Clinical Neuropsychiatry (2012) 9, 3, 123-128

A SEMI STRUCTURED, PHENOMENOLOGICALLY-ORIENTED PSYCHIATRIC INTERVIEW:

DESCRIPTIVE CONGRUENCE IN ASSESSING ANOMALOUS SUBJECTIVE EXPERIENCE
AND MENTAL STATUS

Julie Norgaard and Josef Parnas

Abstract
Objective: The contemporary methodology in obtaining psychopathological information relies almost exclusively
on the use of structured questionnaires and interview schedules. These interviews yield high interrater reliability and
reduce cost. The assessments of anomalous self-experience and of mental status (disorders of experience and expression)
are often considered as soft, subjective and hence unreliable. In spite of the advantages of the structured interviews,
concerns have been raised about the epistemological coherence and the validity of the structured interviews.
To examine the interrater congruens between experienced clinicians with a semi structured, phenomenologically
oriented psychopathological interview assessing anomalous self-experience and mental status.
Method: Seventeen inpatients were interviewed by one of the raters, with both raters were present. The interview
comprised of a thorough psychosocial history and the EASEscale.
Results: The interater-congruens for the total EASE-scale showed nearly perfect agreement with kappa=0.94.
The interrater-reliablility for the MSE assessment showed substantial to complete agreement with kappa above 0.81,
except for four items: Withdrawn/shy (kappa=0.77), Suspicious, guarded and hostile (kappa=0.77), Raport insecure
and anxious (kappa=0.76), Restless (kappa=0.64).
Conclusions: High interrater-congruens can be achieved for the assessment of anomalous self-experience and
mental status in the context of conversational, phenomenological-oriented semi-structured interview.
Limitations: The major limitation of the study is a relatively small sample size, conditioned by the time-consuming
nature of the individual interviews. Second, we should have included a measurement of reliability in a less experienced-
recently EASE-introduced rater, since it is that kind of researchers that are typically enrolled for the empirical data
collections.

Key words: interrater agreement, semi structured, phenomenological, interview, examination, anomalous, self-experience,
EASE, mental, status.

Declaration of interest: Julie Norgaard was speakers bureau with Bristol - Myers Squibb

Julie Norgaard, MD1 and Josef Parnas, MD, Dr.MSc.1,2

University Department of Psychiatry, Mental Health Center Hvidovre
1.
Mental Health Center Hvidovre, Copenhagen, Denmark
2.
Center for Subjectivity Research, University of Copenhagen

Corresponding author
Dr. Julie Nordgaard
Mental Health Center Hvidovre, Broendbyoestervej 160, 2605 Broendby,
Denmark. Ph. no. +45 38 64 57 33
Julie.nordgaard.frederiksen@regionh.dk

