SCID 5 Training

Ryan Melton, EASA Clinical Director

Oregon Health & Science University
rymelton@pdx.edu
www.easacommunity.org

Disclosures
Dr. Melton has never received any funding or
consulting fees from the American Psychiatric
Association or from any pharmaceutical company.
DSM and DSM-5 are registered trademarks of the
American Psychiatric Association. The American
Psychiatric Association is not affiliated with nor
endorses this seminar.

"I am an MD and I can prescribe drugs

for mental disorders, but mental
disorders are extremely rare." and
"People don't come to counselors with
mental disorders but with problems in
living.Those problems are normal, and
our clients deserve to be treated as
normal.They need help solving those
problems, not diagnoses.“
-William Glasser

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 “If the disorder does not
usefully inform that
person’s diagnosis,
treatment, or prognosis,
then the diagnosis is
considered inappropriate”
(Nussbaum, 2013, p. 10)

Mental illness and substance use disorders

account for 60% of the non-fatal burden of
disease amongst young people aged 15-34 (Public
Health Group 2005)
• 75% of mental health problems occur before
the age of 25 (Kessler et al 2005)
• 14% of young people aged 12-17, and 27% of
young people aged 18-24 experience a mental
health problem in any 12 month period
(Sawyer et al 2000, Andrews et al 1999)

Who CSC Programs Accept (typical but

varies program to program)
• Age 15-25, consistent with psychosis risk,
schizophrenia related psychosis or bipolar psychosis.
(Variation across programs regarding age)
• First psychosis within last 12 months (some go a few
as 6, others go 5 years)
• People screened out are supported to engage with
appropriate services
• No IQ under 70, symptoms due to medical condition
or clearly due to illicit drugs.
• Many programs using SCID and/or SIPS for
eligibility criteria

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 7

Symptoms of Acute Psychosis

Hallucinations
Delusions
Disorganized speech
and behavior
Negative Symptoms
Cognitive & sensory
problems
Inability to tell what
is real from what is
not real

What Can Cause Psychosis?

 Vulnerability
 Steroids
 Frontal lobe epilepsy
 Stimulants
 LOTS of medical
 Methamphetamine
conditions
 Brain tumors
 Schizophrenia
 Trauma
 Bipolar disorder
 Sleep deprivation
 Depression
 Severe stress
 Anxiety disorder
 Sensory deprivation
 Bullying
 And others…

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Symptoms of psychosis do not imply
diagnosis of schizophrenia
Drugs Stress
Medical Illness

Trauma

ADHD
PSYCHOSIS Autism/Aspergers/P
DD

Depression
Schizophrenia

Facticious/Malingering
Personality

Mania ODD

Differential Diagnosis of
Psychotic Disorders
Psychosis vs. “psychotic-like experiences”
 Challenging dynamic
 Qualities of Psychosis include:
◦ Egosyntonic and yet role functioning impairment
◦ Bizarre
◦ Frequent (daily for hours)
◦ Described as outside of self (hallucinations) (3rd person-look at him)
◦ Objective findings (mental status changes: thought processes, emotional
expression)
◦ Disorganized speech & behavior
 Qualities of “PLEs” include:
◦ Egodystonic and less role impairment
◦ Nonbizarre
◦ Episodic (once a day), brief
◦ Described as “inside” of self
◦ Visual hallucinations
◦ Lack of objective findings on MSE
◦ Alternative meaning or value

Differential Diagnosis of
Psychotic Disorders
 Benign Psychosis
◦ Sleep and stress
 DSM rules on Differentials (SUD/MED)
 Medical symptoms to explore
◦ Fidgety
◦ Catatonia
◦ Tremor
◦ Protruding eyeballs
◦ Attention/Concentration problems
 Psychosis associated with a medical condition
◦ Migraines
◦ Delirium
◦ Seizures

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Differential Diagnosis of
Psychotic Disorders
 Must rule these out as primary Dx for EPP (Also
stressed in DSM)!
◦ 30 days!
 Psychosis associated with medication
◦ Antibiotics
◦ Accutane
 Psychosis associated with psychotropic medication
◦ Stimulants (RARE)
◦ Steroids
 Substance Use
◦ Methamphetamine
◦ Cannabis

