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3
STRUCTURED AND
SEMISTRUCTURED INTERVIEWS
J ULIE N. H OOK , E LISE H ODGES , K RISCINDA W HITNEY,
AND DANIEL L. S EGAL
D
iagnostic interviewing is one of corner­
stones of modern clinical psychology.
The earliest forms of interviewing typi­
cally involved a free-flowing, unstandardized for­
mat in which professionals relied on their clinical
acumen to generate appropriate questions. As
the field progressed, standardization of clinical
diagnosis was emphasized, a concept marked
by the publication of the first Diagnostic and
Statistical Manual of Mental Disorders (DSM;
American Psychiatric Association, 1952). Since
that time, the DSM has gone through many revi­
sions, and with its growth and development
structured and semistructured interviews have
also evolved, mirroring the DSM criteria.
The inherent nature of an unstructured inter­
view leaves the type of questions and manner in
which questions are asked to the discretion of the
professional, which can be influenced by the pro­
or applicable copyright law.
fessional’s theoretical orientation, training, mood,
and interaction with the patient. With the advent
of structured interviews, several limitations of
the unstructured interview were addressed. The
structured interview provides a standardized
method for asking and answering questions and
recording and interpreting responses. As a con­
sequence, variability and inconsistency across
24
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professionals are decreased (Rogers, 2001; Segal &
Coolidge, 2003). Improvement of diagnostic con­
sistency has helped make the structured interview
a useful tool not only in clinical practice but also
in clinical research and training of professionals
(Rogers, 2001).
In the past few decades, there has been a pro­
liferation of structured interviews, and a number
of important differences between instruments
have emerged. First, the structured interview can
vary in the stringency of the user’s ability to devi­
ate from the interview protocol. The most strict
is a fully structured interview, which requires that
all questions be asked as written, allowing few
or no deviations from the interview format.
Alternatively, a semistructured interview is less
strict, typically beginning with standard ques­
tions but allowing optional probes or follow-up
questions from the interviewer. Second, struc­
tured interviews vary in the content and depth of
coverage. For example, some instruments may
include most clinical (Axis I) or personality (Axis
II) disorders, whereas others focus on a specific
subset of disorders, such as anxiety or mood dis­
orders, but with greater depth. Structured inter­
views have also been developed to assess specific
areas of clinical interest (e.g., malingering, the
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Structured and Semistructured Interviews
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five-factor model of personality). Third, the ease
of use for the interviewer, the level of training
needed to administer the measure, and the psy­
chometric properties also differ between the dif­
ferent structured interviews.
Although there are advantages of structured
interviews, critics of these instruments point out
that their use can damage rapport, particularly in
the context of a therapeutic relationship (Rogers,
2001; Rubinson & Asnis, 1989). Furthermore,
a structured interview is only as valid as the
diagnostic criteria on which it is based. Many
researchers have argued that the DSM criteria
should not be the sole determinant of diagnoses
or be used as a substitute for clinical expertise
(First, Frances, & Pincus, 2004). A structured
interview can also limit the depth and breadth of
coverage of particular diagnostic or clinical issues
(Rogers, 2001; Rubinson & Asnis, 1989). Although
there are advantages and disadvantages of relying
solely on a structured interview, the interviewer is
not prohibited from following up with individual­
ized or unstructured questions (i.e., before or after
the structured interview is completed).
This chapter first provides the reader with
information to evaluate structured interviews,
particularly in regard to psychometric proper­
ties. Next, a review of commonly used instru­
ments of Axis I and II disorders is provided,
followed by a chapter summary.
PSYCHOMETRIC CHARACTERISTICS
Reliability and validity are essential aspects of
psychological measurement. Therefore, a review
of these terms as they apply to structured inter­
views is provided.
Reliability
Reliability is the degree of consistency of a
measure, such that a perfectly reliable measure
theoretically would give the same result every time
or applicable copyright law.
it was used (barring significant changes in the
measured construct; Segal & Coolidge, 2006a).
The reliability of structured interviews can be
assessed at different levels of analysis, ranging
from item-specific reliability within an interview
to the resultant diagnoses. The majority of relia­
bility studies of structured and semistructured
interviews focus on diagnostic consistency across
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25
raters (called interrater reliability) or across differ­
ent points in time (called test-retest reliability;
Rogers, 2001). In addition, but less often, the inter­
nal consistency within a measure is also reported
(called coefficient alpha; Clark & Watson, 1995).
However, because of the polythetic nature of most
structured interviews, coefficient alpha is not con­
sidered an appropriate statistic in demonstrating
reliability (Rogers, 2001).
Test-retest reliability is a measure of consis­
tency of performance across time, such that a
client is given a structured interview at time one
and then administered the same interview by
a different rater at another time. Two different
raters are needed to ensure independence of
assessment. Duration of the test-retest interval
depends on the stability of the trait being mea­
sured. For example, personality disorders, which
are thought to be quite stable over long periods
of time, may necessitate a much longer test-retest
interval than would a measure of an acute stress
disorder. Interrater reliability is a measure of con­
sistency across raters, in which one interview is
performed with two or more raters observing (or
evaluating) the interview; this type of reliability is
one of the most commonly used methods of
assessing reliability for the structured interview.
Interrater reliability estimates for categorical
diagnoses typically are reported in terms of
kappa, although Yule’s Y and intraclass coefficient
(ICC) are also used (Rogers, 2001). The kappa
coefficient is the most commonly reported mea­
sure of agreement between two raters (Cohen,
1960). Although kappa does correct for chance
agreements (Bakeman & Gottman, 1989), it may
be influenced by base rates, making it difficult to
compare kappas across studies (Thompson &
Walter, 1988). Although Yule’s Y is recommended
for use with low–base rate phenomena (Spitznagel
& Helzer, 1985; Summerfeldt & Antony, 2002),
it is less commonly reported in validation stud­
ies. ICCs are used as measures of reliability
when there are more than two raters (Keller et al.,
1981). With large samples, ICCs are considered
to be similar to a weighted kappa (Fleiss &
Cohen, 1973).
