How Diagnostic Interviews Translate Situational Behavior Into Pathology

Study finds that, in diagnostic interviews, clinician interpretations of context-specific behaviors lead to personality disorder diagnoses.

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A new study conducted in Finland and published in the journal Health examines in-depth interviews of clinicians and patients diagnosed with personality disorders, paying particular attention to the discrepancies between clinician and patient regarding the generalizability of their behavior.

Through interactional research and conversation analysis, the results revealed that patients frequently contextualized their behavior as an outcome of an array of situational factors that clinicians then translated into the psychiatric language of personality traits. The findings suggest the importance of making visible the subjective practices that shape the diagnostic process in psychiatry.

Further, the authors problematize translating patients’ accounts into psychiatric language to fit diagnostic criteria.

“We have shown some problematic patterns in which the assumption of de-contextualized symptoms become challenged. Our observations show that patients often emphasize contextual over-generalizing factors. This explanatory model is sometimes in conflict with SCID-II, which seeks for inherent and long-lasting traits that cause certain behavior.”

the psychologist is recording data obtained from patient interviews and prepare  medical steps.Broadly, a psychiatric interview has no formal definition but is a variant of a medical interview in which the participants create meanings for events in their lives and thus construct reality. Typically, the interviewer controls the topic by directing the discussion based on questions, silences, and redirection.

A more formal type of psychiatric interview is the Structured Clinical Interview for DSM-IV Axis II Personality Disorders, SCID-II, developed in 1997 to determine if an individual meets the criteria for a diagnosable personality disorder. This follows a set of predetermined questions but still has variability based on the interviewer’s style and is meant to be used in conjunction with “clinical judgment.”

The authors, led by Maarit Lehtinen at the University of Helsinki, highlight the difficulties of adhering to the medical framework in which the purpose of the interview is to obtain “factual” information for the diagnosis, often forcing psychiatrists to transform context-bound behavior into an intrinsic, stable trait.

Within psychiatry, there are two primary manuals for psychiatric diagnoses in western countries: the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Statistical Classification of Disease Related to Health Problems (ICD) by the World Health Organization (WHO). Although these manuals have received much criticism, it remains the primary use for Western psychiatric diagnosis.

The idea of a disordered personality has been highly contested. Research has pointed out that among psychiatric diagnoses, which are generally contested constructs, personality disorders are especially difficult to categorize. There are known issues with construction validity, comorbidity, and etiology. Regarding borderline personality disorder, there is no clear agreement on whether it should be treated as a personality disorder or a trauma response condition. Further, an analysis of the history of antisocial personality disorder showed that terms and definitions have changed depending on the DSM committee group member’s personal influence on the decision process.

The current study analyzed ten video-recorded adult patients during a SCID-II interview conducted by a psychiatric nurse in an outpatient clinic in Finland. The method focused on using discursive psychology, which is the study of psychological issues from a participant’s perspective, as well as conversation analysis, which is an approach to studying social interaction and language. The authors argue that applying conversation analysis to the psychiatric field enables the investigation of psychiatric practices from a sociological view.

The results revealed six primary takeaways.

First, patients frequently made sense of their own behavior differently than SCID-II predicts and primarily considered their behaviors as an outcome of many situational factors.

Second, patients rarely straightforwardly opposed the format of the interview questions, but their responses sometimes countered the underlying assumptions of the questions.

Third, when patients excluded information about personality in explaining their behavior, they were referring to the social context.

Fourth, patients sometimes referred to acute inner states as important factors affecting their behavior for a specific context and thus did not see it as generalizable to other situations.

Similarly, patients tended to think that behavior touches only one small area of life and cannot be generalized based on that. So, for example, in many cases, they were able to come up with a context in which they behave as asked, but they would not see this as describing their overall personality.

Lastly, patients did not necessarily think of their personality as remaining stable across adulthood; rather, they might notice changes over time due to life experiences. The authors write”

“We have observed how clinicians operate within medically oriented psychiatry and thus need to isolate the patient’s conduct from the contextual variables before making their evaluations.”

While the research presented has no causal data, it provides observable insight into how a patient’s formulation becomes problematic in the SCID-II interview framework. To fit within the confines of the SCID-II interview, part of the patients’ answers must be reformulated or ignored, which manipulates the response into psychiatric language.

The authors highlight two levels of uncertainty regarding personality disorders. First, the construct itself remains in question, including the overlap between personality disorders and other psychiatric symptoms. This leads to the fundamental question of why certain personality traits are being held as disorders in our society and questioning where the line is drawn between “normal” and “pathological” personality.

Second, there is an issue with the diagnostic process, its objectivity, and the institutional underpinnings of the SCID-II interviews. Scholars have emphasized the importance of a critical understanding of psychiatric diagnosis among mental health professionals, including critical awareness of how different institutions shape the constructs of disorders and manuals, such as that of the SCID-II, and therefore the possible consequences of personality disorder diagnosis for a patient.

In closing, the authors hope that the research presented here will increase the likelihood of developing such awareness.

