David C. Rettew, MD

A recent meta-analysis showed that diagnoses generated from clinical evaluations often do not agree with the results of structured and semistructured interviews-together called standardized diagnostic interviews (SDIs).

 Such a study could easily be overlooked as another dry and “methodological” investigation. Yet the implications of this meta-analysis are enormous.

Whenever clinicians pick up a journal to learn the latest clinical research, it is very likely that the patients described in those studies received their diagnosis in no small part from an SDI. Indeed, it is very difficult to publish a clinical study without using one. SDIs, which can be performed by both clinicians and nonclinicians, are designed so that interviewers ask the same diagnostic questions in the same way, thereby minimizing variability within and across studies. The findings of clinical research are obviously intended to be applicable to the clinician in routine clinical practice, where SDIs are seldom used. This discrepancy in diagnostic approach would not be a problem if, regardless of method, the results of both strategies generally led to the same diagnostic conclusion.

The problem is that they do not. Instead, the diagnoses generated from SDIs tend to be different from the diagnoses derived from standard clinical evaluations. The 38 studies assessed in our meta-analysis included nearly 16,000 patients and encompassed 10 different standardized interviews as well as a wide range of diagnoses, ages, and clinical settings. One requirement for the included studies was that the interviewers using SDIs and the clinical evaluators did not know the diagnostic results of the other method.

Most of these studies calculated a Κ statistic as their measure of agreement between SDIs and clinical evaluations. While there is debate on the subject, Κ values of 0.6 to 0.8 are generally considered acceptable to good, depending on the context.

In our meta-analysis, the overall Κ value across all diagnoses was 0.27. Some individual diagnoses clearly fared better than others. The Κ for anorexia nervosa was 0.86 while the Κ for generalized anxiety disorder was a meager 0.19. Many diagnoses had a Κ between 0.30 and 0.40.

SDIs come in 2 main types-structured and semistructured. Semistructured interviews allow for more flexibility in their delivery, whereas the questions on structured interviews are intended to be read as written. While one might expect semistructured interviews to correspond more closely to clinical evaluations than to structured interviews, no statistical differences were found. There was some indication that agreement was better in outpatient settings and children. However, these improvements were minor and statistically nonsignificant when all potential modifiers were entered in a meta-regression.

These findings mean that if an SDI or a clinical evaluation produced a positive diagnosis for a particular disorder, the majority of time the other diagnostic system did 

 produce the same diagnosis. Why was agreement overall so poor? The study was not equipped to look directly at this question, and the authors were careful not to assign blame to either clinicians or SDIs. Interviewers using SDIs tended to generate a higher number of diagnoses than clinicians. However, this difference cannot make a judgment about who is correct.

Possible sources for the poor agreement included features of both clinical evaluations and SDIs. Clinicians, on the one hand, might tend to pick a single diagnosis on the basis of clinical impressions-even if a patient meets criteria for several. They may also tailor their interviews more closely around the chief complaint and weigh contextual information, such as family history, in the diagnosis.

Clinicians may also hold back on making diagnoses out of concern about stigma. SDIs, by contrast, could elicit a lot of negative responses because of the sheer number of questions that are typically asked. These interviews also tend to rely more heavily on the impression of the patient or a parent about what constitutes a clinically significant symptom.

To illustrate how these processes may work in a clinical situation, consider the hypothetical example of 15-year-old Billy who presents initially to a psychologist in the community.

Billy was neglected and abused by his biological parents who struggled with their own mental health problems. He was removed from home at age 3 and lived in several foster homes before he was adopted into a stable household. He has been observed in multiple settings to be impulsive, aggressive, anxious, and prone to intense behavioral outbursts with minimal provocation. The adopted parents take Billy to a community clinician who conducts an evaluation without an SDI and makes a diagnosis of posttraumatic stress disorder, noting the history of trauma and profound behavioral disturbance even in the absence of symptoms such as prominent flashbacks or nightmares. The clinician begins trauma-based psychotherapy and considers such interventions as eye movement desensitization and reprocessing. 