Validity
Validity is the precision of measurement,
how accurately a construct is assessed, and what
can be inferred from the test scores (Anastasi &
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26 GENERAL ISSUES
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Urbina, 1997; Segal & Coolidge, 2006b).
Criterion-related and construct validity are the
two most commonly examined types of validity
for structured interviews.
Criterion-related validity is the degree to
which scores on one measure predict scores on
another measure considered to be the criterion or
gold standard. This can be assessed at the same
time (concurrent validity) or at a specified time
in the future (predictive validity; Cronbach,
1990). Most studies that have examined criterion-
related validity of structured interviews compare
the consistency of a diagnosis from the interview
to the diagnosis provided by an expert clinician
or diagnostician. However, some critics argue
that clinical judgment should not be considered a
gold standard because of the inherent fallibility in
clinical decision making (Garb, 2005). Predictive
validity is of particular concern for measures
designed to forecast future outcomes. An example
would be the use of professional aptitude tests
in determining a person’s success or failure at a
career.
Construct validity is the degree to which an
obtained score reflects the theoretical true score
of the phenomena under investigation (Cronbach
& Meehl, 1955). Construct validity typically is
examined through convergent and discriminant
validity studies or a multitrait, multimethod
matrix (Campbell & Fiske, 1959). In general, con­
vergent validity is demonstrated when the score
from one measure of a disorder is more highly
related to a score of another measure of the same
disorder than to a score from a measure of a
different disorder. For instance, scores obtained
from a new structured interview for anxiety dis­
orders would be expected to be highly similar to
the obtained score from an existing measure of
anxiety disorder. On the other hand, to demon­
strate the discriminant validity of a measure, one
would expect that the obtained score would be
less related to the scores from a measure of a
dissimilar trait or disorder. In this example, the
obtained score from the new structured interview
or applicable copyright law.
of anxiety disorders should not be highly related
to the obtained scores on an intelligence measure.
SEMISTRUCTURED INTERVIEWS
FOR AXIS I DISORDERS
This section provides an overview of the measures
including their development, administration
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information, and a review of the literature related
to reliability and validity (when available). Four
of the most widely used semistructured inter­
views are reviewed: the Diagnostic Interview
Schedule (DIS) for DSM-IV, the Structured
Clinical Interview for DSM-IV Axis I Disorders
(SCID-I), the Schedule for Affective Disorders
and Schizophrenia (SADS), and the Anxiety
Disorders Interview Schedule (ADIS) for DSM­
IV. Each of these instruments assesses a variety of
disorders and is useful in providing differential
diagnoses.
Diagnostic Interview Schedule (DIS)
The DIS is a fully structured interview devel­
oped for clinicians and nonclinicians to assess
a range of DSM-based psychiatric diagnoses
(Robins, Cottler, Bucholz, & Compton, 1995).
Because the DIS is completely structured with
very specific questions and follow-up probes,
the need for clinical judgment during question­
ing is minimized, which reduces reliance on
the examiner’s clinical training. The most recent
version, DIS-IV (Robins et al., 1995), is based on
the DSM-IV major psychiatric disorders.
The DIS was developed in 1978 at the request
of the National Institute of Mental Health
(NIMH) in response to the development of the
Epidemiological Catchment Area (ECA) research
program. This project resulted in a need for
a comprehensive assessment tool that could be
used for large-scale, multicenter epidemiolog­
ical studies by interviewers with limited or
varied clinical experience. Because the DSM-III
(American Psychiatric Association, 1980) was in
use at that time, many DSM-III disorders were
the basis for the DIS and the ECA study. Over the
course of changes associated with the DSM, the
DIS followed, and upon publication of the DSM­
IV (American Psychiatric Association, 1994), the
DIS-IV was developed.
The interview begins by having the respon­
dent provide demographic information and
includes sections that pertain to chronological
dates that aid the respondent’s recall of symptom
onset and also includes questions related to risk
factors (e.g., living circumstances). The DIS then
includes a series of questions that pertain to psy­
chiatric symptoms in a standardized order. These
questions are further organized into 19 modules
that evaluate 30 DSM-IV Axis I psychiatric disor­
ders including mood disorders, anxiety disorders,
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substance use disorders, and psychotic disorders,
as well as antisocial personality disorder, coded
on Axis II (Rogers, 2001). In most cases, the DIS
modules are independent, unless one module
precludes administration of another. For each
module, if a symptom is reported as present,
closed-ended questions are asked related to sever­
ity, frequency, and time course, as are questions
that may provide information related to the
potential for organicity (Summerfeldt & Antony,
2002). Once the core and probe questions have
been asked, responses are coded as follows: 1 for
did not occur, 2 for lack of clinical significance, 3 for
medication, drugs, or alcohol, 4 for physical illness
or injury, and 5 for possible psychiatric syndrome.
If the number of symptoms for a threshold
of a diagnosis is met, the interview proceeds.
Additional questions are asked about the episode
or disorder, including the frequency of occur­
rence, the respondent’s age at onset, and age dur­
ing the last occurrence. These data are then used
to generate a diagnosis, including current and
lifetime diagnoses.
No clinical experience is needed to adminis­
ter the DIS, but familiarity with the administra­
tion protocol is recommended before use of the
measure (Rogers, 2001; Summerfeldt & Antony,
2002). With users who are new to the DIS,
administration of the entire measure may take
up to 150 minutes. The format of the DIS allows
omission of specific modules if the diagnosis is
not being studied or if a diagnosis falls below the
clinical threshold.
