals are interviewed can be important and can influence the process of diagnosing. Clinicians should be mindful that informants may be discrepant in their reporting about the child. While children behave differently in different environments, informants may also view problems differently, resulting in reporting discrepancies. Clinicians must integrate information provided by all informants to understand the presenting concerns and should therefore consider the vantage points of the informant in the child’s life (e.g., the child’s teacher versus parent) and how the environment may impact the child’s behavior with that informant. Although the child himself or herself is a critical source of information for the interview process, parents or guardians are often the people responsible for bringing children to the clinic and scheduling services, so it is important that they be interviewed to obtain relevant information about the child. Often, the parent/guardian is the most reliable source of information about the child’s developmental history, the history of their presenting problems, and the targets of intervention. As children get older and develop more insight, however, they may become a more reliable source of information, particularly information about their internal experience of symptoms. At times, children may be referred for evaluation or treatment by other providers or adults who are not the primary caregivers (e.g., teachers, healthcare professionals), and the parent may have less information about the presenting concerns because they have not observed these issues, or they do not perceive these issues as a problem. For example, children demonstrating behavioral concerns in the school setting may be referred for services by school personnel, and the parent may not observe the same problematic behavior at home. In cases like these, speaking with the referral source can be important, but meaningful information can still be obtained from the parent by asking questions specific to the reason for referral. Furthermore, parents expressing that they do not perceive their child to have a problem despite concerns raised by others is informative in itself. This may suggest, for example, that the child’s behavior is quite different across environments, or that parents perceive the problems as being manageable without mental health intervention. Interviewing parents can also provide useful information about the targets for treatment and the child’s environment. In addition to gathering information from parents about the child, meeting with the parents allows the clinician to obtain information about the parents and family that is pertinent to diagnosis and treatment. The way parents react to problematic behavior or clinical concerns, their perception of the causes of the problem, parenting stress, parent psychopathology, and their resources or motivation to address the problem are all important for diagnosis, case conceptualization, and treatment. If children spend a great deal of time with other caregivers (e.g., a nanny, grandparent), obtaining consent from the parent to speak with these people may also be helpful. In addition to interviewing the child and parent, information from others who observe the child in different settings may be useful. Teachers or other service 432 R. A. Grossman et al. providers can often provide helpful information about the child’s behavior in different settings. It is important to obtain consent from the guardian to communicate with these individuals. When interviewing teachers, it can be helpful to interview more than one teacher. Speaking with the parent/caregiver about which teachers would be most willing to communicate and able to provide information about the child’s school behavior may be necessary. Asking to speak to a teacher in a class where the child is doing well and one where the child is having more challenges is a useful way to understand the child’s strengths and difficulties, as well as the ways in which the environment impacts their behavior. Other service providers, such as psychiatrists and former psychotherapists may also be helpful for getting information about the child. Many times, children are referred for services by other providers, and obtaining information about the reason they referred the child for services can be useful. A summary of the sources of information and types of information that may be provided by each source is included in Table 17.1. While interviewing multiple informants across settings may be useful for obtaining comprehensive and thorough information about a child, this requires additional effort and time on the part of the clinician. Such extensive interviewing may be customary in some clinics for different types of services (e.g., psychoeducational evaluation versus intake for therapy). However, it is important to consider when efficiency should be prioritized over breadth of the interview, particularly if speaking with additional informants will unnecessarily delay the initiation of treatment or increase the cost of services.

Table 17.1 Sources of information Source Type of information Child Direct information about their own experience of symptoms or presenting concerns Parents/guardian Developmental history Treatment history History of presenting problems and current concerns Family dynamic and parenting strategies Referral source Information about the reason for referral, particularly helpful if parent does not perceive a problem Teachers Observations of the child in a different setting, outside the home Information about child’s school functioning Other service providers Treatment history Prior effective and ineffective strategies Medical/psychiatric history Direct observations School observation: child’s behavior in the school context Home/family observation: family dynamic and home environment 17 Children 433

General Interview Guidelines

The goal of a diagnostic interview is typically to identify the major problem or problems, assign a diagnosis, and develop an initial plan for intervention or treatment. In order to do this, the diagnostic interview should provide information that will be helpful for developing a case conceptualization. That is, the interview should provide the clinician with information about possible preceding and maintaining factors of the child’s current concerns in order to identify targets for intervention. Therefore, the interview should not only collect information necessary to diagnose but also to treat. The type or format of the interview will depend on the setting, the available time, the referral question, and the purpose of the interview. Clinicians may choose to conduct an unstructured interview, a semi-structured interview, or a structured interview. Each of these confers different advantages and disadvantages and may require different types of skills to be administered effectively. Despite their name, unstructured interviews typically involve a structure laid out by the interviewer with questions posed to the client (child and/or caregiver). Unstructured interviews do not utilize a standardized format, which allows questions to be asked in any order. The accuracy of diagnoses established from an unstructured interview can vary depending on the skill of the interviewer and the interviewer’s thoroughness in obtaining information necessary to confirm whether certain diagnostic criteria are met. The primary advantage of an unstructured interview is that it often follows the flow of the conversation, and this style can facilitate the development of rapport and trust between the interviewer and interviewee by creating a sense of comfort during the interview process. However, unstructured interviews tend to be narrow and hypothesis-driven, which leads to significant limitations for obtaining diagnostic accuracy. Semi-structured interviews provide guidelines for questions to be asked and follow-up prompts for additional information in order to assess the child and determine a diagnosis. Semi-structured interviews may include suggested questions and probes, but these types of interviews allow the clinician flexibility to ask additional questions and discuss other relevant information. While semi-structured interviews appear to improve diagnostic reliability, they may be more time-consuming and require additional training. Structured interviews follow more rigid rules, with questions being presented in a specific order, utilizing strict skip-out and follow-up rules (i.e., “if yes, proceed to next question; if no, proceed to next section”). They minimize variability and bias from the clinician and can provide information that is more objective. Such tools are often preferable in research settings that require reliability across evaluators and accuracy of diagnoses. Furthermore, because follow-up probes and questions are typically not included within the interview, they can often be conducted in a shorter period. However, structured interviews may not capture critical information necessary for a diagnosis, particularly where children have more limited insight. Structured interviews also capture the presence or absence of specific symptoms, 434 R. A. Grossman et al. but they may not capture information necessary for understanding the preceding and maintaining factors of the child’s presenting problem, which is critical for differential diagnosis, developing a case conceptualization, and establishing a treatment strategy. Regardless of the style of the diagnostic interview employed, to facilitate an open and honest discussion, rapport building is an essential first step when meeting with a parent or a child. Diagnostic interviewing often involves speaking about difficult topics and sharing personal information on the part of both kids and their caregivers. It is the responsibility of the interviewer to create a warm and supportive atmosphere; without such an atmosphere, children and their caregivers may be less willing to share information freely and answer questions openly. Several minutes should be set aside for rapport building with the child and with the caregiver to allow them to share general information about themselves or discuss topics that are unrelated to the reason for the clinic visit, as they acclimate to the interviewer and clinic setting. Asking children about things they enjoy can be a helpful way to make them feel listened to during the initial stages of an interview or to further personalize the interaction throughout. As noted earlier, another strategy to provide a supportive and welcoming environment is to introduce the steps of the interview or intake process with the parent and/or with the child. For many families, the diagnostic interview may be their first experience with a mental health professional, so proving clear information about the process and creating a welcoming environment can reduce anxiety about the experience. The order in which children and caregivers are interviewed can also impact the experience of the client and the type of information obtained by the clinician. Depending on the nature of the referral question and the family dynamic, it may be preferable to meet with the child first to obtain information and build rapport. In cases where there is conflict or discrepancy between the parent and child, interviewing the parent first may put the child on the defensive and may make him/her feel as though the clinician has aligned with the parent. In some cases, it may be appropriate to interview the parent first if, for example, the service being provided will be focused on the parents (e.g., parent management training), or if the child is younger. However, in situations where the child will be the focus of services (e.g., child- focused therapy), maintaining rapport with the child through the intake process is important. In cases where the child is resistant to therapy, it may also be helpful to meet with the child first in order to help build rapport and address any resistance with appropriate strategies. When meeting with the child, it is critical to set aside the necessary time to build rapport and address any concerns he/she may have about the assessment and/or treatment process. This is particularly important if the clinician conducting the diagnostic interview will also be the clinician responsible for treatment. In this case, the diagnostic interview is often the first meeting between the child and the clinician, so developing rapport and making the child feel comfortable sets the stage for a good therapeutic alliance. Meeting alone with the child also allows him/her the opportunity to speak freely about things he/she may not be comfortable discussing in front of parents and enables the clinician to understand the child’s perspective about the 17 Children 435 presenting problems. Children can be valuable sources of information regarding parent behaviors and strategies for managing the child’s presenting symptoms. It is also important when meeting with families to establish confidentiality within the clinic setting, but also to discuss issues of privacy relating to information that the child shares with the therapist, particularly for older children and adolescents. While parents have the right to know all information for children under age 18, it is important to briefly discuss with the parent and child what information they feel is necessary to be shared and how this information will be shared. Of course, it is important to establish that information that may jeopardize the safety or well-being of the child must be shared with the parent, and all applicable regulations and codes regarding reporting of such information must be followed. However, many children may be struggling with issues that they are worried about discussing with their parents, so creating an environment in which the child feels comfortable sharing these concerns with the clinician is helpful for obtaining a complete diagnostic picture. It is also important to interview the parent(s) or guardian(s) alone to obtain information about the child’s developmental history, the history of presenting concerns, family psychiatric history, and information about the presenting problems. While meeting with the parents, the clinician can discuss the assessment process and treatment, as well as provide information about what can be expected from the assessment and during treatment. Many parents may feel anxious and have questions about their child’s problems or treatment of these problems, so listening openly and providing reassurance to parents about the process is important during the diagnostic interview. Finally, to the degree that it is important to the diagnostic assessment, an opportunity to meet with and observe the child and the parent together is helpful for understanding the family dynamic. This meeting can be brief and can take place during the initial introduction at the start of the visit, or it can be more extensive depending on the information required by the clinician. Sometimes, a very brief observation can be sufficient, particularly in cases where there is obvious tension between the parent and the child. In these situations, navigating the diagnostic interview carefully is critical in order to obtain the perspective of the parent and the child independently.

Direct Observations

Observing behavior in various environments can be a useful source of data for establishing child diagnoses and developing a case conceptualization. Direct observation of the child can take place in more naturalistic environments, including the home or school. Using direct observation, the clinician can identify factors in the environment that contribute to the child’s behavior or maintain problematic behavior. In addition, through naturalistic observation, the clinician can identify antecedents of presenting concerns or targets for intervention in the environment. Direct observation can take place formally, using structured coding systems or functional 436 R. A. Grossman et al. assessment tools, or informally. In either case, it is important for the observer to establish the purpose and the focus of the observation in order to obtain useful data and consider whether an observation is necessary for the interview process, as this often requires significant time and may be costly for families. Observations may take place in the home or the school, although they should ideally be done unobtrusively. While observing the child at home can be useful for obtaining information about the family dynamic or home environment, it is often difficult to do this, as the presence of an observer at home may change the family’s behavior and/or may produce a more socially desirable presentation. Therefore, obtaining information about the family dynamic in the clinic is often a suitable alternative. Observing the child in the school may be especially relevant in situations where the presenting concerns are most impairing in this setting. In order to ensure natural behavior, it is often best to have the clinician send someone whom the child does not recognize. If the clinician has not yet met the child, he/she may be able to conduct the observation. It is necessary to obtain parent permission to conduct such an observation and to communicate with the child’s school to set up the observation and ensure that the school does not notify the child that he or she is being observed. For a summary of information that can be obtained through direct observation, see Table 17.1.

Additional Assessment

In some cases, it may be relevant to communicate with other healthcare or mental health providers to get information pertinent to the child’s presenting problems. Prior to such communication, it is necessary to have the parent/guardian provide a release to speak with other professionals that have seen the child. Speaking with physicians who have treated the child can help the clinician understand the interaction between medical and psychological concerns, which may be relevant for distinguishing somatic symptoms from those that result from an underlying biological condition, for example. Primary care physicians can also provide information about the child’s medical and developmental history. To facilitate communication with physicians, who may work on a different schedule from that of the therapists, it may be helpful to have the families alert the provider in advance of the clinician’s efforts to reach them. To reduce the burden on clinicians, families can also obtain copies of relevant medical records to share for assessment purposes. Speaking with other mental health providers, including psychiatrists or previous therapists, is also helpful to understand the presenting problems and prior treatment efforts in order to establish strategies that have or have not been helpful for the child. This also opens up a channel of communication between the interviewing clinician and other therapists or doctors who may be treating the child concurrently. Finally, depending on the referral question and the nature of the assessment, it may be 17 Children 437 necessary to use additional standardized tools, including cognitive and achievement tests, behavior rating scales, and personality inventories. These approaches are discussed later in the chapter.

Case Illustration

Katie is an 11-year-old White, Hispanic female referred by her parents for difficulties at home and at school. Laura X, Katie’s mother, brought her in for the interview. Her father was not present for the evaluation. On the phone screen, Mrs. X noted that Katie had been having significant anxiety-related difficulty at home, particularly around sleeping and going to school in the morning. During the first meeting, the clinician attempted to gather information from Mrs. X regarding Katie’s difficulties, as well as develop an understanding of the antecedents and consequences around her behaviors, both at home and in other settings (e.g., school). The purpose of the case illustration is to demonstrate methods of building rapport and setting the stage for a structured diagnostic interview, which will not be presented here. However, if using a diagnostic interview, this interaction may be incorporated into the interview itself. Clinician: Thank you for coming in today Mrs. X. What is the main reason you’re bringing Katie in today? Mrs. X: Well I’m just really worried about Katie’s difficulties around going to sleep at night and going to school in the morning. It’s a constant battle and there are days where I just give in and let her stay home. At night, her father and I have just given in at this point. She’s sleeping in our bed every night and her younger brother – he’s seven – is sleeping alone in his room. So, I know this isn’t typical. I just want to make sure I get her the help that she needs. Clinician: It sounds like you and Katie’s father are feeling pretty frustrated about this. So, it seems that Katie’s main areas of difficulty are around going to sleep alone and going to school in the morning. Does that sound right? Mrs. X: We’re so frustrated, but also just worried about her! Yes, those are the two big areas, but really, other times that I try to leave her with a baby- sitter, or even with her grandmother, she gets very upset and makes it very hard for us. Clinician: Oh, okay, so it sounds like really whenever you try to separate from her, she becomes pretty upset. Mrs. X: Exactly. Clinician: When you do get her to school, what’s she like at school? Mrs. X: Oh, not good. She probably calls me or messages me on her iPad 3 to 5 times per day. Clinician: And what do you usually do when she messages you? 438 R. A. Grossman et al.

Mrs. X: Well, I respond usually, unless I’m in a meeting or something. If I do take a while to respond, she starts getting even more upset and that usually leads her to go to the school nurse, who ends up calling me. So I usually try to answer as soon as I see it because I figure it’s probably better that she’s in her classroom, but I don’t know. It’s hard to keep up with this. At the most recent parent-teacher conference, I found out that she was getting Bs and Cs now and she’s always been a straight A student, so I’m afraid that she’s really distracted in school. Mrs. X’s description of the problem behaviors appears consistent with separation anxiety disorder or generalized anxiety disorder, as defined in the DSM-5. It is common with young children who present with anxiety concerns to exhibit symptoms consistent with more than one anxiety disorder. It is the goal of the diagnostic interview to obtain information to clarify the diagnosis. To be diagnosed with separation anxiety disorder, an individual must exhibit significant, developmentally inappropriate difficulty when separated from a loved one, and this difficulty must be present for at least 4 weeks. These symptoms must cause clinically significant distress and impairment. To be diagnosed with generalized anxiety disorder, an individual must exhibit significant worries in multiple domains (e.g., school, performance, safety). These worries must be present for at least 6 months and cause clinically significant impairment. The clinician will attempt to obtain information about why Mrs. X believes that Katie is exhibiting these behaviors. Clinician: Right, so it sounds like you’re really worried about how these behaviors are impacting her academic progress. You’re also struggling with how best to respond to her when she is checking in with you throughout the school day too. I wonder, do you have any ideas about what Katie is afraid of when separated from you? Has she mentioned why she needs to check in with you or why she wants to sleep in bed with you and dad? Mrs. X: I don’t think so. I mean in terms of the sleeping, it’s really just habit at this point. I mean, we used to try to send her back to her bed, but she would just get really upset and cry hysterically. My husband and I always just assumed that she was scared, but we weren’t really sure what it was exactly that scared her. I mean we live in a nice neighborhood, a gated community, so I can’t imagine that she’s afraid for her safety. But I don’t know. Clinician: So, it sounds like you and her dad are not really sure what it is that makes her want to sleep with you at night. What about her difficulty going to school in the morning? Do you have any ideas about what is causing that? Mrs. X: I’m not sure about that either. She does tell me that she’s going to miss me, and she asks me a lot of questions about what I’m going to be doing that day, when I will pick her up, whether I will pick her up or not. So, I don’t know, maybe she just doesn’t want to be away from me? Maybe she’s worried that I’ll forget her? That’s never happened though! 17 Children 439

Clinician: So, it sounds like maybe we have a little more insight into her difficulty going to school in the morning. Perhaps it’s because she doesn’t want to be separated from you, or maybe she’s worried about being left at school. Mrs. X: Right. Clinician: Okay – well thank you so much for all of that information. It’s very common to be unclear about why young kids have difficulties in certain situations. It sounds like you have some good hypotheses though and we’re going to ask Katie many different questions to try to get a sense from her about what makes these things difficult. Does that sound okay to you? Mrs. X: Yes, absolutely. Parents often do not fully understand the cause of some of their children’s avoidance behaviors. As such, it is very important to try to obtain this information from the child directly. Next, the clinician brought Katie into the room. With children, behavioral observations at the time of separation from the caregiver can provide important information, especially when there are symptoms of separation anxiety. Katie was noted to ask her mother multiple questions, including “Where will you be sitting?” and, “Are you going to leave?” Mrs. X responded to her questions, letting her know that she would be in the waiting room and that Katie could check on her if needed. Katie appeared reassured by Mrs. X’s responses and was able to stay in the room with the clinician. The interview started with some general rapport building with Katie, as well as an explanation of the rewards that Katie could earn by engaging with the interviewer. With children, reinforcement system may be necessary to keep the child engaged in the interview process, as some questions may elicit strong emotions in the child or cover difficult topics. Katie was easily engaged with the interviewer and rapport was easily established. As such, the interview moved into an open-ended conversation with Katie regarding her perception of the presenting problem. Clinician: Why do you think you’re here today, Katie? Katie: I don’t know. Clinician: Well, why do you think mom brought you in today? Katie: Um, I think she wants me to sleep in my own bed. Clinician: Thanks for telling me that! So, it sounds like maybe mom wants you to sleep in your bed. What makes sleeping in your own bed hard? Katie: I just don’t like it. I like sleeping with mommy and daddy. Clinician: It sounds like you just like it more in there. I understand that. Well, today we’re going to talk a lot more about that and I’m going to ask you a bunch of different questions that have to do with feeling anxious, nervous, or sad. Some of those questions are going to sound like you, and we’ll spend a lot more time talking about those things. Does that sound okay to you? 440 R. A. Grossman et al.

Katie’s description of the presenting problem was consistent with what was discussed by Mrs. X. The clinician hypothesized that Katie’s unwillingness to sleep in her own bed may be related to anxiety. However, at this point in the interview, it was appropriate to accept the child’s explanation for the problem (e.g., just not lik- ing sleeping in her own bed). As the child built rapport with the clinician, the clinician could become more pointed in her questions regarding the reason for sleeping in her parents’ bed. The clinician used the Anxiety Disorders Interview Schedule for DSM-IV Child/Parent version (ADIS-IV-C/P; Silverman & Albano, 1996), which is a semi-structured interview designed for differential diagnosis of anxiety and emotional disorders, as well as screen for other presenting problems. This interview was administered to Katie alone, and took approximately 90 minutes. Followed by a 10-minute break, the interview was then administered to Mrs. X and took approximately 90 minutes. A portion of the separation anxiety disorder section, as well as Katie’s answers, is provided. Clinician: Some children worry a lot about being away from their parents or from home. Do you feel very scared or worried when you are away from mom or dad and do whatever you can to be with them? Katie: Yes. Clinician: Thanks for telling me that! Do you get really upset, cry, or beg your parents to stay home when they plan to go somewhere without you? Katie: Yes! I hate it when they try to go to dinner without me. Clinician: Thanks for letting me know! Why do you think you hate it? Katie: I just miss them and sometimes I get scared that something bad might happen to them. Like what if they get into a car accident or something? Clinician: So, you miss them a lot and get scared that something bad might happen. I can see why that would make you want them to stay home! When your parents do leave, do you cry or feel very bad because you miss them a lot? Katie: I miss them a lot! I use my iPad to text mom and dad and that makes me feel better when they answer because I know that they’re okay. Clinician: Oh, okay – so you use your iPad to check in on them. Are there other times where you check in on mom and dad when you’re not with them? Katie: Sometimes I message mom when I’m at school too, but not that much. Clinician: Thanks for telling me that. Why do you think that you need to check in on mom when you’re in school? Katie: Well, I just want to make sure that she’s okay and like I like to know where she is. Sometimes, she leaves the house to go places, and that makes me nervous that she’s going to get hurt or something. I don’t know. Clinician: So sometimes, you get worried about how mom is even when you’re at school. Is that right? 17 Children 441

Katie: Yea. I’m always worried about mom when I’m not with her. I love her so much. Clinician: Yea it sounds like you care about mom a lot! The semi-structured interview format allowed the clinician to ask follow-up questions after the child’s “yes” or “no” response. Given what the clinician knew from the interview with Mrs. X, the clinician was able to expand on Katie’s responses to gather clarifying information regarding the cause of some of Katie’s behaviors. After the interview with Katie, the clinician completed the ADIS-IV-C/P with Mrs. X to gather more information. When making the diagnosis, the clinician brought together the information obtained from Mrs. X and Katie, as well as behavioral observations. It was clear from the interviews that Katie’s behaviors were consistent with a diagnosis of separation anxiety disorder. Mrs. X noted that these behaviors (e.g., difficulty sleeping on her own, distress at separation, and checking on her parents when separated) had been present for more than 4 weeks and were causing her significant distress and impairment. Katie explained that her difficulty separating was related to her fear that something bad would happen to her parents. Using the ADIS-IV-C/P, the clinician was also able to rule out other comorbid diagnoses (e.g., generalized anxiety disorder). Katie denied significant worries in any other domain other than worrying about her parents’ safety. Mrs. X also denied any other significant areas of worry. Because of this, the clinician diagnosed Katie with separation anxiety disorder, and offered Mrs. X several recommendations for addressing these concerns, including individual cognitive-behavioral therapy.

Recommendations for Formal Assessment

In addition to interviewing and observing children, several standardized assessment tools can complement the evaluation by providing quantitative information in a number of domains. If diagnostic accuracy is the goal, such standardized tools are preferable. Assessment tools include those designed to evaluate cognitive abilities, academic achievement, personality inventories, and behavior rating scales that screen for a variety of problems (i.e., wide band scales) and those that assess specific symptom domains (i.e., narrow band assessment scales). If the goal is diagnostic accuracy, it is recommended that the clinician has good knowledge of the DSM-5 and utilizes either a semi-structured or structured interview (described below). Cognitive and achievement measures are utilized primarily in the process of psychoeducational evaluation, in order to establish a child’s qualifications for special education services. Cognitive assessments provide information about a child’s intellectual functioning (i.e., IQ) and are important for establishing diagnoses related to neurodevelopmental disorders, such as intellectual disability. Commonly used cognitive measures include the Wechsler Intelligence Scale for Children (WISC-5; Wechsler, 2014), the Wechsler Preschool and Primary Scale of Intelligence 442 R. A. Grossman et al.