After a violent episode at school, Billy is hospitalized at an academic medical center where an SDI is conducted as part of the admission process. According to this interview, Billy meets criteria for attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder, and conduct disorder. Treatment with a psychostimulant is started, and recommendations are made for parent behavioral training using a cognitive-behavioral context. 

After discharge, Billy is evaluated by a local psychiatrist who notices the level of impairment and extreme mood swings and diagnoses pediatric bipolar disorder-even without a history of sustained manic symptoms lasting several days. The psychiatrist begins treatment with an antipsychotic agent and considers discontinuing the stimulant.

The example demonstrates the decision making that can underlie the widely divergent diagnoses and treatment plans. Indeed, when these data were first presented as a poster at a meeting of the American Academy of Child and Adolescent Psychiatry, the informal comments made by viewers reflected the different perspectives. Those who tended not to use SDIs interpreted these findings as confirmation that SDIs were not useful, while academics who conducted research trials found the results to be validation that continued use of SDIs was needed to produce accurate diagnoses. Indeed, the source studies included in the meta-analysis also had divergent interpretations of their results. In some individual studies, the design was framed in a way that diagnoses based on clinical evaluations were the “gold standard” so as to put SDIs to the test. Other studies were designed to challenge the validity of diagnoses from clinical evaluations.

In much of clinical research, skepticism about using either clinical evaluations or SDIs as the sole source of diagnostic information is reflected in the generally accepted practice of using a “best estimate” procedure. Here, senior investigators review the diagnostic results of SDIs and assign final diagnoses after reviewing all the clinical data. This procedure is thought to add incremental validity to the final diagnoses, although its utility has rarely been tested formally against potential benchmarks that may be difficult to define.

My coauthors and I also discuss the possibility that the dichotomous nature of diagnoses may contribute to disagreement. For example, if a clinical evaluation determines that a patient meets 5 of 9 criteria for the inattentive items of ADHD while an SDI reports that 6 of 9 criteria are met, the final diagnosis is 100% disagreement (since at least 6 items are required)-even though the 2 methods may have agreed for 8 of 9 criteria. While disagreement in such instances may be viewed as something of an artifact, it does reflect current practice and the need to often make binary decisions-such as whether to prescribe a medication.

In summary, our meta-analysis has revealed the somewhat alarming finding that diagnoses generated from SDIs (the prevailing method used in clinical research studies) and the diagnoses generated from clinical evaluations (the prevailing method used in routine practice) frequently disagree. The sources of this disagreement are probably complex and a result of features of both diagnostic methods. While researchers in practice frequently try to combine SDI results with clinical judgment, much remains to be learned about how scientists, clinicians, and perhaps DSM5 can synthesize often divergent information in the service of a valid and clinically meaningful assessment.

 Rettew DC, Lynch AD, Achenbach TM, et al. Meta-analyses of agreement between diagnoses made from clinical evaluations and standardized diagnostic interviews. 

Articles

Diagnoses From Clinical Evaluations and Standardized Diagnostic Interviews Don’t Agree

A recently published a meta-analysis showed that diagnoses generated from clinical evaluations often do not agree with the results of structured and semi-structured interviews-together called standardized diagnostic interviews (SDI).

Such a study could easily be overlooked as another dry and “methodological” investigation. Nevertheless, the implications of this meta-analysis are enormous.

Whenever clinicians pick up a journal to learn the latest clinical research, it is very likely that the patients described in those studies received their diagnosis in no small part from an SDI. Indeed, it is very difficult to publish a clinical study without using one. These interviews, which can be performed by both by clinicians and by nonclinicians, are designed so that interviewers ask the same diagnostic questions in the same way, thereby minimizing variability within and across studies. The findings of clinical research are obviously intended to be applicable to the clinician in routine clinical practice, where SDIs are seldom used. This discrepancy in approach would not be a problem if, regardless of method, the results of both strategies generally lead to the same diagnostic conclusion.