The psychometric properties of the DIS in its
original and revised versions range from poor to
excellent. Unfortunately, there have been only lim­
ited investigations of the psychometric properties
of the DIS-IV, but because of the similarities
across versions of the DIS, it has been proposed
that research on the psychometric properties of
prior versions is applicable to the DIS-IV (Rogers,
2001; Summerfeldt & Antony, 2002).
Investigations into the reliability of the DIS
have yielded mixed results. Robins and colleagues
or applicable copyright law.
(Robins, Helzer, Croughan, & Ratcliff, 1981;
Robins et al., 1982) examined the test-retest relia­
bility of the DIS-II, which focused on DSM-III
lifetime disorders; results from these studies sug­
gest moderate kappas for most assessed disorders.
For later versions of the DIS, results were similar,
citing mostly moderate agreements between
raters across populations and over time. More
recent studies, using the DIS-III (Vandiver &
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Sher, 1991) found median kappa coefficients of
.46 for current diagnoses and .43 for lifetime
diagnoses over a period of 9 months.
Most studies examining validity for the DIS
focus on concurrent or convergent validity using
a kappa rating for a particular diagnosis across
instruments. Overall, the reported kappas in val­
idation studies are similar to the reliability stud­
ies, ranging from moderate to high agreement
(Gavin, Ross, & Skinner, 1989; Whisman et al.,
1989). For example, Robins et al. (1982) reported
a mean agreement of .55 between lay-administered
DIS and medical chart diagnoses. Whisman
et al. (1989) compared diagnoses resulting from
the DIS and the interview version of the
Hamilton Rating Scale for Depression (Hamilton,
1960) and reported a high median ICC of .89
(moderate to high agreement).
Structured Clinical Interview
of DSM-IV Axis I (SCID-I)
The Structured Clinical Interview for DSM-IV
Axis I Disorders (SCID-I; First, Gibbon, Spitzer,
Williams, & Benjamin, 1997a) is a semistruc­
tured interview designed for interviewers with
clinical experience. The SCID-I provides diag­
noses for many DSM-IV Axis I diagnoses. It is
reported to be the most widely used diagnostic
instrument in the United States (Rogers, 2001;
Summerfeldt & Antony, 2002). The SCID-I has
undergone revisions to mirror the most current
DSM criteria. At present, the SCID-I has two
versions: the SCID-CV (Clinician Version; First,
Spitzer, Gibbon, & Williams, 1997) and the
SCID-RV (Research Version; First, Gibbon,
Spitzer, & Williams, 1996). The research version
covers more disorders, subtypes, and course
specifiers than the SCID-CV and consequently
takes longer to administer.
The SCID-CV is designed for clinical settings
and focuses on the most common diagnoses in
clinical practice. The organization of the SCID­
CV is hierarchical, with very specific decision
trees and discontinuation criteria for each mod­
ule. Like the DIS, it is also arranged in a modular
format and covers many DSM Axis I diagnoses.
Specifically, it includes the most commonly seen
diagnoses in a clinical setting: mood episodes,
mood disorders, psychotic symptoms, psychotic
disorders, substance abuse disorders, and anxiety
and other disorders. The organization of the
SCID-CV is flexible, which allows an interviewer
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to supplement existing questions and alter the
selection and order of administration of modules.
The SCID-I begins with a demographic infor­
mation section and provides a 12-item screen to
help determine which sections to administer or
omit. Each module begins with specific diag­
nostic questions and offers additional probes for
follow-up questions. The related DSM-IV diag­
nostic criteria for each disorder are presented.
Each criterion is rated on a three-point scale: 1 for
absent or false, 2 for subthreshold, and 3 for true or
present. A fourth rating, ?, is used if there is insuf­
ficient information. Ratings are determined on
the basis of the probe and the follow-up ques­
tions. Administration times range between 45
and 90 minutes.
Although there is limited research on the reli­
ability for the full DSM-IV SCID-I, a great deal of
data have been accumulated for earlier versions
of the instrument. However, reliability estimates
for the current SCID-I are at or above those
reported for the earlier versions (Levin, Evans, &
Kleber, 1998; Ventura, Liberman, Green, Shaner,
& Mintz, 1998; Zimmerman & Mattia, 1998).
Studies examining interrater reliability generally
have focused on current, as opposed to lifetime,
diagnoses. Reliabilities reported have been good,
ranging from greater than .75 (Riskland, Beck,
Berchick, Brown, & Steer, 1987) to greater than
.85 (Sato, Sakado, & Sato, 1993; Williams et al.,
1992; Zimmerman & Mattia, 1998). However, in
one of the largest studies (Williams et al., 1992)
of test-retest reliability, moderate reliabilities
were reported (mean kappa = .61) for assess­
ment of current diagnoses in a clinical popula­
tion, with higher reliabilities reported for panic
disorder. For the nonclinical group included in
this study the reliabilities were low, with a mean
kappa reported of only .37.
Regarding validation studies, Maziade et al.
(1992) examined the concurrent validity of
SCID-I mood and schizophrenic disorders and
reported a high level of agreement (kappa =
.83). However, in studies that have examined
or applicable copyright law.
convergent validity of newer interview measures
using the SCID-I as the gold standard, the
reported values were not optimal. For example,
Ross, Swinson, Larkin, and Doumani (1994)
compared the computerized version of the DIS
with the SCID-I among a group of substance
abusers. A median kappa of .56 was reported for
the most common substance abuse disorders;
however, they reported poorer values in terms of
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the agreement between mood and anxiety disor­
ders (median kappa = .22).