(WPPSI-IV; Wechsler, 2012), and the Kaufman Assessment Battery for Children (KABC-II; A. S. Kaufman & Kaufman, 2004). Intelligence measures are often used in conjunction with measures of academic achievement in order to determine whether there is a discrepancy between a child’s ability (i.e., IQ) and achievement. Such information can be gathered by administering achievement measures such as the Woodcock-Johnson Tests of Achievement (Schrank, McGrew, Mather, & Woodcock, 2014) and the Wechsler Individual Achievement Test (WIAT-III; Wechsler, 2009). These tools are typically necessary for the diagnosis of a specific learning disorder. Personality assessment can be used to obtain data on unobservable or internal psychological processes that are not thought to be context-dependent or time bound (as may be the case for symptoms of a psychological disorder). The most widely known tool for personality assessment in youth is the Minnesota Multiphasic Personality Inventory for Adolescents (MMPI-A; Butcher et al., 1992), which is considered a multidimensional assessment tool with a variety of subscales (e.g., Anxiety, Cynicism, Negative Treatment Indicators). Such tools often require extensive training in order to interpret and involve several hundred questions, which may take adolescents several hours to complete. Broad measures that assess children’s functioning across multiple domains and include multiple subscales are often important for comprehensive screening in clinical settings. Examples of such tools include the Child Behavior Checklist (CBCL; Achenbach & Rescorla, 2001) and the Behavior Assessment Scales for Children (BASC-3; Reynolds & Kamphaus, 2015). Both the CBCL and BASC-3 include preschool, school age, adolescent, and young adult versions of the parent report measure, as well as a corresponding teacher-report forms. In addition, self-report versions of the tools are available for older children (ages 8 and older for the BASC- 3, ages 11 and older for the CBCL), as well as forms for conducting behavioral observations of children. Broad measures can be a useful strategy for obtaining information from teachers, and for confirming information obtained through the diagnostic interview. In addition, such tools can be used to screen for other disorders that may not have been heavily discussed during the clinical interview. Narrow assessment tools are those that measure specific sets of symptoms or clinical phenomena. Such tools are useful for quantifying the presence of symptoms within a specific disorder, and can add specific information about disorder severity, or they can be used to measure symptom change over the course of treatment (i.e., progress monitoring). A common example of such a tool is the Vanderbilt ADHD Diagnostic Rating Scale (Wolraich et al., 2003), which is a rating scale used to assess symptoms of ADHD in children ages 6–12 and screen for other externalizing disorders. The measure includes both parent and teacher versions; a follow-up form to assess symptom change as well as side effects of medication is also available. Another example of a narrowband assessment tool is the Revised Children’s Anxiety and Depression Scale (RCADS; Chorpita, Yim, Moffitt, Umemoto, & Francis, 2000), which is a questionnaire that assesses internalizing disorders, including anxiety disorders, obsessive-compulsive disorder, and major depressive disorder. 17 Children 443

The RCADS is available in parent-rated and self-rated versions, as well as short- forms of the measure, and it has been normed on children in grades 3 through 12. While wideband and narrowband assessment tools can be useful for establishing a diagnosis and case conceptualization, such instruments should be selected carefully. Clinicians must consider whether the assessment tool has been standardized for use with children of the appropriate age and population. Furthermore, it is important to consider available literature and research on the measure to facilitate accurate interpretation and determine if the measure’s psychometric properties are suitable (i.e., the instrument measures what it intends to measure, it has adequate internal consistency, and adequate test-retest reliability, if relevant). Clinicians should also consider the feasibility of having parents and children complete rating scales. Some parents may be overwhelmed or burdened by having to complete longer assessment scales. Children’s developmental level may also inform whether they can appropriately complete a rating scale; a child with reading difficulties, for example, may struggle to finish a self-report questionnaire. When selecting which measures to administer and to whom, clinicians should be sensitive to the needs of the family and the child and carefully consider the utility of such scales and avoid unnecessarily or inappropriately burdening the family. See Table 17.2.

Table 17.2 Formal assessment tools Domain Purpose Example(s) Cognitive Obtain information about child’s IQ Wechsler Intelligence Scale for Children (WISC-5) Wechsler Preschool and Primary Scale of Intelligence (WPPSI-IV) Kaufman Assessment Battery for Children (KABC-II) Achievement Academic achievement, discrepancy Woodcock-Johnson Tests of between ability and achievement Achievement (WJ-A) Evaluate presence of Specific Learning Wechsler Individual Achievement Disorder Test (WIAT-III) Personality Evaluate psychological processes that Minnesota Multiphasic Personality may not be context-dependent or Inventory for Adolescents time-bound (MMPI-A) Broadband Obtain information about child’s Child Behavior Checklist (CBCL) measures functioning across domains Behavior Assessment Scales for Comprehensive screening of concerns Children (BASC) Includes teacher-, parent-, and self- report versions Narrowband Measure specific sets of symptoms or Vanderbilt ADHD Diagnostic measures clinical phenomena Rating Scale Quantify symptoms or obtain Revised Children’s Anxiety and information about symptom severity Depression Scale (RCADS) Measure symptom change over time 444 R. A. Grossman et al.

Standardized Interview Formats

Structured Interviews Structured interviews are those interviews with predetermined question format and order, as well as specific follow-up questions based on responses obtained. These interviews are advantageous in research settings and settings where clinician variability and bias need to be reduced. While they may reduce the time required for completing intake interviews, additional questions may be necessary for obtaining idiographic information to personalize treatment. Several widely available structured interviews for children and their parents are detailed below.

The MINI-Kid The Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-Kid; Sheehan et al., 2010) is a structured diagnostic interview to assess the presence of DSM-5 diagnoses in children and adolescents ages 6–17. It assesses the 30 most common and clinically relevant diagnoses in children and adolescents. The MINI-Kid was designed as a more efficient diagnostic tool for clinical and research settings and uses a branching format to determine which items must be administered. It is available in a standard child version, which can be administered to the child and parent together, with the questions directed to the child, while the parent is asked to respond only when he/she believes the child has not provided accurate information. The parent version of the interview can be used when the parent is interviewed alone about the child. In addition, a screening version of the tool is available to facilitate shorter interviews by allowing the clinician to determine which additional sections of the MINI to administer. Where additional detail is needed, several nonstandard versions are available for use, including the MINI-Kid for Psychotic Disorders Studies, the MINI Kid with Tobacco Use Disorder Module, and the MINI-Kid for Suicidality Disorders Studies. In order to track treatment progress over time, the MINI-Kid Tracking version converts yes/no responses into dimensional options to assess the severity of each symptom. Although no standardized training is offered in the MINI-Kid, individuals with clinical training can use the tool after a brief session of instruction in the measure (Sheehan, personal communication, April 23, 2018). For those with less clinical experience, more extensive training is required. The MINI-Kid has been shown to be highly concordant with other semi-structured interview tools that require additional time to administer (i.e., Schedule for Affective Disorders and Schizophrenia for School Aged Children – Present and Lifetime Version; K-SADS-PL; Sheehan et al., 2010). However, concordance of the MINI-Kid and K-SADS-PL in psychotic disorders was shown to be more variable. The interview’s ability to detect the presence of disorder (i.e., sensitivity) was adequate for 15 of 20 individual disorders in the DSM-IV version of the interview. In addition, the MINI-Kid had a good ability to detect those without diagnoses (i.e., specificity) for all 20 diagnoses in the DSM-IV version of the measure.

DISC-IV The Diagnostic Interview Schedule for Children – Fourth Edition (DISC-IV; Shaffer, Fisher, Lucas, Dulcan, & Schwab-Stone, 2000) is a highly 17 Children 445 structured clinical interview for children ages 6–17, which includes a child form (DISC-Y) and a parallel parent form (DISC-P). The DISC-IV has frequently been used in research studies where categorical diagnoses must be determined for data collection purposes. Prior studies have used the DISC-P with parents of children as young as 4–5 years old and the DISC-Y with children older than 17. The DISC-Y can be administered directly to children who are 9 years and older, and the option of parallel forms allows raters to combine parent and child reports or to examine their responses separately. Several versions of the DISC-IV are available in order to assess the lifetime presence of diagnoses and current symptom status (within the last year and within the last 4 weeks). Similar to the MINI-Kid, the DISC-IV uses a branching system of stem questions and follow-up items that are administered con- tingent on the previous response. The interview comprises primarily yes/no questions and reportedly takes between 90 and 120 minutes to administer in clinical populations, although removal of modules that are not relevant can reduce administration time. The DISC-IV can be completed and scored by a diagnostic interviewer using a paper-and-pencil version or a computer-assisted version, which allows for automatic scoring and skip-out of questions. In addition to diagnostic status, the DISC-IV also produces a series of impairment or frequency ratings that are presented at the end of each diagnostic module. Impairment questions are only presented if half or more of the symptoms required for diagnosis are endorsed in a given section (a “clinically significant” number of symptoms). Impairment/frequency is rated using a 1–3 scale, with lower scores indicating greater impairment or frequency. Ratings are obtained in six social domains: getting along with parents/caregivers, participating in family activities, participating in peer activities, academic/occupational functioning, relationships with teachers/boss, and distress attributable to symptoms. As with many structured and semi-structured interview tools available currently, the DISC-IV has not yet been published using DSM-5 criteria. However, the DISC-IV and other similar interview tools can be relatively easily adjusted to match the updated diagnostic criteria (Leffler, Riebel, & Hughes,2015 ). Although psychometric data on the DISC-IV is limited, studies demonstrate that test-retest reliability for the 1-year diagnosis of selected diagnoses (e.g., externalizing problems, anxiety disorders, major depressive disorder) is adequate. Results of psychometric studies in clinical samples demonstrate that test-retest reliability is higher for the DISC-P than the DISC-C, although the reliability of the combined parent and child reports is higher than the child report alone. Validity data for the DISC-IV have not yet been reported, though research on an older version of the DISC (DISC-2.1) demonstrates that the tool has good to excellent sensitivity for detecting the true presence of several uncommon disorders when compared to expert clinician diagnosis (Fisher et al., 1993). More recently, a study examining the criterion validity of the DISC-IV ADHD section indicated that there was significant agreement between independent clinician diagnoses and diagnoses based on the DISC-P and DISC-C (McGrath, Handwerk, Armstrong, Lucas, & Friman, 2004). Training for the DISC-IV reportedly takes several days (1–2 days for the computerized version, 4–5 days for the 446 R. A. Grossman et al. paper version), though the measure can be administered by individuals who have no formal clinical training.

CAPA The Child and Adolescent Psychiatric Assessment (CAPA; Angold & Costello, 2000) is a structured clinical interview for children ages 8 through 17. It comprises a parent component (CAPA-P) and a child component (CAPA-C), and is available in young adult and preschool versions (Angold & Costello, 2000). The CAPA is consistent with DSM-IV and ICD-10 diagnostic criteria. The assessment uses interviewer-based methodology in which ratings are made by the interviewer based on the report of the parent and child. Interviewers are instructed to probe until they can determine whether a symptom is present or not at the time of the interview and within the preceding 3 months. Each section of the interview includes mandatory screening questions, which are followed by additional mandatory probes that are administered based on endorsement of screening items. Additional guidelines are included within the text to help interviewers clarify responses. Symptoms are rated on a 3-point or 4-point scale, with a rating of 0 indicating the symptom is absent, a rating of 1 indicating uncertainty about the presence of the symptom, and higher ratings indicating moderate to more severe symptoms. Criteria for these ratings differ depending on the symptom or behavior within each section. Scores for child ratings and parent ratings can be combined for overall diagnoses, and algorithms are available for combining parent and child diagnoses at the symptom level as well as the disorder level. Scoring is done using an accompanying computer system that determines diagnoses based on codes assigned by the interviewer. The CAPA also includes a detailed assessment of functioning in 19 domains of functioning related to home, school, and other settings in order to understand the impact of symptoms endorsed. The interview takes about one and a half hours to complete, including both the parent and child portions. Because of the interviewer-based methodology, coding of responses is estimated to take 45 minutes, with an additional 30 minutes for supervisor review. Training for the interview must be provided by a certified trainer, and it includes between 1 and 2 weeks of didactic instruction in the interview, as well as role-plays and coding of videos. The CAPA has been widely used in clinical research studies and is said to have high test-retest reliability for internalizing disorders. Test-retest reliability is slightly lower for externalizing disorders, as well as substance use disorders and posttraumatic stress disorder (Angold & Costello, 1995). The CAPA is thought to have good validity, as rates of diagnoses captured by the measure closely match those reported in epidemiological studies.

Semi-structured Interviews Semi-structured interviews can be utilized as a guideline for clinical interviewing. Such interviews include predetermined questions that may serve as a suggestion for interviewers, or as a basis for continued follow-up questions. While semi-structured interviews may reduce variability and clinician bias, the flexibility conferred by such an approach may require additional training to reach reliability and may further extend the time required for administration. Several semi-structured interview tools are subsequently reviewed. 17 Children 447

K-SADS The Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS; Kaufman et al., 2016) is a semi-structured interview, appropriate for children and adolescents ages 6–18 years old. Currently, only the present/lifetime version of the interview (K-SADS-PL) is updated for DSM-5 criteria, although the epidemiological version of the interview (K-SADS-E) and the Present version of the interview (K-SADS-P IVR) are available for DSM-IV. The K-SADS-P/L assesses the presence of symptoms over the course of the child’s lifetime and at the time of the interview. Consistent with dimensional measures available in the DSM-5, the updated K-SADS-P/L includes crosscutting dimensional rating scales completed by the parent and the child prior to the interview, which can be utilized to inform diagnosis and case conceptualization. The interview includes modules, which assess for affective disorders, psychotic disorders, substance use disorders, stress-related disorders, obsessive-compulsive disorders, eating disorders, and neurodevelopmental disorders (e.g., tic disorders, attention-deficit/hyperactivity disorder, autism spectrum disorder). It also includes a 10- to 15-minute unstructured section to facilitate rapport building and obtain information about the presenting concerns. A set of screening interview questions are utilized to survey the presence of primary symptoms for all diagnoses. Based on symptoms endorsed within this screening interview, the appropriate interview supplements are then administered to the parent and/or the child. Within the interview, probes to facilitate rating of items are provided as guidelines to the clinician, though these are not intended to be read verbatim. Once sufficient information for the item has been obtained, symptoms are rated on a 0–3 scale by the clinician, with 0 indicating “no information,” 1 indicating that the symptom is not present, 2 indicating that the symptom is subthreshold, and 3 indicating that the symptom is present (J. Kaufman et al., 2016). Final diagnoses are determined on the basis of child and parent ratings, and it is recommended that interviewers use clinical judgment when discrepancies between parent and child report are present. In total, the interview is estimated to take 2.5 hours for both the child and parent portions. Research training for the measure involves a 2-day didactic training followed by post-training reliability checks and consultation. Although psychometric data are not yet available for the DSM-5 version of the K-SADS-P/L, the DSM-IV version of the interview demonstrates excellent test-retest reliability for present and lifetime diagnoses of depression, bipolar disorder, generalized anxiety disorder, conduct disorder, and oppositional disorder. Test-retest reliability is also good for present diagnoses of post-traumatic stress disorder and attention-deficit/hyperactivity disorder. The K-SADS-P/L for DSM-IV also demonstrates concurrent validity with rating scales that measure various symptoms of the disorders assessed (J. Kaufman et al., 1997).

DICA-R The Diagnostic Interview for Children and Adolescents – Revised version (DICA-R; Reich, 2000) is a semi-structured clinical interview used to assess the lifetime presence of DSM-IV disorders in children and adolescents ages 6 through 17. The DICA-R includes a child form (DICA-R-C), an adolescent form (DICA- R-A), and a parent form (DICA-R-P), all of which are available in a computerized version that can be administered by an interviewer and scored automatically. 448 R. A. Grossman et al.

DICA-R is a glossary-based interview, with a manual of definitions utilized by the clinician to determine whether a symptom is present. Interview questions are to be read as presented on the page of the DICA-R, although sample probes and explanations are available to facilitate the interview and can be applied when necessary. Similar to the CAPA, the DICA-R uses interviewer-based methodology that requires interviewers to probe the interviewee until they are able to ascertain whether a symptom is present or not. Respondents are also asked to give examples of behaviors or experiences endorsed. The interview is estimated to take about 2 hours total, after which the interviewer completes a “self-editing” process to check for completeness and identify questions where symptom presence is unclear and supervisor review is required. A final “editing” process with a highly trained “editor” (typically a supervisor) then follows, in which final determinations are made about the presence of symptoms that may have been unclear to the interviewer. Although psychometric data on the DSM-IV version of the DICA is not yet available, test-retest reliability for the DSM-III version of the interview is said to be higher in adolescents than children for internalizing problems, while reliability for externalizing problems in children is more modest (Reich, 2000). Research training for the DICA-R is extensive and can take 2–4 weeks depending on the experience of the interviewer. Continued administration of the measure requires supervision by an editor who is highly trained in the instrument.

ADIS-IV-C/P The Anxiety Disorders Interview Schedule for DSM-IV, Child and Parent version (ADIS-IV-C/P; Silverman & Albano, 1996), is a commonly used semi-structured interview used for differential diagnosis of mood and anxiety disorders, which also screens for other disorders and comorbidities. The interview can be administered to children ages 6–18 years old and their parents and is currently in the process of being updated for the DSM-5 (personal communication, Albano, June 18, 2015). Given the semi-structured format of the measure, questions provided are considered by the authors to be guidelines and are not required to be read verbatim. Additional phrasing suggestions for adjusting questions to the developmental level of the child are also provided in the text. Each section of the interview includes a question to assess impairment, rated from 0 to 8 (8 being the highest level of impairment); impairment ratings are obtained from the parent and child separately. The clinician derives diagnoses on the basis of the parent and child interview, utilizing clinical judgment to determine a principal diagnosis. Although guidelines are available for establishing composite diagnoses in cases where parent and child reports differ, flexibility and use of clinical judgment are recommended. Once diagnoses are assigned, each one is then assigned a clinical severity rating (CSR) by the clinician (Silverman & Albano, 1996). It is recommended that interviewers review composite diagnoses and assigned CSRs with a consensus team or supervisor. The ADIS-IV-C/P is said to have excellent test-retest reliability for combined diagnoses (based on both child and parent reports) of anxiety disorders and anxiety disorder symptoms, while test-retest reliability is good for externalizing disorders (Silverman, Saavedra, & Pina, 2001). In addition, the anxiety disorders section of 17 Children 449

Table 17.3 Standardized interview formats Specific Diagnostic interviewer Ages criteria Time frame training required? Structured interviews MINI International 6–17 DSM-5 Current No, standard Neuropsychiatric Interview symptoms clinical training for Children and sufficient Adolescents (MINI-Kid) Diagnostic Interview 6–17; possible DSM-IV Current Yes Schedule for Children – to use with 4–5 symptoms; Fourth Edition (DISC-IV) and older than lifetime version 17 available Child and Adolescent 8–17; DSM-IV Current Yes Psychiatric Assessment preschool and symptoms (CAPA) young adult versions available Semi-structured interviews Schedule for Affective 6–18 DSM-5 Current and Yes Disorders and lifetime Schizophrenia for symptoms School-Age Children (K-SADS) Diagnostic Interview for 6–17 DSM-IV Current Yes Children and Adolescents – symptoms Revised version (DICA-R) Anxiety Disorders 6–18 DSM-IV Current No, though Interview Schedule for symptoms recommended DSM-IV, Child and Parent procedures version (ADIS-IV-C/P)

the interview has good concurrent validity with rating scales that measure social anxiety, panic disorder, and separation anxiety, but not with rating scales of generalized anxiety disorder (Wood, Piacentini, Bergman, McCracken, & Barrios, 2002). With respect to inter-rater agreement, studies demonstrate that when interviewing both the parent and child, agreement on principal diagnoses and anxiety disorders is excellent, and agreement on comorbid disorders is good. Although no standard training procedure is required, training can be obtained from the authors of the ADIS-IV-C/P. The authors recommend that raters participate in didactic training on the measure and diagnoses, followed by live or video coding of interviews. Finally, a co-rated interview with a trained diagnostician, followed by supervision or matching on diagnoses with the trainer or supervisor, is recommended (Silverman & Albano, 1996; Silverman et al., 2001; Wood et al., 2002). See Table 17.3 for more information. 450 R. A. Grossman et al.

Impact of Gender, Race, Culture, Age, and Other Aspects of Diversity

When assessing and diagnosing children, it is essential to consider the child in context, understanding the systems and environments where they interact, as well as the cultural and developmental context unique to the individual. First, an understanding of developmental milestones and functioning across childhood is essential for any competent clinician working with children. Becoming familiar with development from early childhood through late adolescence or early adulthood is important in establishing a baseline for typical functioning against which to compare children whose functioning may be impaired by presenting concerns. Without such an understanding, it is difficult to determine whether a child’s behavior or functioning is indicative of psychopathology. For example, many young children present with fears of the dark, which is considered developmentally appropriate during early childhood and therefore would not be deemed pathological, particularly in situations where this fear did not result in significant impairment. On the other hand, an adolescent afraid of the dark who requires a parent to accompany him/her to the bathroom at night demonstrates a developmentally atypical fear, which may be causing impairment in the home. Utilizing reference materials available from reputable online sources (e.g., Centers for Disease Control and Prevention, academic health centers) to understand child and adolescent development, as well as interacting with children of varying ages and levels of functioning, is crucial for understanding children in context. Many clinicians receive limited exposure to typically developing children or children outside of clinical settings. Therefore, it is wise for clinicians to seek out opportunities to interact with youth of varying ages in a variety of contexts including schools, camps, or community organizations. In addition to understanding children’s development, clinicians must consider the child’s context. This includes local and regional culture, the community and school environment, as well as cultural and racial/ethnic issues that may inform the diagnostic assessment. Understanding local and community norms can be helpful for determining the impact of psychopathology on functioning. For example, in an urban environment, it may be quite common for older children and adolescents to take public transportation independently; a child who refuses to take public transportation due to anxiety suggests some level of impairment. A child in a rural or suburban community may rely on parents or caregivers for transportation and would not be considered impaired by their avoidance of public transportation. Issues of race, ethnicity, culture, and gender also play an important role in the diagnostic process. For example, cultural differences and family values may impact how families convey presenting concerns and symptoms. Conversely, culture and values may impact the child’s symptom development or maintenance. Diversity issues may also be relevant to the ways in which families view the diagnostic process and the types of information or services they seek. For example, in families or cultures where mental health issues are heavily stigmatized, parents may present seeking confirmation that a child doesnot have a diagnosis, or they may react 17 Children 451 negatively to receiving a formal diagnosis. Culture and values may also inform the attributions families make for a child’s behavior or presenting symptoms. Some symptoms that the clinician considers problematic or evidence of a disorder may be thought of by the family as typical within the cultural or family context. For example, in Chinese culture, it is often considered impolite to make frequent and direct eye contact, whereas in most Western cultures, this is considered socially appropriate. In American culture, poor eye contact is often suggestive of social or interpersonal deficits or anxiety and may therefore be considered evidence of some psychopathology, though it might be considered culturally appropriate within the context of the child’s home or community. It is important for clinicians to be mindful that the majority of assessment instruments have been developed and normed within largely Caucasian and Western samples. Keeping this in mind allows the clinician to more appropriately assess issues of diversity that may not be captured by structured or norm-referenced assessment tools. Rather than establishing preconceived boundaries and expectations for cultural differences, clinicians should ask openly about the role of culture and diversity during the diagnostic interview process. This can be done in an interview format (e.g., DSM-5 Cultural Formulation Interview; American Psychiatric Association, 2013) or by simply asking the child and/or caregiver how they feel their culture or values may impact current concerns or treatment. In addition, clinicians should be attuned to issues of culture and diversity that may be embedded within the interview responses, even if these are not endorsed when asked about directly. Further information on issues of culture and diversity, as well as a framework for how clinicians can consider this in practice is outlined by Johnson and Tucker (2008). Finally, clinicians must be aware that issues of diversity extend beyond race, religion, and gender. Even within cultural groups, there may be differences in values or experiences that are relevant to the diagnostic process. Broad categories such as race and gender may not capture the varied experiences of children and their caregivers. It is important to consider the range of identities or experiences one child may have. Socioeconomic status, gender identity, sexual identity, disability status, and race/ethnicity are especially relevant to mental health, as the experience of living in poverty and/or being part of a marginalized or minority group may impose unique stressors for children and families. Clinicians must also develop an understanding of how these identities and experiences intersect for the individual or the family, and how this might inform the diagnosis or interview process. While issues of diversity play an important role in mental health and well-being, assessment of such issues should help clinicians understand the child’s concerns in context in order to develop a plan that works within this context, rather than against it.

Information Critical to Making a Diagnosis

The diagnostic interview should take into account various factors that are critical to making a diagnosis. Most importantly, the interviewer should obtain information about the frequency of the presenting symptoms, their severity, and their duration. 452 R. A. Grossman et al.

When considering each of these three domains, the clinician should also assess the settings in which these symptoms occur and should evaluate whether there are certain settings in which the symptoms present more frequently or severely. This would allow for more effective and specific treatment planning, by considering environmental factors that may impact symptom presentation. Clinicians must be aware of environmental factors such as parent-child interactions, structure in the home, and classroom variables (e.g., structure, seat placement), among others. In addition to the child and caregiver perspectives about presenting problems, clinicians should also obtain information from other individuals in the child’s life that may have information that would inform the diagnosis. For school-related concerns, for example, information from the child’s teacher would be integral for making an appropriate diagnosis. When gathering information from various informants, it is important to identify individuals who spend a significant amount of time with the child (e.g., the homeroom teacher who sees the child each day, a caregiver that spends the majority of the time with the child), as these people are likely to provide the most useful information about the child’s behavior over time.