The problem is that they don’t. Instead, the diagnoses generated from SDIs tend to be different from the diagnoses derived from standard clinical evaluations. The 38 studies assessed in our meta-analysis included nearly 16,000 patients and encompassed 10 different standardized interviews as well as a wide range of diagnoses, ages, and clinical settings. One requirement for included studies was that the interviewers using SDIs and the clinical evaluators did not know the diagnostic results of the other method. Most of these studies calculated a kappa statistic as their measure of agreement between SDIs and clinical evaluations. While there is debate on the subject, kappas of 0.6 to 0.8 are generally considered acceptable to good, depending on the context. In our meta-analysis, the overall kappa across all diagnoses was 0.27. Some individual diagnoses clearly fared better than others. The kappa for anorexia nervosa was 0.86 while the kappa for generalized anxiety disorder was a meager 0.19. Many diagnoses had kappas between 0.30 and 0.40. 
 

Standard diagnostic interviews come in 2 main types names: structured and semistructured.  Semistructured interviews allow for more flexibility in their delivery and usually need to be administered by people with more clinical training, whereas the questions on structured interviews are intended to be read as written. While one might expect semistructured interviews to correspond more closely with clinical evaluations than structured interviews, no statistical differences were found.  There was some indication that agreement was better in outpatient settings and among children; however, these improvements were minor and statistically nonsignificant when all potential modifiers were entered together in a meta-regression.

These findings mean that if an SDI or a clinical evaluation produced a positive  diagnosis for a particular disorder, the majority of time the other diagnostic system did not produce the same diagnosis. Why was agreement overall so poor? The study was not equipped to look directly at this question and the authors were careful not to assign blame to either clinicians or SDIs. SDIs tended to generate a higher number of  diagnoses than clinicians. However, this difference cannot make a judgment about who is correct.

Possible sources for the poor agreement include features of both clinical evaluations and SDIs. Clinicians, on the one hand, might tend to pick a single diagnosis based on clinical impression-even if a patient meets criteria for several. They may also tailor their interviews more closely around the chief complaint and weigh contextual information, such as family history, in the diagnosis. Clinicians may also hold back on making diagnoses for concern of stigma. SDIs, by contrast, could elicit a lot of negative responses due to the sheer number of questions that are typically asked. These interviews also tend to rely more heavily on the impression of the patient or a parent as to what constitutes a clinically significant symptom.

To illustrate how these processes might work in a clinical situation, the following example might be useful.

 Consider the hypothetical example of 15-year-old Billy who presents initially to a psychologist in the community. Billy has a history of being neglected and abused by his biological parents who struggled with their own mental health problems. He was removed from the home at age 3 and lived in several foster homes before he was adopted into a stable household. He has been observed in multiple settings to be impulsive, aggressive, anxious, and prone to intense behavioral outbursts with minimal provocation. The adopted parents take Billy to a community clinician who conducts an evaluation without an SDI and makes a diagnosis of posttraumatic stress disorder (PTSD), noting the history of trauma and profound behavioral disturbance even in the absence of symptoms such as flashbacks or nightmares. She begins trauma-based psychotherapy and considers interventions such as eye movement desensitization and reprocessing. 


After a violent episode at school, Billy is hospitalized at an academic medical center where a structured diagnostic interview is given as part of the admission process. According to this interview, Billy meets criteria for ADHD, oppositional defiant disorder and conduct disorder. Treatment with a psychostimulant is started in addition to recommendations for parent behavioral training using a cognitive-behavioral context. After discharge, Billy is evaluated by a local psychiatrist who notices the level of impairment and extreme mood swings and diagnoses pediatric bipolar disorder-even without a history of sustained manic symptoms lasting several days. The psychiatrist begins treatment with an antipsychotic agent and considers discontinuing the stimulant.

