Assessment of clinical information: Comparison of the validity of a Structured Clinical Interview (the SCID) and the Clinical Diagnostic Interview.

Adaptive functioning is a key aspect of psychiatric diagnosis and assessment in research and practice. This study compared adaptive functioning validity ratings from Structured Clinical Interviews (SCIDs, symptom-focused structured diagnostic interviews), and Clinical Diagnostic Interviews (CDIs, systematic diagnostic interviews modeling naturalistic clinical interactions focusing on relational narratives). Two hundred forty-five patients (interviewed by two independent interviewers) and their interviewers completed the Clinical Data Form which assesses adaptive functioning and clinical information. Both interviews converged strongly with patient-reports, with no significant differences in validity of the interviews in measuring global and specific domains of adaptive functioning variables. Findings suggest that CDIs provide adaptive functioning data comparable to SCIDs (often considered "gold standard" for assessment but difficult to use in practice) and have important implications for bridging the research-practice gap. By incorporating clinicians' everyday methods, CDIs yield information that is psychometrically sound for empirical investigation, diagnostically practical, and clinically meaningful and valid.

Clinical validity of prototype personality disorder ratings in adolescents.

A growing body of research shows that personality pathology in adolescents is clinically distinctive and frequently stable into adulthood. A reliable and useful method for rating personality pathology in adolescent patients has the potential to enhance conceptualization, dissemination, and treatment effectiveness. The aim of this study is to examine the clinical validity of a prototype matching approach (derived from the Shedler Westen Assessment Procedure-Adolescent Version) for quantifying personality pathology in an adolescent inpatient sample. Sixty-six adolescent inpatients and their parents or legal guardians completed forms of the Child Behavior Checklist (CBCL) assessing emotional and behavioral problems. Clinical criterion variables including suicide history, substance use, and fights with peers were also assessed. Patients' individual and group therapists on the inpatient unit completed personality prototype ratings. Prototype diagnoses demonstrated substantial reliability (median intraclass correlation coefficient =.75) across independent ratings from individual and group therapists. Personality prototype ratings correlated with the CBCL scales and clinical criterion variables in anticipated and meaningful ways. As seen in prior research with adult samples, prototype personality ratings show clinical validity across independent clinician raters previously unfamiliar with the approach, and they are meaningfully related to clinical symptoms, behavioral problems, and adaptive functioning.

Dimensional assessment of self- and interpersonal functioning in adolescents: implications for DSM-5's general definition of personality disorder.

Central to the proposed DSM-5 general definition of personality disorder (PD) are features of self- and interpersonal functioning. The Social Cognition and Object Relations Scale-Global Rating Method (SCORS-G) is a coding system that assesses eight dimensions of self- and relational experience that can be applied to narrative data or used by clinically experienced observers to quantify observations of patients in ongoing psychotherapy. This study aims to evaluate the relationship of SCORS-G dimensions to personality pathology in adolescents and their incremental validity for predicting multiple domains of adaptive functioning. A total of 294 randomly sampled doctoral-level clinical psychologists and psychiatrists described an adolescent patient in their care based on all available data. Individual SCORS-G variables demonstrated medium-to-large effect size differences for PD versus non-PD identified adolescents (d = .49-1.05). A summary SCORS-Composite rating was significantly related to composite measurements of global adaptive functioning (r = .66), school functioning (r = .47), externalizing behavior (r = -.49), and prior psychiatric history (r = -.31). The SCORS-Composite significantly predicted variance in domains of adaptive functioning above and beyond age and DSM-IV PD diagnosis (ΔR(2)s = .07-.32). As applied to adolescents, the SCORS-G offers a framework for a clinically meaningful and empirically sound dimensional assessment of self- and other representations and interpersonal functioning capacities. Our findings support the inclusion of self- and interpersonal capacities in the DSM-5 general definition of personality disorder as an improvement to existing PD diagnosis for capturing varied domains of adaptive functioning and psychopathology.

Clinical validity of a dimensional assessment of self- and interpersonal functioning in adolescent inpatients.

