[Timothy a. Brown, David H. Barlow] Anxiety and Related Disorders Interview Schedule for DSM-5

Anxiety and Related Disorders Interview Schedule for DSM-5® (ADIS-5) Adult and Lifetime Version

Clinician Manual Timothy A. Brown David H. Barlow

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3 Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With offices in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam Oxford is a registered trade mark of Oxford University Press in the UK and certain other countries. Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016

© Oxford University Press 2014 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by license, or under terms agreed with the appropriate reproduction rights organization. Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above. You must not circulate this work in any other form and you must impose this same condition on any acquirer. Library of Congress Cataloging-in-Publication Data Brown, Timothy A., 1960– author. Anxiety and related disorders interview schedule for DSM-5, adult and lifetime version : clinician manual / Timothy A. Brown, David H. Barlow. pages cm ISBN 978–0–19–932474–3 (acid-free paper) 1. Anxiety—Diagnosis—Handbooks, manuals, etc. 2. Mental illness—Classification—Handbooks, manuals, etc. 3. Interviewing in psychiatry. 4. Diagnostic and statistical manual of mental disorders. I. Barlow, David H., author. II. Title. RC531.B76 2014 616.85′22—dc23 2013033944

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ABOUT THE AUTHORS

Timothy A. Brown received his PsyD from the Virginia Consortium for Professional Psychology in 1988. He has published numerous scientific articles and chapters in the area of anxiety and mood disorders, and quantitative research methods. Presently, he is Professor in the Psychology Department at Boston University, and Director of Research and Research Administration of the Center for Anxiety and Related Disorders at Boston University. In addition to his own funded research on the classification and psychopathology of emotional disorders, he has been a statistical investigator/ consultant on numerous federally funded research grants. He was a member of the DSM-5 Research Planning Committee and was an Advisor to the DSM-5 Anxiety Disorders Workgroup. Currently, his research has focused on dimensional approaches to emotional disorder classification, the role of temperament in the psychopathology and longitudinal course of emotional disorders, and diathesisstress models of emotional disorders (e.g., interaction of novel candidate genes and life stress on the temporal course of emotional disorders). David H. Barlow received his PhD from the University of Vermont in 1969 and has published over 500 articles and chapters as well as over 60 books and clinical manuals, mostly in the area of emotional disorders and clinical research methodology. The book and manuals have been translated into over 20 languages, including Arabic, Chinese, Hindi, and Russian. He was formerly Professor of Psychiatry at the University of Mississippi Medical Center and Professor of Psychiatry and Psychology at Brown University and founded clinical psychology internships in both settings. He was also Distinguished Professor in the Department of Psychology at the University at Albany, State University of New York. Currently, he is Professor of Psychology and Psychiatry, and Founder and Director Emeritus, of the Center for Anxiety and Related Disorders at Boston University. Dr. Barlow is the recipient of the 2000 American Psychological Association (APA) Distinguished Scientific Award for the Applications of Psychology, and the James McKeen Cattell Fellow Award from the Association for Psychological Science, honoring individuals for their lifetime of significant intellectual achievements in applied psychological research. He is also the recipient of the 2008 Career/Lifetime Achievement Award, Association for Behavioral and Cognitive Therapies (ABCT); and recipient of the 2000 Distinguished Scientific Contribution Award from the Society of Clinical Psychology of the APA. He also received an award in appreciation of outstanding achievements from the General Hospital of the Chinese People’s Liberation Army, Beijing, with an appointment as Honorary Visiting Professor of Clinical Psychology. During the 1997–1998 academic year, he was Fritz Redlich Fellow at the Center for Advanced Study in Behavioral Sciences, in Palo Alto, California. Other awards include Career Contribution Awards from the Massachusetts, California, and Connecticut Psychological Associations; the 2004 C. Charles Burlingame Award from the Institute of Living in Hartford, Connecticut; the First Graduate Alumni Scholar Award from the Graduate College, University of Vermont; the Masters and Johnson Award, from the Society for Sex Therapy and Research; a certificate of appreciation for contributions to women in clinical psychology from the Society of Clinical Psychology, Section IV: the Clinical Psychology of Women; and a MERIT award from the National Institute of Mental Health for long-term contributions to iii

iv the clinical research effort. His research has been continually funded by the National Institutes of Health for over 40 years. In 2004 he received an Honorary Doctorate in Humane Letters from the Massachusetts School of Professional Psychology, and in 2006, the American Board of Professional Psychology’s Distinguished Service Award to the Profession of Psychology. He is Past-President of the Society of Clinical Psychology of the APA and the ABCT, Past-Editor of several journals including Clinical Psychology: Science and Practice and Behavior Therapy, and currently Editorin-Chief of the “Treatments That Work” series for Oxford University Press. He was a member of the DSM-IV Task Force of the American Psychiatric Association, and a Co-Chair of the Work Group for revising the anxiety disorder categories. He is a Diplomate in Clinical Psychology of the American Board of Professional Psychology and maintains a private practice.

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Introduction The Anxiety and Related Disorders Interview Schedule for DSM-5 (ADIS-5; Brown & Barlow, 2014a) is a structured interview designed to diagnose current anxiety, mood, obsessivecompulsive, trauma, and related disorders (e.g., somatic symptom, substance use) and to permit differential diagnosis among these disorders according to DSM-5 criteria (American Psychiatric Association, 2013). In most diagnostic sections, the ADIS-5 also provides (a) dimensional assessment of the key and associated features of disorders and (b) inquiry to foster the functional analysis of the various disorders (e.g., nature of situations avoided, content of fear cognitions). Diagnostic sections in addition to anxiety and mood disorders are included because of their high comorbidity rate with these conditions and because the presenting symptoms of these other disorders are often quite similar to those of the anxiety and mood disorders (e.g., illness anxiety disorder and generalized anxiety disorder). The ADIS-5 contains screening questions for a variety of other conditions including hoarding disorder, impulse control disorders, eating disorders, attention deficit disorder, dissociative disorders, and psychotic disorders. Other sections of the ADIS-5 include the assessment of episodic and ongoing life stress, medical and psychiatric treatment history, and familial psychiatric history. The Anxiety and Related Disorders Interview Schedule for DSM-5: Lifetime Version (ADIS-5L; Brown & Barlow, 2014b) contains all of the sections included in the ADIS-5. However, unlike the ADIS-5, the ADIS-5L is designed to establish past (lifetime) diagnoses as well. The ADIS-5L also contains a Diagnostic Timeline to assist in the determination of the onset, remission, and temporal sequence of disorders. This manual has been developed to accompany both the ADIS-5 and ADIS-5L. Because the ADIS-5 and the ADIS-5L differ only in that the latter contains sections to assess past diagnoses, the abbreviation “ADIS-5” will be used throughout the manual in discussing information germane to both schedules. When discussing issues specific to the ADIS-5L, the abbreviation “ADIS-5L” will be used. Because the ADIS-5 is designed for the detailed examination of the emotional disorders and related problems, it will be of most value for research and clinical applications directly related to these problem areas. More comprehensive structured interviews may be better suited for general outpatient clinics or more broad-based research efforts that aim to evaluate all the DSM-5 disorders. For these purposes, we recommend the Structured Clinical Interview for DSM-5. However, such interviews provide a considerably less detailed evaluation of the emotional disorders than does the ADIS-5. The ADIS-5 and its predecessors (the ADIS, ADIS-R, and ADIS-IV for DSM-III, DSM-III-R, and DSM-IV, respectively) were developed over the years at the Center for Anxiety and Related Disorders at Boston University (and previously, the Center for Stress and Anxiety Disorders at the University of Albany, New York), supported in part by funds from the National Institute of Mental Health. The content and wording of questions, as well as the general organization of the interview, are based on several years of experience in interviewing and diagnosing patients with emotional disorders. Previous editions of the ADIS have demonstrated good reliability for the majority of disorders covered (e.g., Di Nardo, Moras, Barlow, Rapee, & Brown, 1993). Our most recent study entailing two independent administrations of the ADIS-IV (Brown, Di Nardo, Lehman, & Campbell, 2001) indicated good-to-excellent interrater agreement for current DSM-IV disorders (range of κs = .67 to .86), except dysthymia (κ = .31).