Differential Diagnosis of
Psychotic Disorders:
Drugs
◦ Most complicated and challenging
◦ Quite common
◦ Presence of active substance use
◦ Very similar to the quality of psychosis seen in
major thought and mood disorders
◦ Can be co-morbid
◦ Late adolescent to young adult
◦ Acute onset and speedy resolution
◦ Visual hallucinations, disorientation, labile mood
and affect

Cannabis
 Increases the risk of schizophrenia by 6
times
 Earlier age of onset (3 years earlier)
 More psychotic symptoms
 Poorer response to medications
 Poorer functional outcome
 Increased hospitalization rate

 Patel (2016)

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Cannabis
 Cannabis psychosis
◦ odd and bizarre behavior
◦ violence and panic
◦ less thought disorder
◦ better insight
 People who use cannabis on a daily basis were 2.4
times more likely to report psychotic symptoms
than non-users
 Up to half with CIP convert to Schizophrenia with
higher rate of conversion with younger use.
◦ Higher rate of conversion than meth and hallucinogens
 Ghose (2018)

Methamphetamine
 Methamphetamine is  Psychotic sxs. Occur
an addictive in about 40% of meth
stimulant drug depend. Persons
 releases high levels
 Psychotic sxs. Can
of dopamine
occur in response to
 damages brain cells
stress
that contain
dopamine and
serotonin

Methamphetamine
 Methamphetamine psychosis:
◦ Can look similar to schizophrenia or bipolar
◦ Extreme irritability
◦ Visual hallucinations
◦ Aggressive behavior
◦ Paranoia
◦ Post-episode depression and withdraw

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Psychosis in drugs
 CAN YOU TELL THE DIFFERENCE?
 1st episode differentials (premorbid):
◦ Family HX of SUD
◦ DX of SUD
◦ Antisocial personality traits or DX
◦ More likely to have friends
◦ Age

Psychosis in drugs
 1st episode differential (current episode)
◦ Acute onset
◦ Positive UDS
◦ Visual Hallucinations
◦ Increased insight into psychosis
◦ If delusions present more likely to be
paranoid.
◦ Increased agitation and violence
◦ Less negative symptoms and disorganization
◦ More difficult to engage in MH tx.

By ManuelFD

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The SCID!!!
 What it does and what it doesn’t do.
 Who to use the SCID with and who not to
use it with.
 Follows DSM 5 decision tree.
 Although it is a structured interview but
it still requires clinical judgment and
competence.
 Do’s and Don’ts
 Practice Practice Practice!!!

Specifics of the SCID

 Multiple versions  Primary and
including separate secondary
SCID PD disorders
 Most appropriate for
adults but can be  Can use multiple
modified for younger sources.
clients.  45-90 mins to
 10 Modules with complete
varying time frames*
 You rate criteria
items and not
responses.

Specifics of the SCID

 3 column format for  Multiple clauses in
most sections and diff criterion sets
dx decision tree for
others.  Consideration of tx
 Use of “skip-outs” effects
 When to use lifetime  Other specified and
questions. unspecified
 Verbatim questions. disorders
 Parenthetical  The double negative
questions. dilemma.
“own words”

 Clinical significance
 Descriptive info criteria

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Definition of a Mental Disorder
“A syndrome characterized by clinically
significant disturbances in an individual’s
cognition, emotion regulation, or behavior that
reflects a dysfunction in the psychological
Genetics
biological, or developmental processes underlying
distress or disability in social,
occupational, or other important activities.
Common
An expectable or culturally approved response
to a common stressor or loss…is not a
mental disorder.
Neurocircuitry Environmental
Socially deviant behavior…and conflicts that
Exposure are primarily between the individual and
society are not mental disorders unless the
deviance or conflict results from a
dysfunction in the individual, as described
above” (APA, 2013, p. 20).