The Social Cognition and Object Relations Scale-Global Version (SCORS-G) is a clinical rating system assessing 8 domains of self- and interpersonal relational experience that can be applied to narrative response data (e.g., Thematic Apperception Test [TAT; Murray, 1943], early memories narratives) or oral data (e.g., psychotherapy narratives, relationship anecdotal paradigms). In this study, 72 psychiatrically hospitalized adolescents consented and were rated by their individual and group therapist using the SCORS-G. Clinicians also rated therapy engagement, personality functioning, quality of peer relationships, school functioning, global assessment of functioning (GAF), history of eating-disordered behavior, and history of nonsuicidal self-injury. SCORS-G composite ratings achieved an acceptable level of interrater reliability and were associated with theoretically predicted variables (e.g., engagement in therapy, history of nonsuicidal self-injury). SCORS-G ratings also incrementally improved the prediction of therapy engagement and global functioning beyond what was accounted for by GAF scores. This study further demonstrates the clinical utility of the SCORS-G with adolescents.

An empirically derived classification of adolescent personality disorders.

OBJECTIVE: This study describes an empirically derived approach to diagnosing adolescent personality pathology that is clinically relevant and empirically grounded. METHOD: A random national sample of psychiatrists and clinical psychologists (N = 950) described a randomly selected adolescent patient (aged 13-18 years, stratified by age and gender) in their care using the Shedler-Westen Assessment Procedure-II-A for Adolescents (SWAP-II-A) and several additional questionnaires. RESULTS: We applied a form of factor analysis to identify naturally occurring personality groupings within the patient sample. The analysis yielded 10 clinically coherent adolescent personality descriptions organized into 3 higher-order clusters (internalizing, externalizing, and borderline-dysregulated). We also obtained a higher-order personality strengths factor. These factors and clusters strongly resembled but were not identical to factors similarly identified in adult patients. In a second, independent sample from an intensive day treatment facility, 2 clinicians (the patients' treating clinician and the medical director) independently completed the SWAP-II-A, the Child Behavior Checklist (CBCL), and a measure of adaptive functioning. Two additional clinicians, blinded to the data from the first 2 clinicians, independently rated patients' ward behavior using a validated measure of interpersonal behavior. Clinicians diagnosed the personality syndromes with high agreement and minimal comorbidity among diagnoses, and SWAP-II-A descriptions strongly correlated in expected ways with the CBCL, adaptive functioning, and ward ratings. CONCLUSION: The results support the importance of personality diagnosis in adolescents and provide an approach to diagnosing adolescent personality that is empirically based and clinically useful.

Attachment, social cognition, and posttraumatic stress symptoms in a traumatized, urban population: evidence for the mediating role of object relations.

Research has linked multiple risk and resiliency factors to developing posttraumatic stress disorder (PTSD). One potentially important construct for understanding connections between trauma and PTSD is attachment. Although relationships between attachment and risk for PTSD have been described theoretically, limited research has addressed these relationships empirically. Furthermore, aspects of object relations overlap with attachment and PTSD, but have not been adequately incorporated in empirical research. One proposed pathway between attachment and PTSD involves the mediating role of object relations, particularly views of self and others. Present data were from a larger study investigating environmental and genetic risk factors for PTSD in an impoverished, primarily African American sample seeking care at a public urban hospital. Correlations indicated that adult attachment (with the exception of dismissing) and object relations relate to childhood traumas, (|r|s = .19-.29), adult traumas (|r|s = .14-.20), and self-reported PTSD symptoms (|r|s = .20-.36). Analyses also found support for mediational roles of object relations in relationships between attachment and PTSD symptoms (Model R(2) range = .136-.160). These data have theoretical, clinical, and research implications for understanding how particular aspects of attachment, specifically its effects on object relations, may protect against or predispose one to develop PTSD.

Validity of prototype diagnosis for mood and anxiety disorders.