Dos and Don’ts

Clinicians should spend time warming the child and parent up to the interview before beginning. Do spend time developing a visual schedule or reinforcement system that could serve as a motivator for the child to keep him/her on task. Do build in breaks throughout a long interview to keep the child engaged. Do express empathy and openness to the child and parent; they may share personal information or discuss topics that are difficult to talk about. While it is the goal of the clinician to use this information to arrive at a diagnosis and plan treatment, the interview process itself can be quite therapeutic for children and parents who have been struggling and are able to express themselves in a comfortable environment. Recognizing this allows the clinician to maintain a balance between facilitative skills while also obtaining important information. Do not speak about the child’s behaviors in front of him/her without asking the child for his/her opinion. Do not speak down to the child or speak in words that are developmentally inappropriate (e.g., jargon). Avoid terms that may be unfamiliar to laypeople outside the mental health field. Do not demonstrate or convey judgment or negative reactions to information provided by the family; this includes verbal reactions and nonverbal reactions.

Summary

The purpose of this chapter was to provide students and clinicians with a central overview of the diagnostic interviewing process for children. It began with a summary of issues specific to children that should be considered during the interview 17 Children 453 and intake process. A discussion of interview techniques and structure followed, highlighting how to use the referral question, whom to interview, and methods for gathering information. In addition, a case illustration and recommendations for formal assessment tools, as well as a brief review of structured and semi-structured diagnostic interviews were discussed. Finally, a review of the impact of race, culture, age, and other diversity issues in the context of diagnostic interviewing was provided, followed by a brief discussion of important dos and don’ts for interviewing. A well-conducted and thorough diagnostic interview requires both a keen awareness of diagnostic criteria and structured tools, as well as sufficiently developed clinical skills to facilitate a comfortable and open environment for the child and caregiver. These competencies allow the clinician to collect the necessary data and make families comfortable enough to share such data. Furthermore, the diagnostic interview serves as the starting point for case conceptualization and treatment planning and may set the stage for a strong therapeutic relationship.

References

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Rachael Spalding, Emma Katz, and Barry Edelstein

Description of the Population

Older adults are one of the fastest growing segments of the US population. In 2016, more than 48 million people over age 65 lived in the country, accounting for over 15% of the population and representing a 30% increase since 2005 (Administration on Aging, 2016a). Moreover, by 2060, the number of adults living in the USA who are over age 65 is expected to double, reaching an anticipated 98 million (Administration on Aging, 2016a). This growth is due in large part to increases in ethnic minority populations. Since 2005, racial and ethnic minority populations in the country have increased from 6.7 million to over 11 million, with projections estimating an increase to 21 million by 2030 (Administration on Aging, 2016a). Individuals of racial or ethnic backgrounds make up a significant portion of the total population over age 65; in 2015, 22% of older adults identified as an ethnicity other than “White,” with the highest proportions being African-American (not Hispanic) or Hispanic (Administration on Aging, 2016a). When working with older adults, clinicians must be sensitive to the increasingly heterogeneous nature of this population, a point which will be further discussed in this chapter. Approximately 15% of American adults over age 60 suffer from a mental disorder (World Health Organization, 2017). Anxiety disorders, mood disorders, and substance use disorders are among the most common disorders diagnosed in this population (World Health Organization, 2017). However, late-life mental disorders are undertreated. In a study of mental health service usage among older adults, Byers et al. (2012) found that 70% of their sample who suffered from mood or anxiety disorders did not use services. Certain factors, such as being of an ethnic/racial minority or of low-income status, increased the odds of non-usage. Promoting accessibility and awareness of mental health services among older adults is vital,

R. Spalding · E. Katz · B. Edelstein (*) West Virginia University, Morgantown, WV, USA e-mail: [email protected]

© Springer International Publishing AG 2019 455 D. L. Segal (ed.), Diagnostic Interviewing, https://doi.org/10.1007/978-1-4939-9127-3_18 456 R. Spalding et al. particularly given that nearly 25% of the country’s deaths due to self-injury are completed by older adults (World Health Organization, 2017). The prevalence, nature, and course of mental disorders among older adults notably differ from that of younger adults, which can affect the assessment and diagnostic process. This chapter aims to offer a concise discussion of older adult interviewing with a focus on diagnostic assessment and the issues important to consider. First, we provide methods for gathering information, emphasizing multi-method methods of assessment. A case study detailing the complex nature of differential diagnoses with older adults follows. Then, we discuss structured interviews and specifically focus on instruments often used with or developed for older adults. Age-relevant concerns that may influence the diagnostic process are then described, followed by a discussion of certain factors specific to older adults that one must anticipate and consider when interviewing members of this population.

Procedures for Gathering Information

Multi-Method Assessment: Minimizing Threats to Validity

The focus of this chapter is the clinical interview, which is one of several methods for gathering relevant clinical information. Each assessment method (e.g., interview, direct observation, report-by-others, self-report, and psychophysiological recording) can provide relatively unique information that is only moderately correlated across methods (Meyer et al., 2001). Single assessment methods may lead to method variance (method bias) specific to a single method (Furr,2017 ), which can lead to an incomplete or even inaccurate formulation of the presenting problem(s) and diagnosis. Although non-interview-based assessment methods are not the focus of this chapter, we will include information gathering from other sources that supplement or complement the clinical interview. For example, considerable information is available through direct observation of the client during the clinical interview that can inform diagnosis and case formulation.

Clinical Interview

Interviews range from unstructured to structured, although virtually all fall into three categories: unstructured, semi-structured, and structured (Segal & Williams, 2014). The unstructured clinical interview is arguably the most frequently used assessment method and, depending on the constraints in the setting in which the individual is being assessed, may be the sole assessment method employed. One advantage of the unstructured interview is its flexibility. Another advantage of unstructured interviews is that one can rephrase questions and even retract earlier questions. Finally, the unstructured interview allows the opportunity to obtain 18 Older Adults 457 information regarding age-related symptom presentations, particularly for anxiety and depression, which are not included in the current diagnostic systems. This will be discussed in greater detail later in the chapter. The unstructured interview offers the opportunity for the clinician to establish rapport, which is particularly important with older adults, who may minimize or deny symptoms and be more cautious in their responding to questions (Blazer, 2015). Greater rapport may also lead to greater self-disclosure of sensitive information by culturally diverse groups of older adults (Wong & Baden, 2001). Information obtained from the client can be supplemented by information obtained from family, friends, and staff members. These interviews offer the opportunity to obtain sensitive information that the client might be reluctant to provide (for example, regarding incontinence, sexual issues, or functional deficits). Examination of medical records can be invaluable in developing a case conceptualization and diagnosis. These records might provide information on the client’s psychiatric and medical history, including the onset and duration of psychological symptoms.

Structured and Semi-Structured Diagnostic Interviews

Structured interviews provide specific questions and probes for clarification, which are to be used in the interview, in addition to rules that guide the interview process. Semi-structured interviews are more flexible in terms of the nature of the questions asked and the probes. Structured interviews offer a significant advantage over unstructured interviews, with substantially greater reliability and validity. In the interest of space limitations, we will refer to structured and unstructured diagnostic interviews as structured interviews. In contrast to structured interviews, unstructured interviews are typically guided by the individual clinician, who is free to ask any questions deemed relevant to the interview. The flexibility of unstructured interviews is lost with structured interviews, but increased reliability and validity are gained. Moreover, less clinical expertise is required for structured than unstructured interviews. Structured interviews do not tend to be used frequently in clinical practice, especially with older adults, due to the time required for administration. Nevertheless, they are invaluable for clinical research and can often enable one to address difficult diagnostic issues. In addition to these psychometric differences, agreement between diagnoses made on the basis of clinical evaluations and structured interviews is relatively low and varies by disorder (Rettew, Lynch, Achenbach, Dumenci, & Ivanova, 2009). A review of applicable structured interviews is beyond the scope of this chapter. To our knowledge, there are no published psychometric data specific to older adults for any of the most commonly used structured interviews. However, virtually all of the more current structured interviews have included older adults in their development samples, and most have been used with older adults in published research. The validity (item content or content validity) of structured interviews rests in large part 458 R. Spalding et al. on the fact that they are constructed based on published diagnostic criteria, for example, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) and the International Classification of Diseases (ICD-10; World Health Organization, 2018). Contemporary attempts to examine validity beyond content, especially for the more comprehensive interviews, are complicated by the lack of commonly accepted criteria (Groth-Marnat & Wright, 2016). A few representative interviews based on the most current diagnostic classification systems are discussed. Structured interviews tend to be either comprehensive or focused. An example of a more focused interview is the Anxiety and Related Disorders Interview Schedule (ADIS-V; Brown & Barlow, 2014). In contrast to more comprehensive structured interviews, the ADIS-V covers only anxiety disorders and related disorders that permit differential diagnosis among the anxiety and related disorders. The Structured Clinical Interview for DSM-5 (SCID-5; First, Williams, Karg, & Spitzer, 2015) is the most popular comprehensive (semi-structured) interview based on the DSM-5 diagnostic criteria. There are three versions of the SCID-5 that address the major DSM diagnoses and a fourth version (SCID-PD) that focuses on the DSM personality disorders. The SCID-5-CV (Clinician Version) is available for clinicians. Two electronic SCID products are also available. The Clinician Version of the SCID-5 requires 30–120 minutes to administer. A potentially significant limitation of all versions of the SCID-5 is that they do not include neurocognitive disorders. The Mini-International Neuropsychiatric Interview 7.0 (M.I.N.I.; Sheehan et al., 1998) is a structured interview that requires 15–45 minutes to complete, which is an advantage when assessing older adults. It requires minimal training to administer and is tied to both the ICD-10 and DSM-V criteria. In addition to the foregoing advantages, and in contrast to the SCID-5, the M.I.N.I is available for a very modest charge or free. There are also more specialized versions of the M.I.N.I. for specific disorders; however, neither the standard version nor the specialized version addresses neurocognitive disorders. Administration of a structured interview to an older adult may require additional elaboration of the rationale for the interview and would likely benefit from the establishment of rapport before proceeding. One potential limitation of the use of structured interviews with older adults is their lengthy administration time. Older adults may have more complex histories than younger adults, thus requiring more time. Some older adults might become fatigued over the course of the interview, requiring a brief respite. Even if one does not administer a full structured interview, the clinician might benefit from utilizing some of the questions found on the interviews, as they have proven to be reliable elicitors of information.

Mental Status Examination

The mental status examination involves the assessment of psychiatric symptoms and is commonly used to help establish a psychiatric diagnosis (see Chap. 4). Mental status examinations may vary in format but usually include an assessment of the 18 Older Adults 459 client’s general appearance, mood, affect, overt behavior, cognitive functioning, judgment, insight, orientation, thought content, and the presence of suicidal and homicidal ideation, mania, delusions, and/or hallucinations (Groth-Marnat & Wright, 2016). All elements of the mental status examination are of potential importance, but two of them (i.e., suicide risk and cognitive functioning) are of particular importance when interviewing older adults because of their greater likelihood being problematic with older adults. Individuals with mild cognitive impairment are at an increased risk of developing Alzheimer’s disorder or another dementia; thus, it is important to assess cognitive functioning in older adults. Understanding the history of onset and progression of the patient’s cognitive impairment can provide supplementary information on diagnosis and development. This can be accomplished through an interview, though a standardized screening instrument will likely prove more reliable and valid. There are a variety of screening instruments that can be utilized, although there is no gold standard. Three commonly used instruments are the Mini Mental State Examination, Second Edition (Folstein, Folstein, White, & Messer, 2010), Mini-Cog (Borson, Scanlan, Brush, Vitaliano, & Dokmak, 2000), and the Montreal Cognitive Assessment (Nasreddine et al., 2005). If cognitive impairment is suspected based on preliminary assessment, the clinician can conduct a formal evaluation of the individual’s cognitive functioning or refer the individual for more formal neuropsychological evaluation.. Additionally, further detection of cognitive impairment can be strengthened by asking the older adult and family or staff members about any changes in language, memory, and the individual’s ability to complete routine tasks (Cordell et al., 2013). When assessing psychopathology, there is often a reliance on symptoms self- reported by the individual. For older adults who are exhibiting or reporting symptoms of cognitive impairment, the reliability and validity of their self-reported symptoms may be questioned. Therefore, involving a variety of reporters during the assessment can be important. The assessment for suicidal risk is important, as the highest rates of suicide globally occur among individuals 70 years of age and older (World Health Organization, 2014). There are numerous risk factors for older adult suicide that should be considered when conducting a diagnostic interview (e.g., Van Orden & Conwell, 2011; Joiner, Walker, Rudd, & Jobes, 1999). While there are a variety of assessment measures developed to help determine suicide risk, most were developed with a young adult population. Two scales that were designed for older adults include the Geriatric Suicide Ideation Scale (Heisel & Flett, 2006) and the Reasons for Living – Older Adults scale (Edelstein et al., 2009; Lutz, Edelstein, Katz, & Gallegos, 2018).

Functional Assessment

The interview is often the source of information that forms the basis of functional assessment. Functional assessment is an idiographic, behavioral approach to the assessment of an individual (Haynes, O’Brien, & Kaholokula, 2011). The goal of 460 R. Spalding et al. functional assessment is not a diagnosis; it enables the clinician to understand the function (intended effect) of a problem behavior through discovery of the conditions under which problem behaviors occur. The goal of using this knowledge is to design an intervention program. The focus is on the antecedents of the problem behavior (conditions under which it is likely to occur) and the consequences of the behavior that maintain or strengthen the behavior. The functional assessment relies upon the self-report of the client and, if possible, the observations of the client by others (e.g., family members, staff members). For example, an older adult resident of a long-term care facility may become aggressive with staff members for no apparent reason. Questioning of the staff might reveal that the aggressive behavior occurs only during particular times of the day. These times are often when care is being provided to the resident. However, there are times when care is provided and the resident is not aggressive. Further questioning might reveal that the aggressive behavior occurs only when one particular staff member is attempting to bathe the resident. Observation of that care might reveal that the staff member fails to explain to the resident what is going to be done, the staff member fails to check the water temperature to be sure it is not too cold, and the staff member grabs the resident’s arm and demands that the resident enter the shower or tub. The resident strikes the staff member in an attempt to avoid a shower or bath in cold water. See Fig. 18.1 for a sample functional assessment of this situation.

New male staﬀ Staff member member isunfamiliar begins to undress resident without to resident and scowls New, unfamiliar staﬀ when approaching explaining what he is doing memberleaves resident bathroom

Resident has a neurocognitive Water disorder and temperature Resident often doesn’t is too cold strikes new recognize staﬀ staﬀ member members

More desirable staﬀ member continues Resident demonstrates with bathing preference for certain familiar staﬀ members, particularly females Probability of hitting unfamiliar staff member in the future is increased

Fig. 18.1 Functional assessment 18 Older Adults 461

Behavioral Observations

A substantial amount of relevant information can be obtained by observing the client from the moment he or she enters the room. Behavioral observations can be particularly helpful when one is interviewing an older adult with impaired cognitive skills or limited communication skills. Observation of the client’s gait, balance, coordination, and posture can offer clues regarding potential medical conditions (e.g., arthritis, multiple sclerosis) and medical adverse effects that can help explain the individual’s symptom presentation. Balance and coordination are important for the avoidance of falls, which can have devastating psychological consequences, including the fear of falling, which results in immobility. Apparent muscle weakness may be due to a stroke, which often has psychological consequences (e.g., depression). Slowed movement (bradykinesia) or psychomotor retardation can reveal potential problems (e.g., depression, Parkinson’s disease, muscle or neurogenic pain, medication adverse effects). Squirming, fidgeting, constant hand or foot movements, and restlessness may also reveal potential problems (e.g., hypomania, attention deficit, mania). One can also gain information while observing a client complete tasks or answer test items. For example, it is not uncommon for older adults with cognitive impairment to begin a test with items of increasing difficulty and then stop once the items becoming challenging. This may reflect depression, for example, if the individual does not wish to expend the “cognitive effort” demanded by a task. Such behavior may also reflect an unwillingness to reveal cognitive deficits that may be associated with cognitive decline due to a neurocognitive disorder. Hand tremors can be observed during the completion of self-report inventories or when the individual’s arms and hands are at rest. These are but a few of the many ways in which the observation of behavior can aid one in understanding the symptom presentation of the individual and in the differential diagnosis of psychiatric disorders.

Review of Records

Psychosocial history. Reviewing clients’ psychological and medical records can provide valuable information to the diagnostic process. Psychosocial histories can help determine the client’s current functional status and any changes from previous levels of functioning. Information provided by informants (such as family members or, if the client resides in a long-term care facility, staff) may yield additional information that can be helpful in understanding the client’s current functioning. Since criteria for several diagnoses require that symptoms represent a change over time, such as in cognitive functioning or mood (American Psychiatric Association, 2013), this information can be very useful. Prior records can also reveal information regarding whether the client has exhibited or experienced the present symptoms for a period sufficient to warrant a particular diagnosis (e.g., symptoms of Generalized Anxiety Disorder for at least 6 months) or whether a diagnosis can be ruled out if 462 R. Spalding et al. the client has not experienced symptoms for the required period of time. If there is evidence of cognitive impairment, informants can provide further information regarding any potential prior episodes of the presenting disorder or other psychiatric symptoms that may not have been discussed or endorsed by the client. Interviewers should be cautious when considering previous records of behaviors, symptoms, and diagnoses reported by past examiners, particularly if no information is provided regarding how they arrived at their diagnoses. In some cases, individuals carry diagnoses that were given years ago without documentation that would support the diagnosis.

Consideration of medical history. In 2016, 78% of the US population over the age of 65 reported their health as “good” or better. However, important racial differences in subjective health status were noted: while 80% of white Americans rated their health as “good” or better, only 65% of non-Hispanic blacks and 66% of Hispanics reported as such (Administration on Aging, 2016b). This discrepancy may be due to factors related to care access (i.e., economic or geographical barriers) and cultural or attitudinal differences (Dunlop, Manheim, Song, & Chang, 2002). Racial and ethnic differences in usage of mental health services may have important implications in psychological treatment settings, which will be further discussed in this chapter. An older client’s medical history is particularly important for a clinician to consider given that certain medical conditions can produce psychological symptoms. The onset of delirium, an acute disorder of attention and cognition, among older adults is often predicted by one or more conditions, including urinary tract infections, malnutrition, bladder catheterization, and polypharmacy (Inouye, Westendorp, & Saczynski, 2014). Thus, in order to form a complete case conceptualization, one must consider the physiological condition of a client who presents with symptoms of delirium. Moreover, when assessing any older client’s psychological symptoms, clinicians should be aware that certain vitamin deficiencies and endocrine dysfunctions, such as hypothyroidism, can manifest as mood symptoms like depression or irritability (Joffe, Pearce, Hennessey, Ryan, & Stern, 2013). Laboratory tests and medical records can therefore provide useful information for diagnosing and con- textualizing the client’s presenting problem.

Consideration of laboratory test results. Laboratory tests provide useful information that can assist in reaching an accurate diagnosis and ascertaining whether underlying medical conditions or deficiencies contribute to an individual’s psychological symptoms. Results of brain scans can potentially reveal causes of impaired cognitive functioning. Tests of certain vitamin deficiencies may also reveal potential sources of cognitive impairment. For example, vitamin D insufficiency, particularly among older minority group members, can be associated with declines in episodic memory and executive functioning skills (Miller et al., 2015). Severe Vitamin D deficiency also appears associated with declines in mood and cognitive performance in older adults (Wilkins, Sheline, Roe, Birge, & Morris, 2006). Vitamin B12 is increasingly recognized as contributing to age-related cognitive decline, as B12 18 Older Adults 463 insufficiency appears directly linked to cognitive impairment and a risk factor for cerebrovascular disease (Stover, 2010). However, more research is needed to determine the implications of vitamin insufficiencies on long-term cognitive functioning and whether supplementation is beneficial. Currently, findings regarding the cognitive benefits of Vitamin B and Vitamin D supplementation are mixed (Sturges, Cannell, & Grant, 2017; Zhang, Ye, Mu, & Cui, 2017). Older adult clients who present with depressive symptoms should also be tested for endocrine disorders that could be contributing to their symptoms. Thyroid function in particular is thought to be related to the development of mood disorders and hypothyroidism is associated with an increased risk of cognitive and mood dysfunction among older adults (Joffe et al., 2013). Cushing’s Syndrome, a disorder of the adrenal gland, co-occurs with depressive symptoms in 50–60% of clients and is particularly pronounced among older adults who have the disorder (Conner & Solomon, 2017). The disorder is also associated with anxiety and panic symptoms in some clients (Starkman, 2013). Among clients with Type 2 diabetes, clinically significant depressive symptoms and poor self-image are relatively common (Nam, Chesla, Stotts, Kroon, & Janson, 2011). Knowledge of these associations can inform one’s approach to assessing a client’s presenting problem. As previously stated, more research is necessary to determine whether there is a causal link between these vitamin deficiencies and psychological symptoms.

Case Illustration

One of the more commonly asked assessment questions encountered by interviewers who assess older adult clients is whether a client is suffering from depression, dementia, or both, as symptoms of depression can often be mistaken for dementia (Bennett & Thomas, 2014). The following case, adapted from the previous edition of this book (Edelstein et al., 2007), illustrates the challenges of arriving at a differential diagnosis when faced with this diagnostic question. Christine is an 83-year- old Caucasian woman who has resided in a nursing home for several months following injuries suffered in a fall. You are seeing her at the request of the Director of Nursing, who is concerned about Christine’s increased forgetfulness and withdrawn behavior over the past few weeks. Christine is accompanied by her son, Ryan. Ryan is concerned that Christine appears apathetic at times and no longer attends social activities. When Ryan tries to engage his mother in activities during their visits, Christine appears less interested in the activities that she used to enjoy. Christine complains of difficulties with concentration and memory and has experienced difficulty remembering the subject of conversations. She is also disoriented at times and becomes frustrated and angry when this occurs. Last night, Christine walked into the bedroom of a male resident and climbed into his bed. When the resident explained to Christine that she was in the wrong room and tried to move her, Christine struggled with him and then began crying. Ryan reports that Christine 464 R. Spalding et al. seems unhappy and withdrawn most of the time. Ryan explains that he has never seen Christine like this before. You examine Christine’s chart and find that she has a family history of Alzheimer’s disease, but she has no known history of mental illness. She has not had any recent changes in her medication. She has lost eight pounds in the past 3 weeks, putting her just under her ideal weight range. After speaking with staff, you learn that 4 weeks ago, Christine was given a new roommate after her roommate of 9 months died. Christine’s new roommate is bedridden and non-communicative. Christine’s son tells you that he has not been able to visit as often because he is going through a custody battle with his ex-wife. He further reports that each time he has visited in recent weeks, he has noticed a decline in Christine’s memory abilities and that she spends more time alone in her room. When you interview Christine, you notice that her gait is slow and unsteady. She is still wearing her bedclothes and her hair is uncombed at 3 PM. She has forgotten her glasses. She seems to hesitate and look around the room between steps. As you interview her, she is polite but tearful. She reports that she is not interested in activities that she formerly enjoyed, she sleeps much more often, her appetite is almost non-existent, and she worries constantly about her daughter and grandchildren. Her memory and concentration are markedly impaired, a source of great distress for her, and she reports feeling worthless and unhappy. Christine frequently needs to be prompted to complete sentences because her sentences trail off as she stares out the window. She asks you to repeat questions several times because she reports having forgotten the question. In light of Christine’s symptoms (e.g., memory and concentration deficits and reports of depressed mood), you are uncertain whether Christine is experiencing depression or dementia. You interview nursing staff about Christine’s behavior at various times during the day and find that she leaves her room only for meals and more frequently requests that meals be brought to her room. She also has difficulty finding her room when she returns from mealtimes and becomes agitated and tearful when trying to locate her room. When other residents approach her, she either complains or does not respond at all; they quickly leave her alone. You verbally administer a self-report measure of depression (Geriatric Depression Scale; GDS; Yesavage et al., 1983). Christine endorses 12 out of 15 items on the brief version of the GDS. The GDS is chosen rather than a lengthy, time-consuming, structured interview because of Christine’s apparent depression and cognitive deficits. Then, you interview Christine to assess her grief and bereavement following the death of her roommate 9 months prior. Christine reports being sad about her roommate’s death, but it does not appear to be accounting for her other symptoms of depression. During this interview, Christine makes several statements suggesting that she is feeling hopeless. After assessing for suicide risk, you find out that Christine feels that she is a burden on her son, but Christine does not endorse any suicidal ideation and does not have a plan. When administered the short version of the Reasons for Living Scale (RFL-OA; Lutz et al., 2018), she identifies several reasons why she would not take her own life. 18 Older Adults 465

You then assess her memory using a few simple working, short-term and long- term memory tasks to evaluate the extent of her memory impairment. You assess Christine’s memory using the Hopkins Verbal Learning Test (HVLT-Revised; Shapiro, Benedict, Schretlen, & Brandt, 1999) and find that her performance is inconsistent, sometimes within normal limits, other times far below. Christine performs well on simple tests of short-term memory (e.g., recalling a series of numbers), but performs poorly on tests that require greater concentration and working memory (e.g., digits backward). Although she cries throughout the interview process and reports feeling frustrated and worthless, you find that Christine’s memory is not as bad as she reports it to be. When you tell this to Christine, she shakes her head and tells you that the reason she has done well on some of the memory items is that the tasks were easy. To further assess for possible dementia, the Boston Naming Test (Goodglass & Kaplan, 1983), a test of language and word finding ability, is administered. Christine performs within normal limits. On follow-up tests, her rate of forgetting is within normal limits. In light of Christine’s high score on the GDS (she endorsed out of 15 depression items), specific questions regarding possible depression are asked to flesh out the clinical impression yielded by the GDS and to determine whether Christine meets DSM-5 criteria for a depressive disorder. Based upon Christine’s reports, her performance, your observations, and reports from staff and family, you conclude that Christine is probably experiencing a major depressive episode. This conclusion is based on Christine’s rate of decline (moderately rapid; more rapid might have suggested a stroke), complaints of deficits (abun- dant), emotional reaction to deficits (marked distress), evaluation of accomplishments (minimized), and poor performance on memory tasks requiring concentration, but not simpler memory tasks. These symptoms are all indicators of depression. Had Christine been experiencing dementia, the rate of decline would have been slower and her complaints about her decline, as well as her emotional reaction to them, would probably have been inconsistent (sometimes complaining, other times not reporting any distress related to her decline). A stroke or transient ischemic attack probably would have produced a more rapid decline in cognitive functioning. It is possible that Christine’s recent experiences (new roommate, concern for her son) may have resulted in depression, which affects concentration abilities, mood, and memory.