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Uses of the ADIS-5 Clinical applications. Diagnostic evaluation is crucial to treatment planning. Before treatment planning can be initiated, it is important to obtain a comprehensive evaluation of the presenting complaint and any co-occurring disorders, both psychological and medical. The ADIS-5 was developed to facilitate differential diagnosis among the emotional disorders and commonly cooccurring disorders. This inquiry also enables the clinician to understand the functional relationships among these disorders and their associated symptoms. In many diagnostic sections, the line of inquiry goes beyond establishing DSM-5 diagnoses to focus on the functional relationships among specific symptoms. For instance, there are many symptoms that are shared among the range of emotional disorders (e.g., panic attacks, social anxiety, worry, and situational avoidance). Moreover, many patients with emotional disorders present with more than one disorder, referred to as comorbidity (cf. Brown, Campbell, Lehman, Grisham, & Mancill, 2001). DSM-5 allows for multiple diagnoses, following certain exclusionary rules. For example, generalized anxiety disorder (GAD) can be assigned in the presence of other disorders, provided that the focus of anxiety and worry is not confined to features of another disorder, and the excessive worry does not occur exclusively during the course of certain other conditions (e.g., mood and psychotic disorders). Thus, a potential issue for differential diagnosis involving GAD is to determine if all of the symptoms reported by the patient should be subsumed under a co-occurring disorder or whether the symptoms form an independent disorder. Even for purely clinical applications, we favor a structured interview format such as the ADIS-5 for differential diagnosis because it ensures the systematic inquiry necessary to determine the relationships among emotional disorder symptoms. In each diagnostic section of the ADIS-5, there are questions designed to determine if the patient meets the diagnostic criteria for that disorder, the exact focus of concern associated with each symptom, and the relationship of the symptom to symptoms reported by the patient in other diagnostic sections. Systematic and detailed questioning of this nature is necessary for reliable differential diagnosis. Research applications. In clinical research, it is essential that the methods used to diagnose patients for inclusion in a study have demonstrated reliability and validity. Therefore, a structured interview is needed to reduce information variance and interviewer variance, and to ensure replicability of diagnostic procedures. In addition to items assessing basic diagnostic criteria (and differential diagnosis), the ADIS-5 includes a number of questions designed to provide a systematic and quantifiable assessment of the various dimensional aspects of the disorder. In most diagnostic sections, the initial screening questions are linked to the key features of the disorder, and have been designed to be rated on a dichotomous basis (i.e., yes/no). After the initial screening items, the inquiry proceeds to symptom ratings that are also linked to the key features of the disorder, but these ratings are made dimensionally (i.e., 0–8 scales) rather than dichotomously. This assessment approach is based on a vast literature attesting to the fact that the key and associated features of disorders operate on a continuum rather than in a binary (presence/absence) fashion (e.g., symptoms of social anxiety are not specific to social anxiety disorder but are found in varying degrees in other disorders and in individuals without a DSM-5 disorder; cf. Brown & Barlow, 2005, 2009). Dimensional assessment has many advantages over a purely binary (DSM-5 diagnosis) approach, including the ability to better capture individual differences in disorder severity and to detect salient subclinical presentations

3 (e.g., individuals who evidence several features of a disorder, but not to an extent that crosses the DSM-5 threshold). In applied research, these dimensional ratings (e.g., composite of the fear ratings for the 15 social situations in the Social Anxiety Disorder section) are often used as treatment outcome variables (e.g., more sensitive to change than binary outcomes) as well as dimensional indicators of disorder features in factor analytic, regression, and structural equation models (e.g., Brown, 2007; Naragon-Gainey, Gallagher, & Brown, in press).

Changes Introduced in the ADIS-5 Although many of the revisions to the ADIS-5 and ADIS-5L are also discussed intermittently in subsequent sections of this manual, this section provides a condensed, nonexhaustive overview of the changes and new features of the interview, for individuals who have used previous versions of the ADIS. Name of interview. It would be appropriate to begin this section by acknowledging that although the ADIS acronym has been retained, the actual name of the interview has been changed to “Anxiety and Related Disorders Interview Schedule for DSM-5.” Given the breadth of diagnostic coverage provided by the ADIS-5, it would be misleading and would sell the interview short to refer to it simply as an anxiety disorders interview. In fact, especially after the reorganization of diagnoses in DSM-5, anxiety disorders represent a small number of the diagnoses covered by full diagnostic sections in the ADIS-5. Of the 16 full diagnostic sections in the ADIS-5, only 6 are anxiety disorders per the DSM-5 classification. The remaining 10 diagnostic sections, all of which corresponding to disorders that overlap or co-occur with anxiety disorders (e.g., mood disorders, somatic symptom disorders), provide the same high level of diagnostic assessment as the anxiety disorder diagnostic sections. Thus, the name of the interview was revised to better reflect the range of diagnostic coverage offered by the ADIS-5. Deleted sections. The ADIS-5 no longer includes the Hamilton Rating Scales for Anxiety and Depression given the rather outdated nature and poor psychometric quality of these ratings. The Mixed Anxiety Depression diagnostic section has been deleted given the elimination of this category from DSM-5. In the ADIS-5, a separate section no longer exists for Acute Stress Disorder because all of the information necessary for assigning this condition can be obtained in the Posttraumatic Stress Disorder diagnostic section. New diagnostic sections. Because separation anxiety disorder is now classified by DSM-5 as an anxiety disorder that can be assigned to adults, the ADIS-5 contains a Separation Anxiety Disorder section. The inclusion of this section in the ADIS-5L will also foster the evaluation of separation anxiety disorder as a past (childhood) diagnosis, a common type of comorbidity that may have been missed in earlier versions of the ADIS. In addition, the ADIS-5 includes a diagnostic section for body dysmorphic disorder (now classified by DSM-5 as an “obsessive-compulsive and related disorder”), a condition that may have considerable diagnostic and phenotypic overlap with other emotional disorders such as obsessive-compulsive disorder and social anxiety disorder. Organizational changes. As discussed in more detail later, the Medical/Treatment History section has been moved to the front of the interview to assess such matters as the status and