MODULE A: MOOD
EPISODES AND
PERSISTENT DEPRESSIVE
DISORDER

Differential Diagnosis of
Psychotic and Affective
Disorders
 Prevalence in clinical populations:
◦ Adolescence 8%
◦ Children 4%
 Children and adolescents with psychosis had the following
conditions:
◦ Major Depressive Disorder 41%
◦ Bipolar Disorder 24%
◦ Depression NOS 21%
◦ Schizophreniform 14%
Findling & Schultz, 2005. Juvenile Onset Schizophrenia

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Differential Diagnosis of
Psychotic Disorders
 Affective psychosis:
◦ Most common psychotic conditions of
childhood
◦ Higher rate of psychosis than their adult
counterparts
◦ Psychosis often related to the mood disorder
◦ Hallucinations are more common in children
 Observed in one-third to one-half of depressed
children
◦ Delusions are more common in adolescents
◦ Mania is rare in children.
Findling & Schultz, 2005. Juvenile Onset Schizophrenia

Types of Mood Episodes

(current and past)
 Manic Episode
◦ Essential feature: Distinct period of elevated mood and
increased activity/energy lasting at least a week
◦ Symptom count: Three other manic symptoms during
that period
◦ Impairment: The mood disturbance is severe
 Hypomanic Episode
◦ Essential feature: Distinct period of elevated mood and
increased activity/energy lasting at least four days
◦ Symptom count: Three other manic symptoms during
that period
◦ Impairment: The mood disturbance is not severe
 Major Depressive Episode
◦ Essential feature: Five depressive symptoms that
persist for at least two weeks

Major Depressive Episode

 Essential features: Either depressed
mood or loss of interest or pleasure
plus four other depressive symptoms
 Duration: At least two weeks (suicide
the exception)
 Common rule outs: Medical condition,
medications, substance use, bipolar
disorder, or a psychotic disorder
 Note: Be careful about diagnosing
major depression following a
significant loss because normal grief
“may resemble a depressive episode.”

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 Grief vs. a Major Depressive Episode in
DSM-5
Grief Major Depression

 Dominant affect is feelings  Dominant affect is depressed

of emptiness and loss
 Dysphoria occurs in waves,
vacillates with exposure to
reminders and decreases
with time
 Capacity for positive
emotional experiences
 Self-esteem preserved
 Fleeting thoughts of joining
deceased
mood
 Persistent dysphoria that is
accompanied by self-critical
preoccupation and negative
thoughts about the future
 Limited capacity to
experience happiness or
pleasure
 Worthlessness clouds esteem
 Suicidal ideas about escaping
life versus joining a loved one

Other Depressive Disorders

 Persistent Depressive Disorder
◦ Rationale for changes
◦ General criteria
◦ Course specifiers
 With pure dysthymic syndrome
 With persistent major depressive episode
 With intermittent major depressive
episodes, with current episode
 With intermittent major depressive
episodes, without current episode

Bipolar I Disorder
 Essential Feature: History of a
manic episode which is usually
accompanied by other types of mood
episodes
 Common rule outs: Disorders in the
schizophrenia spectrum, substance
use (stimulants especially),
medication or medical condition

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 Bipolar II Disorder
 Essential Feature: History of a major
depressive episode and a hypomanic episode
but never has had a manic episode
 Common rule outs: Schizophrenia spectrum
disorders, substance use, medication or
medical condition
 Note by current mood:
- Bipolar II Disorder, current episode
depressed
- Bipolar II Disorder, current episode
hypomanic

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MODULE B: PSYCHOTIC
AND ASSOCIATED
SYMPTOMS

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 Schizophrenia
 Essential features:
◦ Active phase that lasts at least a month. Two or more of the
following are present, with at least one being 1, 2 or 3:
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms
◦ Impairment: Functioning in one or more life areas has markedly
declined since onset
◦ Duration: Symptoms persist for at least 6 months (active phase
plus prodromal or residual symptoms)
◦ Common rule outs: Schizoaffective disorder, bipolar disorder,
depressive disorder, substance use, medication or medical
disorder

SCID Criteria for Schizoaffective Disorder

A. An uninterrupted period of illness during which time,

at some time, there is either a Major Depressive
Episode or a Manic Episode concurrent with
symptoms that meet Criterion A for Schizophrenia

B. During the same period of illness, there have been

delusions or hallucinations for at least 2 weeks in
the absence of prominent mood symptoms

C. Symptoms that meet criteria for a mood episode are

present for a substantial portion of the total
duration of the active and residual periods of the
illness.