Impact of Gender, Race, Culture, Age, and Other Aspects of Diversity

The US older adult population is diverse in many ways: socioeconomically, racially/ ethnically, sexually, and countless others. Ethnic diversity among this group has been particularly well-studied and is projected to increase markedly over the coming years; by 2050, non-Hispanic whites will account for only 58% of the 466 R. Spalding et al. population over 65, representing a decline of almost 20% from 2010 statistics (Center for Disease Control, 2013). The increasing diversity of this population mer- its consideration, especially since recent research indicates the presence of racial diagnostic biases in mental health treatment settings. For instance, clinicians seem to overvalue psychotic symptoms among African-Americans, such that African- American clients are more than three times as likely as white clients to receive a schizophrenia diagnosis (Gara et al., 2012). Racial and cultural factors can affect the clinical interview process. Evidence suggests that clients may be more communicatively active with same-race providers (Saha, Komaromy, Koepsell, & Birdman, 1999). Moreover, subtle cultural stereotypes may affect how clients and providers form judgments of each other (Tait & Chibnall, 2014). If language barriers exist between client and provider, an interpreter may be necessary during the interview. Haralambous et al. (2017) interviewed clinicians who regularly work with interpreters and found that clinicians generally affirmed the utility of interpreters, particularly for enhancing client comfort, but also noted that certain difficulties may arise. Central among these was the issue of differing expectations for the interpreter’s role, which can create tension between interpreter and provider. Clinicians often described interpreters as a “mouthpiece” through which to conduct an interview, whereas interpreters identified their role as both interpreting the assessment and providing cultural information relevant to the client (Haralambous et al., 2017). When working with interpreters, clinicians may carefully consider how to best incorporate their unique skills and knowledge. Certain issues relevant to older people may be differentially influenced by cultural factors. Older adults of racial and ethnic minorities generally wait until they are in a later stage of dementia to seek a professional diagnosis and, upon receiving a diagnosis, are less inclined to access anti-dementia medication, research trials, and supportive care (Cooper, Tandy, Balamurali, & Livingston, 2010). This discrepancy may be attributed to sociocultural sources of health disparities, but further research is needed to determine these reasons and, more importantly, a means to resolve them. Regarding the development of late-life depression, acculturation and high levels of social engagement appear as protective factors among samples of Korean- American (Jang & Chiriboga, 2011) and Hispanic (Kwag, Jang, & Chiriboga, 2012) older adults. Similar to ethnic and racial minority groups, older adults who belong to sexual and gender minorities may be susceptible to mental health disparities. While lesbian, gay, bisexual, and transgender individuals are becoming more visible in geriatric communities, relatively little is known about the aging experience of LGBT individuals (Witten & Eyler, 2012). LGBT older adults may face health inequalities related to stigma, discrimination, and denial of rights. Some LGBT older adults who did not have the opportunity to be publicly identified or transitioned in younger adulthood may also experience stressors associated with the “coming out” or transitioning process (Witten & Eyler, 2012). Clinicians can remain sensitive to these issues and allow LGBT clients to share their unique experiences. At all stages of the interview process, therapist characteristics of warmth and empathy can promote a safe, inclusive space for clients of all backgrounds and orientations. 18 Older Adults 467

Critical Information for Making a Diagnosis

Consideration of Medical Conditions

More than 90% of American older adults have at least one chronic illness and nearly 75% have multiple chronic illnesses (Tinetti, Fried, & Boyd, 2012). Findings among a sample of older adults (Chen, Lee, Su, Mullan, & Chiu, 2017) indicated a reciprocal relation between chronic disease and psychological health, such that having a chronic illness predisposes one to developing a mental disorder, and vice versa. Thus, information regarding an older adult’s medical conditions is important to obtain. Arthritis is the most common cause of disability in the USA, affecting over 50% of adults over age 65 (Barbour et al., 2013). There are two main types of arthritis: osteoarthritis, a degenerative joint disease which often affects the hips, knees, and lower back, and rheumatoid arthritis, an autoimmune inflammatory disease that destroys the lining of joints in areas such as the wrists, knees, and fingers (NIH Osteoporosis and Related Bone Disease Resource Center, 2016). Both types of arthritis are frequently comorbid with depression and anxiety (Matcham, Rayner, Steer, & Hotopf, 2013). Cancer diagnoses are also more common among older adults. Compared to those under age 65, older adults have an 11-fold increased cancer incidence, and an estimated 67% increase in cancer incidence among older adults is projected by 2030 (Smith, Smith, Hurria, Hortobagyi, & Buchholz, 2009). Cancer diagnoses are often comorbid with anxiety and depression (Krebber et al., 2014). Older adults with comorbid depression and cancer diagnoses are at a heightened risk for suicide at the time of cancer diagnosis and for several years after (Quan, Arboleda-Flórez, Fick, Stuart, & Love, 2002). After Alzheimer’s disease, Parkinson’s disease is the most common degenerative cognitive disorder among older adults, with a prevalence as high as 9.5/1000 among those over age 65 (Wirdefeldt, Adami, Cole, Trichopoulos, & Mandel, 2011). Approximately 25–35% of individuals with Parkinson’s disease meet criteria for an anxiety disorder (Prediger, Matheus, Schwarzbold, Lima, & Vital, 2012), and 40–50% experience clinically significant depressive symptoms (Marsh,2013 ). Certain medical conditions, including those mentioned above, can cause behaviors that may be mistakenly interpreted as symptoms of a psychiatric disorder, especially if the psychiatric disorder diagnosis precedes the diagnosis of a medical disorder. As previously discussed, certain vitamin deficiencies or endocrine disorders may be responsible for symptoms of cognitive decline or depressive disorders. Delirium, which presents as an acute decline in cognitive functioning, is a fairly common condition that affects up to 50% of hospitalized older adults (Inouye & Charpentier, 1996). The onset of delirium is most often due to multiple factors, such as polypharmacy or psychoactive medication use, deficiencies in any organ system, dehydration, and systemic infections (e.g. urinary tract infections; Inouye & Charpentier, 1996). Given the multitude of medical conditions that can be implicated 468 R. Spalding et al. in older adults’ presentations of psychological problems, the results of a client’s recent medical examinations can be useful to inform a diagnosis.

Consideration of Medication Effects

A thorough interview should always include an inquiry regarding prescription and over-the-counter drug use. Older adults in the USA comprise less than 13% of the population but consume 34% of all the prescription medications and 30% of all the over-the-counter medications (Gerontological Society of America, 2018). A study of almost 3000 ambulatory older adults 75 years of age and older (Qato et al., 2008) revealed that 37.1% of the men and 34% of the women used at least five prescription medications. In a study of hospitalized older adults, Hajjar et al. (2005) found that 37.2% were taking nine medications, 41.4% were taking five to eight medications, and 21.4% were taking one to four medications. In a study of nursing homes, Dwyer et al. (2009) found that 39.7% of the residents were taking nine or more medications. Much of this medication consumption is driven by the chronic diseases of older adults. For example, over half of older adults have hypertension, for which they may take one or more medications (Federal Interagency Forum on Aging Related Statistics, 2012). Adverse drug effects also are relatively common among older adults, which can be due to the effects of an individual drug or the interaction of multiple drugs. Approximately 22.6% of older adults in ambulatory care experience adverse drug effects (Taché, Sonnichsen, & Ashcroft, 2011), some of which can contribute to the clinical presentation of the individual (e.g., lethargy, anxiety, somnolence). In some cases, an additional medication is taken to address the side effects of another medication (e.g., drugs to treat extrapyramidal side effects of antipsychotic medications).

Interaction of Cognitive Impairment and Mental Disorder

When determining clinical criteria for a diagnosis, it is important to consider the complex interactions between any possible cognitive impairment and symptoms of other mental disorders that the client may be experiencing. For example, individuals experiencing high levels of anxiety may perform poorly on cognitive tasks that assess processing of verbal information (Wetherell, Reynolds, Gatz, & Pedersen, 2002), memory, and attention (Derouesne, Rapin, & Lacomblez, 2004). Cognitively impaired older adults also are more likely to exhibit an increased prevalence of anxiety symptoms than non-cognitively impaired older adults (Beaudreau & O’Hara, 2009). Older adults may also be more vulnerable than young adults to the effects of anxiety on cognitively demanding tests due to potentially reduced processing resources and working memory that occur in late-life (Wetherell et al., 2002). 18 Older Adults 469

Depressive symptoms and cognitive impairment can coexist in older adults (de Paula et al., 2016), and as many as 25% of older adults may experience symptoms of both (Morimoto, Kanellopolous, & Alexopoulos, 2014). High levels of depression in older adults have been associated with poorer cognitive performance in the domains of perceptual speed, verbal fluency, and memory in comparison to older adults without depression (Laukka, Dykiert, Allerhand, Starr, & Deary, 2018). Late- life depression is considered a risk factor for cognitive impairment including cognitive decline, vascular dementia, and Alzheimer’s disease (Diniz, Butters, Albert, Dew, & Reynolds, 2013). Also, individuals who experience symptoms of cognitive impairment during a depressive episode are more likely to develop Alzheimer’s disease in the future (Alexopoulos, 2005). Differentiating between cognitive impairment and depression in older adults can be especially challenging, as symptoms of depression can impair performance on cognitive tasks. It is also not uncommon for an older adult to be diagnosed with cognitive impairment instead of being correctly diagnosed with depression (Insel & Badger, 2002), so steps should be taken in the interview to further ascertain the proper diagnosis.

Classification Issues

When interviewing older adults with an eye to diagnosis, clinicians should be aware that older adults often have unique presentations of some disorders (e.g., depression, anxiety), which call into question the current diagnostic criteria for certain disorders when applied to older adults (Edelstein, Bamonti, Gregg, & Gerolimatos, 2015). For example, older adults are more likely than younger adults to report sleep somatic complaints (Hybels, Landerman, & Blazer, 2012), and more likely to report psychomotor slowness or agitation (Hegeman, Kok, Van der Mast, & Giltay, 2012). Older adults also are less likely to report depressed mood and ideational features (e.g., suicidal ideation, guilt; Fiske, Kasl-Godley, & Gatz, 1988; Fountoulakis et al., 2003). Similar problems arise with the diagnosis of anxiety disorders with older adults (Gould, Kok, Vanessa, & Edelstein, in press). Members of the DSM Advisory Committee to the Lifespan Disorders Workgroup (Mohlman et al., 2011) noted that “avoidance and the presence of ‘excessive anxiety,’ hallmarks of DSM criteria for anxiety disorders, may be challenging to detect in older people” (p. 550). Older adults may be less likely to characterize their anxiety as excessive (Mohlman et al., 2012) and report fewer negative emotions and lower levels of shyness, depression, anxiety-guilt, and hostility (Lawton, Kleban, & Dean, 1993). The nature of older adults’ fears and worries also differ from those of younger adults (Gould et al., in press). Another classification issue pertains to age-related bias in assigning personality disorder diagnoses. Balsis, Gleason, and Woods (2007) provided evidence that older and young adults endorsed 27% of the DSM-IV criteria for personality disorder at different rates even when level of personality disorder pathology was controlled. Balsis, Woods, Gleason, and Oltmanns (2007) determined that when older and 470 R. Spalding et al. young adults with equivalent levels of personality disorder pathology were compared, the older adults were less likely to receive avoidant and dependent personality disorder diagnoses and more likely to receive obsessive-compulsive and schizoid personality disorder diagnoses. A third classification issue arises as a function of the categorical diagnostic systems of the DSM-5 and the ICD-10. Many older adults present with clinically significant symptoms that do not meet criteria for diagnoses (subsyndromal symptoms) but nevertheless result in impaired functioning. For example, approximately 13.8% of older adults in the USA experience subsyndromal symptoms of depression (Laborde-Lahoz et al., 2014), which is not only debilitating but also is associated with elevated rates of comorbid mood, anxiety, and personality disorders. These individuals also are at increased risk for major depressive disorder and anxiety disorders. A dimensional classification system or perhaps a combined categorical and dimensional classification system could potentially address the issue ofsubsyndromal symptoms; however, a solution appears complicated, daunting, and unlikely in the immediate future (Phillips, 2016).

Factors to Consider when Interviewing Older Adults

Ageism

The term “ageism” was coined in 1969 by Robert Butler, the first director of the National Institute on Aging, as “a form of bigotry we now tend to overlook: prejudice by one age group toward other age groups” (Butler, 1969; p. 243). Ageism can encompass both positive and negative themes. Negative ageism may be associated with generalizations of older adults as forgetful, slow, burdensome, or ill, whereas positive ageism is linked to stereotypes of kindness, wisdom, and “loving life.” In healthcare contexts, ageism often manifests as misconceptions that problems reported by older clients are instead a “natural part of the aging process,” or that such reports can be ignored because people “complain” more as they age (Levy & Macdonald, 2016). While ageism is relatively under-studied compared to other types of prejudice (i.e., racism, sexism), such misconceptions can be dangerous to the extent that they promote negligence or, in the extreme, elder abuse (North & Fiske, 2012). Unfortunately, one in ten American older adults is a victim of some form of elder abuse (Dong, 2014). Ageism may influence the extent to which older adults utilize mental health care services. Although the need for psychological treatment is relatively equal across age groups, older adults use disproportionately fewer services than younger people (Wang, et al., 2005). Hypotheses that this discrepancy is due to older adults’ negative attitudes towards mental health care have been increasingly challenged, with findings reporting that older adults’ help-seeking attitudes towards mental health services are generally even more positive than their younger counterparts (Mackenzie, Gekoski, & Knox, 2006). However, it is important to recognize that 18 Older Adults 471 these findings may not reflect the attitudes of each older client, as certain clients may be more or less accepting of psychological treatment. Ageist biases may exist within the healthcare system and contribute to the underutilization of mental health services among older adults. Ivey et al. (2000) investi- gated the process of physician psychotherapy referrals and found that physicians may hold ageist stereotypes regarding older adults’ inability to change or cognitively engage in therapy, which may inhibit the extent to which they refer older clients to these services. Even mental health professionals may hold similar biases, as evidenced by findings from James and Haley 1995( ) that some clinicians are skeptical of the suitability of older adults for treatment. Clinicians should stay informed about popular myths regarding aging and the empirical literature that serves to erad- icate such misconceptions. Clinicians should also monitor their own biases to ensure that they do not interfere with their ability to objectively interview and treat older clients.

Sensory Processes

The clinical interview relies heavily on the client’s hearing and vision. Hearing is important for communicating with the interviewer, although not essential. In addition, it is important as a sensory modality through which the client may experience the world. Vision is also important as a sensory modality for the same reasons. This is not to say that one could not successfully interview a client with substantially impaired vision and hearing, although that would offer some challenges. When interviewing older adults, it is important to understand the age-related changes that occur in both vision and hearing that can influence the process and outcome of an interview and the ways in which their deficits can affect the everyday life of a client. It is also important to be knowledgeable of the options for minimizing and accommodating deficits in these sensory modalities when conducting the interview. Changes in our visual system begin early in adulthood and progress as we age. As our vision becomes impaired, it can affect our reading ability, mobility, driving, social behavior, and use of cell phones and computers. These changes can contribute to diminished quality of life and psychological well-being. Eye diseases that are common among older adults include cataracts, diabetic retinopathy, dry eye, low vision, and glaucoma (National Eye Institute, 2018). The most common eye diseases and conditions that affect older adults include age-related macular degeneration (AMD), cataract, diabetic retinopathy, dry eye, glaucoma, and low vision. Cataracts, for example, can cause increased sensitivity to glare, cloudy or blurred vision, halos around lights, and diminished visual acuity, and increase the risk for falls (Owsley, 2016). Individuals with impaired vision may be less inclined to participate in social activities and drive cars. They also may have difficulty reading printed material presented in the interview. If written material is presented, it should be printed on non-glossy paper to reduce glare, using a 14 to 16-point font. The client should also be encouraged to bring reading glasses if needed. 472 R. Spalding et al.

Hearing loss associated with age (presbycusis) affects approximately 33% of older adults between the ages of 65 and 74, and almost 59% of those 75 years of age and older (National Institute on Deafness and Other Communication Disorders, 2018) have difficulty hearing. The hearing impairment can make it difficult for the client to hear the clinician’s questions and can affect their social lives as well. Indeed, one can feel isolated when hearing impairment affects social relationships and even the enjoyment of watching movies and listening to the radio. Clients should be asked whether they use a hearing aid or other corrective device and, if so, encouraged to use them during the interview. The clinician should be attentive to behavioral clues that the client is experiencing hearing difficulties during the interview (e.g., adjusting their head, leaning forward, asking for questions to be repeated). Some older adults may be embarrassed by their hearing impairment and reluctant to admit that they are having difficulty hearing. Ideally, the interviewer should sit fac- ing the client so that the client can see facial expressions and read lips movements. If the client has significantly impaired hearing, a piece of paper or “whiteboard” can be used to write questions. The interviewer should speak somewhat louder than usual if the client is having difficulty hearing but should not shout. Over-exaggeration of words should be avoided, as it can impair lip reading.

Memory and Cognitive Abilities

Awareness of normative and pathological changes in cognitive capabilities is essential to consider when interviewing older adults. Nearly 40% of older adults have some form of mild cognitive impairment (Langa et al., 2012), and of those diagnosed with mild cognitive impairment, almost half will be diagnosed with dementia at some time later on (Mitchell & Shiri‐Feshki, 2009). Memory and cognitive changes in older adults’ abilities may include late-life declines in processing speed, encoding information, episodic memory, and reasoning (Harada, Natelson Love, & Triebel, 2013). Perceptual reasoning abilities also decline with age (Harada et al., 2013), as do working memory abilities that utilize verbal and visual information (Park et al., 2002). Yet, other cognitive abilities like recognition and semantic memory remain unchanged or increase with age (Luo & Craik, 2008). Age-related changes in cognitive functioning should be considered when conducting interviews with older adults. Questions asked during interviews should be short and concise to help reduce challenges to working memory, and double-barreled questions should be avoided (Gerolimatos, Gregg, & Edelstein, 2015). Instructions should be given slowly and clearly. It is recommended that the interviewer provide response scales on cards for clients to ease the challenge of remembering response choices and to check every once in a while if the older adult understands the response scale (Mohlman et al., 2012). Clients should also be given time to formulate responses to questions asked to help account for any slower information processing speeds. If there is a long delay between the interviewer asking the question and a response from the client, the interviewer can ask the client if they would like the question repeated 18 Older Adults 473 and if they understood the question (Gerolimatos et al., 2015). Taking short breaks during the interview may also help improve concentration and performance. As discussed in greater detail below, older adults may experience different peak cognitive performance times than young adults, so it is recommended that the time of day the interview took place should be noted and taken into consideration.

Circadian Issues

Circadian rhythms help regulate a wide variety of rhythmic activities including sleep/wake patterns, hormone secretions, and temperature regulation. Older adults’ biological clocks change with age and can influence waking activity, fatigue level, and sleep cycles (Hood & Amir, 2017). Performance on cognitive tasks is influenced by circadian rhythms and thus varies depending on the time of day (Schmidt, Fabienne, Cajochen, & Peigneux, 2007), with peak task performance occurring concurrently with peak physiological performance (May, Hasher, & Stoltzfus, 1993). Due to circadian shifts in late-life, older adults often experience peak cognitive performance early in the day (Yoon, May, & Hasher, 1999). Differences in cognitive functioning may be noticeable in older adults throughout the day, and performance on tasks that require more effortful processing like working memory and problem solving is improved. Interviewers should be mindful of the time of day that diagnostic interviews are conducted, so that the client’s performance on the interview can be informed and interpreted in relation to their optimal circadian peak time (Edelstein, Koven, Spira, & Shreve-Neiger, 2003). Interviewers should also be mindful of other circadian-related issues like fatigue, which could cause diminished attention, especially if the interview is taking place at a non-peak performance time (Gerolimatos et al., 2015). When scheduling assessments and conducting interviews, interviewers should take into consideration assessment time, peak circadian periods, and the potential for diminished performance during non-optimal times.

Cohort Issues

The age cohort to which a client belongs may influence the clinical interview process, affecting the client’s views towards privacy, sexuality, gender roles, and mental health itself. In general, earlier cohorts of older adults may be less familiar with options for mental health care and may be more likely to negatively associate mental health services with personal weakness or spiritual deficiency (Robb, Haley, Becker, Polivka, & Chwa, 2003). However, as previously discussed, there is little empirical evidence to support assumptions that older adults place less value on psychological health and are more averse to seeking mental health services (Kessler, Agines, & Bowen, 2014). During the clinical interview, therapist characteristics of warmth and empathy can encourage older clients to share their unique perspectives. 474 R. Spalding et al.

Summary

When conducting assessments with any client, including with older adults, the interview is one of the most important means of gathering information and facilitates the development of rapport and potentially a therapeutic relationship. However, it is only one method to consider and therefore has its strengths and weaknesses, as any single assessment method. The interview is therefore most effective if one is knowledgeable of the many age-related changes that can occur across a wide variety of domains (e.g., cognition, sensation) and uses this knowledge to inform the interview and assess the outcome. Moreover, clinicians should be sensitive to the diverse nature and needs of this population and avoid allowing stereotypes or biases to unduly influence the interview assessment. We have briefly reviewed several of the main factors to consider when interviewing older adults and, in many cases, provided practical suggestions for accommodating or addressing these concerns. Older adults offer complex and interesting challenges in the interview that can prove highly satisfying and rewarding to the clinician, lending the opportunity to meaningfully integrate various elements into the assessment process.