4 stabilization of medical and psychological treatments, and the existence of medical conditions that may be germane to differential diagnosis and the overall clinical picture. In the Agoraphobia and Major Depressive Disorder sections, dimensional ratings of these disorders are now made regardless of the patient’s replies to questions in Initial Inquiry. It was deemed important to obtain dimensional assessment of these conditions in all patients given (a) agoraphobia’s status as a stand-alone disorder in DSM-5 and (b) the need to have a dimensional representation of depression in addition to the anxiety disorders. Last, the interviewer can now skip out earlier in the Alcohol Use Disorder and Substance Use Disorders sections if no evidence of excessive use is noted. Expansions to diagnostic sections. In the Generalized Anxiety Disorder section, there is an optional subsection for rating worry behaviors, based on a diagnostic criterion that was considered but ultimately rejected for DSM-5. In Specific Phobia, the rating for animals has been expanded from a single rating (in the ADIS-IV) to entail four common types of animal phobias (also with space to rate an “other” animal phobia). The Posttraumatic Stress Disorder section has been revised substantially to incorporate major revisions to this diagnosis, but also to provide a systematic evaluation of trauma exposure history (which was an open-ended question in earlier versions of the ADIS). The Substance Use Disorders section was expanded to foster the rating and diagnostic assessment of multiple current and past substance use disorders. The Other Disorders Screening section has been expanded to screen for additional disorders and symptoms including hoarding, eating disorders, and homicidal thought/ intent. In the Major Depressive Disorder and Bipolar/Cyclothymia sections of the ADIS-5, the PAST EPISODES subsection is included. Although the ADIS-5 is not designed to assess for all past diagnoses, it was deemed important to assess past episodes of these conditions given the episodic nature of these disorders and to promote accurate assignment of DSM-5 course specifiers (e.g., single versus recurrent episode). Clinical severity rating and dimensional ratings. For reasons discussed in the Assigning Diagnoses section of this manual, it is no longer required that the principal diagnosis be assigned the highest clinical severity rating (i.e., principal diagnosis is denoted by a label, not by a quantitative rating). In addition, significant changes have been made with regard to the decision rules and order in which dimensional ratings are assigned in the RATINGS subsection of the diagnostic sections. The nature and reasons for these changes can be found in the “Organization of Diagnostic Sections” portion of this manual. Miscellaneous revisions. The Clinician’s Ratings and Diagnoses page has been revised considerably, in part to be consistent with the fact that DSM-5 no longer uses a five-axis diagnostic system (e.g., no differentiation is made between Axis I and Axis II disorders). In addition, many more specific changes have been made throughout the interview protocol such as revising the wording of items to improve the ease and clarity of administration, and reorganization and expansion of symptom ratings in accord with DSM-5 changes and to improve coverage. For instance, the SITUATION RATINGS subsection in Social Anxiety Disorder has been reorganized and expanded to foster the assignment of the new diagnostic specifier, “Performance only.” The SITUATION RATINGS subsection in Agoraphobia has been rearranged to assist with the evaluation of the new DSM-5 requirement that the agoraphobic fear must apply to two of five types of situations (public transportation, open spaces, enclosed places, crowds/lines, being outside of home alone).

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Coverage of the ADIS-5 The ADIS-5 begins by gathering demographic information (e.g., age, race, ethnicity, marital status). Next, a brief description of the presenting problem is obtained, which provides the interviewer with a general sense of the problem areas to be pursued in more detail and establishes a common reference point for the interviewer and patient. Next, the interviewer should record a verbatim response to the question, “If you had to identify one issue, what would you say is the main reason that brought you here today?” The patient’s response to this question may be helpful later in establishing a principal diagnosis and may be useful for certain research applications. This inquiry is followed by evaluation of episodic and ongoing stress in a number of life areas within the past year (e.g., family, social life/relationships, finances). This provides an opportunity to obtain a broad overview of the patient’s life circumstances. This information is important for establishing a context for the current symptoms and may be helpful for diagnostic purposes (e.g., consideration of stressors that triggered the onset of a disorder). Moreover, these data may provide further information about the circumstances prompting the current presentation. New to the ADIS-5, the Medical/Treatment History section immediately follows the assessment of the presenting complaint and life stressors. This section was moved to the front of the ADIS-5 for a few reasons. Before proceeding into the diagnostic sections, the interviewer will ascertain the patient’s current medication and psychological treatment status (e.g., in research applications, this is important to ensure the patient meets medication and psychological treatment stabilization criteria; clinically, this information is important to determine the extent and nature of treatment history, medication use that may be exacerbating symptoms, etc.). Moreover, collecting a detailed medical history is important to determining the presence of current or past medical conditions that bear on differential diagnosis with DSM-5 disorders (e.g., panic disorder, somatic symptom disorder) and contribute to the patient’s overall level of functioning. Ascertaining this information early on should also reduce redundancy in the diagnostic sections and streamline their administration (i.e., inquiry involving medical rule-out diagnostic criteria). The 16 diagnostic sections are next. The order in which the diagnostic sections are presented was guided in part by the base rates of disorders in outpatient settings (e.g., panic disorder, social anxiety disorder, and generalized anxiety disorder are the most common anxiety disorders seen at our Center), to facilitate continuity (e.g., the Agoraphobia section follows the Panic Disorder section) and to facilitate differential diagnosis (e.g., juxtaposition of the Generalized Anxiety Disorder and Obsessive-Compulsive Disorder sections). The diagnostic section for Panic Disorder appears first due to the high rate at which this disorder is encountered in outpatient settings and because, in DSM-5, panic attacks can be assigned as a specifier for disorders other than panic disorder (e.g., “social anxiety disorder with panic attacks”). Agoraphobia follows this section (although highly comorbid with panic disorder, agoraphobia is assigned as a separate, stand-alone disorder in DSM-5). Social Anxiety Disorder follows these sections because social anxiety and avoidance often overlap with some of the symptoms of Agoraphobia (e.g., fear of entering situations due to the social consequences of panic). Separation Anxiety Disorder, a diagnostic section new to the ADIS-5, is placed between Social Anxiety Disorder and Generalized Anxiety Disorder, given the potential diagnostic overlap of these conditions (as well as panic disorder, in the case of separation anxiety disorder).

6 Obsessive-Compulsive Disorder follows the General Anxiety Disorder section, which may assist in differentiating GAD excessive worry from obsessional thoughts. In DSM-5, obsessivecompulsive disorder (OCD) is now classified under the category of “Obsessive-Compulsive and Related Disorders,” along with a number of other conditions (e.g., hoarding disorder, trichotillomania). Another disorder from this category is now included in the ADIS-5, body dysmorphic disorder (BDD). The Body Dysmorphic Disorder diagnostic section follows Obsessive-Compulsive Disorder due to similar diagnostic features of these conditions (e.g., obsessional thinking, repetitive behaviors); however, the interviewer should also be mindful of the potential phenotypic similarities of BDD with other disorders (e.g., social anxiety disorder). The diagnostic section for Specific Phobia is next. A commonly encountered issue in the differential diagnosis of specific phobia is determining whether the anxiety or avoidance of specific objects or situations could be subsumed under other disorders such as agoraphobia (e.g., fear of air travel is due to apprehension of having unexpected panic attacks that occur in a variety of situational contexts). The diagnostic section for Posttraumatic Stress Disorder/Acute Stress Disorder follows. This section has undergone a major overhaul both to be consistent with extensive criteria changes introduced in DSM-5, and to provide a more comprehensive assessment of the nature and severity of traumatic events. The next three diagnostic sections are devoted to the following mood disorders: Major Depressive Disorder, Persistent Depressive Disorder (Dysthymia in DSM-IV), and Bipolar/ Cyclothymia. Following the mood disorders, there are diagnostic sections for two disorders from the category “Somatic Symptom and Related Disorders”: Illness Anxiety Disorder (Hypochondriasis in DSM-IV) and Somatic Symptom Disorder (subsumes several DSM-IV somatoform disorders including somatization disorder, undifferentiated somatoform disorder, and pain disorder). Although classified differently in DSM-5, both these conditions possess many of the hallmark features of an anxiety disorder (e.g., excessive worry about having or acquiring a serious illness in illness anxiety disorder). These diagnostic sections were designed to foster the same level of differential DSM-5 diagnosis and functional analysis found in the preceding anxiety, mood, and related disorder sections. The final full diagnostic sections are Alcohol Use Disorder and Substance Use Disorders. Given that more extensive comorbidity is often present, the Substance Use Disorders section has been redesigned to allow the interviewer to rate two current and two past substances/use disorders. The next section contains screening questions for a number of conditions or symptoms that may co-occur with the disorders formally evaluated by the ADIS-5. These include: hoarding disorder, habit disorders, eating disorders, attention deficit/hyperactivity disorder, selective mutism (an anxiety disorder in DSM-5), dissociative disorder, and psychotic symptoms, as well as thoughts about harming others. Affirmative response to these screening questions will often merit follow-up evaluation. These screening questions are followed by items assessing family history of psychological disorders. These items are intended for screening purposes only and are not sufficient for establishing DSM-5 diagnoses. Two final questions of the ADIS-5 appear in the SUMMARY section. The first question asks the patient what is the primary problem that they want help with; the second asks whether the patient feels that there is any other material that should be discussed that has yet to be covered. The first item is very similar to the question asked near the beginning of the interview. However, it is not uncommon to observe variability in the patient’s response to this item once all of the diagnostic