CONTEXT With growing recognition that most forms of psychopathology are best represented as dimensions or spectra, a central question becomes how to implement dimensional diagnosis in a way that is empirically sound and clinically useful. Prototype matching, which involves comparing a patient's clinical presentation with a prototypical description of the disorder, is an approach to diagnosis that has gained increasing attention with forthcoming revisions to both the DSM and the International Classification of Diseases. OBJECTIVE To examine prototype diagnosis for mood and anxiety disorders. DESIGN, SETTING, AND PATIENTS In the first study, we examined clinicians' DSM-IV and prototype diagnoses with their ratings of the patients' adaptive functioning and patients' self-reported symptoms. In the second study, independent interviewers made prototype diagnoses following either a systematic clinical interview or a structured diagnostic interview. A third interviewer provided independent ratings of global adaptive functioning. Patients were recruited as outpatients (study 1; N = 84) and from primary care clinics (study 2; N = 143). MAIN OUTCOME MEASURES Patients' self-reported mood, anxiety, and externalizing symptoms along with independent clinical ratings of adaptive functioning. RESULTS Clinicians' prototype diagnoses showed small to moderate correlations with patient-reported psychopathology and performed as well as or better than DSM-IV diagnoses. Prototype diagnoses from independent interviewers correlated on average r = .50 and showed substantial incremental validity over DSM-IV diagnoses in predicting adaptive functioning. CONCLUSIONS Prototype matching is a viable alternative for psychiatric diagnosis. As in research on personality disorders, mood and anxiety disorder prototypes outperformed DSM-IV decision rules in predicting psychopathology and global functioning. Prototype matching has multiple advantages, including ease of use in clinical practice, reduced artifactual comorbidity, compatibility with naturally occurring cognitive processes in diagnosticians, and ready translation into both categorical and dimensional diagnosis.

An empirically derived approach to the classification and diagnosis of mood disorders.

This article describes a system for diagnosing mood disorders that is empirically derived and designed for its clinical utility in everyday practice. A random national sample of psychiatrists and clinical psychologists described a randomly selected current patient with a measure designed for clinically experienced informants, the Mood Disorder Diagnostic Questionnaire (MDDQ), and completed additional research forms. We applied factor analysis to the MDDQ to identify naturally occurring diagnostic groupings within the patient sample. The analysis yielded three clinically distinct mood disorder dimensions or spectra, consistent with the major mood disturbances included in the DSM and ICD over successive editions (major depression, dysthymia, and mania), along with a suicide risk index. Diagnostic criteria were determined strictly empirically. Initial data using diagnostic efficiency statistics supported the accuracy of the dimensions in discriminating DSM-IV diagnoses; regression analyses supported the discriminant validity of the MDDQ scales; and correlational analysis demonstrated coherent patterns of association with family history of mood disorders and functional outcomes, supporting validity. Perhaps most importantly, the MDDQ diagnostic scales demonstrated incremental validity in predicting adaptive functioning and psychiatric history over and above DSM-IV diagnosis. The empirically derived syndromes can be used to diagnose mood syndromes dimensionally without complex diagnostic algorithms or can be combined into diagnostic prototypes that eliminate the need for ever-expanding categories of mood disorders that are clinically unwieldy.

Quality of object representations related to service utilization in a long-term residential treatment center.

The current study examines patient factors related to service utilization during intensive treatment for 66 residential patients suffering from severe mental illness. We examined the relationship among demographic, psychiatric severity, and quality of object representation variables with individual and group psychotherapy sessions attended and emergency department transfers. Hierarchical linear regression models indicate malevolent affective expectations of interpersonal relationships embedded in patient narratives is uniquely related to individual psychotherapy attendance. A three-variable model consisting of higher educational status, number of axis I/II disorders, and poor understanding of social causality was related to transfers to emergency departments owing to self-destructive behavior. Quality of object representation of self and others was uniquely related to treatment use and self-destructive behaviors. Results highlight the importance of a comprehensive multimodal evaluation for improving treatment preparation, planning, and intervention. Clinical implications are considered.

An empirically derived taxonomy for personality diagnosis: bridging science and practice in conceptualizing personality.