 

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Lehtinen, M., Voutilainen, L., & Peräkylä, A. (2022). ‘Is it in your basic personality?’ negotiations about traits and context in diagnostic interviews for personality disorders. Health: An Interdisciplinary Journal for the Social Study of Health, Illness, and Medicine, 136345932210947. https://doi.org/10.1177/13634593221094701  (Link)

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Madison Natarajan, MS
Madison Natarajan is a master’s level psychotherapist and current doctoral student at the University of Massachusetts Boston. As a researcher, her focus is on the impact of religious trauma on female sexual development, specifically assessing the subculture of the evangelical purity movement. Madison has a family history that has been intertwined with psychiatric care, ranging from family members who were institutionalized to those practicing psychiatry, both in the US and India. Madison seeks to challenge the current structure of psychiatric care in the West and disseminate honest and empowering information to the community at large.

5 COMMENTS

  1. I love being interviewed. It is so preposterous and yet intimate, my favourite combination, like when primates pick out fleas from each others pelts. But in humans it inevitably leads to heirarchical nonsense, when one persons asks…

    “When was the last time you picked your nose?”

    If you answer an hour ago that may mean you are reprehensible.

    All diagnoses are made by interview, even diagnosing someone as a cabbage.

    They are all whimsical and not much to do with science.

    I cannot see any difference between the diagnosis of psychosis and schizophrenia really. Both require an interview and so both require vague sentiments and self-disclosures from the “individual” who feels those hallucinatory symptoms, it is just that schizophrenia is such an extended chronic state of psychotic episodes that it feels to me after twenty years like a disease.

    Nobody likes the disease word, perhaps finding it negative, repellant, stigmatizing. But I find most diseases quite fascinating. Many do. In a homeless hostel I lived in once all the residents were most miffed by a fire alarm that went off during a television show titled something like extraordinary bodies. At is root the word disease just means “dis-ease”.

    They keep talking about the Hoover Dam but only show Lake Mead turning into a puddle. Today I wondered would the concrete shift without that pressure, then maybe the dam walls would crumble?

    I feel sure in my prophecies that it will be carpet bombed.

  2. There are a couple ways out of this conundrum. One is on page 132 of the DSM-5 which says, “A diagnosis of personality disorder should not be made during an untreated mood episode”, (i.e. manic, mixed or depressed). Because if the mood disorder is treated first and fully, what was thought to be a personality issue most often goes away so it would not be co-morbid. Unfortunately this happens all the time.
    Another is the “psychological falacy” explained by the researchers of split-brain experiments after corpus callosotomy years ago showing that when the laft and right brain are unable to communicate people will confabulate an answer just to give an answer. To them is seems like common sence but we all do it. “I think I got depressed or manic because of a,b & c”. Those researchers concluded that our brains are “rationialzing machines”, that we come up with “common sence” reasons for our experiences which usually are not causative.
    Personality disorders are last on the list of a Diagnostic Hierarchy (see Ghaemi’s Clinical Psychopharmacology-2019) with Mood disorders i.e. manic, depresssed or mixed #1, psychotic disorders of schizophrenia and schizoaffective #2, anxiety disorders of OCD, PTSD #3 and ADD, personality disorders #4. This hierarchy is used in other medical specialities and recommended for psychiatry over 40 years ago but never adopted.

    I review come of these concepts at https://medicalmodelredux.com/

    • I am sorry, but the DSM is really a bunch of gibberish to me. And not because I’m not smart enough to understand it. It’s because I am smart enough to recognize gibberish when I see it. How, for instance, would one determine if a client is having an ‘untreated mood episode?’ It would be entirely a matter of the opinion of the clinician, and 50 clinicians might come up with 50 different answers. It also presumes that ‘treating’ the ‘mood episode’ would resolve it, and if it does not, the personality disorder should be applied, even though there is a ton of information suggesting that the ‘treatment’ of ‘mood episodes’ is extremely unpredictable and can make things worse. It also presumes that the ‘mood episode’ is not caused by another psychiatric drug, even though stimulants and antidepressants are well known to create manic episodes in some of their recipients. So we have an undefinable criterion (mood episode) ‘diagnosed’ by pure clinical opinion, being ‘treated’ with something that may or may not help, and assume that the failure for ‘treatment’ to help means the person has a ‘personality disorder,’ without considering that lack of treatment effect, or even the ‘treatment’ itself, may be responsible for the subjectively ‘diagnosed’ ‘mood episode’ which failed to be ‘treated’ successfully. Not to mention that the ‘personality disorder’ diagnoses themselves are even MORE subjective and vague than the ‘mood episodes’ whose ‘failure to respond’ to ‘treatment’ can apparently lead to such a diagnosis by default.

      From a scientific viewpoint: gibberish! Science should make things clearer, simpler, more successful. These ‘diagnoses’ clearly make things vaguer, more complex, and impossible to even define let alone improve success measures. How on earth can anyone make sense of this bizarre and unhelpful array of subjective ‘diagnoses’ all of which lack any legitimate scientific underpinnings to speak of, and are essentially constructed by committee and most commonly voted in or out of existence by a bunch of ‘professionals’ without any resort to any kind of scientific verification?

      Gibberish!

      • GIBBERISH! Love that word.
        I must say at this age, what I know now, a seasoned shrink MUST know
        it is gibberish.
        And oh my, the public is taught about “stigma”. It is only relevant within
        the health and psych circles.

        Upon someone dying, they “diagnose” them as depressed. Sure, sick and dying people should show happiness and no suffering.

        Amazing the crap docs have borrowed from psych for their convenience. And sadly the “AD” makes not one dif in that dying person’s life, yet the doc makes just one more itty bitty penny from the departure of life.

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