The example demonstrates the decision-making that can underlie the widely divergent diagnoses and treatment plans. Indeed, when these data were first presented as a poster at a meeting of the American Academy of Child and Adolescent Psychiatry, the informal comments made by viewers reflected the different perspectives. Those who tended not to use SDIs in their practice interpreted these findings as confirmation that SDIs were not useful, while academics who conducted research trials found the results as validation that the continued use of SDIs were needed to produce accurate diagnoses. Indeed, the source studies of the meta-analysis also diverged in the interpretation of their results. For some individual studies, the design was framed in a way that diagnoses based on clinical evaluations were considered to be the “gold standard” so as to put SDIs to the test. Other studies were designed to challenge the validity of diagnoses from clinical evaluations.

In much of clinical research, skepticism about using either clinical evaluations or SDIs as the sole source of diagnostic information is reflected in the generally accepted practice of using a “best estimate” procedure. Here, senior investigators review the diagnostic results of SDIs and assign final diagnoses after reviewing all the clinical data. This procedure is thought to add incremental validity to the final diagnoses although its utility has rarely been tested formally against potential benchmarks that may be difficult to define.

My coauthors and I also discuss the possibility that the dichotomous nature of diagnoses may also contribute to disagreement. For example, if a clinical evaluation determines that a patient meets 5 of 9 criteria for the inattentive items of ADHD while an SDI reports that 6 of 9 criteria are met, the final diagnosis is in 100% disagreement (since at least 6 items are required)- even though the 2 methods may have agreed for 8 of 9 criteria. While disagreement in such instances may be viewed as somewhat of an artifact, it does reflect current practice and the need often to make binary decisions such as whether or not to prescribe a medication.

In summary, our meta-analysis has revealed the somewhat alarming finding that diagnoses generated from SDIs (the prevailing method used in clinical research studies) and the diagnoses generated from clinical evaluations (the prevailing method used in routine practice) frequently disagree. The sources of this disagreement are likely complex and a result of features of both diagnostic methods. While researchers in practice often try to combine SDI results with clinical judgment, much remains to be learned regarding how scientists, clinicians, and perhaps DSM5 can synthesize often divergent information in the service of a valid and clinically meaningful assessment.

1. Rettew DC, Lynch AD, Achenbach TM, et al. Meta-analyses of agreement between diagnoses made from clinical evaluations and standardized diagnostic interviews. Int J Methods Psychiatr Res. 2009;18:169-184.

A recently published a meta-analysis showed that diagnoses generated from clinical evaluations often do not agree with the results of structured and semi-structured interviews-together called standardized diagnostic interviews (SDI).1 Such a study could easily be overlooked as another dry and “methodological” investigation. Nevertheless, the implications of this meta-analysis are enormous

Diagnoses from Clinical Evaluations and Standardized Diagnostic Interviews Don’t Agree

Avoidant personality disorder (APD) is characterized by a general tendency to fear and avoid social interactions-even interactions with persons who are well known to the individual. In addition to deserving our clinical and research attention in its own right, APD highlights some of the key controversies with our current classification system. These debates include the "horizontal" boundaries between different Axis I and Axis II conditions as well as the "vertical" boundaries between a clinical disorder and certain personality or temperamental traits. In pediatric psychiatry, use of the diagnosis underscores the conflict between the motivation to avoid Axis II diagnoses in children and adolescents and the motivation toward early identification and early intervention of psychiatric illness.

In this article, I will briefly summarize some of the key components of APD, with a focus on epidemiology, assessment, diagnostic dilemmas, and treatment.

 defines APD as "a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation that begins by early adulthood and is present in a variety of contexts." In persons with APD, the avoidance of, and restraint during, social contact is the result of fears of rejection and humiliation.

APD is one of the cluster C personality disorders, along with dependent and obsessive-compulsive personality disorders. The level of impairment associated with APD is high; employment, interpersonal relationships, and global functioning are all negatively affected. The morbidity associated with APD rivals and even exceeds that associated with such Axis I disorders as major depressive disorder.

APD is relatively common; the prevalence is about 5% in the community

 and nearly 15% among psychiatric outpatients.

 As such, APD is one of the most-if not the most-prevalent personality disorders. APD occurs about equally between males and females.