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Jay M. Behel and Bruce Rybarczyk

Introduction

Psychologists, particularly those with specialty training in clinical health psychology, are employed in a wide variety of healthcare settings. In these settings, they address a wide range of mind-body issues, ranging from health behavior change work to psychotherapy focused on adjustment to often-catastrophic changes in health. This shift away from the centuries-old Cartesian mind-body dualism is succinctly described as the biopsychosocial model (Engel, 1977). This influential paradigm recognizes that the interrelationship between medical, psychological, behavioral, sociocultural, and environmental factors impacts the objective and subjective experiences of health and illness. The dualistic question of whether a patient has a “mental or physical problem” is viewed as an artificial one, as psychologists strive to facilitate an integrative understanding and treatment of psyche and soma. As an extension of the biopsychosocial model, psychologists in healthcare settings are simply health professionals, rather than mental health professionals, in recognition of their participation in improving both the mental and physical health of their patients. They are, in fact, regarded as a central part of the healthcare team in many settings discussed here. Biopsychosocial orientation notwithstanding, it remains crucial for psychologists in healthcare settings to be strongly grounded in mental health diagnosis and treatment. Other health professionals rely on psychologists to be experts in identifying comorbid mental disorders and providing treatment or treatment recommendations for those disorders. As such, clinical psychologists in healthcare settings

J. M. Behel (*) Department of Behavioral Sciences, Rush Medical College of Rush University, Chicago, IL, USA e-mail: [email protected] B. Rybarczyk Department of Psychology, Virginia Commonwealth University, Richmond, VA, USA

© Springer International Publishing AG 2019 481 D. L. Segal (ed.), Diagnostic Interviewing, https://doi.org/10.1007/978-1-4939-9127-3_19 482 J. M. Behel and B. Rybarczyk ought to have a strong generalist foundation before progressing to more specialized training in clinical health psychology. Similarly, psychologists need to draw upon a wide scope of theories of behavior, personality, and psychopathology. For this reason, beyond their initial training, clinical health psychologists must continue to update their knowledge in mental health diagnosis and treatment throughout their careers. This chapter describes a range of settings and populations in which clinical health psychologists provide assessments, the procedures for gathering information for assessment, some important information needed to make psychiatric diagnoses, examples of two assessments that incorporate these methods, and the consideration of diversity issues in this specialty population. Finally, we provide a set of “dos and don’ts” derived from several decades of combined clinical experience by the authors as well as the advice given by seasoned professionals in clinical health psychology.

Description of Healthcare Settings and Populations

Because virtually every person is a patient at some point in their life, it is difficult to describe “typical” medical patients. One can, however, describe the healthcare settings and situations in which psychologists are most called upon to evaluate patients. For the purposes of the current chapter, the term healthcare setting will refer to any venue in which physicians, physician assistants, or advanced practice nurses are the primary clinicians and in which physical health is the primary focus. Such settings would include primary care and specialty offices and clinics; acute care, inpatient facilities; and acute, sub-acute, and outpatient physical rehabilitation programs. Under this definition, an outpatient breast cancer clinic would be classified as healthcare but an inpatient psychiatry unit would not. Although the principles outlined in this chapter would certainly apply to psychologists who see medically ill patients in their outpatient practice or offer health promotion interventions in the community, those settings are not explicitly considered or discussed in this chapter. Before exploring the more common patient scenarios, it is important to understand the psychologist’s role in healthcare settings. Most commonly, psychologists are regarded as consultants; that is, a specialist called upon by an attending physician (inpatient), primary care provider (outpatient), or another specialist to evaluate, deliver an opinion about, and perhaps treat a certain aspect of the patient’s presentation. Consequently, psychological evaluations on inpatient units often are referred to as “consults,” and the division within a hospital-based psychiatry department where psychologists are frequently employed is often referred to as a “consultation and liaison service.” The consultant role, itself, does not shape the content of the evaluation, but it can define the primary relationship in the evaluation process. Specifically, by requesting the psychologist’s expertise, the consulting provider is implicitly defining the critical relationship as that between physician and psychologist. This obviously does not 19 Interviewing in Health Psychology and Medical Settings 483 preclude a full and ultimately independent therapeutic relationship with the patient. However, it is important that the patient be made aware of the dimensions of the initial evaluation and be given an opportunity to consent to or decline an evaluation, the results of which will be shared with their provider. Nevertheless, providing the consulting provider a clear description of findings and associated recommendations in writing (and often verbally as well) is a critical component of the evaluation. The patient factor(s) that psychologists are asked to evaluate may be as broad as “emotional functioning” and as specific as the patient’s ability to adhere to a medication regimen. Referral patterns are highly variable. Some providers refer a significant portion of their patients. Others refer patients with specific diagnoses, and still others refer patients whom they regard as difficult or whose condition is treatment-resistant. An additional concern is that of the referral question. Across healthcare settings, psychological evaluations are requested for a specific purpose (even if that purpose is as broad as an “emotional evaluation”) usually termed the referral question. Again, these questions may be very specific, very general, or may be omitted altogether. Well-framed referral questions can help psychologists shape clinical interviews that are thorough yet efficient, while overly broad or inappropriate questions can make the interviewing task more difficult. Regardless of how specific and well- crafted a referral question is, it is important for psychologists to keep their own professional standards and responsibilities in mind and not be guided by the referral question alone. Keeping these general considerations in mind, we can turn to some specific settings for psychological consultation as well as some specific medical diagnoses that more often call for a psychologist’s involvement. The traditional acute care inpatient hospital unit is, perhaps, the quintessential healthcare environment. In this setting, psychologists are called upon to address a wide range of issues. Such consults may be requested to assess medically ill patients for the presence and severity of primary psychiatric disorders whether alluded to in the patient’s history or not. They may also be asked to provide maintenance care to patients who are receiving more long-term mental health services outside of the hospital. The relevance of ongoing or historic psychiatric difficulties to current medical problems and procedures often is central to acute care referrals. Psychologists also are asked to weigh the relative contribution of emotional distress and physical discomfort to a patient’s overall presentation. Cognitive assessment, from brief screenings to comprehensive neuropsychological assessment, may also be a target of psychological assessment in acute care. Finally, psychologists frequently are called upon to help patients and their families process and cope with distressing diagnostic and prognostic information. Increasingly, integrated primary care is becoming a venue where psychologists practice psychological assessment and intervention. A consensus definition of integrated behavioral health in primary care is “care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population” (Peek & National Integration Academy Council, 2013). As with acute care, the interrelation of psychic and physical distress can be 484 J. M. Behel and B. Rybarczyk an important component of psychological practice in a primary care setting. Similarly, primary care offers an excellent opportunity to conveniently address psychiatric disorders that have otherwise been ignored, missed, or undertreated by other care providers (Davis, 2004). However, primary care also is a setting in which health promotion, secondary prevention, treatment adherence interventions, and other interventions to reduce the maladaptive patterns of healthcare utilization may be effectively undertaken (Peek & National Integration Academy Council, 2013). Consequently, assessments in these settings ought to explore not only physical and mental health but also patients’ health habits and beliefs, their understanding of and ability to comprehend medical information, and attitudes toward their doctors and the healthcare system. In the Primary Care Behavioral Health Model (Reiter, Dobmeyer, & Hunter, 2018), psychologists provide brief, problem-focused services to a wide range of patients rather than extensive services to fewer patients. Instead of being regarded as consultants to the rest of the team, psychologists play a key role in proactively screening for and treating behavioral health issues among all patients in a given practice where they work as a core team member. This population-based approach to practice means that psychologists must be available to provide brief services to a wide range of patients. They typically provide up to five 30-minute sessions of treatment to a given patient, often spread out over several months (see Sadock, Perrin, Grinnell, Rybarczyk, & Auerbach, 2017), and refer patients who need more intensive services to specialty mental health practices. Within this model, the goal of treatment is functional gains rather than full remission of symptoms (Reiter et al., 2018). Thus, the role of clinical interviewing in this model is to rapidly identify the core problem that is interfering with functioning and, within the same visit, to transition to a plan of action using an evidence-based, brief behavioral intervention. Table 19.1 summarizes the significantly different objectives and characteristics of clinical interviewing in a specialty mental health setting compared to integrated behavioral health in primary care settings. A third, broad setting to consider is inpatient rehabilitation program. These are units within larger healthcare centers or freestanding facilities that provide intensive physical medicine and rehabilitation services to patients experiencing significant debility secondary to an acute or chronic medical condition. Rehabilitation services include medical monitoring by a physiatrist, nursing care, and daily physical, occupational, and (depending on the diagnosis) speech therapy. Opportunities to work with a recreational therapist and chaplain are frequently offered as well. Moreover, unlike most acute and primary care settings, many inpatient rehabilitation programs include psychologists as integral members of the treatment team with psychological assessment and intervention playing a critical role in treatment and discharge planning. In some facilities, this means that a psychologist evaluates every patient whereas in other facilities, only patients with specific medical or psychiatric histories are referred for evaluation. Although evaluations in rehabilitation settings remain thorough, special attention is paid to a patient’s current and historic level of physical, cognitive, and emotional functioning, their goals and expectations for rehabilitation and recovery, and the support available to help the patient bridge 19 Interviewing in Health Psychology and Medical Settings 485

Table 19.1 Clinical interviewing in specialty mental health vs. primary care behavioral health Specialty mental healthcare initial Primary care behavioral health initial interview interview Term used to Psychologist Behavioral health consultant – to avoid describe clinician stigma when introduced to patient Time lag from initial Several weeks typically Same day handoff or return visit within a few referral to initial days interview Objective of initial Comprehensive Targeted assessment to identify an initial interview assessment to determine treatable problem; intervention explained and diagnosis, in order to initiated in the second half of the initial begin treatment planning interview Time length of initial 90 minutes 30–45 minutes interview Type of self-report Package that includes Brief screening measures of 10 items or less, instruments comprehensive measures typically targeting depression and anxiety employed of psychological and/or cognitive functioning Role of making a Usually viewed as Not essential beyond patient’s self-report or psychiatric diagnosis essential for treatment medical record of prior diagnoses; focus on plan and referral for description of specific symptoms (e.g., medication as needed anxiety, depression, insomnia) Documentation of Multi-page report with 1–2 paragraph note focusing on key problem initial interview detailed history, areas, initial psychoeducation, and homework symptoms, diagnosis, and assignment provided to the patient as well as treatment plan any guidance for other team members (e.g., “ask patient about X at next appointment”)

discrepancies between the level of functioning and preferred discharge plan. Because significant numbers of rehabilitation patients are admitted following acute neurological changes, such as stroke and traumatic brain injury, cognitive assessment is an important component of rehabilitation, and psychological services on these units often are provided by or in concert with a neuropsychologist. Although medical diagnoses in and of themselves are relatively poor predictors of affective distress and need for psychological services, several diagnostic groups are more likely to receive specialized psychological services. First, patients broadly described as having chronic pain are frequently referred for psychological evaluation. These evaluations typically include a detailed pain history, including the duration, location, and intensity of the pain, as well as an accounting of medical interventions undertaken to address the pain, current and past medication regimens, and the impact of the pain on the patient’s occupational, physical, relational, and sexual functioning. Another key area of inquiry is variability in pain, including situational and other factors that palliate or exacerbate pain. In evaluating patients with chronic pain, the clinical interview often is supplemented with both a pain-specific objective measure such as the Multidimensional Pain Inventory (MPI; Kerns, Turk, 486 J. M. Behel and B. Rybarczyk

& Rudy, 1985) as well as one or more general measures of distress, for example, the Symptom Checklist-90-Revised (SCL-90-R; Derogatis, 1994) and personality, for example, the Personality Assessment Inventory (PAI; Morey, 2007). Evaluation of a patient with chronic pain may be undertaken for a variety of reasons. The assessment may simply be a prelude to psychotherapy, and the patient’s pain experience obviously remains relevant, even when treatment goals are unrelated to the pain. A chronic pain evaluation may also be requested by the physician treating the pain either as part of a work-up preceding a new course of medical treatment or surgical intervention or to initiate pain-specific psychological interventions such as biofeedback. In considering work with individuals with chronic pain, two widely held patient and physician biases should be kept in mind. First, chronic pain patients may be labeled as “drug-seeking,” “manipulative,” or “attention-seeking,” and some physicians only refer pain patients who they so label. While there certainly are challenging patients for whom such labels are justifiable, it is important that psychologists monitor their own responses to patients and avoid letting such pejorative labels color their assessment. On the other hand, patients with chronic pain often regard referral to a psychologist as an implicit judgment by their physician, indicating a belief that their pain is “in my head” or “not real.” Consequently, providing education about the multidimensional nature of chronic pain can be an important part of the initial assessment. Individuals with cancer and those who have survived cancer often receive specialized psychological services (often termed psychosocial oncology). The availability of mental health services to cancer patients and survivors is supported by the Commission on Cancer’s requirements that accredited cancer treatment centers screen for affective distress and develop survivorship plans which often have a significant psychosocial component (Commission on Cancer, 2016). Although there is considerable variability in the decisions and issues confronting an individual with cancer, most evaluations should include an assessment of the patient’s understanding of their diagnosis and prognosis, the extent to which they have shared healthcare information with their family and friends, expectations, beliefs, and preferences about pain and pain control, body image concerns, and, as relevant, end-of-life issues. Psychologists may be asked to evaluate a patient at any point in the diagnostic and treatment process. Common settings for such evaluations include outpatient, diagnostic clinics such as a breast cancer clinic, inpatient units when a patient is hospitalized, and hospice units with patients who are near the end of their lives. Psychologists working with cancer patients also see these individuals in the more traditional outpatient office settings, often providing psychotherapy over the entire course of an illness and beyond. Patients awaiting heart, lung, and liver transplant and those referred for stem cell/bone marrow transplants comprise a third category of patients frequently referred for psychological evaluation. Although psychotherapeutic work may follow such an evaluation, pre-transplant assessments are almost always requested as a means of determining whether the transplant candidate has the cognitive and emotional resources to understand the risks and benefits of the transplant, adhere to post-transplant treatment regimens, and, if applicable, maintain abstinence from 19 Interviewing in Health Psychology and Medical Settings 487 alcohol, cigarettes, or illicit drugs. A similar approach is taken to candidates for bariatric surgical procedures that reduce the size of the stomach in morbidly obese individuals. The goal of these evaluations is to determine whether patients have made a sufficient effort to lose weight by more conservative means, have realistic goals about losing weight, and understand the risks and limitations of such procedures. Psychologists providing these interventions often are in multiple roles, including as an objective evaluator who assists in making decisions about whether the patient is a good candidate for a transplant or related procedure. As such, patients may be reticent to reveal information that may affect their chances of receiving the surgery, so creating rapport and trust are essential to the evaluation. Convincing the patient that you are acting in their best interest and that you base your recommendations on the best data available regarding the chances of success following the procedure is essential as well.

Procedures for Gathering Information

Chart Review A review of the patient’s health record usually occurs prior to the clinical interview. This allows the examiner to focus on what is not already known and documented. Although there may be much redundancy and detail that goes beyond the scope of what psychologists need to know, the chart provides several important kinds of information including demographic and social history, current medical problems and medical history, and current medications and medical issues that remain unresolved. Nurse and physician observations about cognitive functioning, interpersonal conflicts with staff, compliance with treatment and safety precautions, and any particular sources of anxiety may also get charted. It is essential for psychologists to learn medical terminology, jargon, and acronyms. For example, the notation “AMS” in a healthcare chart is used to indicate altered mental status and often is used as a shorthand indicator for a wide array of cognitive and behavioral issues. Apart from asking healthcare staff and patients themselves to educate you, various websites that educate the public about medical conditions and their treatments are an excellent starting point for information.

Clinical Interview The clinical interview is by far the most valuable tool for the psychologist in the health setting. Perhaps more than in most settings, the introduction is a crucial element of the interview. Since the patient has often not been informed of the purpose of the assessment or was given a very cursory explanation, it falls upon the psychologist to clarify their role or the purpose of the assessment. It is important to be both frank and tactful. One of the most common responses to the unexpected appearance of a psychologist is the half-joking question “are you going to figure out if I am crazy or not?”. Similarly, in primary care, the patient may have agreed to meet with the psychologist because they trust their provider who “told me to talk to the psychologist.” 488 J. M. Behel and B. Rybarczyk

Psychologists must experiment with and develop their own style of putting patients at ease and answering any questions they may have. One element of an effective introduction is a statement that psychologists are an essential part of a healthcare team that aims at treating the whole person and that quality of life is one of the most important aspects of good healthcare. Sometimes, it helps to underscore that psychologists in healthcare settings do not focus on “abnormal people” but “normal people in abnormal situations.” If the patient is known in advance to be reticent, it can be beneficial to have the physician make the introduction or have the psychologist participate in medical rounds initially. Other effective techniques include avoiding stereotypic psychologist behaviors and jargon, starting with a light topic of mutual interest that provides an opportunity for self-disclosure by the psychologist and using respectful humor where possible (Van Egeren, 2004). The examiner should begin by asking broad, open-ended questions that encourage the patient to relate their perspective as a cohesive narrative. Opening interviews in this way serves several purposes. First, the patient is given a degree of control over the evaluation and is encouraged to relate their story in a way that is comfortable for them. This issue is particularly important in the inpatient setting, as patients often frequently feel “bombarded” by a long series of focused questions; moreover, the lack of conversational give and take can inhibit the development of rapport. As patients relate their history, they typically provide many potential openings for the examiner to ask follow-up questions with the patient’s own story offering an implicit invitation to explore more sensitive topics. This open-ended approach also gives the examiner a valuable opportunity to make behavioral observations about the patient’s cognition, energy level, observable pain, and affective regulation. After the patient is finished with their narrative, the psychologist can switch to focused inquiry to fill in the missing information and detail. Table 19.2 outlines the typical elements that should be included in this phase of the interview in general healthcare settings. The somatically focused patient is a common interviewing challenge. Such patients may spend the entire interview time reiterating painstaking details of what has happened to them medically and may be reluctant to discuss psychosocial factors of their illness. The best interviewers are able to draw out the broader illness narrative and pick out underlying themes, such as uncertainty and fear about the future, disappointment with the care that has been received, loss of faith in trusted providers, perceived skepticism on the part of providers and family regarding the legitimacy of the illness, and so on. Joining with the patient by empathizing with these experiences is an important first step toward building rapport. Additionally, when somatically focused patients are resistant to discussing psychosocial issues related to their illness, it is more prudent to take an indirect approach by keeping inquiries about an individual’s psychosocial history separate from inquiries about the healthcare history (Van Egeren, 2004). An advanced skill described by Belar and Deardorff (1995) is for health psychologists to “both elicit and negotiate the patient’s health belief model” (p. 116) during the interview. This means that the psychologist attempts to understand the strict and often rigid biomedical views of the patient but also to reinforce and teach views that are more compatible with the biopsychosocial model. This may include 19 Interviewing in Health Psychology and Medical Settings 489

Table 19.2 Brief outline for general clinical health psychology interview Medical history and narrative Patient narrative emphasized, facts taken from chart Patient’s explanatory model of illness including causes, why it started when it did, how severe is it, and what he or she thinks would be the best treatment Previous psychiatric history, including diagnoses and treatments (counseling included) Understanding of purpose of any current psychiatric medications Social history Family of origin, including any major medical or psychiatric illnesses Current social support system, including significant others Education and employment, including financial stressors Religious community Legal history, including litigation related to medical conditions and disability Coping and psychological functioning Clinical and sub-clinical depression or anxiety symptoms Coping, including strengths and benefits finding from chronic medical conditions “Given the challenges of your medical condition, what things do you do to try to maintain a positive outlook and mood?” “What, if any, positive changes have occurred in your life as a result of your illness?” Hobbies and activities for recreation and how they have changed due to illness Alcohol and “recreational” drug use Sleep, including perception of quality, type of difficulties, caffeine use, and regularity of schedule Satisfaction with sexuality, even when partner is not reported Religious/spiritual coping What part, if any, do spiritual beliefs and religion play in coping Cognitive functioning Behavioral observations: Speech patterns, remote memory and chronology of events, behaviors, insight into deficits. Subjective and/or collateral report. “Have you or your family noticed any changes in memory or concentration since your illness?” Formal screening or referral for neuropsychological testing as needed. introducing the role of stress in illness, the concept of secondary pain brought about by tensing muscles, how medical symptoms differ in their psychological experience depending on their predictability and controllability, etc. This “negotiation” process has the goal of finding a common ground of agreement and providing foundation for any future interventions that address psychological factors. A thorough discussion of cognition and cognitive testing is beyond the scope of this chapter (see Chap. 5 for a full discussion of neuropsychological testing and interviewing). It is, however, necessary to assess for cognitive deficits in all patients because of the effects that a great range of illnesses and their treatments have on cognition, including those that are not neurological diseases per se (e.g., diabetes, chemotherapy). This component of the assessment may include collecting 490 J. M. Behel and B. Rybarczyk

information from collateral sources (e.g., family, nurses) and employing both formal and informal assessment approaches throughout the interview. For assessment in this setting, it is important to recognize the potential interplay of physical, emotional, and cognitive factors in all medical patients, particularly those with acute sources of physical distress. An individual with generally intact cognition can appear quite impaired in the context of acute illness or sedating medications. Conversely, examiners can be misled into interpreting genuine cognitive deficits as simple fatigue. Consequently, a reliable screening measure should be included as a routine part of most, if not all, psychological evaluations of medical patients. Reliable and valid screening instruments range in brevity from the Mini Mental Status Exam or Modified Mini-Mental Status Examination (3MS; Teng & Chui, 1987) to the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Randolph, Tierney, Mohr, & Chase, 1998).

Case Examples

Case #1: The Rehabilitation Patient The patient is a 76-year-old Caucasian woman admitted to an acute rehabilitation unit following a left total hip arthroplasty (THA) undertaken secondary to advanced degenerative joint disease (DJD). Psychological evaluation was requested as a routine part of the rehabilitation program.

Chart Review Per the electronic health record, the patient has a past history notable for osteoarthritis, DJD, hypertension, diabetes mellitus, spinal stenosis, and a right THA 8 years ago. Although no psychiatric history is noted, her current medication regimen includes citalopram (40 mg/daily). Her social history, per the health record, is negative for cigarette smoking and alcohol and drug abuse. She lives in a “senior building” and has family nearby. Additionally, a social worker’s note describes the patient as a retired factory worker and religiously active Roman Catholic. She has five adult children and several grandchildren. An initial nursing note describes the patient as alert, oriented, and cooperative.

Clinical Interview The patient was evaluated in her private hospital room in the afternoon. The examiner explained the role of the Rehabilitation Psychology service on that unit and began the evaluation. The patient was agreeable to assessment, although she reported having a “rough” day. The examiner encouraged the patient to clarify the factors contributing to her bad day, and she reported having difficulty in physical therapy earlier in the day and noted that her pain seemed greater and her subjective rate of recovery slower than her prior hip surgery 8 years earlier. In initially relaying her history, the patient provided only a brief description of both recent and remote facts and needed frequent prompting and follow-up questions to provide a complete history. For example, the patient initially offered simply that she was widowed and that she was living alone in an apartment building for senior citizens. Direct and specific follow-up questions were necessary to elicit the 19 Interviewing in Health Psychology and Medical Settings 491 details of her husband’s death and the reasons for and her feelings about the move to the apartment building. With more such prompting, the patient related the many difficulties she had experienced in her life including the early deaths of her mother and husband as well as several miscarriages early in her marriage. The patient also described close relationships with her children and grandchildren but observed that she rarely sees them. She repeatedly used the word “alone” to describe her typical state. She described generally good health and mobility. Sad affect with restricted range was observable. The patient denied any history of receiving formal mental health services. She reported “maybe” having “a little” depression in the past and noted that she “worries” a great deal. She also denied any family psychiatric history. The patient was aware that an anti-depressant was part of her medication regimen and reported that it had been prescribed by her primary care physician. She was uncertain of the reason for the medication having been prescribed or whether it had been effective. The examiner further explored the patient’s psychiatric history by (1) encouraging her to elaborate on experiences of “worry” and feeling “alone,” and (2) by asking more pointed questions about psychiatric hospitalization, psychosis, and traumatic experiences. With such prompting, the current patient was able to provide considerable additional information. Specifically, she acknowledged chronic, mild low mood for much of her adult life. She was unable to recall any prior periods of more intense symptoms of depression but did report increased worry, delayed sleep onset and nervousness during times of stress, noting that she had always regarded these periods of anxiety as “like depression.” She denied any history of suicidality, panic, trauma, or psychosis. The examiner also was able to draw upon information from earlier in the evaluation to help the patient place her episodes of distress in context with major life events. The end of the psychiatric history often is a good time to obtain substance abuse histories and explore a patient’s typical health habits, including exercise, diet, and adherence to healthcare recommendations and medication regimens. For the current patient, there was no significant substance abuse history, and her physical health habits and treatment adherence were good. Although the patient characterized her recent mood as “okay, I guess,” she endorsed many physical symptoms of distress (low energy, disturbed sleep, variable appetite) and reported decreased motivation just prior to and since her recent surgery. She also acknowledged significant worry about her health. However, she denied low mood, anhedonia, feelings of guilt, worthlessness, helplessness or hopelessness, and suicidal ideation. However, her overall presentation and score of 9 out of 15 on a verbally administered Geriatric Depression Scale-15 (GDS-15; Sheikh & Yesavage, 1986) pointed to a likely major depressive episode of mild to moderate severity. This diagnostic picture of a person denying most positive symptoms of depression while endorsing clinically significant levels of negative symptoms is fairly common in older adults (Gallo & Rabins, 1999), and for the current patient, this was further complicated by her long-standing tendency to mislabel anxiety as depression. 492 J. M. Behel and B. Rybarczyk

The examiner then pursued a discussion of the patient’s current difficulties with the rehabilitation program. He asked specific questions about the patient’s post- surgical pain and other physical demands of physical and occupational therapy. She rated her pain as manageable (typically 1–4/10) and responsive to medication. However, she again noted feeling fatigued and overly challenged by the activities suggested by her physical and occupational therapists. She also offered that many of the therapeutic exercises did not “make sense,” that is, she did not see a link between the activities and the ability to resume her accustomed lifestyle. She acknowledged that she had not expressed these concerns to her therapists. Next, the examiner asked about the patient’s typical and current means of coping with challenging and distressing situations. The patient reported using distraction (watching television) and prayer to deal with the negative affect but also reported that she typically avoided discussing her feelings with her family because she wanted to avoid worrying them. She also acknowledged difficulty distracting herself during her hospitalization, and she reported feeling cut-off from her church because she had been unable to attend services for several weeks. The examiner provided a moment of empathic reflection and assured the patient that he would revisit her concerns at the end of the evaluation. Finally, the examiner proceeded to the cognitive assessment, administering the Modified Mini-Mental Status Examination (3MS; Teng & Chui, 1987). The patient achieved 89/100, reflecting no gross cognitive impairment. At the closing of this initial evaluation, the examiner summarized his initial impressions for the patient. He related the impression that long-standing anxiety and acute physical distress had precipitated an episode of depression and that all three factors were interfering with her participation in the rehabilitation program. He further recommended working with her on focused, cognitive-behavioral interventions to improve mood. He explained that longer-term psychotherapy and consultation with psychiatry were additional treatment options to be considered later. The patient was receptive to these initial recommendations and agreeable to working with the examiner. Following this initial assessment, the examiner spoke with the referring physician and wrote a brief (one-page) report including the recommendation for psychotherapy during her rehabilitation stay. The report was added to the patient’s health record.