7 sections have been completed. Although the clinician’s judgment should weigh most heavily in the determination of the principal diagnosis, the patient’s responses to these questions may assist in this endeavor if multiple disorders are present. Last, the interviewer inquires about whether important areas have been omitted or covered insufficiently in an effort to ensure that all material relevant to the current clinical presentation has been collected. Following these items, the ADIS-5 provides space for information on mental status, behavior during the interview, and a diagnostic narrative, to be recorded by the interviewer after the patient has departed. If the ADIS-5L was used, administration of the Diagnostic Timeline (DTL) may be administered next to obtain more accurate information about the onset/remission and temporal sequence of current and past disorders (discussed later in this manual).

Organization of Diagnostic Sections The ADIS-5 renders detailed inquiry for all aspects of the DSM-5 criteria for the disorders mentioned above, and suggested phrasing of questions appears in bold print throughout the protocol. Occasionally, nonbolded material is embedded in a bolded question; this is material that should not be read verbatim, but contains information or examples the interviewer may use when administering the item. For example, the interference/distress questions (e.g., Question #3 of CURRENT EPISODE in Agoraphobia section) include life areas that the interviewer could cite as examples when administering this item. The diagnostic sections of the ADIS-5 have been structured to be as consistent as possible. Except for a few sections where a different structure was more appropriate, each diagnostic section contains the following subsections: INITIAL INQUIRY, RATINGS (e.g., SYMPTOM RATINGS, SITUATION RATINGS), CURRENT EPISODE, and PAST EPISODE (ADIS-5L). The items within the CURRENT EPISODE and PAST EPISODE subsections have designed to be as similar as possible across the diagnostic sections. Each diagnostic section begins with INITIAL INQUIRY, which typically contains dichotomous items (yes/no) that have been designed to assess the key feature(s) of the disorder. The screening items assess for current and then past occurrences of these key diagnostic features. If the patient has responded affirmatively to some of these items, the interviewer will then ask a few questions to try to begin to establish the date of onset/remission of symptoms and whether or not more than one discrete episodes of disturbance have been present (e.g., Items 5a. and 5b. in Panic Disorder section). These items alone are not intended to establish the presence of current and past episodes of the disorder, but instead to foster the administration of subsequent subsections (e.g., if evidence of discrete episodes is noted, extra care should be taken when obtaining current and past symptom ratings to avoid obfuscating the episodes). Unlike the ADIS-5L, the ADIS-5 does not contain separate subsections for inquiry of past disorders (except for Major Depressive Disorder and Bipolar/Cyclothymia). Nevertheless, the ADIS-5 contains screening items for past episodes in INITIAL INQUIRY (as well as another item at the end of the CURRENT EPISODE section), so that the clinician may inquire about possible past disorders. Depending on the patient’s response to these items, the clinician may wish to adapt the CURRENT EPISODE section to inquire about previous disorders. This may be particularly useful if

8 the existence of past disorders has a potential impact on current presentation or differential diagnosis (e.g., differential diagnosis of GAD and persistent depressive disorder). With few exceptions (see below), the next subsection is RATINGS where the features of the disorder are rated dimensionally. This exact name of this subsection varies across diagnostic sections (e.g., SITUATION RATINGS in Social Anxiety Disorder, WORRY RATINGS in Generalized Anxiety Disorder). In many diagnostic sections, this subsection is administered regardless of the patient’s responses to the items in INITIAL INQUIRY (to provide a dimensional assessment of the key features of major disorders). The diagnostic sections where these dimensional ratings are always obtained are: Agoraphobia (new to ADIS-5), Social Anxiety Disorder, Generalized Anxiety Disorder, Obsessive-Compulsive Disorder, Specific Phobia (where the dimensional ratings comprise INITIAL INQUIRY), and Major Depressive Disorder (new to ADIS-5). Diagnostic sections where the dimensional ratings do not have to be administered if the patient has not endorsed any of the INITIAL INQUIRY items are: Panic Disorder, Separation Anxiety Disorder, Posttraumatic Stress Disorder, Persistent Depressive Disorder, Bipolar/Cyclothymia, Alcohol Use Disorder, and Substance Use Disorders (of course, for any section this guideline can be overridden by the researcher in scenarios where obtaining dimensional ratings on all participants is warranted). Three diagnostic sections do not have a RATINGS subsection: Body Dysmorphic Disorder, Illness Anxiety Disorder, and Somatic Symptom Disorder. Another change in the ADIS-5L is the order in which these dimensional ratings are collected. The instructions for administration, which vary somewhat from diagnostic section to diagnostic section, are provided at the beginning of the RATINGS subsection. The key revisions are that (a) current and past dimensional ratings are no longer collected at the same time in any diagnostic section; and (b) in many cases, past ratings will not need to be collected at all. In our experience, the simultaneous collection of current and past ratings was often confusing to patients. The reordering of administration now present in the ADIS-5L may foster the accuracy of current and past dimensional ratings. The omission of past ratings, when not needed, will save administration time. Using the Social Anxiety Disorder section as an example, below are abridged instructions from the SITUATION RATINGS subsection: CURRENT social situation ratings should be obtained for: (a) patients who do not report current or past social anxiety; and (b) patients who report current social anxiety only. If patient only reports past social anxiety, initially obtain PAST social situation ratings. In these cases, CURRENT symptom ratings should then be obtained after establishing either: (a) a past diagnosis of Social Anxiety Disorder in the PAST EPISODE section (e.g., to determine partial/full remission); or (b) the absence of past Social Anxiety Disorder diagnoses after administration of the PAST EPISODE section or determining the absence of clinically significant social anxiety symptoms after administering PAST social situation ratings. For patients endorsing both current and past episodes, CURRENT social situation ratings should be obtained first and PAST ratings should be obtained after completing the CURRENT EPISODE section.

