Posted: April 13th, 2023

Assessing Comorbidity essay

Title: Structured Clinical Interview for DSM-IV Axis II Personality Disorders By: First, Michael B., Gibbon, Miriam, Spitzer, Robert L., Williams, Janet B. W., Benjamin, Lorna Smith, 19970101, Vol. 14

Database: Mental Measurements Yearbook with Tests in Print

Review of the Structured Clinical Interview for DSM-IV Axis II Personality Disorders by PAUL A. ARBISI, Minneapolis VA Medical Center, Assistant Professor Department of Psychiatry, and Assistant Clinical Professor Department of Psychology, University of Minnesota, Minneapolis, MN:
The Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II) is a semistructured diagnostic interview for assessing the 10 Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) personality disorders and Personality Disorder NOS. Two provisional personality disorders provided in DSM-IV for “further study”-Depressive Personality Disorder and Passive-Aggressive Personality Disorder-are also included in the SCID. The SCID-II was designed to provide DSM-IV Axis II diagnoses in both research and clinical settings. In clinical settings the SCID-II can be used in a number of ways. The clinician may use the SCID-II to confirm clinical impression. That is, after completing an unstructured clinical interview, the clinician may administer portions of the SCID to confirm and document one or more suspected Axis II disorders. Further, in a comprehensive, albeit time-consuming intake procedure, the entire SCID-II can be administered. Finally, the SCID-II can be used as a didactic device to improve the interviewing skills of students in the mental health professions.
Specifics of the instrument will be discussed, following several general issues that must be addressed prior to discussion of the merits of this semistructured interview. The first issue relates to the tautological nature of the validity data presented in the manual. That is, because the SCID-II is essentially a series of questions designed to elicit information regarding personality disorders based on the DSM-IV definition of a personality disorder, it is not surprising that the SCID-II agrees well with DSM-IV Axis II criteria. A more salient issue is that there are essentially no validity or reliability data presented in the manual nor are there currently any research studies contained in the literature directly related to the validity or reliability of this version of the SCID-II. The rather scant data that are reported in the manual pertain to the previous Diagnostic and Statistical Manual-III-Revised (DSM-III-R) version of the SCID-II. Indeed, this is not directly acknowledged in the manual until the Reliability and Validity section (user’s guide, p. 33). In fact, in a somewhat misleading manner, the second paragraph in the Introduction section of the manual states “The SCID-II has been used in three different types of studies” (user’s guide, p. 1). The manual goes on to detail the types of studies where the “SCID-II” was used. These studies all used the DSM-III-R version of the SCID-II. This represents a particularly troubling and misleading lack of candor on the part of the authors because they later describe the alterations that occurred between the DSM-III-R version and the DSM-IV version of the SCID. After the publication of DSM-IV in 1994, the SCID-II was revised with many of the SCID-II questions reworded, “to make them more reflective of the subject’s inner experience” (user’s guide, p. 2). The final version of the revised SCID was published in 1997. Not only are the two versions not equivalent because the diagnostic criteria for several personality disorders changed between DSM-III-R and DSM-IV, but the questions were reworded to capture a different source of information. Therefore, to imply equivalency of the two versions is, at best, ingenuous.
The other issue involves the use of a categorical model rather than a dimensional model in DSM-IV for diagnosing personality disturbance. The issue of DSM’s reliance on a categorical rather than a dimensional understanding of personality disorder has been the subject of discussion for some time (Widiger, 1993; Widiger & Costa, 1994). Recently, the finding of a stable structure of personality traits across clinical and nonclinical samples was interpreted as consistent with a dimensional classification of personality disorders (Livesley, Jang, & Vernon, 1998). Despite findings such as this, the DSM-IV and, in turn, SCID-II strictly adhere to a categorical diagnostic strategy despite the assertion to the contrary. The manual notes “SCID-II can be used to make Axis II diagnoses, either categorically (present or absent) or dimensionally (by noting the number of personality disorder criteria for each diagnosis that are coded ‘3’)” (user’s guide, p. 1). The implication that counting the number of symptoms present is somehow a dimensional approach is inaccurate. The finding of a significant residual heritability to lower order traits beyond that found for the broader traits drawn from higher in the hierarchy of personality suggests that specific symptoms may tap important molecular aspects of personality, but fail to tap the same higher-order dimensions within a particular disorder. Simply tallying up the symptoms will not necessarily lead to the accurate assessment of disorders of personality in any meaningful way (Livesley et al., 1998; Widiger & Costa, 1994).