Case #2: The Primary Care Patient The patient is a 57-year-old African- American man seen in his primary care physician’s office following a yearly physical examination. His PMH was notable for diabetes mellitus, hypertension, and benign prostatic hypertrophy. His doctor had asked the psychologist to evaluate the patient in advance of the exam and had alerted the patient to this request. In this physician’s practice, a psychological evaluation was recommended for all patients managing more than one chronic illness. The patient was seen in a casually fur- nished office separate from the examination room. 19 Interviewing in Health Psychology and Medical Settings 493

Chart Review The health record revealed the above-reported healthcare history, a medication regimen including medications for hypertension and diabetes, a 1.5- pack per day smoking history for more than 30 years, and a family history of colon cancer and heart disease.

Clinical Interview This interview began with a description of the psychologist’s role in that practice as well as some very general information about the challenges of managing multiple healthcare problems. The examiner then proceeded to inquire about the patient’s prior experiences with mental health professionals. Although asking about psychiatric history so early in an interview is not typical, this tactic can be effective when the referral question and patient history suggest a focus on health and health habits rather than psychiatric factors. The current patient denied any personal psychiatric history. The interview progressed to a review of the patient’s psychosocial history. He described a happy marriage to his second wife of 18 years and positive but somewhat distant relationships with his three adult children from his first marriage. Other sources of social support included two brothers, a brother-in-law, and cousins. The patient noted that he and his wife provided substantial assistance to their 82- and 84-year-old mothers. He reported completing high school and vocational training and had been working as a tool and dye maker for the past 29 years. He expressed the sentiment that he “makes a good living” but that the possibility of being laid off from his work was frequently discussed. The patient described his life as “active” and “busy,” and he identified several outdoor hobbies (golfing, ice fishing, hunting) as sources of enjoyment and relaxation. The patient demonstrated a good understanding of his healthcare conditions and reported good adherence to his medication regimen. However, he acknowledged poorer adherence to the dietary restrictions related to his hypertension and diabetes as well as difficulty maintaining an exercise regimen. Consequently, he had been unable to achieve the 20–30 pound weight loss recommended by his doctor. He also was frank in acknowledging his ongoing smoking habit. He reported two brief periods of heavy alcohol consumption (following high school and at the end of his first marriage) but denied any ongoing alcohol abuse and reported drinking fewer than three drinks per week. With regard to his current health habits, the patient expressed good motivation to improve his diet, get more exercise, and lose weight. He expressed an intellectual understanding of the potential benefits of not smoking but reported feeling “not ready” to “give it up.” With some encouragement from the examiner, the patient identified socialization (talking with friends while smoking) and subjective relaxation as primary factors maintaining his smoking. At this juncture, it would have been very easy for the examiner to deliver a lecture about smoking and potential avenues for smoking cessation. This approach rarely is successful, and the examiner chose to focus on the health behaviors that the patient appeared motivated to change. 494 J. M. Behel and B. Rybarczyk

As with the patient’s smoking habit, the examiner helped the patient explore factors maintaining current patterns of diet and exercise, factors motivating changes in these behaviors, and potential barriers to making such changes. This approach of using components of a lengthier motivational interviewing intervention (VanBuskirk & Wetherell, 2014) may be conceptualized as an intervention-assessment hybrid technique. Employing this “double duty” approach often is effective and necessary in primary care, as the evaluation session may be the only opportunity to intervene. The current patient was responsive to this approach and was able to identify significant barriers to improved health behaviors and was able to engage in problem- solving as to how to overcome these impediments. One barrier to behavior change identified by the patient was the amount of subjective stress he experienced on a day-to-day basis and his consequent tendency to use food and sedentary activities like television as a means of managing stress. This insight allowed the examiner to not only explore the patient’s experiences of and responses to stress but to also begin more formally examining the patient’s current emotional state. This examination, of course, included questions about symptoms of depression, anxiety, and other psychiatric conditions. However, questions about physical symptoms (fatigue, pain, sleep, appetite, and sexual functioning) were also included. Again, this discussion allowed the examiner to explain the potential interrelation of physical and emotional distress and explore the patient’s experiences of this relationship. He was able to quickly identify multiple instances in which he had experienced fatigue and headaches in response to stressful workdays as well as many examples of his using food and smoking as a response to such stress. However, he denied any broader signs or symptoms of affective or physical distress. With regard to positive coping, the patient again referenced his many close relationships as well as his hobbies. As no gross cognitive impairments had been observed over the course of the evaluation, a formal screening was not undertaken. Likewise, given his insight and forthright discussion of his health habits, the patient was not asked to complete any objective measures assessing mood, coping, or health beliefs. At the conclusion of the current evaluation, the examiner summarized his impressions that the patient engaged in a mixture of adaptive and maladaptive coping responses and that many of his maladaptive responses directly impacted his physical health. The examiner further offered that a brief course of treatment targeting stress management could help the patient decrease the frequency of maladaptive coping responses and improve adherence with recommendations for weight loss and increased exercise. The patient was quite amenable to this plan and scheduled a follow-up appointment with the examiner. The examiner wrote a brief summary in the electronic medical record and, having discussed in advance that important information obtained in the interview will be shared with the team, discussed the findings with his physician. 19 Interviewing in Health Psychology and Medical Settings 495

Impact of Race, Culture, Diversity, and Age

As part of the biopsychosocial approach, it is critical for psychologists in the healthcare setting to attune to diversity issues in both the assessment process and content. In terms of process, for example, some racial and ethnic groups are reluctant to disclose beliefs, attitudes, and health practices that differ from the dominant culture. There may also be a culturally transmitted distrust of healthcare professionals based on perceived inequities in the healthcare system and historical experiences with exploitation by healthcare researchers. Although a given patient may start with distrust and privacy, a well-trained psychologist is often the member of the healthcare team that has the interviewing time and skill to build the trust necessary to elicit critical information related to beliefs and practices. On the other hand, in some cases, a bias against seeking care from psychologists found among some cultural groups may provide an extra barrier in communication and rapport relative to other healthcare team members. Additionally, the use of an interpreter can be very effective for some healthcare communications but in the realm of psychological assessment can be problematic due to privacy issues and translational difficulties with more abstract psychological concepts and nuances of emotion. In terms of the content of the assessment, cultural factors have an influence on risk factors for illness, the interpretation of symptoms, health behaviors, and ways of seeking help from health professionals. It is generally agreed that having a broad knowledge of common cultural issues in healthcare is a valuable starting point, but it is equally apparent that such generalizations can be very problematic and are often overshadowed by individual issues and life experiences. Therefore, clinical health psychologists must strike a balance between addressing cultural issues in their patients but, at the same time, not clumping patients together based on ethnic or racial group membership. Additionally, issues related to intersectionality (overlapping identities related to class, sexual orientation, ethnicity, race, and gender) add further complexity to understanding the experience of a given patient. One important cultural issue in assessing healthcare populations is the degree to which somatization is employed as an idiom for the expression of psychological distress. Cultures vary in both the extent to which somatization is used and the specific symptom domains where psychological distress is expressed. For example, stomach disturbances, excessive gas, palpitations, and chest pain are common domains in Puerto Ricans, Mexican Americans, and whites (Escobar, Burnam, Karno, Forsythe, & Golding, 1987) while some Asian groups express more cardio- pulmonary and vestibular symptoms, such as dizziness, vertigo, and blurred vision (Hsu & Folstein, 1997). Even when somatization is the most comfortable and acceptable way for expressing distress, many individuals will acknowledge psychological symptoms when questioned further. Religion is a sociocultural domain that should be considered in most if not all assessments in the healthcare setting, as it serves as an important coping resource for many patients. In particular, it can particularly be important in the context of coping with disabling and chronic illness, life-threatening illness, and death and 496 J. M. Behel and B. Rybarczyk dying issues. It can also be important as a factor in health behavior and health outcomes. For example, in the general population and among African Americans in particular, church attendance has been linked to better health outcomes (Powell, Shahabi, & Thoresen, 2003). Yet, the biases found among psychologists and training programs for psychologists have generally favored avoidance of the topic in assessment. It also is important to cultivate awareness of and sensitivity to the unique healthcare needs and vulnerabilities of lesbian, gay, bisexual, transgender, and queer (LGBTQ) patients. Such sensitivity certainly is important in traditional mental health settings but may be even more critical in healthcare settings, as has been recognized by the United States Department of Health and Human Services’ acknowledgment of LGBTQ health disparities (Healthy People 2020). Many LGBTQ patients experience enforced invisibility in healthcare settings. This invisibility can stem from the patient’s subjective sense that a particular venue is not a safe or comfortable place to be open about their sexuality or gender identity or from past unpleasant experiences (Durso & Meyer, 2013). Perhaps, more commonly, though, this invisibility is an outgrowth of assumptions of cisgender identity and heterosexuality embedded in care providers’ language. In other words, clinicians often frame questions about sex, sexuality, and relationships with the assumptions that such relations involve heterosexual, and only heterosexual, behavior. For example, asking a new female patient about her “husband” both fails to invite discussion of any female partners and implicitly communicates a dismissal of such relationships as unimportant and irrelevant. Furthermore, when their sexuality or identity is acknowledged, LGBTQ individuals may encounter subtle assumptions and blatant biases that inform how care providers ask about sexual history, relationships, and family structure. For example, gay men may encounter expectations of promiscuity, lesbian women may be met with assumptions about gender roles in their relationships, bisexual people may encounter challenges to the authenticity of their sexuality, and transgender and gender-nonconforming people may be confronted by attempts to implicate their gender identity in unrelated medical problems. Moreover, older LGBTQ individuals may encounter additional forms of bias, as they attempt to access care systems and facilities that are organized around heterosexist assumptions and meant to serve a cohort less familiar and comfortable with sexual diversity (McMahon, 2003). Even if one assumes that negative experiences in healthcare are relatively rare and decreasing, it is not surprising that LGBTQ people, particularly those identifying as transgender, queer, or questioning, are less likely to access routine healthcare (Macapagal, Bhatia, & Greene, 2016). Given this context of potential mistrust, it obviously is important to “build” clinical interviews that are sufficiently flexible as to invite open discussion of a patient’s sexuality and gender identity while making no assumptions about the nature of that sexuality. Openness to discussing sexuality does not require that questions about sex and sexuality be central in an evaluation. However, it is important that a sexual history be thorough and that the questions about sexuality be respectful, specific, and informed (Bonvicini & Perlin, 2003). Questions that are 19 Interviewing in Health Psychology and Medical Settings 497 too broad, vague, or poorly worded can communicate a sense that the clinician is inexperienced, uncomfortable, or both. Consequently, it is important that clinicians familiarize themselves with clinically and socially appropriate language for discussing sex and sexuality with all of their patients. It may also be helpful to become familiar with slang terms from LGBTQ culture, although it is not appropriate for a clinician to introduce such terms into an interview. Furthermore, some slang terms are seen as “belonging” to LGBTQ people. In certain contexts, the use of such terms (e.g., “queer”) by LGBTQ clinicians may be acceptable, whereas the use by a cisgender, heterosexual clinician would most likely be perceived as inappropriate or even offensive.

Information Critical to Making a Psychiatric Diagnosis

In contrast to traditional mental health settings, psychological work in healthcare settings typically is less focused on establishing formal manual-based diagnoses for each patient. Even when they are identified and reported, such diagnoses may not be the actual focus of the assessment and subsequent therapy. In fact, the Current Procedural Terminology (CPT) Health and Behavior codes allow health psychologists and other practitioners to provide evaluations and interventions designed to address the psychological sequelae of confirmed healthcare diagnoses. Because these services are reimbursed on the basis of the relevant healthcare diagnosis, psychiatric diagnoses may, at times, seem almost beside the point. In general, when psychiatric diagnosis is a significant component of an evaluation, the examiner should include the relevant questions about history (personal and family, healthcare, and psychiatric), symptomatology (depression, anxiety, etc.), support, coping, and self-care that would be included in any intake interview. For healthcare patients, it may be helpful to explicitly link medical and psychiatric matters, both in introducing the assessment and in posing specific questions. Moreover, it is important to include questions about treatment adherence in the evaluation of the patient’s self-care behavior. For depressed patients, poor treatment adherence should be explored in particular detail, as it may represent a passive form of suicidal behavior. As with any patient, a detailed substance abuse history also is important. This should include questions about the full range of psychoactive substances (including prescription medication misuse and caffeine intake), preferred type of alcohol (as relevant), mode of ingestion, frequency and duration of use, and the course of past use, including any treatment or support group history. Use patterns, prior quit attempts, and psychosocial and legal difficulties associated with substance use should also be explored. A symptom checklist such as CAGE (Ewing, 1984) or the Michigan Alcohol Screening Test (MAST; Selzer, 1971) may also be helpful. However, in working with healthcare patients, a couple of additional points should be kept in mind. First, patients may, correctly or otherwise, associate their substance use and abuse with their healthcare problems. Consequently, it is 498 J. M. Behel and B. Rybarczyk important to carefully frame questions about substance abuse to avoid any implied judgment or criticism of the behavior while eliciting as much information as possible. A normalizing invitation like, “Tell me about your alcohol use,” can be a particularly effective way to set the stage for a frank discussion of substance use. The tone and wording of these questions are critical, and it may also be helpful to pursue questions about patient health and substance abuse at different points in the interview. An additional challenge comes in obtaining substance abuse histories from patients for whom that history is remote. Patients who stopped smoking, drinking, or drug use 30, 40, or 50 years ago are not uncommon, and such patients may have difficulty recalling the details of their usage or simply regard it as irrelevant. Nevertheless, because even remote substance abuse can impact sleep, cognition, and other factors, it is important to obtain as much information as possible. Psychologists in healthcare settings also tend to need more detailed information about sleep quality and the nature of sleep disturbances. When a patient complains of poor sleep, it is important to clarify the frequency and duration of the sleep disturbance and to understand whether the insomnia is characterized by delayed sleep onset, fragmentation of sleep, or early morning awakenings. The potential role of pain and urinary issues in sleep disturbance must also be considered. Furthermore, familiarity with the behavioral signs and symptoms of obstructive sleep apnea (OSA), period limb movement disorder (PLMD), restless leg syndrome (RLS), and narcolepsy also is helpful. Understanding the cumulative impact of healthcare factors on a patient’s presentation and then parsing apart the relative contribution of psychological and healthcare factors in that presentation is not a simple task, and there are no absolute rules for making these determinations. In general, care should be taken to not over- interpret vegetative symptoms that are consistent with a patient’s healthcare diagnosis. However, it is equally important to avoid categorizing clinically significant affective distress as a “normal” or “understandable” response to illness, as this may result in the undertreatment of depression and anxiety disorders. A couple of safeguards against such errors should be kept in mind, particularly when working with hospitalized patients. First, it can be valuable to make multiple observations of a patient’s behavior. Variability in energy level over the course of a day is quite common with late afternoon and early evening, and multiple observations of patient behavior allow one to draw firmer diagnostic conclusions about the patient. Similarly, it is quite common for acutely ill patients to respond differently to loved ones than to clinicians, and they also commonly evince different levels of engagement and motivation for different clinicians. In addition to making multiple observations for oneself, it can also be useful to obtain collateral information from those loved ones and other clinicians. Reaching firm diagnostic conclusions about patient cognition requires a similar balancing act. In acute care settings, a patient may present with marked cognitive impairments that simply reflect a reaction to narcotic medication. On the other hand, a similar degree of confusion in another patient may represent the combined impact of chronic mild cognitive impairment (MCI), a recent stroke, and acute delirium. In primary care, a patient who seems distractible and easily confused may, in fact, be 19 Interviewing in Health Psychology and Medical Settings 499 quite functional in the familiarity of their home environment. As discussed above, the initial assessment of cognition in healthcare settings ought to include thorough behavioral observations as well as an appropriate screening measure. Finally, throughout the evaluation process, one must be mindful of the context in which the evaluation occurred. First, when working with hospitalized patients, it is important to remember that the hospital setting typically provides cues that reinforce “sick” behavior as well as drowsiness and fatigue. In other words, the presence and centrality of a bed and pajama-like clothes may magnify a patient’s sense of fatigue and debility while reinforcing the view that looking and acting unwell are the expected and appropriate responses. On another level, patients’ awareness of and investment in common beliefs about hospitals (bad food, difficult to sleep, difficult to get to the washroom) may lead to self-fulfilling prophecies of poor appetite, insomnia, and incontinence. Given these hospital-bound behaviors, it is important to not assume that hospital behavior is a representative sample of a given patient’s behavior. Similarly, outpatient healthcare offices frequently generate a certain amount of discomfort and anxiety (e.g., “white coat hypertension”). Moreover, the structure of such office visits and the perceived authority of treating clinicians may pressure patients to endorse a comprehension of healthcare matters and an intention to adhere to healthcare recommendations that are not genuine. Consequently, it is important that conclusions about anxiety or adherence not be based solely on the behaviors observed in the healthcare office.

Dos and Don’ts

Do approach the interview as both an assessment and an opportunity for a single session intervention. It provides the patients with a rare opportunity to explore their illness experience in depth and the therapeutic effects of this should not be underestimated. For example, research has shown that the simple process of sharing one’s life narrative with a skilled interviewer is an effective stress reduction method for healthcare settings (Rybarczyk & Bellg, 1996). Do clearly and frankly describe the purpose and scope of the evaluation. Patients in healthcare settings often are not well informed about the purpose of the assessment. By explaining the referring provider’s rationale in requesting the assessment, the examiner helps the patient understand the basis for the content of the evaluation. Do allow patients to describe their medical condition(s) in their own words. This approach encourages development of rapport while allowing the examiner to assess a patient’s understanding of their condition. Do get comfortable with both technical and lay descriptions of common medical conditions. A fully developed medical vocabulary allows one to have meaningful discussions with patients of all levels of health literacy. Do consider modesty concerns when conducting inpatient evaluations. A hospitalized patient may not have control over their state of (un)dress. Helping patients 500 J. M. Behel and B. Rybarczyk

cover themselves with a blanket or asking a member of nursing staff to reposition the patient may increase their comfort. Do be aware of one’s own responses to illness, mortality, and healthcare settings. It is important for clinicians to manage their own discomfort with the sights, sounds, and smells of illness in ways that do not impact patient care. Do consider a patient’s sensory limitations when conducting an evaluation. Although especially true in working with older adults, it always is a good idea to ask a patient about their hearing and vision and whether they use glasses, hearing aids, or other sensory aids. Sitting closer and speaking slightly louder can be beneficial. Do be aware of the potential impact of fatigue and pain on a patient’s participation and performance. These factors can directly impact effort, motivation, and cognitive performance. Sensitivity to these factors early in an evaluation can help an examiner conduct a more-focused, briefer evaluation or decide to conduct the assessment over two or more brief sessions. Do maximize privacy and minimize disruptions when evaluating inpatients. Although these factors often are beyond a clinician’s control, reducing the likelihood of interruptions by entering the appointment in a hospital schedule or placing a “Do Not Disturb” sign on the patient’s door can make for a much more cohesive assessment. It is often necessary and desirable to ask visitors to leave the room. Do expect that patients in healthcare settings will have different needs and expectations than traditional psychotherapy patients. In healthcare settings, patients may expect psychologists to take on tasks traditionally accomplished by physicians, nurses, and case managers. It is important to clarify one’s role in response to such requests in a way that is clear but not off-putting to the patient. Obviously, it is important to maintain clear professional boundaries with regard to these expectations. However, on occasion, patients will ask for a kind of assistance, such as help arranging transportation to appointments, that, while not strictly psychological, can be easily and ethically offered. Do provide the patient feedback about findings and recommendations. Although routine in traditional settings, providing feedback is sometimes overlooked in healthcare settings but is an important part of the evaluation process. In some situations, it can be valuable to offer initial impressions at the end of an assessment with more detailed feedback provided when all of the assessment data have been processed. Do not overstep professional competencies in disseminating medical information. Although it usually is appropriate to reference medical information provided by the patient and general information such as admitting diagnosis, it is important that psychologists in healthcare settings not offer patients either new diagnostic and prognostic information or medical explanations that are beyond the competencies covered by their training and licensure. Do not automatically insist that a patient be seen alone. Although it may be best to politely dismiss spouses, children, and loved ones in most circumstances, there certainly are circumstances in which patient fears, cultural expectations, cognitive 19 Interviewing in Health Psychology and Medical Settings 501

limitations, and the value of collateral information offered by loved ones outweigh the value of a one-on-one assessment. Do not overwhelm patients with too many formal measures. It certainly is important to include sufficient measures of psychological and cognitive function to draw clear conclusions and make reliable diagnoses. However, again, it is important to keep in mind patients’ energy limitations and potential reluctance to complete such measures. One or two carefully selected, well-designed measures should be sufficient for most settings. If more extensive testing is indicated, it may be helpful to explain such testing at the end of the interview and to schedule a separate session for completion of the testing. Do not offer empty reassurance as a means of either advancing the evaluation or encouraging the patient. Genuine, empathic responses to patients’ concerns and gentle encouragement are appropriate examiner responses, but vague, overly optimistic statements, such as “everything will be fine,” are rarely helpful. Do not be too lengthy in your documentation of an evaluation. In most situations, it is much more effective to be brief and concise. The time constraints of other health professionals should be respected and such techniques as using bullet points and focusing on recommendations rather than problem descriptions or causes can serve well. Additionally, staying away from psychological jargon and providing your evaluations in a timely fashion are even more essential in the healthcare setting. Do not challenge patients who exhibit denial as a coping mechanism. This may present itself in the interview in a variety of ways, including an apparent lack of knowledge about the prognosis of an illness or lack of appreciation of the significance of one’s functional declines. Most patients will come to terms with their illness in due course of time and this self-protective response should be viewed as a healthy way to ease into bad news. Do not focus exclusively on dysfunction, but rather also focus on coping strengths. Recommendations should be written to reinforce and promote the stability of coping strengths (e.g., “Mr. Jones obtains much satisfaction from working in his elaborate garden and an effort should be made to find assistance and adaptive equipment to enable him to continue this important hobby at his home.”).

Summary

As can be seen throughout this chapter, psychologists practicing in healthcare settings face a wide range of challenges related to integrating knowledge and understanding of both the psyche and soma, working within large teams, having the ethical challenge of working on behalf of both the healthcare team and the patient, and working with patients who are not initially receptive to a psychologist and/or naïve to the role of psychologists in medicine. These challenges and complexities make the work experience substantially different from what is found in more traditional mental health settings. However, rather than viewing these issues as 502 J. M. Behel and B. Rybarczyk negatives, health psychologists almost universally speak of these aspects of the job as part of what makes this specialty work so gratifying. The opportunity to open the door to psychological help for someone who has never sought help before, to empower an individual by enlarging their understanding of how their mind and body interrelate, to work amongst dedicated and mutually supportive helpers from different fields, and to develop a useful body of medical knowledge over time are what gets psychologists “hooked” on this unique field. It is an ideal career for those who aspire to a career that continually challenges you to “think on your feet,” that is different every day, and that demands a lifetime of learning.