The symptoms of APD often appear early and the disorder can be distinguished from other personality disorders by elementary school or even earlier. Adults with APD reported less involvement in extracurricular activities and sports, and were less popular than adults with another personality disorder or major depression.

 have characterized a temperamental trait labeled behavioral inhibition that applies to children who have a strong tendency to be shy and restrained in novel situations. Behavioral inhibition-a potential precursor to later social anxiety and avoidance-has been reliably assessed in children 2 years old and perhaps even younger.

Longitudinal research has demonstrated detectable, although certainly not inevitable, links between behavioral inhibition and many disorders in childhood and adolescence. These include social anxiety disorder and avoidant disorder (as defined in 

 Emotional disorders, such as anxiety, depression, and eating disorders, in adolescence predict cluster C personality disorders in adulthood in women.

While there appears to be at least some continuity between adult APD and childhood symptoms, accumulating research is beginning to demonstrate a more waxing and waning course of APD symptoms through adulthood than had originally been expected. A 2-year prospective study from the Collaborative Longitudinal Personality Disorders Study found that over time, feelings of inadequacy and social ineptness and the need to be certain of being liked before entering into social situations were more stable than worries about shame and risks of exposure in one's employment.

Considerably less is known about APD as affected persons age. The disorder is scarcely studied in geriatric psychiatry.

The finding in APD and other personality disorders that there is an onset of symptoms in childhood and adolescence represents a dilemma for many clinicians. On one hand, our training dictates the general principal of early identification and intervention to help avoid or reduce long-term suffering. At the same time, clinicians tend to avoid diagnosing personality disorders in children and adolescents.

 While the reasons for this practice are not entirely clear, the tendency may be based in part on the notion that a child's personality is still "in progress" and thus he or she should not be labeled as "disordered" for fear of stigmatization.

While this concept has some merit, it is also flawed. Symptoms of Axis I disorders, such as attention-deficit/hyperactivity disorder, also tend to undergo change through the course of the person's development, yet this does not prevent clinicians from making a diagnosis at a particular point to allow for the amelioration of impairing symptoms.

Furthermore, personality development does not stop when a patient reaches age 18. As for stigmatization, it is not intuitively obvious why a diagnosis of APD carries a higher burden than many other conditions that can be diagnosed before adulthood, such as social anxiety disorder.

A final obstacle to diagnosing APD in children is the criterion that a cause for social avoidance be identified (eg, fear or shame or embarrassment). Such a cause may be difficult to detect in younger children, whose self-consciousness is still developing.

There has been little research into the cause and pathophysiology of APD per se, although much literature exists about related Axis I conditions or traits, such as shyness. Behavioral inhibition and other temperament traits like it (eg, harm avoidance) are thought to be related to overactivity of regions of the brain that are involved in the fear response. One recent study found evidence that high levels of harm avoidance were related to decreased coupling between the amygdala and the anterior cingulate gyrus which, in turn, may be related to genes involved in serotonin transmission.

The heritability of behavioral inhibition ranges from 25% to 44%, as measured in toddlers.

 Interestingly, there is some evidence to support stronger genetic associations with the personality dimensions that may underlie APD than with the specific APD symptoms themselves.

The differential diagnosis of APD (or its "horizontal" boundaries) includes mainly other psychiatric disorders. While there may be theoretical distinctions between APD and related diagnoses, these differences can be very difficult to untangle in practice, especially if one takes a developmental perspective of the patient. The 

 lists some features that may distinguish other traits and disorders from APD.

The main theoretical distinction between APD and both schizoid personality disorder and an autistic spectrum disorder is the notion that persons with APD very much want social contact-but are afraid to seek it out, while those with schizoid personality disorder or an autistic spectrum disorder are less intrinsically interested in social contact. However, many individuals with an autistic spectrum disorder do seek out human contact but struggle with how to achieve it. It is thus advisable to obtain a good developmental history if both of these disorders are being considered as alternatives to APD.

Developmentally, it is also possible that over time a person with APD who initially craves social contact will begin to settle into a pattern in which this contact is no longer sought. Another point of divergence between APD and an autistic disorder relates to social cues. Children with an autistic spectrum disorder tend to ignore these cues, while those with APD are hypersensitive to them.