OBJECTIVE: The authors describe a system for diagnosing personality pathology that is empirically derived, clinically relevant, and practical for day-to-day use. METHOD: A random national sample of psychiatrists and clinical psychologists (N=1,201) described a randomly selected current patient with any degree of personality dysfunction (from minimal to severe) using the descriptors in the Shedler-Westen Assessment Procedure­II and completed additional research forms. RESULTS: The authors applied factor analysis to identify naturally occurring diagnostic groupings within the patient sample. The analysis yielded 10 clinically coherent personality diagnoses organized into three higher-order clusters: internalizing, externalizing, and borderline-dysregulated. The authors selected the most highly rated descriptors to construct a diagnostic prototype for each personality syndrome. In a second, independent sample, research interviewers and patients' treating clinicians were able to diagnose the personality syndromes with high agreement and minimal comorbidity among diagnoses. CONCLUSIONS: The empirically derived personality prototypes described here provide a framework for personality diagnosis that is both empirically based and clinically relevant.

The effects of sertraline on psychopathic traits.

We examined whether antidepressants alter expression of psychopathic personality traits in patients with major depressive disorder (MDD). Data were collected from a double-blind, placebo-controlled 8-week trial evaluating the efficacy of sertraline (50-200 mg/day) combined with either tri-iodothyronine (T3) or matching placebo in adult outpatients with major depressive disorder. Administration of sertraline was open-label; T3/placebo was double-blind. At the baseline and week 8 visits, patients completed the short form of the Psychopathic Personality Inventory (PPI), a well-validated self-report measure assessing two major factors of psychopathy: Fearless Dominance (PPI-1) and Self-Centered Impulsivity (PPI-2). Change in PPI scores were assessed using paired t-tests for all participants who completed a baseline and postrandomization PPI. Ninety patients (84 completers and six who terminated the trial early) were eligible for the analysis. Both PPI factors changed significantly from baseline to endpoint, but in opposing directions. The mean score on PPI-1 increased significantly during treatment; this change was weakly correlated with change in depression scores. In contrast, the mean score on PPI-2 decreased significantly, but these changes were not correlated with changes in depression scores. Independent of their effects on depression, antidepressants increase adaptive traits traditionally observed in psychopathic individuals, such as social charm and interpersonal and physical boldness. Antidepressants reduce other, more maladaptive, traits associated with psychopathy, including dysregulated impulsivity and externalization.

Emotion dysregulation and negative affect: association with psychiatric symptoms.

OBJECTIVE: A growing body of research focuses on the development and correlates of emotion dysregulation, or deficits in the ability to regulate intense and shifting emotional states. Current models of psychopathology have incorporated the construct of emotion dysregulation, suggesting its unique and interactive contributions, along with childhood disruptive experiences and negative affect, in producing symptomatic distress. Some researchers have suggested that emotion dysregulation is simply a variant of high negative affect. The aim of this study was to assess the construct and incremental validity of self-reported emotion dysregulation over and above childhood trauma and negative affect in predicting a range of psychopathology. METHOD: Five hundred thirty individuals aged 18 to 77 years (62% female) were recruited from the waiting areas of the general medical and obstetric/gynecologic clinics in an urban public hospital in Atlanta, Georgia. Participants completed a battery of self-report measures obtained by interview, including the Childhood Trauma Questionnaire, the Positive and Negative Affect Schedule, and the Emotion Dysregulation Scale. Regression analyses examined the unique and incremental associations of these self-report measurements of childhood traumatic experiences, negative affect, and emotion dysregulation with concurrent structured interview-based measurements of psychiatric distress and history of self-destructive behaviors. These measures included the Clinician-Administered PTSD Scale, the Alcohol Use Disorders Identification Test, the Short Drug Abuse Screening Test, the Beck Depression Inventory, and the Global Adaptive Functioning Scale from the Longitudinal Interval Follow-Up Evaluation. The presented data were collected between 2005 and 2009. RESULTS: Regression models including age, gender, childhood trauma, negative affect, and emotion dysregulation were significantly (P ≤ .001) associated with each of the study's criterion variables, accounting for large portions of the variance in posttraumatic stress symptoms (R² = 0.21), alcohol and drug abuse (R² = 0.28 and 0.21, respectively), depression (R² = 0.55), adaptive functioning (R² = 0.14), and suicide history (omnibus χ² = 74.80, P < .001). Emotion dysregulation added statistically significant (P < .01) incremental validity to each regression model (ß = 0.25, 0.34, 0.35, 0.34, and -0.18, and Wald = 24.43, respectively). CONCLUSIONS: Results support the conceptualization of emotion dysregulation as a distinct and clinically meaningful construct associated with psychiatric distress that is not reducible to negative affect. Emotion dysregulation is a key component in a range of psychiatric symptoms and disorders and a core target for psychopharmacologic and psychosocial treatment interventions.