References

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A Alcohol Abel and Becker Cognitions Scale Black and Latino users, 340 (ABCS), 362 in moderation after treatment, 333 Acute stress disorder prevalence, 339 avoidance symptoms category, 187 SIP-AD, 332 categories, 186 substance-use, 329 depersonalization, 187 Alcohol-induced persisting dementia, 113 derealization, 187 Alzheimer’s disease (AD), 103, 104, 108, 116, diagnosis, 186 117, 123, 124, 226, 459 diagnostic features, 181–182, 186 American Academy of Pediatrics, 394 dissociative responses, 187 American Psychiatric Association (APA), 9, dissociative symptoms category, 187 30, 216, 223 DSM-5, 187 Anderson, J.O., 361 duration, 186 Andreski, P., 202 duration of symptoms, 187 Anorexia nervosa (AN) negative mood category, 187 ARFID, 378 prevalence, 188 BMI, 376 symptoms, 186 body weight, 376 Adaptive and maladaptive coping, 494 characterization, 376 Addiction Severity Index (ASI), 332 Antisocial PD, 300 Adjusting assessment procedures, 230, 231 Antisocial personality disorder, 62 Adjustment disorder Anxiety definition, 189 ADIS, 141 diagnostic features, 181–182 advantages and disadvantages, 136 prevalence, 189–190 agoraphobia, 132, 140 stressor, 189 avoidance and escape behaviors, 135 symptoms, 189 BATs, 139 time limit, 189 biased thinking and avoidance Adlerian psychotherapy, 299 behaviors, 147 Affective empathy, 46 childhood and adolescent, 143 Afifi, T.O., 202 cognitions, behaviors and feelings, PD, 130 Ageism, 470 cognitive-behavioral model, 129 Age-related macular degeneration (AMD), 471 cognitive distortions, 147 Agoraphobia, 132, 140 cultural factors, 144 Akinesia, 82 development and maintenance, 129, 130 Aklin, W.M., 20 diagnostic interviewing skills, 149

Anxiety (cont.) dimensional approach, 331 differential diagnosis, 141, 145, 146 substance-use, 327 emotion-focused coping, 142 tools, 441 emotions, 147 variation, in assessment environments, 327 evidence-based assessment, 134 Auster, S., 46 and fear, 129 Austin, S.B., 200 formal assessment Autism Spectrum Disorder (ASD), 29 ADIS-5, 136 Avoidant and restrictive food intake disorder behavioral observation, 139 (ARFID), 29, 378 DIAMOND, 137 Avoidant PD, 302 informants, 137 MINI, 136 SCID-5, 136 B self-monitoring, 137 Bachem, R.C., 189 self-report, 137 Bailey, R.W., 46 functional impairment, 149 Bailey, T.D., 401–421 GAD, 131 Baker, F.M., 33 heterogeneity, 146, 147 Beck Depression Inventory-II (BDI-II), 220 OCD, 141 Beck Depression Inventory—Primary Care older adults, 142, 143 (BDI-PC), 221 panic attacks, 140 Beck, A.T., 33, 138, 305 PD, 131 Behavioral avoidance tasks (BATs), 139 perinatal depression, 145 Behavioral observations, 461 physical sensations, 135 Behel, J.M., 481–501 race, 143, 144 Bell, C.C., 33 SCID, 140 Bemak, F.P., 18, 22 selective mutism, 133, 134 Benjamin, L., 301 self-monitoring, 140 Bergeron, L., 47 self-reports, 138, 140 Berthiaume, C., 47 semi-structured interviews, 134 Billingsley, A.L., 129–149 separation, 133 Binge eating disorder (BED), 29, 375 social, 132 ICBs, 377 socioeconomic status, 144, 145 marked distress, 377 specific phobias, 132, 133 therapist, 383 structured interviews, 134 Biopsychosocial assessment, 230 symptoms, 135 Bipolar disorders transdiagnostic factors, 146 age, 254 uncertainty and rumination, 149 antidepressant medication, 253 unstructured interviews, 134, 135 assessment worry-thoughts, 141 screening measures, 250–251 Anxiety and Related Disorders Interview semi-structured interview, 247–249 Schedule for DSM-5 (ADIS-5), 43, standardized format, 246 136, 166, 458 structured interviews, 249 Anxiety Disorders Interview Schedule, 440 symptoms, 246 Anxiety Disorders Interview Schedule for bipolar I disorder, 240, 241 DSM-IV, Child and Parent version bipolar II disorder, 241, 242, 253 (ADIS-IV-C/P), 448 color blind, 254 Anxious distress, 232, 233 community health center, 252 Anxious distress specifier, 225 cyclothymic disorder, 242 Apgar score, 62 description, 239, 240 Arthritis, 467 diagnosis, 255 Asmundson, G.J., 202 factors, 254 Assessment HCL-32, 253 biological, 334 hypomanic episodes, 243, 253 Index 507

low mood, 252 Breton, J., 47 major depressive episodes, 243, 252 Brief Negative Symptoms Scale (BNSS), 268 medical condition, 243 Brief Psychiatric Rating Scale (BPRS), 268 medication, 253 Broca’s aphasia, 81 medication’s side effects, 252 Brown, L.M., 179–206 mental health clinic, 251 Bruni, T., 378 minority patients, 254 Bulimia nervosa (BN) monogamous relationship, 252 ICBs, 377 multiple periods, 251 LOC, 377 patient’s religious beliefs and practices, 254 Burke, W.F., 308 procedures, gathering information Burns, R.M., 201 comorbid conditions, 245 Bush, S.S., 115 decision-making process, 245 Byers, A.L., 455 depressive episodes vs. hypomanic/ manic episodes, 245 diagnostic impression, 246 C in-person diagnostic interview, 245 Caldarone, L.B., 201 interview, 245 Camberwell Assessment of Need for the interviewer, 245 Elderly (CANE), 230 patient’s significant, 246 Cambridge Depersonalization Scale (CDS), 410 time constraints/situational factors, 246 Capgras syndrome, 86 race, 254 Carleton, R.N., 138 recommendations, 256 Cartesian mind-body dualism, 481 recreational/prescription drug, 252 Cash, T.F., 161 religiosity and spirituality, 254, 255 Center for Epidemiological Studies- SCID for DSM-5, 253 Depression Scale (CES-D), 220 specifiers, 244–245 Cerebrovascular accident (CVA), 107 substance/medication-induced bipolar and Chambless, D.L., 138 related disorder, 242, 243 Chapa, D.A.N., 375–396 symptoms of anxiety, 253 Charles Bonnet syndrome, 88 unspecified, 244 Charney, D.S., 193 Bipolar I disorder, 240, 241 Cheng, J., 363 Bipolar II disorder, 241, 242, 253 Child and Adolescent Psychiatric Bipolar spectrum diagnostic scale (BSDS), 251 Assessment, 446 Blacker, D.E., 192 Child Behavior Checklist, 442 Blake, D.D., 193 Children Bleuler, M., 263 avoidance behaviors, 439 Blevins, C.A., 195 behavioral concerns, 431 Bluthenthal, R.N., 340 behavioral observations, 441 Bockian, N., 293–321 caregivers, 434, 452 Body dysmorphic disorder (BDD), 162 clinicians, 431 Body mass index (BMI), 376 cognitive and emotional development, 427 Bogaerts, S., 364 contextual factors, 428 Bohnert, A., 30 cost of services, 432 Bohrer, B.K., 375–396 diagnostic assessment, 435 Bondi, M.W., 112 diagnostic interview, 433, 434 Borderline PD, 301 direct observation, 435, 436 Boyer, S.M., 401–421 environment, 435 Boyes, A., 363 generalized anxiety disorder, 438 Bradykinesia, 82 healthcare or mental health, 436 Bradyphrenia, 83 interview, 430, 437 Brand, B.L., 401–421 interview process, 428 Breslau, N., 202 mental health concerns, 427 Bresnick, M.G., 188 mental health disorders, 428 508 Index

Children (cont.) reflection statement, 14, 15 motivation, 428 self-disclosure, 16, 17 observations, 436 structured vs. non-structured, 25 observing behavior, 435 technical (see Technical skills) open-ended conversation, 439 using humor, 16 oppositional behavior, 430 Clinical severity rating (CSR), 448 parent behaviors, 435 Clinician-Administered PTSD scale (CAPS), parent/guardian, 431 193, 194 reference materials, 450 Clock drawing test, 97 referral question, 430 Cocaine use, 333 semi-structured interview, 441 Cognition and cognitive testing, 489 service providers, 432 Cognitive assessments, 441 speaking, 436 Cognitive-behavioral models, 129 structured diagnostic interview, 437 Cognitive-behavioral therapy, 441 symptom presentation, 428 Cognitive empathy, 46 teachers, 431 Cognitive processing therapy treatment process, 434 (CPT), 206 young, 430 Cohen, M., 188 Children’s Yale-Brown Obsessive-Compulsive Color blind, 254 Scale (CYBOCS), 166 Comorbid anxiety disorder, 225 Chiu, W.T., 185 Comorbid disorders, 202 Chorea, 82 Complex PTSD, 203 Christine’s symptoms, 464 Complex trauma (CT), 411 Chronic alcohol abuse, 113 Complicated grief, PTSD, 203, 204 Chronic obstructive pulmonary disease Compo, N.S., 44 (COPD), 142 Composite International Diagnostic Interview Chung, R.C., 18, 22 Version 3.0 (CIDI), 249 Circadian rhythms, 473 Concussion, 106 Client symptomatology, 32 Conelea, C.A., 161 Clinical Assessment Interview for Negative Confidentiality Symptoms (CAINS), 268 age, 10 Clinical interview APA ethical principle, 9 assessment procedure, 30 clinician-client relationship, 10 client diversity, 4 duty to warn and protect, 11, 12 emergency and crisis settings, 4, 5 informed consent, 9 emotional reactions, 26 limitations, 9 empathy, 14 temptation to discuss cases, 12, 13 establishing rapport, 13, 14 written records, 10, 11 functioning, 4 Connolly, S.L., 239–257 goals, 24 Consultation and liaison service, 482 interpersonal (see Interpersonal skills) Corliss, H.L., 200 interview formats, 30 Cornell Scale for Depression in Dementia jail, prison, corrections and courthouse (CSDD), 221 settings, 7–9 Countertransference, 306–309 medical settings, 6, 7 Cox, B.J., 202 mental disorders, 25 Criminal justice system, 328 multiple hypotheses, 25 Criminal Sentiments Scale (CSC), 362 opinions/values, 26 Cukor, J., 185 opportunity, 25 Cultural formulation, 21 outpatient mental health settings, 5, 6 Cultural formulation interview (CFI), panic attacks, 25 20, 229 paying attention to language and avoiding Current procedural terminology (CPT), 497 jargon, 15 Cushing’s Syndrome, 243, 463 psychotherapeutic process, 3 Cyclothymic disorder, 217, 242 Index 509

D mental health organizations, 220 Dana, R.H., 18 outcomes/clinical change, 223 Dancu, C.V., 194 screening measures, 220, 221 Daughters, S.B., 325–342 self-monitor depressive symptoms, 223 Davis, G.C., 202 self-report measures, 220 Davis, M.L., 155–175 self-report screening measures, 221, 222 Davis, M.T., 195 semi-structured interviews, 222, 223 de Vogel, V., 364 structured interviews, 222, 223 de Vries, M., 364 vs. psychiatric conditions, 231–232 Degenerative joint disease (DJD), 490 race and ethnicity, 226 Delusions, 264, 269–272 rapport building, 226, 227 Dementia, 103–105, 107–109, 113, 122–125 socioeconomic status, 226 Demler, O., 185 specifiers Department of Defense (DoD), 201 anxious distress, 232, 233 Dependent PD, 302–303 atypical features, 232 Depression, 190 clinical status, 232 Depressive and bipolar related disorders, 279 melancholic features, 232 Depressive disorders mood episode, 232 adjusting assessment procedures, 230, 231 psychotic features, 233 age, 226 severity, 233 assessment, 223, 224, 226 symptom, 233 assessment and treatment, 233, 234 standardized diagnostic and screening biopsychosocial assessment, 230 tools, 227, 228 cultural formulation substance/medication-induced depressive CFI, 229 disorder, 218 client-clinician relationship, 228 unspecified, 219 cultural identity, 228 Depressive episode with insufficient DSM-IV, 228 symptoms, 219 immigration status, 228 Depressive PD, 305 mood symptoms, 228 Depressive symptoms, 225, 469 psychosocial environment and levels of Desire disorders, 351 functioning, 228 Detailed Assessment of Posttraumatic Stress standardized tools, 228 (DAPS), 410 zero-sum model, 228 Diagnostic and Statistical Manual of Mental description, 213 Disorders (DSM-5), 29, 458 differential diagnosis, 215, 231–232 Diagnostic and Statistical Manual of DMDD, 214 Mental Disorders, 4th edition DSM-IV-TR, 213 (DSM-IV), 161 dysthymia, 217 Diagnostic interview, 427, 451 limited assessment, 219 Diagnostic Interview for Anxiety, Mood, and MDD, 215–217 OCD and Related Neuropsychiatric medical condition, 219 Disorders (DIAMOND), 42, 137 minority older adult with MDD, 224, 225 Diagnostic Interview for Children and pathomechanisms, 214 Adolescents, 447 PDD, 217 Diagnostic Interview Schedule (DIS), 36, 37 PMDD, 217–218 Diagnostic Interview Schedule for Children – primary care patient, 225, 226 Fourth Edition, 444 procedures, gathering information Diagnostic interviewing, 434 clinician/mental health practitioner, 220 Dieting behaviors, 393 clinician-administered measures, 223 Difede, J., 185 direct observation, 223 Diffuse axonal injury (DAI), 107 evidence-based perspective, 220 Dimensional approach, 329, 331, 332, 334 informal assessment, 220 Dimensional Obsessive-Compulsive Scale interview, 220 (DOCS), 167 510 Index

Disorganized speech, 272 drug cravings, 336 Display paranoia-like symptoms, 254 drug-related crimes, 328 Disruptive mood dysregulation disorder medical care and drug treatment, 335 (DMDD), 29, 214 screens, 336 Dissociative disorders (DDs) with SUDs (see Substance use disorders African American male, 412–413 (SUDs)) assessment, 404 Dunn, E.J., 46 behavioral indicators, 404 Dwyer, L., 468 CT-based problems, 411 Dysarthria, 81 DDIS, 410 Dysthymia, 217 depersonalization and derealization, 408 Dystonia, 82 development, 401 diagnosis, 405, 415 dissociative symptoms, 402, 416 E DSM-5, 403 Eating disorder examination (EDE), 386, 388 emotion regulation, 413 concepts and diagnostic criteria, 388 epidemiological research, 403 EPSI-CRV, 389 fluctuations, skills, 409 factor structure, 388 4-D model, 402 sub-scales, 388 memory and amnestic gaps, 415 Eating Disorder Inventory 3 (EDI-3), 387 memory disruption, 407 Eating disorders (EDs) MID, 410 African American persons, 391 OSDD, 408 AN, 376 passive influence, 408 ARFID, 378 prevalence rate, 403 assessment, 390 PTSD, 403, 409, 416 athletes, 394 SCID-D, 404, 405 BED, 375, 377 SCID-D-R, 405 BN, 376 self-report measures, 409 diagnoses, 375, 393 semi-structured interviews, 404 DSM-5, 375 somatoform symptoms, 408 EDI-3, 387 symptoms, 404 EPSI, 387 therapeutic relationship, 407 ethnicity and culture, 390 TOMM, 419 ethnic-racial minority patients, 391 trauma, 419 exercise, 385 trauma processing, 412 gender, 392 Dissociative Experiences Scale (DES), 410 health risks and medical Dissociative identity disorder (DID), 403 complications, 394 Ditlevsen, D.N., 199 ICBs, 381 Diversity medical complications, 390, 394 clinical diagnosis, 20–22 mental health condition, 386 cultural identity, 17 non-athletes, 394 culture, 17 OSFED, 377 multicultural competence, 18 physical examination, 389 therapeutic relationship, 18, 19 prevalence, 390, 392 Dolan, K., 334 psychiatric, 386 Domino, J.L., 195 psychiatric disorders, 375, 378 Donders, J., 116, 117, 125 psychological assessment, 389 Dorahy, M.J., 409 psychopathology, 386 Draguns, J.G., 22 SCOFF, 387 Drayton, A., 378 sexual-minority populations, 392, 393 Drugs sexual-minority women, 393 classes, 329 transgender experiences, 392 Drug Abuse website, 329 women, 391 Index 511

Eating pathology symptoms inventory Feliciano, L., 213–234 (EPSI), 387 Female orgasmic disorder (FOD), 351 Eating Pathology Symptoms Inventory— Female sexual arousal disorder (FSAD), 351 Clinician Rated Version (EPSI- Fetal alcohol syndrome, 122 CRV), 388 Fingerhut, R., 13 Echolalia, 85 First, M.B., 37, 38, 192 Ecologic adaptation, 296 Fleet, C., 202 Ecologic modification, 296 Fleisher, C.L., 188 Edelbrock, C., 30 Flessner, C.A., 161 Edelstein, B., 455–459, 461–473 Flint, M., 55–75 Edwards, C.B., 129–149 Florida Obsessive-Compulsive Interview Ego-dystonic vs. ego-syntonic thoughts, (FOCI), 167 158, 159 Foa, E.B., 186, 194 Ehrenreich-May, J., 427–453 Forbush, K.T., 375–396 Elklit, A., 199 Formal assessment Emerging professionals cognitive and functional impairment, 267 client’s ambivalence, 23 standardized interview formats, 267–269 clinical interview, 22 thorough clinical evaluation, 267 clinical supervision and personal tools, 443 psychotherapy, 24 Freud, A., 298 clinician-client relationships, 24 Frost, R.O., 161 clinician’s anxiety/discomfort, 22 Functional assessment, 459, 460 consultations, 24 content, 23 diagnostic interviews, 22 G financial assistance, 23 Gaher, R., 138 information-gathering process, 22 Gara, M.A., 274 personal questions, 24 Gastrointestinal (GI) complications, 389 psychotherapy, 23 Gauvin, S., 350–369 young clinicians, 23 Gender dysphoria (GD), 352 Emotional functioning, 483 in children and adolescents/adults, 353 Empathic accuracy, 46 comprehensive psychosocial Erbaugh, J.K., 33 assessment, 356 Erectile disorder (ED), 351 diagnosis, 352 Evidence-based treatment, 206 and paraphilic disorders, 367 Excoriation disorder, 163 General behavior inventory (GBI), 251 Executive functioning, 123 General clinical health psychology Exum, A., 375–396 interview, 489 Eye diseases, 471 Generalized anxiety disorder (GAD), 131 Eye movement desensitization and Generalized Anxiety Disorder-7 items reprocessing (EMDR), 206 (GAD-7), 225 Genetic malformations, 122 Genitopelvic pain/penetration disorder F (GPPPD), 352 Family Accommodation Scale (FAS), 167 Geriatric Anxiety Inventory, 142 Farias, S.T., 123 Geriatric Anxiety Scale, 142 Fauerbach, J.A., 188 Geriatric Depression Scale (GDS), 221, 464 Fear Geriatric Depression Scale-15 (GDS-15), 491 anxiety, 129, 133, 148 Geriatric Suicide Ideation Scale, 459 and avoidance, 140 Glasgow Coma Scale (GCS), 121 bodily sensations, 130 Goodman, W.K., 155–175 phobia, 133 Gore, W.L., 305 social situations, 132 Grau, K., 214 Fear of fear model, 131 Greenbaum, P.E., 360 512 Index

Gress, C.L.Z., 361 Houston, W.S., 112 Grisham, J., 161 Hrabosky, J.I., 161 Grossman, R.A., 427, 428, 430, 431, 433–448, Huntington’s disease, 82, 105 450–452 Hypoactive sexual desire disorder (HSDD), 351 Groth-Marnat, G., 47 Hypochondriasis, 86 Gum, A.M., 213–234 Hypomania checklist (HCL-32), 250 Gusman, F.D., 193 Hypomanic episodes, 214, 241–246, 248, 250, 252–255 Hypotheses, 470 H Hysteria disorders, 183 Haag, A.M., 363 Hair-pulling disorder, 162 Haley, W.E., 471 I Hallucinations, 264, 269–272 Inappropriate compensatory behaviors Halpern, J., 46 (ICBs), 377 Hamilton Rating Scale for Depression Informants, 313 (HRSD), 221, 223 Instrumental activities of daily living (IADLs), Hanson, R.K., 360, 362, 363 92, 103 Haralambous, B., 466 Integrated primary care, 483 Hardy, K.V., 367 Integumentary system, 389 Hare, R.D., 362 International Classification of Diseases Harm reduction programs, 328 (ICD-10), 458 Harvard Trauma Questionnaire-Part IV International Classification of Diseases, (HTQ-IV), 199 Eleventh Revision (ICD-11), 331 Hays, P.A., 413 Interpersonal skills Health care setting, 482 empathy, 46 Health psychology rapport, 44–46 biopsychosocial approach, 495 Intersubjectivity, 413, 414 cancer, 486 Interviewing, schizophrenia cultural factors, 495 clinical expertise, 287 evaluation process, 482 diagnosis, 287 gross cognitive impairments, 494 don’t apologize for questions, 286 health care settings and situations, 482 empathic and patient approach, 286 integrated primary care, 483 primary care setting, 327 LGBTQ, 496, 497 PRISM-5, 334 medical diagnoses, 485 specific time periods/events, 287 population-based approach, 484 veracity of, psychotic experience, 286 procedure, 487 Intra-interview behaviors, 407 psychological evaluations, 482 Ivey, D.C., 471 referral question, 483 rehabilitation program, 484 religion, 495 J settings and populations, 482 Jacobson, J.O., 340 sexuality, 496 James, J.W., 471 training, 481 Jimenez, D.E., 228 Hemiparesis, 82 Johanson, K.A., 213–234 Herbs and dietary supplements (HDS), 71 John, S.E., 77–101 HIPAA-compliant databases, 248 Johnston, F.E., 44 Histrionic PD, 301 Julien, R.M., 333 Hoarding disorder, 162 June, A., 3–26 Homicidal thoughts, 87 Hopkins verbal learning test (HVLT), 465 Hormone therapy, 357 K Horowitz, M.J., 203 Kaloupek, D.G., 193 Hospital bound behaviors, 499 Karney, B.R., 201 Index 513

Kassam-Adams, N., 188 APA, 216 Katz, E., 455–459, 461–473 classification, 216 Kaufman Assessment Battery for Children, emotional/physical functioning, 215 442 grief and bereavement, 216 Keane, T.M., 193, 195, 203 manic/hypomanic episodes, 215 Keith-Spiegel, P., 13 medical settings, 216 Kelley, J.M., 46 minority older adult, 224, 225 Kernberg, O., 308 palliative care recipients, 216 Kessler, R.C., 185 prevalence, 216 Keuthen, N.J., 161 psychosis, 216 Kiddie Schedule for Affective Disorders and specifiers, 216 Schizophrenia for DSM-5 symptoms, 215, 216 (K-SADS-5), 40, 41 Major depressive episodes (MDEs), 215–217, Kimber, J., 334 219, 232, 243, 252 Knapp, S.J., 13 Major/mild neurocognitive disorder, 104 Knight, R.M., 378 Malingering, 204 Kobak, K.A., 41 Mania, 240, 242–246, 248, 255 Koenen, K.C., 200 Manic episodes, 214, 240–246, 248–250, 254, Koocher, G.P., 13 255 Korsakoff’s syndrome, 113 Marx, B.P., 195 Koster, K., 364 Mattia, J.I., 32 Kraeplin, E., 263 McGoldrick, M., 313 K-SADS-PL (Present and Lifetime version), 40 McIngvale, E., 155–175 McKibben, J.B., 188 McPhail, I.V., 361 L Medication-assisted treatment (MAT), 327 Laboratory tests, 462 Mendelson, M., 33 and medical records, 462 Mental disorders, 29 Lang, P.J., 138 Mental health literacy, 227 Language functioning, 123 Mental Health Parity and Addiction Equity Act Larrabee, G.J., 115 (MHPAEA), 29 Laszloffy, T.A., 367 Mental health professionals, 3, 356 Laws, D.R., 360, 361 Mental health vs. primary care behavioral Lesbian, gay, and bisexual (LGB), 392 health, 485 Lesbian, gay, bisexual, transgender, and queer Mental status examination (MSE), 458, 459 (LGBTQ), 200, 496 appearance, 79, 80 Liebowitz, 138 arrival, 79 Life event checklist (LEC) assessment trauma-related self-report measures, 194, 195 procedures, gathering information, 96, 98 Likert-type scale, 33 behavior and psychomotor activity, 81, 82 Litz, B.T., 195 client clock drawing, 97 Loewenstein, R.J., 404, 405 client’s symptoms, 78 Lonner, W.J., 22 cognition Lorenz, L., 189 abstract reasoning, 94 Loss-of-control (LOC), 376 adaptive and social functioning, 92 Lovibond, P.F., 138 attention, 92 Lovibond, S.H., 138 intellectual functioning, 91, 92 Lupesko-Persky, O., 179–206 memory, 93, 94 orientation, 91 components, 78 M comprehensive examination, 78 MacNeil, A., 363 descriptions, 77 Maercker, A., 189 emotion Magidson, J.F., 325–342 affect, 89, 90 Major depressive disorder (MDD), 189 mood, 88, 89 514 Index