Thus, for the patient who only endorses current social anxiety, or denies a history of current or past social anxiety, only CURRENT dimensional ratings are obtained (unlike the ADIS-IV-L, PAST ratings are not administered). For a patient who endorses past social anxiety only, the PAST situation ratings are obtained first. If evidence of past social anxiety disorder is noted, the interviewer then

9 administers the PAST EPISODE subsection. CURRENT situation ratings are then administered (e.g., to determine partial/full remission of the disorder). If no evidence of past social anxiety disorder is noted after administering the PAST situation ratings, the CURRENT situation ratings are nonetheless collected next (Social Anxiety Disorder is one of the diagnostic sections mentioned above where the key features of the disorder are rated dimensionally for patients, regardless of whether a full DSM-5 diagnosis is under consideration). For patients who endorse both current and past episodes, CURRENT social situation ratings are obtained first and PAST ratings are obtained after completing the CURRENT EPISODE section. Hopefully, this revised order of administration will bolster the quality of the dimensional ratings (e.g., PAST ratings are obtained after a current episode has been assessed, both sets of ratings are collected separately and in context of the type of episode that is being evaluated). The third section is CURRENT EPISODE, which contains the items necessary for establishing a current DSM-5 diagnosis as well as items to assist in differential diagnosis (e.g., whether the symptoms might be due to a medical condition or the effects of a substance). This section also includes questions to ascertain the date of onset of the disorder as well as factors that may have had etiological significance in the emergence of the disorder (e.g., stressful life events). In determining the onset of a disorder (and remission of a disorder in the PAST EPISODE section of the ADIS5L), the items in this section are intended to distinguish between the emergence of the “features” of the disorder and the onset of the disorder itself (i.e., the date in which the symptoms constituted a diagnosable condition by DSM-5 standards). Many patients, when questioned about the onset of a problem, will relate this question to the beginning of the symptoms rather than to when the symptoms met diagnostic threshold for a DSM-5 disorder. For example, patients with panic disorder may relate the onset of their problem to their initial panic attack, which may or may not have coincided with the beginning of their panic disorder. Additionally, patients with GAD often report that they have been worriers all of their lives. However, closer questioning reveals that the worry did not create significant distress or impairment until a more recent time, perhaps in response to a specific change in life circumstances. Although the ADIS-5 questions regarding onset are worded quite succinctly (e.g., “When did your fear and avoidance of social situations become a problem?”), these questions are notated with the reminder to the interviewer that onset refers to the date when the symptoms met the threshold for a DSM-5 disorder; i.e., the interviewer may need to engage in additional questioning to ensure that dates provided by the patient correspond to the time when the symptoms first met the DSM-5 threshold. When the patient is vague in relating the date of onset, a more specific date of onset might be obtained by having the patient associate the time of onset to objective life events with known dates (e.g., marriage, graduation, start of job, etc.). For clinical and research purposes where the temporal sequence of disorders or dates of onset and remission of disorders needs to be established even more precisely, the ADIS-5L contains a Diagnostic Timeline (DTL) that should be administered at the end of the interview. The specific instructions for the administration of the DTL are found in Appendix A of this manual. The final questions in the CURRENT EPISODE subsections inquire about whether past episodes of the same disorder may have existed. Although a similar item resides in the INITIAL INQUIRY section, these questions are asked here because the interviewer now has a firm sense of whether the patient currently meets diagnostic criteria for the disorder in question. With this knowledge, the interviewer can establish with greater certainty whether a separate, prior episode has occurred.

10 In the ADIS-5L, the section for PAST EPISODE is located after the CURRENT EPISODE section. (Of course, if the patient’s responses to the items in INITIAL INQUIRY indicate the presence of a past disorder only, the interviewer would skip over the CURRENT EPISODE section). In most cases, this section is identical to the CURRENT EPISODE section with the exception that the items have been altered to the past tense. Additional items that occur in this subsection concern the assessment of the date of remission of the disorder, the factors that may have been related to the remission, and queries as to whether additional, discrete episodes of disturbance have occurred (either before or after the episode that was just assessed). For disorders that tend to be more episodic in nature (e.g., panic disorder, major depression), the PAST EPISODE subsection was designed to allow the interviewer to record more than one past episode. In the Major Depressive Disorder and Bipolar/Cyclothymia sections, when multiple past episodes are present, the ADIS-5 prompts the interviewer to collect information on the first episode and the second or worst episode (more detailed instructions can be found in these diagnostic sections). The Major Depressive Disorder and Persistent Depressive Disorder sections contain an additional subsection, SPECIFIERS. DSM-5 has introduced a much more elaborate array of specifiers that can be applied to a mood disorder diagnosis. Although most of the information needed for these specifiers is obtained in other areas of the ADIS-5, the SPECIFIERS subsection contains additional inquiry needed for assigning these specifiers.

Administering the ADIS-5 General considerations. Although all attempts have been made to make the inquiry in the ADIS-5 as detailed and explicit as possible, at times further elaboration or clarification will be required for the patient on the various items. Often, the interviewer will need to exercise clinical judgment to determine if further inquiry is necessary, and to ascertain whether the patient’s response is satisfactory for the information that is being requested. Thus, it is critical that the interviewer be familiar not only with the ADIS-5 protocol and this manual, but with DSM-5. This also implies that, although items presented in bold type represent the suggested phrasing of the inquiry, clinical judgment may be necessary to determine if the item should be administered as worded or whether the item should be rephrased to meet the demands of the patient or to maintain continuity of the interview. For example, depending on the intellectual or educational characteristics of the patient, some items in the ADIS-5 may need to be reworded due to the reading level or length of the item. Similarly, as the interview progresses, symptoms that the patient endorsed in prior sections of the ADIS-5 may overlap with symptom inquiry in subsequent sections (e.g., administration of screening items for Persistent Depressive Disorder following the Major Depressive Disorder diagnostic section). In many instances, there are specific questions in the diagnostic sections that address these relationships, and the interviewer can alter the wording of some questions to reflect the fact that prior inquiry has been made for these symptoms. For example, if it has been previously established that the patient meets diagnostic criteria for panic disorder, the initial screening item in the generalized anxiety disorder section might be rephrased by asking: “Other than the worry that you have about having panic attacks, over the last several months, have you been continually worried or anxious about a number of events or activities in your daily life?”

11 In some sections (e.g., Panic Disorder), it is possible to reach an ADIS-5 skip-out after only a few dichotomous items have been administered. In these instances, some elaboration or clarification of the patient’s initial response may be necessary to determine whether a positive or negative rating is warranted. When establishing dimensional ratings within the RATINGS subsection or when administering the items contained in CURRENT and PAST EPISODES, clinical judgment is often necessary to determine the extent to which additional inquiry beyond the items presented in the ADIS-5 is needed to record the most accurate response (e.g., ascertaining whether the patient’s symptom endorsement relates to the disorder in question or whether these symptoms relate to a cooccurring disorder; determining if the patient is differentiating past and current episodes adequately; determining if the patient comprehends the question sufficiently). During the CURRENT EPISODE subsection (as well as the subsection for PAST EPISODE), clinical judgment is necessary to determine whether the remainder of the section can be skipped if the patient’s responses indicate the diagnostic criteria are not met. For example, in a patient who has responded affirmatively to the initial questions for social anxiety disorder, and who shows some current anxiety and avoidance of social situations from responses to the dimensional items contained in SITAUATION RATINGS, inquiry should proceed to the CURRENT EPISODE section. If questioning in this section reveals a negligible degree of distress or interference associated with the social concerns, the interviewer may decide to omit the remaining questions. Establishing current and past diagnoses. As noted earlier, the final items in INITIAL INQUIRY are intended to permit the interviewer to make an initial determination of whether the key features of the disorder have been present continuously, or if there have been discrete episodes, separated by periods of remission. Emotional disorders often have a fluctuating course and the interviewer must attempt to determine if there have been discrete episodes of a disturbance, as opposed to the continuation of a long-standing episode with fluctuations in the severity or persistency of symptoms. Such fluctuations should not be considered as separate episodes unless the inquiry establishes a significant period of time during which the patient was symptom-free. In addition to the initial questions concerning the presence of separate, past episodes, questions residing in the CURRENT and PAST EPISODE sections are provided to assist the interviewer in making this determination with greater accuracy. During the initial inquiry, the interviewer should establish a rough time frame for the onset and remission of the symptoms, and refer to this time frame during the CURRENT and PAST EPISODE sections that follow. If there is evidence of multiple episodes initially, the interviewer should take care to indicate to the patient the particular episode to which the questions refer. Many questions in the diagnostic sections have suggested phrasing to assist the interviewer in this endeavor. As noted earlier, in three diagnostic sections (Panic Disorder, Major Depressive Disorder, Bipolar Disorder), the ADIS-5L provides space to record two past episodes of the disorder. Although occurring less frequently than in panic disorder, major depression, and bipolar disorder, the interviewer will encounter cases of multiple past episodes of disorders where the ADIS-5L provides space to record a single past episode. In these instances, the interview should be adapted to meet the diagnostician’s requirements, whether they be clinical or empirical. For example, the diagnostician may opt to inquire about the worst, first, or most recent episode, or for research purposes, may decide to inquire about all prior episodes by adapting the protocol or by using copies of PAST EPISODE sections from other protocols. For clinical purposes, it may be important to inquire about the episode