Identity disturbance in adolescence: associations with borderline personality disorder.

Although establishing a coherent identity is often viewed as a normative developmental task of adolescence, an important question is whether forms of identity disturbance seen in adult personality disorders can also be distinguished in adolescents. If so, such disturbances would constitute an essential target for research and clinical interventions. The goal of this study is to investigate the nature of identity disturbance in an adolescent clinical sample and to explore its links with personality pathology, particularly borderline personality disorder. A national random sample of 139 psychiatrists and clinical psychologists completed a battery of instruments on a randomly selected adolescent patient in their care, including measures of Axis II symptoms and the Identity Disturbance Questionnaire-Adolescent Version, an instrument designed for clinically experienced observers that assesses a wide range of manifestations of potential identity disturbance among adolescents. Factor analysis of the Identity Disturbance Questionnaire--Adolescent Version yielded four clinically and conceptually coherent factors that resembled dimensions previously identified in adults: lack of normative commitment, role absorption, painful incoherence, and lack of consistency. As in adults, identity disturbance in adolescents is a clinically meaningful, multidimensional construct exhibiting significant relationships with different forms of severe personality pathology, most notably borderline personality disorder. As such, identity disturbance can be a manifestation of psychopathology above and beyond the typical Sturm und Drang (storm and stress) of adolescence.

Agreement between clinician and patient ratings of adaptive functioning and developmental history.

OBJECTIVE: Psychiatric researchers rely heavily on patient report data for clinical research. However, patient reports are prone to defensive and self-presentation biases. Recent research using practice networks has relied on clinician reports, and both forensic and personality disorder researchers have recently turned to quantified data from clinically expert observers as well. However, critics have raised legitimate concerns about the reliability and validity of data from clinician informants. The aim of this study was to assess the validity and diagnostic efficiency of clinician reports of their patients' adaptive functioning and developmental histories, using patient reports as the comparative standard traditionally used in psychiatric research. METHOD: Eighty-four clinicians and their patients completed a clinical data form designed to assess a range of patient functioning, clinical history, and developmental relationship variables used in multiple clinician report studies. The authors correlated clinician and patient reports across a number of clinically relevant adaptive functioning variables and calculated diagnostic efficiency statistics for a range of clinical history variables, including suicide attempts, hospitalizations, arrests, interpersonal conflicts affecting employment, and childhood physical and sexual abuse. RESULTS: Across variables, patient-therapist correlations (0.40-0.66) and overall correct classification statistics (0.74-0.96) were high. CONCLUSIONS: The data demonstrate that clinicians' judgments about their patients' functioning and histories agree with patients' self-reports and that in areas of discrepancy, clinicians tend to make appropriately conservative judgments in the absence of clear data. These findings suggest that quantified clinical judgment provides a vast untapped potential for large-sample research on psychopathology and treatment.

Psychotherapy appointment no-shows: rates and reasons.

Patients who frequently miss or do not show for their scheduled psychotherapy appointments create administrative and clinical difficulties, and may not be receiving effective treatment. Prior research has predominately focused on either identifying demographic and administrative factors related to patient no-show rates or evaluating the effectiveness of administrative procedures for reducing no-shows. This paper attempts to identify rates of missed appointments in clinical practice and explore more specific clinical process factors related to patient no-shows. Psychotherapists (N = 24) and their patients (N = 542) in the outpatient department of a public safety-net hospital were surveyed to examine how frequently patients missed scheduled psychotherapy appointments and for what reasons. Findings indicate that the majority of missed appointments were accounted for by patients with occasional absences (approx. 1 per month), while only a small percentage of patients missed appointments with high frequency. Patients missed their psychotherapy appointments for a number of reasons, including clinical symptoms, practical matters, motivational concerns, and negative treatment reactions.

