Anxiety and Related Disorders

Interview Schedule
for DSM-5 (ADIS-5)
Adult and Lifetime Version

Clinician Manual
Timothy A. Brown
David H. Barlow

3
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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 9780199324743 (acid-free paper) 1. AnxietyDiagnosisHandbooks, manuals, etc.
2. Mental illnessClassificationHandbooks, manuals, etc. 3. Interviewing in psychiatry.
4. Diagnostic and statistical manual of mental disorders. I. Barlow, David H., author. II. Title.
RC531.B76 2014
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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 Peoples Liberation Army, Beijing, with an appointment
as Honorary Visiting Professor of Clinical Psychology. During the 19971998 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

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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
Psychologys 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.

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
s = .67 to .86), except dysthymia ( = .31).

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., 08 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 patients replies to questions in Initial Inquiry. It was deemed important to obtain dimensional
assessment of these conditions in all patients given (a) agoraphobias 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 Clinicians 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).

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 patients 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 patients 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 patients 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 patients 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).

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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 patients response to this item once all of the diagnostic

7
sections have been completed. Although the clinicians judgment should weigh most heavily in the
determination of the principal diagnosis, the patients 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 patients 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
patients 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 patients 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 patients 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 patients 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 patients
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 patients 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
diagnosticians 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, CLINICIANS 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 CLINICIANS
RATINGS AND DIAGNOSES page has been revised extensively from its previous version in
the ADIS-IV. Nevertheless, the CLINICIANS RATINGS AND DIAGNOSES page does provide
space to record open-ended information on the patients 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 patients overall distress/lifestyle impairment using the same 08 clinical rating scale used
for individual diagnoses. Last, space is also provided to record the duration of the interview and a
diagnostic confidence rating (0100 scale, where 100 reflects complete certainty), which is a global
rating to reflect the interviewers 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., patients 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 08 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 patients 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 patients 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 08 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 patients 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. 225226; DSM-5
no longer includes a hierarchy rule with posttraumatic stress disorder). Thus, while retaining some
aspects of this hierarchy, DSM-5s 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, 313328.
Brown, T. A., & Barlow, D. H. (2005). Categorical vs dimensional classification of mental disorders
in DSM-5 and beyond. Journal of Abnormal Psychology, 114, 551556.
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, 256271.
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, 585599.
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, 4958.
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, 251256.
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, 909916.
Naragon-Gainey, K., Gallagher, M. W., & Brown, T. A. (in press). A longitudinal examination of
psychosocial impairment across the anxiety disorders. Psychological Medicine.

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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 patients date of birth (DOB) and todays 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 patients 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
youre sure that your first panic attack occurred after you came back from your trip to Europe
but before you started the job at Macys?).
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 disorders corresponding LES-Ps (Rater: Stress, using 08
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 patients symptoms met DSM-5 diagnostic criteria)
rather than when the features of the disorder first emerged (e.g., the patients initial panic attack may
or may not signify when the onset of panic disorder occurred).

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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 Years); 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).