12 that the patient regards as the worst episode in instances where it is not clear that the diagnostic threshold has ever been met. In other cases, it may be important to inquire about a past episode whose onset appears to be contiguous with the emergence of another disorder, for the purposes of differential diagnosis and to ascertain if diagnostic hierarchy rules apply. Assigning diagnoses. The page with the heading, CLINICIAN’S RATINGS AND DIAGNOSES, is used to record DSM-5 diagnoses, their clinical severity ratings, and their dates of onset and remission. DSM-5 has done away with five-axis diagnosis, and thus the CLINICIAN’S RATINGS AND DIAGNOSES page has been revised extensively from its previous version in the ADIS-IV. Nevertheless, the CLINICIAN’S RATINGS AND DIAGNOSES page does provide space to record open-ended information on the patient’s medical conditions and life stressors (akin to Axis III and Axis IV in DSM-IV). In addition, the clinician may provide a dimensional rating of the patient’s overall distress/lifestyle impairment using the same 0–8 clinical rating scale used for individual diagnoses. Last, space is also provided to record the duration of the interview and a diagnostic confidence rating (0–100 scale, where 100 reflects complete certainty), which is a global rating to reflect the interviewer’s overall confidence in the accuracy of the diagnoses that were assigned. Space is provided to comment on the factors associated with the diagnostic uncertainty in instances where the interviewer assigns a confidence rating of 70 or less (e.g., “patient’s report was quite inconsistent,” “difficulty in establishing the diagnostic boundary between social avoidance and agoraphobic avoidance”). Each current and past diagnosis that is listed should be assigned a separate clinical severity rating (CSR) using the 0–8 scale that appears at the top of the page. This rating reflects the degree of distress/interference associated with the particular diagnosis. Thus, this rating differs from the Axis V GAF rating (in DSM-IV), which was intended to be an index of the patient’s overall level of functioning. Accordingly, the diagnostician assigns a separate CSR for each diagnosis that is recorded. CSRs are used to distinguish clinical and subclinical diagnoses. Accordingly, CSRs of 4 or above signify that the patient’s symptoms meet or surpass the diagnostic threshold to qualify as a DSM-5 disorder (i.e., all the diagnostic criteria for the disorder have been met). Subclinical diagnoses are assigned CSRs of 3 or less. For example, symptoms that are just under the DSM-5 diagnostic threshold might be given a CSR of 3. A clinical example of this would be a person who has a prominent fear of spiders but has never met the DSM-5 interference/distress criterion for specific phobia (e.g., because the person lives in the city and never encounters spiders). CSRs of 3 or less would also be used in association with diagnoses that are in full or partial remission. In instances where more than one diagnosis is assigned, the disorder recorded as the “principal diagnosis” is the disorder that the interviewer determines to be responsible for the greatest level of distress or interference in functioning. However, the interviewer may occasionally determine that two or more diagnoses exist that are equally the most problematic; in such cases, the diagnoses would be recorded as “co-principal diagnoses.” If other disorders are present but are not as problematic, they are listed as “additional diagnoses.” It is important to note that a longer standing disorder is not necessarily the disorder that is assigned as the “principal diagnosis.” Subclinical diagnoses can be recorded in the space provided for additional diagnoses. A noteworthy change in the ADIS-5 pertains to the assignment of CSRs for principal and additional diagnoses. In prior versions of the ADIS (e.g., ADIS-IV), the principal diagnosis was also

13 assigned the highest CSR (when two or more disorders were present). In the ADIS-5, it is permissible for the principal diagnosis to be assigned the same CSR as one or more additional diagnoses, when conditions warrant. Thus, listing a diagnosis under the Principal Diagnosis heading will denote principal diagnosis status, not the CSR. This change was prompted by our experience that having to adhere to the guideline that the principal diagnosis must have the highest CSR often skewed the CSRs that were assigned by interviewers. For instance, consider the example where two current diagnoses are present and both are just above the DSM-5 threshold, but one is slightly more interfering than the other (e.g., the presenting complaint of the patient). Although both diagnoses should probably be assigned a CSR of 4, in earlier versions of the ADIS, the slightly more interfering diagnosis would be “bumped” to a CSR of 5 so it can be listed as the principal diagnosis. In our experience, this adjustment of CSRs was more prone to occur in context of multiple diagnoses where the interviewer wished to convey the proper rank order of relative clinical severity. In the ADIS-5, CSRs should be assigned for a given disorder without consideration of the CSRs provided to co-occurring disorders; principal versus additional diagnostic status will be conveyed categorically (by listing under proper heading), not quantitatively. Hopefully, this revision will bolster the veridicality of the CSR ratings. A caveat on the CSR and guidelines for assigning dimensional ratings. It is important to note that, unlike the dimensional ratings in the ADIS-5 diagnostic sections, the CSR is not truly a dimensional rating because a cutoff of 4 is imposed to denote diagnoses meeting the DSM-5 threshold. Although the CSR is frequently treated as a continuous measure in applied clinical research (e.g., as an outcome measure in treatment research), researchers should be mindful of its non-dimensional qualities (e.g., in a study of patients with DSM-5 panic disorder, none of the participants would have a CSR less than 4 and most would have a CSR between 4 and 6 because the upper end of the CSR scale is not used as frequently). Unlike the CSR, the 0–8 ratings within the diagnostic sections should be treated by the interviewer as dimensional scales. Some interviewers have the mistaken impression that, for a symptom to “count” toward a DSM diagnosis, it must be rated 4 or higher (e.g., to denote that irritability is one of the associated symptoms meeting the threshold for GAD, it must by default be given a severity rating of 4 or above). This is an unfortunate carryover of the CSR guidelines that, for research purposes, compromises the dimensionality of these ratings. Thus, it is important to emphasize that symptoms, interference/distress, and so forth within the diagnostic sections should be rated dimensionally based on their actual severity and without consideration of diagnostic threshold issues. Symptoms do not have to be rated 4 or higher for them to count toward a DSM-5 diagnosis. Last, interviewers are encouraged to use the full range of the CSR and dimensional rating scales. For instance, in our experience, interviewers are often reluctant to assign a CSR of 8 to a very severe disorder based on the reasoning that a rating of 8 should be reserved for the most profoundly severe cases (i.e., although the present case is very severe, there are cases even more severe than this somewhere out in the population). Interviewers should not hold back from assigning high CSRs (or dimensional ratings) based on this reasoning. Although CSRs assigned to DSM-5 threshold diagnoses are generally apt to have a restricted range (e.g., most CSRs range between 4 and 6), this range should not be further compressed by interviewer effects stemming from avoidance of using the extreme ends of the CSR scale. Diagnostic Timeline. The final page of the ADIS-5L contains the Diagnostic Timeline (DTL). The purpose of the DTL is to refine, review, and obtain more specific information regarding the age

14 of onset/remission and relative sequence of past and current disorders and corresponding life events. The DTL is administered after the interviewer has covered all diagnostic sections of the ADIS-5L. Thus, at the point that the DTL is conducted, the interviewer has determined which current and past disorders to inquire about and has the approximate dates of onset/remission. The DTL has been developed primarily for research purposes where it is important to collect specific data on issues such as the temporal sequence of disorders and factors relating to the onset/remission of disorders (e.g., life events). Instructions for the administration of the DTL are found in Appendix A.