Perhaps the greatest diagnostic dilemma pertains to the boundaries between APD and the general subtype of social anxiety disorder (GSAD). The diagnostic criteria overlap considerably. Attempts to find distinguishing characteristics in the epidemiology, physiology, and response to treatment have yielded little in the way of qualitative differences.

 Indeed, there may be more differentiation between the specific and generalized form of GSAD than between generalized GSAD and APD, despite their existence on different axes.

Researchers have similarly been interested in the "vertical" boundaries between APD and established personality or temperamental traits, such as shyness. There certainly appears to be significant overlap between certain disorders, such as APD, and specific personality dimensions. Nevertheless, the increasingly popular hypothesis that APD simply represents the extreme end of a normally distributed trait such as shyness appears to be overly simplistic.

Studies of the relationship between shyness and generalized social phobia show that many people with very high levels of shyness do not meet criteria for GSAD.

 This lack of continuity has stimulated researchers to begin looking for other features that could moderate the relationship between shyness and psychiatric disorders. These include other personality or temperament traits (such as emotion regulation) or specific cognitive factors that may exacerbate shyness into full-fledged APD.

Assessment for APD is part of a general psychiatric evaluation; the condition should be suspected in patients in whom social avoidance, fear of embarrassment, and intimacy difficulties are uncovered. Instruments to aid in the diagnosis of APD and other personality disorders continue to be refined, although their use in routine practice remains limited.

As with most personality disorders, most patients who meet criteria for APD will meet criteria for other Axis I and Axis II conditions. Notable among these are Axis I anxiety and affective disorders, other cluster C disorders, and substance abuse.

Treatment of APD involves psychotherapy and/or medication. Unfortunately, treatment studies rarely focus primarily on APD and instead analyze patients with APD as a subset of those with GSAD or other personality disorders.

 Given this limitation, multiple types of psychotherapy have been shown to be effective in adult APD, including cognitive- behavioral, psychodynamic, and supportive-expressive therapy.

No medications have been specifically approved for the management of APD. However, research has documented improvement in patients who meet criteria for both APD and social anxiety disorder when treated with selected serotonin reuptake inhibitors and benzodiazepines.

 Current recommendations include consideration of pharmacotherapy in APD, regardless of whether a patient meets criteria for a comorbid Axis I disorder,

 although additional research in this area is sorely needed. Given the risk of substance use in APD, physicians should be cautious in prescribing benzodiazepines.

Regardless of treatment modality, however, one of the keys to treatment success (as with other anxiety conditions) is exposure. Patients who simply take a medication or who speak with a therapist are not likely to report symptom relief before they take the risk of confronting their feared situations.

Greater success can be anticipated if the therapist supports patients and encourages them to confront their fears. This can take the shape of a specific homework assignment within a cognitive-behavioral format or therapist support of the patient's willingness to risk intimacy and no longer be the "perfect patient" within a psychodynamically oriented framework.

APD is a relatively common condition that is associated with significant impairment in multiple domains. The boundaries of the disorder-both horizontally with other psychiatric diagnoses and vertically with personality dimensions such as shyness-continue to be blurry and not well established. In particular, there seems to be little to qualitatively distinguish APD from the generalized type of social anxiety disorder.

Research into the course of APD demonstrates the disorder's origin in early temperamental traits. Increasing data exist to suggest that during adulthood APD may be more changeable over time than originally thought. These data suggest that positive responses can occur with psychotherapy and/or medications.

Dr Rettew is assistant professor of psychiatry and pediatrics at the University of Vermont College of Medicine in Burlington.

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A discussion of the epidemiology, assessment, diagnostic dilemmas, and treatment of avoidant personality disorder.

David C. Rettew, MD

Articles

Diagnoses From Clinical Evaluations and Standardized Diagnostic Interviews Don’t Agree

Diagnoses from Clinical Evaluations and Standardized Diagnostic Interviews Don’t Agree

Avoidant Personality Disorder: Boundaries of a Diagnosis