Symptoms of schizophrenia
 Hallucinations
◦ 75% auditory hallucinations
 Delusions
◦ 1/5 delusions
 Thought Disorder
 Negative symptoms
 Cognitive and Behavioral Changes

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Negative symptoms

 The most common negative symptoms

seen in schizophrenia:
◦ Affective flattening
◦ Poverty of speech
◦ Inability to expect to experience pleasure
◦ Limited interest in initiating contact (but
may do ok once with people)
◦ Lack of initiative
◦ Inattentiveness

Cognitive impairments

 Most common neurocognitive

impairments:
◦ Working memory
◦ Verbal processing
◦ Executive functions
◦ Sensory deficits
◦ Social cognition

schizophrenia
 Occurs in late adolescence/early
adulthood
 Socioeconomic status may have
impact
 Stress-Vulnerability Model
 Insidious course with wide range of
variability in prognosis.

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 Genetics

43

e.g. Disease Genes, Social and

Possibly Viral
Infections, Environmental
Environmental Early Insults Triggers
Toxins

Vulnerability: CASIS Disability

Cognitive Affective Sx: Social School

Deficits Depression Isolation Failure
Brain
Abnormalities

Structural
Biochemical
Functional

After Cornblatt, et al., 2005

The Schizophrenia “Prodrome"

 ~90% of patients with schizophrenia
experienced a “prodromal stage”
 ~35% of persons who experience prodromal
symptoms will develop a psychotic disorder
 Characteristic symptoms: at least one of the
following in attenuated form with intact
reality testing, but of sufficient severity
and/or frequency so as to be beyond normal
variation:
(i) delusions
(ii) hallucinations
(iii) disorganized speech
Perkins and Lieberman Prodrome and First Episode e in Essentials of
Schizophrenia APA Press, Washington DC 2011

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Thought Content

Attenuated delusion Delusion

A 15 year old high
school student starts to
sit in the back of the
class because if she sits
in the front she has an
uncomfortable feeling
that other students are
whispering about and
laughing at her. She
knows this is “silly”, but
feels better in the back.
A 15 year old high school
student believes that other
people are talking about her,
read her mind, and making
fun of her where ever she
goes. She is sure this is
happening, and she is
isolating herself at home
because she is
uncomfortable in public.

Perception

Attenuated hallucination
About 2 or 3 times a week a 22
year old cashier sees colors on the
wall seeming to be distorted,
textures and waves on the wall.
He has started hearing beeping
sounds that can last for minutes,
and last week he heard a
momentary (a second or two),
faint, unintelligible voice. He is
not sure, but thinks it is most
likely his mind playing tricks on
him.
Hallucination
On an almost daily basis a 22
year old cashier hears voices
speaking to him. They speak to
him outside of his head. They
refer to him in the third-
person. and sometimes
criticize him or tell him to do
something silly, like “pat the
cat”. He believes these voices
are real and he is very
frightened of them.

Differential Dx
 Schizoaffective D/O: Presence of symptoms
that meet criteria for MDE or manic episode
and those symptoms are present the majority
of the time that active or residual psychotic
symptoms are present. 6 months not required.
 Schizophrenia: No mood episodes or if mood
episodes present they are present minority of
time
 Bipolar or MDD with Psychosis: Psychosis
occurs exclusively during manic or MDE
 Other Specific Schizophrenia Spectrum and
other Psychotic Disorder (APS): Symptoms
below threshold and insight intact.

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Differential Dx
 Schizophreniform: Same as
schizophrenia but duration is at
least month but less than 6.
 Delusional Disorder: Primary
delusions for at least one month, no
criteria for schizophrenia can be
bizarre or non-bizarre.
 Brief Psychotic Disorder: At least
one day but less than a month.