Establishing Differential Diagnoses: Some Examples Throughout the previous sections, it has been noted that considerable clinical knowledge and judgment is necessary to administer structured interviews proficiently and to establish diagnoses accurately. This can be particularly difficult when evaluating patients who present with symptoms that potentially meet criteria for multiple disorders. In these instances, the interviewer must employ DSM-5 guidelines to determine which diagnoses are assigned and which are excluded. Often, differential diagnosis is difficult given the overlapping features of the emotional disorders. In DSM-5, the guidelines for such differentiation are reasonably explicit, although this varies from disorder to disorder. Often, the basic determination is whether certain symptoms can be subsumed under the features of another disorder. For example, a diagnosis of specific phobia would be not be warranted in cases where the phobic stimulus is part of the obsessional symptoms of an OCD. Similarly, avoidance of social situations that has developed as a result of panic disorder would not warrant a social phobia diagnosis. The following examples illustrate the use of some of these guidelines and offer suggestions for the differential diagnosis required by DSM-5. Generalized anxiety disorder. In DSM-5, GAD can be assigned if the focus of excessive anxiety or worry is not confined to the features of the coexisting disorder (Criterion F). Thus, differential diagnosis involving GAD may not always be clear particularly in light of findings that patients with GAD usually have at least one additional diagnosis (cf. Brown, Campbell, et al., 2001). For example, patients with GAD frequently have comorbid panic disorder, yet excessive worry about experiencing a panic attack would not constitute a GAD-related worry. Rather, the focus of the anxiety or worry is on a feature of panic disorder (i.e., having additional unexpected panic attacks). Therefore, as specified in DSM-5, the focus of the patient’s anxiety and worry must not be better accounted for by (or secondary to) another disorder if a diagnosis of GAD is to be assigned. A second example where this differentiation may be difficult is the area of health concerns. These concerns might be found in GAD, but are often prominent in illness anxiety disorder. However, the health-related worries of patients with illness anxiety disorder are typically more persistent, fixed, and enduring, whereas health-related worries of patients with GAD are often more general and future oriented in nature, and constitute just one of several areas of worry. The DSM-5 revisions to the criteria for GAD have introduced one significant source of potential confusion and lack of clarity. In DSM-IV, a diagnostic hierarchy rule existed with mood disorders (and other conditions including posttraumatic stress disorder and psychotic disorder), which stated that GAD should not be assigned if its features occurred exclusively during the course of a mood disorder. This hierarchy rule has been removed from the formal DSM-5 diagnostic criteria

15 set for GAD. However, in the text accompanying the DSM-5 GAD criteria, aspects of the hierarchy rule remain: “Generalized anxiety/worry is a common associated feature of depressive, bipolar, and psychotic disorders and should not be diagnosed separately if the excessive worry has occurred only during the course of these conditions (American Psychiatric Association, 2013, pp. 225–226; DSM-5 no longer includes a hierarchy rule with posttraumatic stress disorder). Thus, while retaining some aspects of this hierarchy, DSM-5’s stance is less defined given lack of formal representation in the diagnostic criteria set. While this hierarchy rule has advantages (it precludes assigning a patient an additional disorder that may simply remit after successful treatment of the “higher order” condition), in our experience it does have several drawbacks, such as failure to formally recognize clinically significant symptoms that are subsumed under another condition (Lawrence, Liverant, Rosellini, & Brown, 2009; in the case of mood disorders, DSM-5 addresses this in part with the new “with anxious distress” specifier). In addition, when GAD is subsumed under another disorder, this may distort the clinical severity rating assigned to the subsuming disorder. In some cases, the GAD symptoms are more severe than the disorder under which it must be subsumed. Consequently, the subsuming disorder is assigned a higher clinical severity rating than it would have received if the co-occurring GAD features were not present. Specific phobia. This diagnosis would be contraindicated if the symptoms of fear and avoidance are better explained by another disorder. For example, an obsessive-compulsive disorder characterized by a fear of contamination might include a phobic avoidance of dirt. If this is the case, a diagnosis of specific phobia of dirt would not be appropriate. Similarly, a fear of heights may be part of agoraphobia, if being in a tall structure represents a situation in which escape would be difficult in the event of a panic attack. Differential diagnosis can be difficult in some instances because patients often report more than one reason for being fearful of the same situation or object. For example, the patient with panic disorder and agoraphobia might state that s/he fears and avoids air travel. Should this fear be subsumed under agoraphobia or does it constitute a separate diagnosis of specific phobia? Ascertaining the focus(es) of concern should begin to resolve this diagnostic issue. In the aforementioned example, the patient could indicate that s/he is apprehensive of air travel because (1) s/he could have an unexpected panic attack on the plane and be unable to escape, and (2) s/he is extremely concerned that the plane will crash. The presence of the second focus of concern raises the possibility that a separate diagnosis of specific phobia should be assigned. In addition, further inquiry may reveal that the fear of flying had a different age of onset than the agoraphobia (e.g., predated the agoraphobia by 15 years), thus providing additional support for the independence of the diagnoses under consideration. Note that the formal typology for panic attacks that was introduced in DSM-IV has been removed in DSM-5. Nevertheless, DSM-5 still recognizes that panic attacks can occur in the context of a range of disorders. This is noted formally by the new “with panic attacks” specifier that can be assigned to accompany any disorder if the condition is associated with features that meet the DSM-5 threshold for panic attacks (e.g., “specific phobia with panic attacks”). The criteria for the panic attack specifier are identical to the panic attack criteria in panic disorder (hence, in the ADIS-5, both the specifier and panic disorder are assessed in the Panic Disorder diagnostic section). Social anxiety disorder. As with specific phobia, the diagnosis of social anxiety disorder would be contraindicated if the symptoms are better accounted for by another condition such as agoraphobia or body dysmorphic disorder. For example, many patients with agoraphobia avoid social

16 situations because of a fear of panic. In such cases, an additional diagnosis of social phobia is not made. In other cases, the interviewer might judge the social avoidance to be related to an independent social phobia, as in patients who have a history of social avoidance that predates the onset of the agoraphobia. An obsessive-compulsive disorder is often associated with avoidance of social situations that might be incorrectly classified as social anxiety disorder. An example of this would be the patient who avoids social situations, particularly church, because these situations trigger obsessive urges to shout obscenities. Another example is the patient who evidences extensive avoidance because s/he is preoccupied with the possibility that s/he will stare at others’ genital areas. This patient may report apprehension of negative social evaluation, but this apprehension is due to his concern that he will get “caught looking.” A final example is the patient who avoids crowds due to the fear that s/he will become contaminated by germs. In all these examples, a diagnosis of social anxiety disorder would not be assigned. It is also noteworthy that social anxiety disorder, as well as specific phobia, is one of the disorders more frequently assigned at intake as a subclinical diagnosis. This is in cases where a prominent social fear is evident, but the fear is associated with minimal interference and distress (e.g., a plumber reporting paralyzing public speaking anxiety in school who states that s/he would still be terrified by this situation, but his/her current life situation precludes public speaking scenarios). An advantage of the ADIS-5 is its ability to recognize these subclinical presentations that are missed by interviews focused exclusively on DSM-5 threshold conditions.