Mental status examination (MSE) (cont.) Minimal clinical training, 43 evaluation, 79, 100 Mini-Mental State Exam (MMSE), 94, 97 factors Minnesota Multiphasic Personality Inventory insight and judgment, 95, 96 (MMPI), 312, 442 reliability, 95 Minnesota Sex Offender Screening Tool impression, 78 (MnSOST), 360, 363 integrative biopsychosocial approach, 100 Minority older adult, MDD, 224, 225 manner of relating and attitude, examiner, Mock, J.E., 33 82, 83 Montgomery Asberg Depression Rating Scale observations, 78, 79, 82, 83 (MADRS), 221 patient-centered approach, 100 Montgomery Asberg Depression Rating populations Scale-Short form (MADRS-S), 220 aging, 98, 99 Montreal Cognitive Assessment (MoCA), 94, 97 cultural considerations, 99 Mood disorder questionnaire (MDQ), 250 settings, 98 Mood disorders, 213, 226, 229, 233 speech and language Mood effects, 243 anomia, 81 Moral injury, PTSD, 204 Broca’s aphasia, 81 Morris, L.B., 301, 305 content, 80 Morris, N., 378 dysarthria, 81 Morrison, J., 45 hypophonia, 80 Motivational Interviewing approach, 297 monotone, 80 Multiaxial system, 29 premorbid functioning and educational/ The Multidimensional Inventory of occupational attainment, 81 Development, Sex, and Aggression prosody, 80 (MIDSA), 360 rate, 80 Multidimensional Inventory of Dissociation tone, 80 (MID), 410 volume, 80 Multidimensional Pain Inventory (MPI), 485 structured, 100–101 Multiphasic Sex Inventory (MSI), 360 thinking Multiple sclerosis, 243 perception, 87, 88 Multiscale Dissociation Inventory (MDI), 410 suicidal and homicidal ideation, 87 Murdock, T., 186 thought content, 85, 86 Muscle dysmorphia, 162 thought process, 83–85 Metaphor, 3 Meyer, T.J., 138 N Michigan alcohol screening test (MAST), 497 Nagy, L.M., 193 Mild cognitive impairment (MCI), 103, 104, 498 Narcissistic PD, 301–302 Miller, C., 29–48 Narrow assessment tools, 442 Miller, C.J., 239–257 National Stressful Events Survey Acute Stress Millman, Z.B., 261–288 Disorder Short Scale (NSESSS) Millon, T., 295, 297, 314, 315 trauma-related self-report measures, Mindfulness, 308, 309, 320 195, 196 Mini International Neuropsychiatric Interview Natural curiosity, 3 for Children and Adolescents, 444 Negative symptoms, 265 Mini International Neuropsychiatric Interview NetSCID-5, 40 for DSM-5 (MINI-5), 41, 42 Neurocognitive disorder, 103, 108, 122–125 Mini-International Neuropsychiatric Interview Neuropsychological assessment interview (MINI), 136, 249, 388 advantages, 110, 111 PTSD, 192, 193 client and caregiver, 117 trauma, 192, 193 cognitive impairments/motivations, 117 Mini-International Neuropsychiatric Interview confirmatory bias, 116 7.0 (M.I.N.I), 458 daily functioning, 115 MINI-Kid, 42 dementia, 122–125 Index 515

developmental history, 113, 114 content themes, 156, 157 factors, 110 description, 156 health care system, 117 diagnostic criteria, 171–173 hypothesis-testing approach, 116 diagnostic interviewing, 155, 164, 174 interruption, 118 differential diagnoses, 172 legal history, 114, 115 evidence-based assessment, 164–166, 175 medical history, 111, 112 excoriation disorder, 163 mental health, 112, 113 factors, 155 model, 110 formal assessment neurocognitive disorder, 122–125 child/parent-specific measures, 167 occupational history, 114 clinician-rated instrument, 166 rambling, 118 family assessment and gathering rapport, 115–118 information, 167 referrals, 118–120 self-report measures, 167 sources, 109 semi-structured clinical interviews, 164 styles, 110 gender, 170 substance use, 113, 117 hoarding disorder, 162 TBIs, 120–122 mind elements, 174 test hypotheses, 109 patient’s level, 173 valuable behavioral observations, 116 race/culture, 170, 171 Neuropsychology responsibility for harm, 156, 158 assessment (see Neuropsychological streptococcal infections, 164 assessment interview) structured assessment, 169 behavioral observations, 104, 105 substance/medication-induced disorder, 163 cognitive/brain dysfunction, 103 symmetry/just right-ness, 160 cognitive symptoms, 107, 108 symptoms, 163, 173 factors, 108 thought content, 169 goal, 103 trichotillomania, 162, 163 medical/neurological history, 105–107 unacceptable, taboo thoughts patients and clinicians, 103 ego-dystonic and ego-syntonic, 158 referrals, 108 immoral thoughts, 160 Newman, M.G., 138 neutralize, 158 Nijenhuis, E.R., 183 sexual thoughts, 159, 160 Ninan, P.T., 161 stigma and shame, 158 Nine-Item Patient Health Questionnaire violent thoughts, 160 (PHQ-9), 221 unstructured clinical interview, 168, 169 Non-interview-based assessment methods, 456 Obsessive-Compulsive Inventory-Revised Non-systematic/idiosyncratic approach, 32 (OCI-R), 167 North, C.S., 32 Obsessive-compulsive PD, 303 Nosological systems, 32, 35 Obstructive sleep apnea (OSA), 498 Office Mental Status Exam for Dissociation (OMSE), 405 O Olden, M., 185 O’Donohue, W., 138 Older adults O’Toole, G., 44 ADIS-V, 458 Obsessive-compulsive disorder (OCD) adverse drug effects, 468 age, 171 age cohort, 473 anxiety disorder, 141 anxiety disorders, 455 assessment tools, 155, 161 assessment method, 456 BDD, 162 cancer diagnoses, 467 body dysmorphic-like disorders, 164 clinical interview, 456–457, 471 body-focused repetitive behavior cognitive effort, 461 disorders, 164 cognitive impairment, 459 contamination, 156 cognitive tasks, 473 516 Index

Older adults (cont.) Patient health questionnaire-9 (PHQ-9), 225–227 depressive symptoms, 463 Pedersen, P.B., 22 DSM, 469 Pediatric Autoimmune Neuropsychiatric DSM-5 and ICD-10, 470 Disorders Associated with factors, 456 Streptococcal Infections functional assessment, 459 (PANDAS), 164 GDS, 464, 465 Pediatric psychiatric disorder, 214 hearing, 471, 472 Peer, J.E., 261–288 hearing loss, 472 Peltier, M.R., 274 instructions, 472 Period limb movement disorder (PLMD), 498 late-life depression, 469 Perkonigg, A., 185 LGBT, 466 Persistent depressive disorder (PDD), 217 medical conditions, 467 Personality assessment, 442 medical history, 462 Personality Assessment Inventory (PAI), 486 medical records, 457 Personality disorders (PD) memory and cognitive changes, 472 adaptation, 296 mental disorders, 456 antisocial, 296, 300, 314 mental illness, 464 architectural structures, 299 mental status examination, 458 assessment of, 294 mood disorders, 455 avoidant, 302 SCID, 458 borderline, 297, 301 structured interviews, 457 clinicians, 295, 313 unstructured interviews, 456 compliant-compulsive personality US population, 455 spectrum, 297 vitamin D deficiency, 462 dependent, 302–303 Oldham, J.M., 301, 305 depressive, 305 Olfactory reference syndrome, 164 description, 293 Oltmanns, T.F., 469 diagnosis, 319 Operation Enduring Freedom (OEF), 190, 201 domains, 298 Operation Iraqi Freedom (OIF), 190, 201 domestic violence against women, 314 Oppositional defiant disorder, 214 DSM principles, 313 Orgasmic disorders, 351 ego-syntonic perspective, 294 Osborn, C.A., 360 evolutionary theory, 297 Osilla, K.C., 201 formal assessment, 311–313 Outline for Cultural Formulation (OCF), 202 gathering information, 306–309 genetic basis and experience, 293 histrionic PD, 301 P identity disturbance, 315 Palmieri, P.A., 195 inflexibility, 293 Paniagua, F.A., 19, 22 initial intake, 294 Panic disorder (PD), 130, 131 law enforcement professions, 294 Panic Disorder Severity Scale, 140 mild, moderate and severe Paquette, C.E., 325–342 psychopathology, 295 Paranoid PD, 299–300 Millon’s theory, 295 Paraphilia, 353 mind-altering drugs, 315 Paraphilic disorders, 353, 355 Motivational Interviewing approach, 297 forensic setting, 358 narcissistic, 301–302 prevalence, 355 obsessive–compulsive, 303, 314 questionnaires, 359 paranoid, 294, 299–300 specifiers, 355 passive–aggressive (negativistic), 303–304 Paresthesia, 82 pathological narcissistic personality Parkinson’s disease, 83, 123, 467 disorder, 299 Passive-aggressive (negativistic) PD, 303–304 planning and reasoning, 314 Pathomechanisms, 214 replication, 296 Index 517

sadistic, 304 Marine combat veteran, 196, 197 sadistic and masochistic, 295 marked alterations in arousal and schizoid, 300 reactivity, 184 schizoid and/or avoidant, 297 mental health professionals, 198 schizotypal, 300 negative alterations in mood and cognition, self-defeating, 304–305, 317 183, 184 self-defeating/masochistic spectrum, 297 PDSQ, 193 social conditions, 315 pleasurable activities, 184 Peterson, E., 202 prevalence, 185, 186 Phallometry, 361, 366 racial and ethnic minorities, 199–200 Phillips, K.A., 161 sexual minority adults, 200 Phillips, M., 46 substance use/medical condition, 184 Phobias, 132, 133 subsyndromal/subthreshold, 179 Physical and occupational therapy, 492 Potts, S., 103–125 Physical symptoms, 494 Pre-interview informational handout, 429 Pifer, M., 3–26 Premenstrual dysphoric disorder (PMDD), Positive and Negative Syndrome Scale 217–218 (PANSS), 268 Premenstrual syndrome (PMS), 218 Positive symptoms, 264 Presenting problem Posttraumatic amnesia, 121 alternative and nonprofessional treatment Posttraumatic stress disorder (PTSD), 281, 403 methods, 61 and anxiety, 182 assessment, 59, 60 armed forces, 201 cultural and contextual framework, 57 assessment depression, 58, 59 CAPS, 193, 194 diagnostic hypotheses, 56, 58 MINI, 192, 193 frequency, 58 PSS-I, 194 inquiry, 55 SCID, 191, 192 insight, 60 trauma-related specific interviews (see intensity, 58 Trauma-related specific interviews) interviewer, 56–58, 61 avoidance of stimuli symptom, 183 interviewing process, 56 car accident survivor, 197 medical and psychotherapeutic clinician compares, 184 techniques, 61 cultural awareness, 201–202 medically oriented practices, 60 cultural competency, 198 mental disorders, 56, 60 culture, 198 panic attacks, 57 depersonalization, 185 psychoactive substance, 56 derealization, 185 psychopathology, 56 description, 180 sleep disturbance, 60 diagnosis stressors, 58 comorbid disorders, 202 time-consuming, 61 complex PTSD, 203 Primary Care Behavioral Health Model, 484 complicated grief, 203, 204 Primary care patient, depressive symptoms, malingering, 204 225, 226 moral injury, 204 Procedures, gathering information symptomatology, 203 assessment approaches, 490 diagnostic criteria, 179 clinical, 487, 490 diagnostic features, 181–182 DJD, 490 Do’s and Don’ts, 205–206 health record, 493 DSM-IV-TR, 180 mental health services, 491 exposure to traumatic event, 182 open ended approach, 488 gender and age, 199 patient’s health record, 487 intrusion symptom, 183 psychiatric history, 491 intrusive symptoms, 183 stereotypic psychologist behaviors, 488 518 Index

Profile of Mood States (POMS), 220 Roberts, A.L., 200 Prolonged exposure therapy (PET), 206 Robinson, P.L., 340 Prospective memory, 94 Rogers, R., 32, 36, 45, 47 Psychiatric diagnosis, 497 Rosenthal, R., 44 Psychiatric diagnostic screening questionnaire Ross, L., 45 (PDSQ) Rothbaum, B.O., 161, 186, 194 PTSD, 193 Rouen, D., 334 trauma, 193 Rush, A. Jr., 192 Psychiatric disorders, 213 Rybarczyk, B., 481–501 Psychiatric history, 491 The Psychiatric Research Interview for Substance and Mental Disorders S (PRISM-5), 334 Sadistic PD, 304 Psychoactive substances, 333 Safety, 8 Psychoeducation, 190 Saint Louis University Mental Status exam Psychological evaluations, 483 (SLUMS), 97 Psychological trauma, 180 Santos, M.T., 161 Psychopathology, 386, 459 Sareen, J., 202 and BPRS, 268 Sattler, J.M., 45, 47, 103 positive, negative and general scales, 268 Sayers, L., 378 Psychopathy Checklist-Revised (PCL-R), 360, Scharron-del Rio, M.R., 22 362, 363, 366 Schedule for Affective Disorders and Psychosis Schizophrenia (SADS), 247, 248 normative development, children and Schizoaffective disorder, 280 adolescents, 275 Schizoid PD, 300 risk factors, 273 Schizophrenia, 82, 112, 254 Psychosocial histories, 461 causes of disability, 262 Psychotherapy services, 253 characteristic symptoms, 277 PTSD checklist for diagnostic and statistical clinical interview, 266 manual of mental disorders (PCL) clinical vignettes, 269 trauma-related self-report measures, 195 cognitive impairment, 284 PTSD symptoms scale interview (PSS-I) complex, heterogeneous disorder, 261 trauma-related specific interviews, 194 conceptualizations and diagnostic Pukall, C.F., 350–369 criteria, 263 constellation of symptoms, 262 depressive and bipolar related disorders, 279 R disorganized speech, 272 Racial and cultural factors, 466 duration, 278 Ramchand, R., 201 environmental factors, risks of, 262 (see Reasons for Living – Older Adults scale, 459 also Formal assessment) Recurrent brief depression, 219 gender, race, culture, age and diversity, Renn, B.N., 77–101 272–277 Repeatable Battery for the Assessment of general medical conditions, 281 Neuropsychological Status genetic factors, 262 (RBANS), 490 guarded and suspicious presentation, Reproductive individuation, 296 284, 285 Reproductive nurturance, 296 hallucinations and delusions, 269–272 Research diagnostic criteria (RDC), 35, 248 negative symptoms, 265, 284 Restless leg syndrome (RLS), 498 patient self-report, 261 Revised Children’s Anxiety and Depression poor insight, 282, 283 Scale, 442 poor social, educational and vocational Richson, B., 375–396 functioning, 265 Riess, H., 46 positive symptoms, 264 Riggs, D.S., 186, 194 progressive disorder, 262 Index 519

PTSD, 281 DIS, 36, 37 risk of suicide, 265 K-SADS, 40, 41 Schizoaffective disorder, 280 MINI-5, 41, 42 SCID-5 (see Structured Clinical Interview SCID-5-, 37–40 for DSM-5 (SCID-5)) Sensory modality, 471 social/occupational dysfunction, 277–278 Separation anxiety disorder, 133 substance-related disorders, 280 Severity specifiers, 233 treatments, 265 Sex Offender Risk Appraisal Guide (SORAG), Schizotypal PD, 300 363 Schneider, S.C., 155–175 Sex therapy, 364, 365 Schnurr, P.P., 195 Sexual desire and arousal disorders, 351 SCID-5-AMPD (Alternative Model for Sexual dysfunctions Personality Disorders), 40 to biological sex, DSM-5, 350 SCID-5-CT (Clinical Trials Version), 39 clinical interview, 355 SCID-5-CV (Clinician Version), 40 clinically significant issues, 350 SCID-5-RV (Research Version), 39 comorbid nonsexual mental disorders, 350 Scientist-practitioner model, 47 four-phase sexual response cycle, 351 Screening measures general biological factors, 355 bipolar disorders “generalized”, 350 advantages and disadvantages, 251 “lifelong”, 350 antidepressant prescriptions, 250 psychological factors, 356 BSDS, 251 psychometric measures, 364 CIDI, 250 questionnaires, 356 depression diagnoses, 250 Sexual functioning, 356 diagnosis, 251 Sexual History Questionnaire-Revised GBI, 251 (SHQ-R), 360 HCL-32, 250 Sexual interest/arousal disorder (SIAD), 351 MDQ, 250 Sexual violence, 182 psychometric properties, 251 Shankman, S.A., 37 SCID, 250 Shay, J., 204 time-constrained situations, 250 Shear, M.K., 138 depressive disorders, 220, 221 Short-duration depressive episode, 219 Screening, Brief Intervention, and Referral to Shorter two-item version of the Patient Health Treatment (SBIRT) model, 327–328 Questionnaire (PHQ-2), 221 Scrupulosity, 160 Shuman, D.W., 32 Segal, D.L., 3–26, 34, 36, 47 Simons, J., 138 Selective mutism, 133, 134 Single assessment methods, 456 Self-defeating PD, 304–305 Skepticism, 416 Self-injurious behaviors, 409 Social anxiety disorder, 132 Self-monitor depressive symptoms, 223 Social functioning, 92 Self-report inventories, 311 Social history, 6 Self-report screening measures and sexual functioning, 65, 66 depressive disorders, 221, 222 biographical method, 62 Semi-structured interviews, 433, 446, 457 chronological method, 62 ADIS-5, 43 developmental milestones, 62, 63 bipolar disorders diversity, 67, 68 administration, 247 educational, 65 comprehensive depression module, 247 family, 63–65 diagnostic criteria, 247 interviewers, 62 SADS, 247, 248 legal, 68, 69 SCID, 247, 248 medical, 72, 73 standardized, 247 substance use and misuse, 70–72 depressive disorders, 222, 223 technique, 73, 74 DIAMOND, 42 transitions, 62 520 Index

Social history (cont.) Substance Abuse and Mental Health Services trauma and abuse, 69, 70 Administration’s (SAMHSA), 328 vocational, 66, 67 Substance use, 190 Social justice, 18 Substance use disorders (SUDs) Social/occupational dysfunction, 277–278 assessment, 327 Somatization, 495 case studies, 335–337 Somatoform Dissociation Questionnaire categorical classification, 332 (SDQ), 410 comorbidity, 326, 334 Spalding, R., 455–459, 461–473 criminal justice system, 328 Spielberger, C.D., 138 description, 325 St. Georges, M., 47 diagnostic assessment, 329 Stages of Change Readiness and Treatment dimensional approach, 331 Eagerness Scale (SOCRATES), 328 DSM-5, 329 Standardized diagnostic interviews, 329, epidemiological data, 326 330, 334 harm reduction, 328 Standardized interview formats, 449 primary care, 327 Stanley, M.A., 161 SBIRT model, 328 Static-99, 363 symptoms, 331 Stein, M.B., 202 treatment goals, 333 Steinberg, M., 402 Substance use symptoms, 331 Steinman, S.A., 129–149 Substance/medication-induced bipolar and Steketee, G., 161 related disorder, 242, 243 Stem cell/bone marrow transplants, 486 Substance/medication-induced depressive Storch, E.A., 155–175 disorder, 218 Storz, S., 185 Substance-related disorders, 280 Stress Substance-use acute stress disorder (see Acute stress assessment, 333 disorder) public health and economic consequences, definition, 180 325 PTSD (see Posttraumatic stress disorder rate of treatment, 326 (PTSD)) screening, 327 Stroke, 243 self-report measures and biological Structure Interview of Reported Symptoms measures, 333 (SIRS), 419 stigma, 335 Structured and semi-structured interviews, 311 Sue, D.W., 19, 22 Structured clinical interview for DSM-5 Suicidality, 87 (SCID-5), 37–40, 136, 166, Summerfeldt, L.J., 43 388, 458 Swaminath, S., 325–342 bipolar disorders, 247, 248 Symptom clustering, 35 diagnostic interview, 266 Szymanski, J., 138 modules, 266 overview, 266 Structured Clinical Interview for DSM-5 T Personality Disorders Tansey, M.J., 308 (SCID-5-PD), 311 Tardive dyskinesia, 82 Structured clinical interview for the DSM Taylor, S., 138 (SCID) Technical skills PTSD, 191, 192 semi-structured interviews, 31, 36–43 trauma, 191, 192 structured interviews, 30, 31, 33–36 Structured interviews, 33–36, 433, 444, 457 unstructured interviews, 30–33 bipolar disorders Test of Memory Malingering (TOMM), 419 CIDI, 249 Thought content epidemiological research, 249 characteristics, 84 MINI, 249 erotomanic delusions, 86 depressive disorders, 222, 223 grandiose delusions, 86 Index 521

nihilistic delusions, 86 Trauma-related specific interviews paranoid delusions, 86 CAPS, 193, 194 persecutory delusions, 85 PSS-I, 194 referential delusions, 86 Traumatic brain injuries (TBIs), 106, 120–122, somatic delusions, 86 190, 243 Thought process Traumatic event, 182 alogia, 85 Traumatic Life Events Questionnaire (TLEQ) bradyphrenia, 83 scale, 195 characteristics, 84 Trichotillomania, 162, 163 circumstantiality, 84 Trimble, J.E., 22 clang associations, 85 Turner, S.M., 20, 138 echolalia, 85 flight of ideas, 83 neologisms, 85 U perseveration, 85 Uniform recording system, 34 poverty of thought, 84 Unspecified depressive disorder, 219 tangentiality, 84 Unstructured interviews, 31–33, 433, 457 thought blocking, 84 Urinalysis, 334 word salad, 85 Thoughts/behavior disorganization, 264 Thyroid function, 463 V Thyroid stimulating hormone (TSH), 112 Valla, J., 47 Tickle-Degnen, L., 44 Vallano, J.P., 44 Tolin, D.F., 42, 161 Van der Hart, O., 183 Tonarely, N.A., 427–453 Vancouver Obsessional Compulsive Inventory Total hip arthroplasty (THA), 490 (VOCI), 167 Trauma, 409 VandeCreek, L.D., 13 assessment Vandeleur, C.L., 216, 217 MINI, 192, 193 Vandermorris, A.K., 200 PDSQ, 193 Vanderploeg, R.D., 116, 119 SCID, 191, 192 Veale, D., 161 self-report measures (see Trauma- Veterans Health Care Administration (VHA) related self-report measures) services, 200 specific interviews see( Trauma-related Violence Risk Appraisal Guide (VRAG), 360, specific interviews) 363, 366 procedures, gathering information Violence Risk Scale: Sex Offender Version biological factors, 190 (VRS:SO), 364 client’s collaboration, 190 Virden III, T.B., 55–75 cognitive and mood assessments, 191 Vitamin D insufficiency, 462 collateral sources, 191 Voss, M.M., 375–378, 381–395 evaluation process, 191 identify, 190 psychological considerations, 190 W ROI, 191 Walsh, W., 186 self-report measures, 191 Walters, E.E., 185 social elements, 190 Walther, M.R., 161 structured/semi-structured Ward, C.H., 33 interviews, 191 Weathers, F.W., 193, 195 treatment goals, 190 Wechsler Individual Achievement Test, 442 unstructured interview, 191 Wechsler Intelligence Scale for Children, 441 psychological trauma, 180 Weiner, S.J., 46 Trauma-related self-report measures Werth, J.L., 12 LEC, 194, 195 Widiger, T.A., 305 NSESSS, 195, 196 Wiechman Askay, S.A., 188 PCL, 195 Williams, K.N., 34, 36, 47 522 Index

Wilson, J.P., 203 Y Winchel, R.M., 161 Yahav, R., 188 Winston, F.K., 188 Yale-Brown Obsessive-Compulsive Scale Wirove, R., 363 (YBOCS), 166 Wittchen, H.U., 185 Yochim, B., 103–125 Witte, T.K., 195 Wolpe, J., 138 Woodcock-Johnson Tests of Achievement, 442 Z Woods, D.W., 161 Zanarini, M.C., 192 Working Alliance Inventory (WAI), 44 Zero-sum model, 228, 234 World Health Organization Five-Item Zimmerman, M., 32 Well-Being Index (WHO-5), 220 Wright, A.J., 47