Prototype Personality Diagnosis in Clinical Practice: A Viable Alternative for DSM-V and ICD-11.

Several studies suggest that a prototype matching approach yields diagnoses of comparable validity to the more complex diagnostic algorithms outlined in DSM-IV. Furthermore, clinicians prefer prototype diagnosis of personality disorders (PDs) to the current categorical diagnostic system or alternative dimensional methods. An important extension of this work is to investigate the degree to which clinicians are able to make prototype diagnoses reliably. The aim of this study is to assess the inter-rater reliability of a prototype matching approach to personality diagnosis in clinical practice. Using prototypes derived empirically in prior research, outpatient clinicians diagnosed patients' personality after an initial evaluation period. External evaluators independently diagnosed the same patients after watching videotapes of the same clinical hours. Inter-rater reliability for prototype diagnosis was high, with a median r = .72. Cross-correlations between disorders were low, with a median r = .01. Clinicians and clinically trained independent observers can assess complex personality constellations with high reliability using a simple prototype matching procedure, even with prototypes that are relatively unfamiliar to them. In light of its demonstrated reliability, efficiency, and versatility, prototype diagnosis appears to be a viable system for DSM-V and ICD-11 with exceptional utility for research and clinical practice.

Patient ratings of psychodynamic psychotherapy session activities and their relation to outcome.

This study examines patient ratings of modality-specific technical interventions and their relation to therapeutic treatment change. The sample consisted of 55 individuals engaged in short-term psychodynamic psychotherapy at a university-based community outpatient treatment center. Results demonstrate that not only were patients capable of recognizing specific technical processes occurring within their psychotherapy, but also that those ratings were significantly related to measures of therapeutic outcome. Furthermore, patient ratings of session activities were found to be stable from early session rating to late in treatment. Findings support the conclusion that, as rated from the patient perspective, some degree of flexibility in and integration of modality-specific techniques is beneficial for outcome. Implications for future research and clinical practice are discussed.

Reliability and validity of the Social Cognition and Object Relations Scale (SCORS) in the assessment of dream narratives.

In this study, we aimed to investigate the application of an externally rated measure of interpersonal representations (Social Cognition and Object Relations Scale [SCORS]; Westen, 1995) to dream narratives. A total of 80 student participants enrolled at a private university in the New York City metropolitan area completed a Dream Log and affect adjective checklist (Wellman, 2002) based on a recalled dream at both 1 month and 3 months following the September 11, 2001, terrorist attacks. Using the dreams provided in this study we examined the interrater reliability of SCORS ratings, the relationship of SCORS variables to an independently rated measure of dream distortion, and the relationship of SCORS variables to participants' own ratings of dream affect. Results indicated that dreams were reliably rated using the SCORS, 3 cognitive SCORS variables were significantly related to dream distortion, and affective SCORS variables were meaningfully related to participants' own ratings of affect in their dreams. Findings from this study provide support for the application of SCORS ratings to dream narratives. We discuss implications for further research and clinical application.

Clinical utility of the Defensive Functioning Scale in the assessment of depression.

The Defensive Functioning Scale (DFS) and Overall Defensive Functioning score (ODF) have been used as reliable and valid measures of defense structure when applied to clinical narratives. This study aims to replicate and extend positive clinical validity data for the ODF in the assessment of depression and examine the relationship between specific defense levels of the DFS and depressive symptoms. Sixty-nine outpatients who completed the Symptom Checklist 90-Revised and Personality Assessment Inventory were rated on the DFS by trained clinicians. Lower (more maladaptive) scores on the ODF were significantly related to the presence and severity of patient-reported depression symptoms. Furthermore, depression symptoms were significantly related to both the presence of low-level action defenses and an absence of higher-range defenses in the mental inhibitions-obsessional level. Findings from this study provide further support for the clinical application and relevance of the DFS system; support the theory of defensive processes falling into a hierarchy of adaptive functioning; and, because of a naturalistic setting, are highly generalizable to real-world practice.