Schedule for Affective Disorders
and Schizophrenia (SADS)
The SADS (Spitzer & Endicott, 1978) is an
extensive, semistructured diagnostic interview
covering 23 diagnostic categories. The SADS
focuses primarily on the assessment of mood and
psychotic disorders. The SADS is divided into two
parts: Part I for current episodes and Part II for
past episodes. The SADS-II is also known as the
SADS-Lifetime version, or SADS-L. In addition,
there is also the Schedule of Affective Disorders
and Schizophrenia–Lifetime Anxiety version
(SADS-LA; Manuzza, Fyer, Klein, & Endicott,
1986). The SADS is designed for use by those
with clinical experience and training.
In Part I, symptoms are rated twice, first for
the worst period of the current episode and sec­
ond for the full duration of the current episode.
By using comparative ratings, clinicians assess
the severity of the disorder (Endicott & Spitzer,
1978). The SADS Part I takes approximately
45 to 75 minutes to administer, whereas the
SADS Part II takes approximately 15 to 60 min­
utes. The SADS scoring results in reliable ratings
of the severity of symptoms and is useful when
evaluations are focused on prior diagnoses or
when issues of response biases may be of con­
cern. The SADS covers 23 psychiatric disorders
with subcategories for schizophrenia, schizoaf­
fective disorder, and major depression. The
SADS was developed before the final revisions of
the DSM-III and does not offer complete cover­
age of DSM-IV disorders. However, there is a
large overlap in the range of symptoms in the
SADS Research Diagnostic Criteria (SADS-RDC;
Spitzer, Endicott, & Robins, 1975, 1978) and
DSM-IV disorders.
In comparison to other semistructured inter­
views, the SADS emphasizes the degree of symp­
tom impairment. That is, most mood, psychotic,
and behavioral symptoms are rated on six-point
scales ranging from 1 for not at all to 6 for extreme
(unremitting symptoms of high intensity).
Within this scale, a score of 3 is required to be
clinically significant, and a score of 0 can be used
to designate no information. Most questions also
include a description and provide representative
examples for ease of administration. The major­
ity of other symptoms are rated on a three-point
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scale (1 = absent, 2 = suspected or likely, and
3 = definite), with 0 indicating no information.
The SADS-II (lifetime) is rated dichotomously
(yes or no) because of the difficulties patients
often experience when asked to provide a retro­
spective rating of symptom severity. Finally, a
global assessment scale is included that provides
a single rating of functioning ranging from 1 to
100, based on 10 levels of impairment, with
lower scores reflecting more severe impairment.
The structure of the SADS includes three levels
of inquiries, with optional probes that clarify
incomplete or unclear responses. Furthermore,
the SADS provides questions that the interviewer
may ask if a particular response is unclear.
Development of the SADS stemmed from the
need for a standardized clinical and research
method for DSM psychiatric diagnoses and
was devised as a method to differentiate between
mood and psychotic disorders for the NIMH col­
laborative study of the psychobiology of depres­
sion (Rogers, 2001; Summerfeldt & Antony,
2002). NIMH researchers conducted several
studies examining the reliability of the SADS
(Andreasen et al., 1981; Endicott & Spitzer, 1978;
Keller et al., 1981). These investigations focused
on three issues: symptoms, summary scales, and
diagnoses across current and lifetime episodes.
The NIMH studies were comprised of large
participant samples and a variety of psychiatric
diagnoses. Generally, results of these studies
supported the reliability of the measure. For
example, Andreasen et al. (1981) used a sample of
50 inpatients and 50 outpatients to assess current
and lifetime diagnoses; ICCs were strong, with
values of .81 and .87. In another study examining
the test-retest reliability of lifetime anxiety disor­
der diagnoses using the SADS-LA, Manuzza et al.
(1989) reported moderate to excellent reliability
ratings. Their group included 104 patients from
an anxiety research clinic, with reliabilities rang­
ing from .60 to .90 for generalized anxiety disor­
der, social phobia, panic disorder, agoraphobia,
and obsessive-compulsive disorder. These authors
or applicable copyright law.
also reported that the major sources of disagree­
ment between raters included variation in patient
reports and criterion ambiguity. In a review of the
SADS, Rogers (2001) reported median kappas of
.85 for diagnoses and .70 for individual symp­
toms and concluded that this measure is highly
reliable.
Validity of the SADS has been examined
through a number of studies that focused on
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criterion-related, convergent, and construct
validity. For example, in terms of construct valid­
ity, Hokanson, Rubert, Welker, Hollander, and
Hedeen (1989) found chronically depressed first-
year college students who met criteria for depres­
sion on the SADS also had low social contact and
increased stress. In terms of concurrent validity,
Hesselbrock, Stabenau, Hesselbrock, Mirkin, and
Myer (1982) examined concordance in diagnoses
between the SADS-L and the DIS; they reported
moderate to excellent kappas ranging from .72 to
1.0 (median of .76). In contrast, studies that have
examined substance abuse populations have
reported mixed findings. In a study comparing
diagnoses based on the Personality Assessment
Inventory (Morey, 1991) and the SADS, Rogers,
Ustad, and Salekin (1998) found moderate
correlations ranging between .40 and .67. Rogers,
Sewell, Ustad, Reinhardt, and Edwards (1995)
used the multitrait, multimethod matrix and
found excellent discriminant validity with the
SADS for depressive, schizophrenia, and bipolar
disorders and moderate to good convergent
validity.