All that being said, the SCID-II provides just what it says it provides: DSM-IV Axis II diagnosis for the following personality disorders: Avoidant, Dependent, Obsessive Compulsive, Passive Aggressive, Depressive, Paranoid, Schizotypal, Schizoid, Histrionic, Narcissistic, Borderline, Antisocial, and Personality NOS. Besides the manual and the interview itself, the material includes a SCID-II Personality Questionnaire. A computer-administered version of both the SCID-II Personality Questionnaire and the SCID-II interview is also available. The questionnaire is a self-report screening instrument designed to elicit behaviors that suggest the presence of a personality disorder and would therefore prompt the interviewer to administer the relevant portion of the SCID-II interview. The items on the questionnaire have a lower threshold than those contained on the interview. Indeed this strategy, as it relates to the DSM-III-R version of the SCID-II, results in lower false negative rates and increased predictive power (Jacobsberg, Perry, & Frances, 1995). For the time-conscious researcher, using the questionnaire provides a significant savings in time by allowing the interviewer to skip disorders where the subject has not endorsed a sufficient number of symptoms to warrant consideration of the disorder.
In general, the interview is well organized and easy to administer. It integrates the screening questionnaire in the probes (you’ve said that you …) or phrases the probes in the present tense (do you …). The interview also provides rule outs and a general description of the personality disorder prior to administering the symptom probes to fix, in the examiner’s mind, what constitutes a particular personality disorder. Each question is tied to a symptom or sign of the particular personality disorder and is rated as ? = inadequate information, 1 = absent or false, 2 = subthreshold, and 3 = threshold or true. The interview encourages the examiner to elicit examples of behaviors to aid in rating the presence or absence of a symptom. Finally, at the end of each personality disorder section are the criteria needed for the diagnosis of that particular personality disorder and a dichotomous rating as to the presence or absence of the disorder.
The manual is well written and clear. It systematically covers each question under each personality disorder by providing an item-by-item commentary explaining the intent of each question, offering examples of what constitutes an occurrence of the symptom, and explaining how the particular symptom may differ from other symptoms within the disorder. Additionally, the manual contains a case example accompanied by a completed SCID-II interview of the case. The manual has utility as a didactic tool for the instruction of mental health professionals in the assessment and diagnosis of DSM-IV personality disorders. Succinct and well-defined descriptions of each disorder as well as each symptom associated with the disorder are provided. This is an excellent place to start in teaching novice mental health professionals because it provides the paradigmatic DSM-IV definition of the disorder and offers rather well-constructed examples of what constitutes each symptom.
The manual provides suggestions for training in the use of the SCID-II. However, no guidelines are offered regarding the necessary level of training or general qualifications for use. A statement regarding user qualifications is required to meet Standard 5.4 of the Standards for Educational and Psychological Testing (American Educational Research Association, American Psychological Association, & National Council on Measurement in Education [Joint Committee], 1985). As mentioned previously, there are absolutely no data presented in the manual on the validity or reliability of the DSM-IV version of the SCID-II. Additionally, available evidence for the DSM-III-R version of the SCID indicates reliabilities varied greatly across disorders in clinical samples and were much lower for nonclinical samples. Indeed, even if the SCID had not been substantially altered between the two versions, extrapolation of reliability data from the DSM-III-R version to the DSM-IV is not warranted because the reported reliabilities are rather low and there is a complete lack of test-retest reliability for the DSM-III-R version (Rogers, 1995).
SUMMARY. Overall, the most recent version of the SCID-II would best be used as a research or didactic tool. In research settings individual investigators will have to establish both test-retest and interrater reliabilities for each personality disorder within the context of their sample. The lack of reliability and validity data for the current version of the SCID-II makes it difficult to develop an informed opinion with respect to the utility of the instrument in clinical practice. Additionally, a leap of faith is required with respect to the validity of the SCID because there are no data available to establish the concurrent validity of the instrument. As a tool for teaching DSM-IV-based diagnosis of personality disorder, the SCID-II shows great promise and stands out as a well-organized guide for the elicitation of symptoms compromising DSM-IV personality disorders. As far as the clinician is concerned, the SCID-II is best left in the lab or the classroom.
REVIEWER’S REFERENCES
American Educational Research Association, American Psychological Association, & National Council on Measurement in Education (Joint Committee). (1985). Standards for educational and psychological testing. Washington, DC: American Psychological Association, Inc.
Widiger, T. A. (1993). The DSM-III-R categorical personality disorder diagnoses: A critique and an alternative. Psychological Inquiry, 4, 75-90.
Widiger, T. A., & Costa. P. T. (1994). Personality and personality disorders. Journal of Abnormal Psychology, 103, 78-91.
Jacobsberg, L., Perry, S., & Frances, A. (1995). Diagnostic agreement between the SCID-II screening questionnaire and the personality disorder examination. Journal of Personality Assessment, 65, 428-433.
Rogers, R. (1995). Diagnostic and structured interviewing: A handbook for psychologists. Odessa, FL: Psychological Assessment Resources.
Livesley, W. J., Jang, K. L., & Vernon, P. A. (1998). Phenotypic and genetic structure of traits delineating personality disorder. Archives of General Psychiatry, 55, 941-948.