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MODULE E:
SUBSTANCE USE
DISORDERS

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 DSM 5: The Diagnosis
Endgame!
“I'm not (bipolar)...
I'm not f**kin'
depressed or manic.
I've been told I was
an axis 2.94 disorder,
but the guy I was
seeing didn't know I
was smokin' crack in
his bathroom. You
can't make a diagnosis
until somebody's
f**kin' sober." (RDJ,
About Health)

Substance Categories in DSM-

5/SCID 5 Alcohol and Non-Alcohol
 Alcohol
 Caffeine
 Cannabis
 Hallucinogen
 Inhalants
 Opioids
 Sedative/Hypnotics/Anxiolytics
 Stimulants
 Tobacco-Related
 Other (or unknown) Substance
 Non-Substance-Related Disorders (Gambling)

Substance-Related and
Addictive Disorders
Criteria
 No more Substance Abuse and Substance Dependence

 Nearly identical to the DSM-IV substance abuse and dependence

criteria combined into a single list

 Nearly all substances are diagnosed based on the same overarching

criteria

 Criteria for intoxication, withdrawal, substance/medication-induced

disorders, and unspecified substance-induced disorders

Threshold = 2 of 11 symptoms
Impaired control (criteria 1-4)
Social impairment (criteria 5-7)
Risky use (criteria 8-9)
Pharmacological criteria (criteria 10-11)
Removed: recurrent legal problems criterion
Added: craving or a strong desire or urge to use a substance

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 Substance-Related and
Addictive Disorders
Substance Use Disorders
 Remission specifiers
 No more partial and full
 Early remission = at least 3 but
less than 12 months without
substance use disorder criteria
(except craving)
 Sustained remission = at least
12 months without criteria (except
craving)
 Severity ratings
2–3 criteria indicate = a mild disorder
4–5 criteria = moderate disorder
6 or more = a severe disorder
Substance Use Disorders
Removed Polysubstance
Abuse/Dependence, Amphetamine &
Cocaine and specifier for a
physiological subtype & On agonist
therapy
 Added
Caffeine Withdrawal
Cannabis Withdrawal
Tobacco-Related Disorder
Stimulant Related Disorder
On maintenance therapy

Alcohol Use Disorder

 Essential feature: Problematic pattern of alcohol use leads to clinically
significant distress or impairment
 Symptom threshold: At least two of the following in a 12-month
period:
1. Taken in larger amounts or over longer period of time than intended
2. Persistent desire or efforts to cut down or control use
3. Much time taken obtaining, using or recovering from substance
4. Cravings or a strong desire or urge to use a substance (new criteria)
5. Recurrent use resulting in failure to fulfill role obligations (work, school, or home)
6. Continued use despite social and interpersonal problems
7. Social, occupational, or recreational activities reduced due to alcohol
8. Recurrent use in hazardous situations
9. Continued use despite physical or psychological problems due to substance
10. Tolerance
11. Withdrawal
 Specifiers:
◦ Early remission
◦ Sustained remission
◦ In controlled environment
 Specify Severity:
Mild (2-3 symptoms), Moderate (4-5 symptoms) or Severe (6 or more)

Substance/Medication-Induced
Psychotic
DSM-5, American Psychiatric Association

A. Hallucinations or delusions
B. Evidence of both:
1. onset during or soon after
intoxication, withdrawal
2. substances capable of inducing
C. Not better accounted for by
another psychotic disorder
D. Not exclusively during delirium
E. Significant distress or functional
impairment

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Differential Dx
 Substance Induced Psychotic DO:
Psychosis present while on or shortly
after use of substance (THC, other
hallucinogens, stimulants, synthetics,
prescribed medications). DSM
recommends 30 days.
 Schizophrenia: No substances
required, and if substances are used,
the sx predated use or does not fit
SUD pattern.

Differentiating SIP from

Schizophrenia
 Are substances triggering or
maintaining?
 Do symptoms correspond to
substance?
 Do symptoms fit psychotic disorder?
 Temporal relationship between
substance use and symptoms
 Behavioral experiment
◦ Do symptoms remit or persist?

60

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 MODULE F: ANXIETY
DISORDERS

Organization of SCID 5/Module F

 Panic Disorder
 Agoraphobia
 Social Anxiety Disorder (Social Phobia)
 Generalized Anxiety Disorder
 Substance/Medication Induced Anxiety
Disorder
 Anxiety Disorder Due to a Medical
Condition

MODULE G: OBSESSIVE
COMPULSIVE DISORDER
AND POSTTRAUMATIC
STRESS DISORDER

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Posttraumatic Stress Disorder