Anxiety Disorders
Interview Schedule (ADIS)
The ADIS was developed by Di Nardo,
O’Brien, Barlow, Waddell, and Blanchard (1982)
to provide reliable diagnoses of anxiety disorders
and to distinguish between anxiety disorders and
other frequently encountered comorbid mood
disorders. In addition, this measure is designed to
establish more precise information about symp­
toms of anxiety. The ADIS is a semistructured
interview organized by diagnosis including
generalized anxiety disorder, posttraumatic stress
disorder, acute stress disorder, panic disorder,
agoraphobia, specific and social phobias, and
obsessive-compulsive disorder. The ADIS also
includes sections that cover mood disorders,
hypochondriasis, somatization, substance abuse,
and psychosis. Furthermore, there are two ver­
sions of the adult ADIS-IV: the standard version,
which provides information about current diag­
noses only (Brown, Di Nardo, & Barlow, 1994),
and the lifetime version (ADIS-IV-L; Di Nardo,
Brown, & Barlow, 1994), which provides diagnos­
tic information about past and current problems.
The ADIS-IV begins with questions pertain­
ing to demographic information, description of
the presenting problem, and information about
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current stressors. This portion is followed by sec­
tions for evaluating the presence of Axis I disor­
ders. Many of the ADIS items are dichotomously
formatted, and it includes nine-point scales to
determine the intensity of specific symptoms for
both severity and frequency. After symptom
endorsement, more detailed questions regarding
the DSM-IV criteria are asked. Symptom denial
results in omission of that particular section. For
patients with an anxiety disorder, the ADIS-IV
can take approximately 2 hours to complete and
can be administered by clinicians or trained
paraprofessionals. The ADIS-IV also includes
a treatment section (Summerfeldt & Antony,
2002), which offers a template for treatment and
assessment of treatment progress.
The reliability studies examining the ADIS
generally involve current diagnoses and have
supported the reliability of the instrument.
Kappa coefficients generally range from moder­
ate to high. For example, Brown, Di Nardo,
Lehman, and Campbell (2001) studied the inter-
rater reliability of the ADIS-based anxiety and
mood disorders in a group of 362 outpatients.
For most of the diagnostic categories, reliabili­
ties ranged from good to excellent, with kappas
between .60 and .86. However, there were lower
kappas in regard to dysthymic disorder and in
some cases kappas as low as .22. In another com­
prehensive study of this instrument, Di Nardo,
Moras, Barlow, Rapee, and Brown (1993) exam­
ined the test-retest reliability of the ADIS-R with
a large group of participants (n = 267) across
varying time points (e.g., 0–44 days) for six
diagnoses. The median kappa was .65, with
poorer findings for mood disorders than for
anxiety disorders. Di Nardo et al. (1993) pro­
posed that the poorer reliability probably
resulted from a low base rate of occurrence of
mood disorders in the study sample. Better reli­
abilities were reported by Abel and Borkovec
(1995) in their study examining 40 outpatients
with respect to generalized anxiety disorder.
There are no validity studies examining the
or applicable copyright law.
full ADIS-IV. However, studies that have used the
ADIS to examine features of specific anxiety dis­
orders are thought to provide support for its con­
struct validity (Summerfeldt & Antony, 2002).
Rapee, Brown, Antony, and Barlow (1992) found
that those diagnosed with panic disorder using
the ADIS-R were more likely to react strongly
to panic induction. However, Paradis, Friedman,
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Lazar, Grubea, and Kesselman (1992) reported
more disappointing findings regarding the ADIS.
Specifically, these researchers examined the diag­
nosis of panic disorders using the ADIS-R and
compared these results to intake diagnosis. This
study reported that 25% of those diagnosed with
panic disorder by the ADIS did not receive this
diagnosis at the intake evaluation.
SEMISTRUCTURED INTERVIEWS
FOR AXIS II PERSONALITY DISORDERS
There are several well-constructed and popular
semistructured interviews for the assessment and
differential diagnosis of the DSM-IV Axis II per­
sonality disorders. These instruments are partic­
ularly valuable because clinicians and researchers
alike have struggled with their ability to accu­
rately diagnose personality disorders and distin­
guish one personality disorder from another
(Coolidge & Segal, 1998; Westen & Shedler,
2000; Widiger, 2005; Widiger & Samuel, 2005).
Interviews described in this section include the
Structured Clinical Interview for DSM-IV Axis II
Personality Disorders, the Structured Interview
for DSM-IV Personality, the International
Personality Disorder Examination, the Personal­
ity Disorders Inventory–IV, and the Diagnostic
Interview for DSM-IV Personality Disorders.
Before describing these instruments, we describe
several options for how the selected personality
disorder interview may be used in clinical and
research settings.
The full semistructured interview may be used
as part of a comprehensive and standardized
intake evaluation. Although this strategy offers
a wealth of diagnostic data and is common in
research settings, routine administration is
uncommon in the clinical setting because of
the time needed for full administration. A more
palatable variation on this theme is that sections
of an interview may be administered after a tradi­
tional unstructured interview to clarify and
confirm the diagnostic impressions. Widiger and
Samuel (2005) recommended the strategy in clin­
ical practice to first administer an objective self-
report inventory followed by a semistructured
interview focusing on the specific personality
disorders that received elevated scores from the
self-report screening. This strategy is responsive
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to time constraints in clinical practice but also
allows collection of standardized, systematic, and
objective data from the semistructured interview.
A final point to highlight is that before
administration of any Axis II interview, the
respondent’s present mental state or Axis I con­
ditions should be fully evaluated. Given that the
self-report of enduring personality characteris­
tics can be seriously compromised in a respon­
dent who is acutely distressed or disorganized,
this practice should not be surprising. The aim of
personality assessment is to rate the respondent’s
typical, habitual, and lifelong personal function­
ing rather than acute or temporary state.