17 REFERENCES

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Brown, T. A. (2007). Temporal course and structural relationships among dimensions of temperament and DSM-IV anxiety and mood disorder constructs. Journal of Abnormal Psychology, 116, 313–328. Brown, T. A., & Barlow, D. H. (2005). Categorical vs dimensional classification of mental disorders in DSM-5 and beyond. Journal of Abnormal Psychology, 114, 551–556. Brown, T. A., & Barlow, D. H. (2009). A proposal for a dimensional classification system based on the shared features of the DSM-IV anxiety and mood disorders: Implications for assessment and treatment. Psychological Assessment, 21, 256–271. Brown, T. A., & Barlow, D. H. (2014a). Anxiety and Related Disorders Interview Schedule for DSM-5 (ADIS-5). New York, NY: Oxford University Press. Brown, T. A., & Barlow, D. H. (2014b). Anxiety and Related Disorders Interview Schedule for DSM-5: Lifetime version (ADIS5-L). New York, NY: Oxford University Press. Brown, T. A., Campbell, L. A., Lehman, C. L., Grisham, J. R., & Mancill, R. B. (2001). Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a large clinical sample. Journal of Abnormal Psychology, 110, 585–599. Brown, T. A., Di Nardo, P. A., Lehman, C. L., & Campbell, L. A. (2001). Reliability of DSM-IV anxiety and mood disorders: Implications for the classification of emotional disorders. Journal of Abnormal Psychology, 110, 49–58. Di Nardo, P. A., Moras, K., Barlow, D. H., Rapee, R. M., & Brown, T. A. (1993). Reliability of DSM-III-R anxiety disorder categories using the Anxiety Disorders Interview ScheduleRevised. Archives of General Psychiatry, 50, 251–256. Lawrence, A. E., Liverant, G. I., Rosellini, A. J., & Brown, T. A. (2009). Generalized anxiety disorder within the course of major depressive disorder: Examining the utility of the DSM-IV hierarchy rule. Depression and Anxiety, 26, 909–916. Naragon-Gainey, K., Gallagher, M. W., & Brown, T. A. (in press). A longitudinal examination of psychosocial impairment across the anxiety disorders. Psychological Medicine.

19 APPENDIX A

Anxiety and Related Disorders Interview Schedule for DSM-5: Lifetime Version (ADIS-5L): Diagnostic Timeline (DTL)

A. Overview As noted in the text of the manual, the purpose of the DTL is to refine, review, and obtain more specific information regarding the age of onset/remission and relative sequence of past and current disorders and corresponding life events. The DTL has been developed primarily for research purposes where it is important to collect specific data on issues such as the temporal sequence of disorders or factors relating to the onset/remission of disorders (e.g., life events). However, the DTL may be useful for certain clinical applications (e.g., determination of the temporal sequence of past or current diagnoses for the purposes of differential diagnosis).

B. Procedures The DTL is administered after the interviewer has covered all diagnostic sections of the ADIS-5L. Thus, at the point that the DTL is conducted, the interviewer has determined which current and past disorders to inquire about and has the approximate dates of onset/remission. 1. As information is subject to revision during the process of completing the DTL, a pencil should be used. 2. Using data obtained from the ADIS-5L, record the following on the DTL: (1) in the boxes labeled “DIAG,” list all disorders assigned at a clinical severity level of 4 or above in order of their tentative temporal sequence; (2) underneath each diagnosis, list the corresponding date of onset (DOS) and, where appropriate, date of remission (DOR); (3) above each diagnosis, list any precipitating life events (LES-Ps) noted during the ADIS-5L. 3. Plot the patient’s date of birth (DOB) and today’s date (DATE) on the appropriate ends of the DTL. List the appropriate years over the hash marks on the DTL using whatever interval is appropriate depending on such factors as the patient’s age or temporal spacing of the disorders’ probable dates of onset and remission. 4. Using data previously obtained during the ADIS-5L as well as from the list of examples provided in this Appendix, ascertain and plot several objective life events (LES-Os). An LES-O is a life event in which the specific date is known (e.g., marriage, purchase of home, relocation). In particular, try to obtain LES-Os that occurred around the same time as the tentative dates of onset and/or remission of disorders. 5. Usually, it is best to inquire about current disorders prior to trying to refine information concerning past disorders, although exceptions often apply. For example, many times the

20 patient is certain about the onset/remission of their disorders (either current or past) due to their recent onset or remission or due to the fact that the disorder began immediately after an objective life event (e.g., initial panic attack immediately following birth of child, posttraumatic stress reaction precipitated by criminal assault). For disorders in which the patient is definite as to the date of onset and/or remission, obtain the first confidence rating for these dates (CONF #1). Plot dates of all disorders on the DTL for which patient reports a definite date of onset (DOS) and/or date of remission (DOR). If CONF #1 ratings are high (≥ 90%), plot the Preceding Year on the DTL. If CONF #1 ratings are low for some dates, use procedures in Step 7. Further refine Precipitating Life Events (LES-Ps) and record or modify them on the DTL. If necessary, employ shaping questions relating to DOSs and DORs by associating the dates with events (LES-Os and LES-Ps) in which the dates are certain (“So you’re sure that your first panic attack occurred after you came back from your trip to Europe but before you started the job at Macy’s?”). 6. Obtain new confidence ratings for these DOSs and DORs (CONF #2). 7. For disorders in which the DOS or DOR is less certain, begin by asking shaping questions as noted in Step 5 (associating the DOS or DOR both in relation to LES-Os as well as in relation to any disorders in which the DOS, LES-Ps, or perhaps DOR is known). Then, obtain initial confidence ratings for the DOS or DOR (CONF #1). Further refine Precipitating Life Events (LES-Ps) and record or modify them on the DTL. If necessary, ask further shaping questions relating to the DOSs or DORs provided in relation to life events (LES-Os and LESPs) for which the dates are known. Then, obtain new confidence ratings for these DOSs and DORs (CONF #2). If CONF #2 remains low (≤ 70%), decide whether further shaping can be done to assist the patient in recalling the correct dates of onset and/or remission. 8. Repeat the steps above for any past diagnosis that was assigned on the ADIS-5L that at one time had a clinical severity of 4 or above. 9. Once all disorders and their corresponding DOSs, DORs, and LES-Ps have been plotted, review the entire DTL one more time with the patient to ensure that the information is correct or whether any additional changes are needed (make any revisions necessary). 10. Immediately after the patient has left, the diagnostician should provide their ratings of: (a) confidence in the accuracy of the dates of onset (Rater: OS) and dates of remission (Rater: OR); and (b) stress ratings for each disorder’s corresponding LES-Ps (Rater: Stress, using 0–8 severity scale). A final note on procedures: As in the ADIS-5L, the interviewer should be certain to inquire about the DOS of the disorder (i.e., date when the patient’s symptoms met DSM-5 diagnostic criteria) rather than when the features of the disorder first emerged (e.g., the patient’s initial panic attack may or may not signify when the onset of panic disorder occurred).

21

C. A nonexhaustive list of examples of life events (either LES-Ps or LES-Os) that might be included in the DTL procedure Annual events: holidays (e.g., Christmas, Thanksgiving, New Year’s); vacations, end of school year, season of the year, family reunions or get-togethers; non-annual: marriage, marriage of family member/close friend, divorce/separation, graduation (self or family member), start or termination of job (self or family member), change in job status (e.g., raise, promotion, demotion), departure of family member from home, change in schools or church, relocation to new area or new home, purchase of home, health problem or operation (self or significant others), injury/accident (self or significant others), financial difficulties, death of family member or significant other, vacation, victim of crime, natural disaster (hurricane, earthquake, flooding).