 Essential feature: Significant reaction to serious traumatic event that

involves actual or threatened death, serious injury or sexual violation
 DSM-5 and SCID 5 specifies how event has to be experienced:
1. Directly experiencing
2. Witnessing in person
3. Learning the event happened to a close family member or friend
4. Repeated exposure to aversive details of event (e.g., first
responders)
 Symptoms are now from four general groups:
◦ Intrusive symptom (1) (e.g., intrusive memories, dreams, flashbacks)
◦ Avoidance of reminders (1) (e.g., avoiding people, places, activities)
◦ Negative alterations in cognition and mood (2) (e.g., self-blame,
hopelessness, dissociative symptoms, negative emotional states)
◦ Alterations of arousal and reactivity (2) (e.g., hypervigilance, sleep
problems, self-destructive behaviors)
 Duration: Symptoms persist for at least a month
 DSM-5 provides an alternative criteria set for children 6 years and
younger

PTSD
 Post-Traumatic Stress Disorder
◦ Less response to medications
◦ Improved with sensitive psychosocial
interventions
◦ Hallucinations in 75-95% of clients
 Often in 2nd person (you are a whore)
◦ psychosis is “trauma” related
◦ Impulsive, aggressive, and self-abusive
behaviors are present
◦ Blames self
◦ Overlap with BPD

Differentiating PTSD &

Schizophrenia
 20% of people with PTSD experience
psychosis
◦ With dissociative symptoms specifier in DSM
◦ No psychotic features specifier
 Childhood trauma - risk for schizophrenia
 Re-experiencing vs hallucinations/delusions
 Are hallucinations related to trauma?
 What are themes of delusions ?
 Graphic nature of experience common

22
Differential Diagnosis of
Psychotic Disorders: Anxiety/Trauma

◦ Quite common
◦ NOT similar to the quality of “psychosis” seen in
major thought and mood disorders
 Fully-formed visual hallucinations
 Transient
 Auditory experiences or intrusive thoughts
◦ Middle to late childhood to early adolescence
◦ Acute onset and speedy resolution
◦ Intact or understandable social behavior
◦ Minimal objective findings on MSE

Clinical Summary/Treatment
◦ Often misdiagnosed as schizophrenia
 Role function changes
 Degree of stress it causes the clinician
◦ The psychosis is less responsive to
neuroleptics
 Multiple medication trials
 Polypharmacy
 Over-medicated
◦ Improved with sensitive psychosocial
interventions-DBT, supportive therapy, time

Differential Dx
 OCD D/O: Presence of symptoms,
obsessions (thoughts, urges images)
that decrease with compulsions.
 Trauma Related D/O: Avoidance not
due to paranoia, dissociative
experiences, para-hallucinations
 Schizophrenia: Delusions not
improved with compulsive behavior,
meets criteria for psychosis.

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 MODULE H: ADULT
ATTENTION-
DEFICIT/HYPERACTIVITY
DISORDER

Attention-
Deficit/Hyperactivity Disorder
(ADHD)
 Essential features:
◦ Symptom threshold: At least 5 symptoms of
inattention and/or 5 symptoms of
hyperactivity/impulsivity that have lasted at least
6 months (6or more in either area for those 17 and
younger)
◦ Age of onset: Several symptoms prior to age 12
◦ Impairment: Several symptoms in two or more
settings that interfere with functioning
◦ Common rule-outs: Mood disorder, anxiety
disorder, substance use or psychotic disorder (age
of onset, areas of disruption, disorganization vs.
inattention, insight).

MODULES I & J: OTHER

CURRENT DISORDERS
AND ADJUSTMENT
DISORDER

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 Organization of SCID 5
Screening for Other Current
Disorers
 Premenstrual Dysphoric Disorder (new)
 Specific Phobia
 Separation Anxiety Disorder (can now dx in adults)
 Hoarding Disorder (new)
 Body Dysmorphic Disorder
 Trichotillomania
 Excoriation Disorder
 Insomnia Disorder
 Hypersomnolence Disorder
 Anorexia Nervosa
 Bulimia Nervosa
 Binge-Eating Disorder (new)
 Avoidant/Restrictive Food Intake Disorder
 Somatic Symptom Disorder
 Illness Anxiety Disorder
 Intermittent Explosive Disorder
 Gambling Disorder

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SCIDERS ASSEMBLE!

75

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 Stay connected!

 https://www.facebook.com/easacommunity

 https://www.easacommunity.org

 rymelton@pdx.edu

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