Structured Clinical Interview for
DSM-IV Axis II Personality Disorders
The Structured Clinical Interview for DSM­
IV Axis II Personality Disorders (SCID-II; First,
Gibbon, Spitzer, Williams, & Benjamin, 1997b)
was designed to complement the Axis I version
of the SCID (described earlier). The SCID-II has
a similar semistructured format as the SCID-I,
but it covers the 10 standard DSM-IV personal­
ity disorders and depressive personality disorder
and passive-aggressive personality disorder
(listed as disorders to be studied further in an
appendix of the DSM-IV).
The basic structure and convention of the
SCID-II closely resemble those of the SCID-I.
An additional feature of the SCID-II is that it
includes a 119-item self-report screening com­
ponent called the Personality Questionnaire,
which may be administered before the interview
portion and takes about 20 minutes. The pur­
pose of the Personality Questionnaire is to
reduce overall administration time because only
the items that are scored in the pathological
direction are further evaluated during the struc­
tured interview portion.
During the structured interview component,
the pathologically endorsed screening responses
are pursued to ascertain whether the symptoms
or applicable copyright law.
are experienced at clinically significant levels.
The respondent is asked to elaborate about each
suspected personality disorder criterion, and
specified prompts are provided. Like the Axis I
SCID, the DSM-IV diagnostic criteria are printed
on the interview page for easy review. The ratings
of each diagnostic criterion are coded as follows:
? indicates inadequate information, 1 indicates
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absent or false, 2 indicates subthreshold, and
3 indicates threshold or true. Twelve personality
disorders are covered on a one-by-one basis. Each
disorder is assessed completely, and diagnoses
are made before the clinician proceeds to the
next disorder. This modular format permits
researchers and clinicians to tailor the SCID-II to
their specific needs and reduce administration
time. Clinicians who administer the SCID-II are
expected to use their clinical judgment to clarify
responses, gently challenge inconsistencies, and
ask for additional information as needed to rate
accurately each criterion. Collection of diagnos­
tic information from collateral sources is permit­
ted. Complete administration of the SCID-II
typically takes less than 1 hour.
Training requirements and interviewer quali­
fications for the SCID-II are similar to those of
the SCID-I. There is no clinician version of the
SCID-II. The psychometric properties of the
SCID-II are strong, and the interested reader is
referred to First and Gibbon (2004) for a com­
prehensive review. Given the extensive coverage
of the personality disorders, modular approach,
and strong operating characteristics, the SCID­
II is likely to remain a popular and effective tool
for personality disorder assessment.
Structured Interview
for DSM-IV Personality
The Structured Interview for DSM-IV
Personality (SIDP-IV; Pfohl, Blum, & Zimmerman,
1997) is a comprehensive semistructured diag­
nostic interview for DSM-IV personality disor­
ders. It covers 14 DSM-IV Axis II diagnoses,
including the 10 standard personality disorders,
self-defeating personality disorder, depressive
personality disorder, negativistic personality
disorder, and mixed personality disorder.
Interestingly, the SIDP-IV does not cover DSM
personality categories on a disorder-by-disorder
basis. Rather, the DSM-IV criteria are reflected in
items that are grouped according to 10 topical
sections that reflect a different dimension of per­
sonality functioning: interests and activities,
work style, close relationships, social relation­
ships, emotions, observational criteria, self-
perception, perception of others, stress and
anger, and social conformity (Pfohl et al., 1997).
These categories are not scored. Rather, they
reflect broad areas of personal functioning under
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32 GENERAL ISSUES
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which personality disorder items can logically be
subsumed.
For the most part, each SIDP-IV question cor­
responds to a unique DSM-IV Axis II criterion.
The specific DSM-IV criterion associated with
each question is provided for interviewers to eas­
ily see. All questions are always administered, and
there are no skip-out options. Most questions
are conversational in tone and open ended to
encourage respondents to talk about their usual
behaviors and long-term functioning. In fact,
respondents are specifically instructed to focus
on their typical or habitual behavior when
addressing each item and are prompted to
“remember what you are like when you are your
usual self.” Based on patient responses, each cri­
terion is rated on a scale with four anchor points.
A rating of 0 indicates that the criterion was
not present, 1 corresponds to a subthreshold level
where there is some evidence of the trait but it is
not sufficiently prominent, 2 refers to the crite­
rion being present for most of the past 5 years, and
3 signifies a strongly present and debilitating level.
The SIDP-IV requires that a trait be prominent
for most of the past 5 years to be considered a
part of the respondent’s personality. This “5-year
rule” helps ensure that the particular personality
characteristic is stable and of sufficient duration,
as required by the general diagnostic criteria for
a personality disorder described in DSM-IV.
A strong point of the organizational format
by personality dimensions (rather than by disor­
ders) is that data for specific diagnoses are min­
imized until final ratings have been collated on
the summary sheet. This feature can potentially
reduce interviewer biases, such as the halo effect
or changing thresholds, if it is obvious that a
respondent needs to meet one additional crite­
rion to meet the threshold for diagnosis. This
topical organization also makes the intent of the
interview less transparent compared with the
disorder-by-disorder approach of some other
semistructured interviews.
Significant clinical judgment is needed to
or applicable copyright law.
properly administer the SIDP-IV because inter­
viewers are expected to ask additional questions
to clarify patient responses when necessary.
Also, data are not limited to self-report.
Significant others who know the respondent well
should be consulted when available, and a stan­
dard informed consent is included for informant
interviews. Collateral information is particularly
prized when one is evaluating personality disor­
dered people, who may lack insight into their
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own maladaptive personality traits and distort
facts about their strengths and limitations.
Informants can also provide diagnostic data that
can help resolve the state-trait distinction about
specific criterion behaviors.