Review of the Structured Clinical Interview for DSM-IV Axis II Personality Disorders by SUZANNE G. MARTIN, Director of Needs Assessment, Charter Fairmount Behavioral Health System, Philadelphia, PA:
TEST COVERAGE & USE. The authors state that this test can be used for both research and clinical purposes. Although it is based on self-report, it does allow room for the clinician to respond with his or her observation of the patient’s behavior during the interview. Where accurate diagnosis of Axis II disorder is necessary for either enrollment in research or for treatment planning, the SCID-II appears to provide an objective basis for diagnostic formulation. The SCID-II can also be used as a learning tool for students to improve interview skills by providing a sample of pertinent clinical questions to help make diagnostic decisions. In this respect, it appears it would be a useful tool for both graduate students and medical students in a training setting.
SAMPLES FOR TEST VALIDATION. No information is provided on test validation other than the fact that the test has been revised based on the changes in DSM-IV.
RELIABILITY. No data are available per the user’s guide. Some clinical judgement is needed to differentiate between “true” and “subthreshold” responses and this may result in some variability in reliability.
PREDICTIVE VALIDITY. No data are available per the user’s guide.
CONTENT VALIDITY. See above. Essentially, no guidance is provided for use of “Personality Disorder NOS.”
TEST ADMINISTRATION. The test can be administered with a self-report completed by the patient (approximately 15 minutes) followed by a clinical interview (about 30 minutes depending on number of “yes” responses) or strictly by clinical interview. However, this latter procedure is very time-consuming for the clinician. Test instructions are provided; however, use of the test is not restricted to individuals trained in DSM-IV.
TEST REPORTING. Scoring is very clear and specific thresholds are specified for diagnosis consistent with DSM-IV criteria. No information is provided on reporting test results to patients or debriefing patients after the interview.
TEST AND ITEM BIAS. No information is provided on sample test groups. Some attempt is made to discriminate beliefs that are unique to the individual versus those shared by the majority of the individual’s cultural group.
SUMMARY. Despite the lack of information provided regarding the reliability, validity, and field trials, the SCID-II appears to be a viable clinical and research tool for those trained in the use of diagnosis using the DSM-IV. The SCID-II offers an objective measure for pathology that is too frequently overlooked on Axis II or misdiagnosed because the same rigid diagnostic criteria applied to Axis I disorders are more casually used for personality disorders.

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