If discrepancies between sources of informa­
tion are noted, interviewers must consider all
data and use their own judgment to determine
the veracity of each source. Making this distinc­
tion can be one of the challenges faced by SIDP­
IV administrators. Given the multiple sources of
diagnostic data, final ratings are made after all
sources of information are considered. Such rat­
ings are then transcribed onto a summary sheet
that lists each criterion organized by personality
disorder, and formal diagnoses are assigned. As
required by the DSM, diagnoses are made only if
the minimum number of criteria (or threshold)
has been met for that particular disorder.
Administration requires knowledge of mani­
fest psychopathology and the typical presenta­
tion and course of Axis I and II disorders (Pfohl
et al., 1997). The SIDP typically takes 60 to 90
minutes for the patient interview, 20 minutes for
interview of significant informants, and 20 min­
utes to fill out the summary score sheet. Studies
documenting the strong psychometric proper­
ties of the SIDP are plentiful, and they are sum­
marized in the manual for the instrument (Pfohl
et al., 1997).
International Personality
Disorder Examination
The International Personality Disorder
Examination (IPDE; Loranger, 1999) is an exten­
sive, semistructured diagnostic interview to eval­
uate personality disorders for the DSM-IV and
the International Classification of Diseases, 10th
edition (ICD-10; World Health Organization,
2004) classification systems. The IPDE was
developed within the Joint Program for the
Diagnosis and Classification of Mental Disorders
of the World Health Organization (WHO) and
U.S. National Institutes of Health, aimed at pro­
ducing a standardized assessment instrument to
measure personality disorders on an interna­
tional basis. As such, the IPDE is the only per­
sonality disorder interview based on worldwide
field trials. The IPDE Manual contains the inter­
view questions to assess either the 10 DSM-IV or
the 10 ICD-10 personality disorders. The two
IPDE modules (DSM-IV and ICD-10) contain
both a self-administered screening questionnaire
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and a semistructured interview booklet with
scoring materials.
The Screening Questionnaire is a self-
administered form that contains 77 DSM-IV or
59 ICD-10 items written at a fourth-grade read­
ing level. Items are answered either True or False,
and the questionnaire typically is completed in
about 15 minutes. The clinician can score the
questionnaire quickly and identify respondents
whose scores suggest the presence of a personality
disorder. Subsequently, the IPDE clinical inter­
view is administered.
The IPDE interview modules (for either the
DSM-IV or ICD-10 systems) contain questions,
each reflecting a personality disorder criterion,
that are grouped into six thematic headings:
work, self, interpersonal relationships, affects,
reality testing, and impulse control (Loranger,
1999). Because disorders are not covered on a
one-by-one basis, the intent of the evaluation is
less transparent, similar to the SIDP-IV. At the
beginning of each section, open-ended inquiries
are provided to enable a smooth transition from
the previous section and to encourage respon­
dents to elaborate about themselves in a less
structured fashion. Specific questions are subse­
quently asked to evaluate each diagnostic crite­
rion. For each question, the corresponding
personality disorder and the specific diagnostic
criterion are identified with precise scoring
guidelines.
Respondents are encouraged to report their
typical or usual functioning rather than their
personality functioning during times of episodic
psychiatric illness. The IPDE requires that a trait
be prominent during the past 5 years to be
considered a part of the respondent’s personal­
ity. Information about age of onset of particular
behaviors is explored to determine whether a
late-onset diagnosis (after age 25 years) is appro­
priate. When a respondent acknowledges a par­
ticular trait, interviewers follow up by asking for
examples and anecdotes to clarify the trait or
behavior, gauge impact of the trait on the
or applicable copyright law.
person’s functioning, and fully substantiate the
rating. Such probing entails significant clinical
judgment and knowledge on the part of inter­
viewers about each criterion. Items may also be
rated based on observation of the respondent’s
behavior during the session, which also takes
clinical expertise. To supplement self-report,
interview of informants is encouraged. Clinical
judgment is needed to ascertain which source is
more reliable if inconsistencies arise.
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Each criterion is rated on a scale with the fol­
lowing definitions: 0 indicates that the behavior
or trait is absent or within normal limits, 1 refers
to an exaggerated or accentuated degree of the trait,
2 signifies criterion level or pathological, and
? indicates that the respondent refuses or is unable
to answer. Comprehensive item-by-item scoring
guidelines are provided in the manual (Loranger,
1999). At the end of the interview, the clinician
records the scores for each response on the
appropriate IPDE answer sheet. Ratings are then
summed by hand or computer. The output is
quite extensive, including the presence or absence
of each criterion, the number of criteria met for
each personality disorder, a dimensional score
(sum of individual scores for each criterion for
each disorder), and a categorical diagnosis (defi­
nite, probable, or negative) for each personality
disorder (Loranger, 1999). Such comprehensive
output is especially valued by clinical researchers
and is an attractive feature of the IPDE.
The IPDE is intended for use by experienced
clinicians who received specific training with the
IPDE. Average administration time is 90 minutes
for the interview, which can be reduced through
use of the screening questionnaire (omitting
interview items associated with unlikely personal­
ity disorders). Because the IPDE has been selected
by the WHO for international application, it has
been translated into numerous languages to facil­
itate transcultural research. Ample evidence of
reliability and validity of the IPDE has been doc­
umented (Loranger, 1999; Loranger et al., 1994).
Because of the instrument’s ties to the DSM-IV
and ICD-10 classification systems and adoption
by the WHO, the IPDE is widely used for inter­
national and cross-cultural investigations of per­
sonality disorders and their features.
Personality Disorder Interview–IV
The Personality Disorder Interview–IV (PDI­
IV; Widiger, Mangine, Corbitt, Ellis, & Thomas,
1995) is a semistructured interview for assessment
of the 10 standard personality disorders in the
DSM-IV and the two proposed personality disor­
ders (passive-aggressive and depressive) presented
in the DSM-IV appendix as criteria sets provided
for further study. The PDI-IV is appropriate for
respondents age 18 years and older, and adminis­
tration time is about 90 to 120 minutes.
A unique feature of the PDI-IV is that it is
available in two separate versions, each with its
own interview booklet. The PDI-IV Personality
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34 GENERAL ISSUES
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Disorders Interview Booklet arranges the diag­
nostic criteria and corresponding questions
by personality disorder. The Thematic Content
Areas Interview Booklet organizes the criteria
and questions by thematic content. The nine
topical areas are attitudes toward self, attitudes
toward others, security of comfort with others,
friendships and relationships, conflicts and
disagreements, work and leisure, social norms,
mood, and appearance and perception. The
questions for each diagnostic criterion are the
same in each interview form, but the organiza­
tion is different. The modular approach easily
lends itself to focused and rapid assessment of
particular personality disorders of interest to the
researcher or clinician. A screening questionnaire
is not provided for the PDI-IV.
The PDI-IV administration book includes
questions for each of the 94 individual personal­
ity disorder diagnostic criteria, cross-referencing
the DSM-IV. Instructions to interviewers and
prompts and suggestions for follow-up ques­
tions are included. During administration, each
criterion is rated on the following three-point
scale: 0 indicates not present, 1 indicates present
at a clinically significant level, and 2 indicates
present to a more severe or substantial degree. A
particular strength of the PDI-IV is its compre­
hensive manual (Widiger et al., 1995), which
extensively discusses the history and rationale
for each diagnostic question and problems that
often arise in the assessment of each criterion.
After the interview is completed, the clinician
summarizes responses to individual PDI-IV cri­
teria and plots the overall dimensional profile.
According to the manual, this profile may help
clinicians rank multiple diagnoses by order of
importance and identify characteristics in the
respondent that are relevant to psychopathology
and treatment. Output provided is both a
dimensional rating for each personality disorder
and a categorical rating. Reliability and validity
data, as summarized in the manual (Widiger
et al., 1995), are solid, although few psychomet­
or applicable copyright law.
ric studies by independent researchers have been
conducted.
Diagnostic Interview for
DSM-IV Personality Disorders
The Diagnostic Interview for DSM-IV Person­
ality Disorders (DIPD-IV; Zanarini, Frankenburg,
Sickel, & Yong, 1996) is a semistructured interview
designed to assess the presence or absence of the
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10 standard DSM-IV personality disorders as
well as depressive personality disorder and passive-
aggressive personality disorder in the DSM-IV
appendix. Before administration of the DIPD-IV,
assessment of the Axis I disorders and the respon­
dent’s general functioning (e.g., in the areas of
work, school, and social life) is advised (Zanarini
et al., 1996).
Like the SCID-II, the DIPD-IV interview is
conducted on a disorder-by-disorder basis. The
interview contains 108 sets of questions, each
designed to assess a specific DSM-IV personality
disorder diagnostic criterion. The initial question
for each criterion is dichotomously formatted
and is followed by open-ended questions for fur­
ther exploration. The interview covers the past
2 years of the respondent’s life with regard to
thoughts, feelings, and behaviors that have been
typical. Although respondents are the sole source
of information for most of the diagnostic criteria,
if a particular behavior exhibited during the
interview contradicts the response, this may be
used instead. Probing on the part of the adminis­
trator is encouraged if responses appear incom­
plete or untrue.
Each diagnostic criterion is rated on the follow­
ing scale: 0 indicates absent or clinically insignifi­
cant, 1 indicates present but of uncertain clinical
significance, 2 indicates present and clinically signif­
icant, and NA indicates not applicable. After all 108
criteria are rated, final categorical diagnosis for
each personality disorder is made based on the
number of criteria met. The final output is
recorded as 2, indicating yes or met full criteria,
1 indicating subthreshold (one less than the
required number of criteria), or 0 indicating no.
Information about administration and scor­
ing of the DIPD-IV is sparse compared with the
other Axis II semistructured interviews. Experi­
ence and knowledge of personality disorders
are recommended for use of the DIPD-IV,
and administration time typically is 90 minutes.
The DIPD-IV is selected as the primary diag­
nostic measure for personality disorders in the
Collaborative Longitudinal Personality Disorders
Study, which is a large, multisite, prospective nat­
uralistic longitudinal study of personality disor­
ders and comorbid mental health problems.
SUMMARY
The interview in its broadest terms is an interac­
tion between a professional and a client. As noted,
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the interview can take many forms, ranging from
an unstructured interaction leaving the questions
up to the interviewer to a fully structured ques­
tion-and-answer format leaving no room for an
off-the-cuff exchange. Certainly, structured and
semistructured interviews have their drawbacks.
Their use can detract from the first encounter,
making it feel more sterile or distant. As previ­
ously noted, the validity of a structured interview
depends on the accuracy of the diagnostic criteria
on which it is based. Furthermore, the structured
interview may be considered fallible in that most
are heavily reliant on self-report data.
Despite these criticisms, structured and semi-
structured interviews offer a number of sig­
nificant advantages. Most notably, structured
interviews minimize the variability between pro­
fessionals with standardization of assessment.
Greater reliability of diagnosis is a precursor for
greater validity or meaningfulness of the diagno­
sis. Advanced degrees typically are not required
for the administration of these interviews, allow­
ing their wider use. In addition, the psychomet­
ric properties of these instruments, particularly
measures reviewed in this chapter, are quite
promising. If the past several decades are a pre­
dictor of the future of structured interviews, then
the field probably will continue to see new struc­
tured interviews and updates on existing mea­
sures. With the upsurge in the use of structured
interviews, it is important to keep in mind that
the administration of a structured interview does
not prevent the user from supplementing with
unstructured questions, before or after the struc­
tured interview, perhaps blending the best of
both worlds.
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