Introduction Initially, the structured interviews, conducted by

Contemporary methods of obtaining psycho-
pathological information consist almost exclusively in
the use of structured questionnaires or checklists
(Faravelli 2004) and self-rating instruments. This
methodology was introduced as a component of the
reliability-driven operational revolution. Robert
Spitzer, in his famous programmatic article, entitled
Are clinicians still necessary? strongly advocated for
the use of structured interviews as a straightforward and
unproblematic solution to psychiatrys nagging
reliability problem (Cooper et al. 1972, Spitzer 1983).
Psychiatrists were both unreliable and expensive.
SUBMITTED MARCH 2012, ACCEPTED APRIL 2012
FIRST EPUB AHEAD OF PRINT 2012 JUNE CN100003
2012 Giovanni Fioriti Editore s.r.l.
trained non-clinicians, were used in large scale
epidemiological surveys for inexpensive estimates of
the prevalence of disorders such as phobias or
alcoholism (e.g. Epidemiological Catchment Area
studies) (APA 2000, Faravelli 2004). With time,
however, all diagnostic categories came to be studied
in this way. Currently, the structured interviews rapidly
find an inroad to clinical practice as well. Main-stream
psychiatry has become explicitly behaviourist, with a
general subjectivity-phobic attitude (Stanghellini
2004).
There have been critical voices questioning the
epistemological foundations of the operationalist
123
 Julie Norgaard and Josef Parnas
assumptions behind the structured interviewing (Parnas
and Bovet 1995, Parnas et al. 2002, Parnas et al. 2008,
Sadler et al. 1994, Stanghellini 2004). Similar worries
have been expressed concerning the validity of a
checklist approach to diagnosis and its dehumanizing
impact on clinical psychiatry (Andreasen 2007, Ghaemi
2012, Parnas et al. 2008). To the best of our knowledge,
the advocates of structured interviews and operational
criteria (with few exceptions, e.g., (Hempel 1965)
never presented a convincing epistemological defence
or rationale for the structured-operational approach,
apart from persistent emphasis of the reliability issue
We have argued in theoretical and empirical
publications that we consider phenomenology to be
indispensable for psychiatry in its praxis of clinician-
patient interaction, diagnosis, therapy, theoretical work,
formation of pathogenetic hypotheses and empirical data
collection. Psychiatric phenomenology is an approach
that targets a faithful description of experience,
expression and existence (Parnas et al. 2002, Parnas et
al. 2008) A cardinal aspect of the phenomenological
stance is a suspension of the background or tacit
assumption of belonging to a shared world, in which
some things are and others are not. Instead, this very domain of schizophrenia spectrum disorders (Jakobsen
assumption is considered as an aspect of experience that
can be made explicit. This allows exploring the sense
of reality itself and the variations and alterations of its
structure. This specifically phenomenological approach
does indeed facilitate a heightened appreciation of the
ways in which, and the extent to which, other peoples
experience of the world can differ from ones own. We
suspect that all curious clinicians, even if implicitly and
unknowingly, adopt what can be called a weak variant
of the phenomenological stance.
The goal of this study (a part of a larger
psychopathological project) was to examine the
agreement between experienced, similarly educated
clinicians, in the process of identifying and typifying
anomalous self-experience assessed with a semi
structured, phenomenologically-oriented psychopa-
thological checklist (Examination of Anomalous
Experience (EASE)). In addition, we examined the
agreement of the ratings of subtle expressive features
characteristic of the schizophrenia spectrum disorders.
Both of these dimensions of descriptive psycho-
pathology (disorders of experience and expression) are
often considered as soft, subjective, and hence ve, yet with a possibility to ask for more detail and
unreliable.
Sample and Methods
The sample
Seventeen patients were randomly drawn from the
inpatient population of the Mental Health Center
Hvidovre, University of Copenhagen, a center that
provides psychiatric in-patient facilities to a population
of 150.000 in a catchment area within the City of
Copenhagen. The patients participated on the condition
of informed consent. The interviews took place on
prescheduled days in 2010-2011.
The sample consisted of eight men and nine
women, with an average age of 28,2 years (range 18-45
years). Patients were included independently of their
124
clinical diagnosis allocated by the clinician in charge.
Yet, we applied the following exclusion criteria: primary,
or clinically dominating alcohol/substance abuse,
history of brain injury, mental retardation, organic brain
disorder, and age above 46 years. Because of ethical
concerns, we excluded involuntarily admitted and legal
patients.
The interviewers
The interviewers alternated in performing the
interview, with the other psychiatrist having observer
status during the session. Thus both raters were present
at the interview (JN & JP). This procedure improves
reliability by providing equal access to paraverbal
information (Cermolacce et al. 2010). The observer was
allowed to ask a couple of clarifying questions at the
end of the session.
JN was, at the time of the study, an experienced
clinician with more than 10 years of clinical experience
and with specific training in psychopathology and
research experience in the diagnostic issues in the
et al. 2005, Jakobsen et al. 2007). She had completed
the Examination of Anomalous Self-Experience (EASE)
course and had performed several, supervised EASE-
interviews prior to the study. The second rater (JP), a
consultant psychiatrist, is the principal author of the
EASE scale (Parnas et al. 2005b), and has decades of
clinical and research experience in the domain of
schizophrenia spectrum disorders.
The interview-approach
The interview was semi structured. That implies
the following features in the context of this study. The
structure of the interview is assured by the obligation
of the interviewer to be able to score all the items of
the interview schedule, implying that all items must
be explored. Yet, the concrete, practical conduct and
the sequence of the interview is dictated by the
dynamics and context of the encounter, i.e. the style is
free and conversational. The questions are contextually
adapted and follow the logic of the patients narrati-
further examples. The patient is encouraged to speak
freely, is rarely interrupted and is given time for
reflection and recollection. The interviewer steers the
interview in the desired direction through questions
and comments. Typically, the interview starts with a
detailed psychosocial history, which creates the
departure points for the EASE-specific probing. All
relevant responses from the patient are examined in
depth: the patient is prompted for more detailed
descriptions and clarifications. In other words, a simple
affirmative answer is never accepted without the
patients own examples and descriptions. The
interviewers task is to detect invariances across
several related experiences or across several examples
of the same experience. The metaphorical responses
call for (if possible) a distinction between their con-
crete or abstract subjective significance. Each
interview session took 60-120 min.
Clinical Neuropsychiatry (2012) 9, 3
 Agreement in a phenomenological inerview
The schedule
The interview comprised a thorough psychosocial
history (including circumstances leading to the hospital
admission) and the EASE-scale was scored on the
lifetime basis. After the interview, the raters scored the
mental status examination sheet and the EASE coding
sheet. The EASE is a descriptive-psychopathological
checklist consisting of 57 main items. The items of the
EASE scale are described through the typical
statements, collected from clinical samples and existing
textual sources examined during the period of EASE
construction (Berze 1914, Gross et al. 1987, Parnas and
Handest 2003). The EASE contain 5 thematic domains:
1) stream of consciousness (and cognition), 2) self-
presence, 3) bodily experience, 4) transitivism, and 5)
existential reorientation. The interviewer was free to
explore the items in the sequence that was felt was
appropriate and adequate to the subjects own concerns
and responses.
The list of items scored on the Mental Status
Examination (MSE) was specifically created for the
rating of subtle expressive features in schizophrenia
spectrum and used in the US-DK adoption-, high-risk
studies (Kety 1975, Kety 1968, Parnas 1993 ) and the
Copenhagen Linkage Study (Matthysse et al. 2004).
Data analysis
The main EASE items and the Mental Status
Examination items were scored dichotomously as 0
(absent or questionably present) or 1 (definitely present,
all severity levels). The descriptive congruence was
assessed by calculating Cohens K (kappa), a measure
of agreement between two raters, corrected for
agreement occurring by chance and taking frequency
into account. The typical interpretation of K values is
0.00 poor agreement; 0.00-0.20 light agreement; 0.21-
0.40 fair agreement; 0.41-0.60 moderate agreement;
0.61-0.80 substantial agreement; 0.81-0.99 nearly
perfect agreement; 1.00 complete agreement (Software
2001).
A minimum cumulative frequency threshold of
10% between the two raters, i.e. estimated frequency
by rater 1 + rater 2 > 10% of the sample (at least 2
subjects out of the 17 subjects), were considered because
the kappa values for very infrequent items are not
meaningful.
Results
The seventeen patients had following primary
clinical diagnoses, allocated by the clinician in charge:
major depressive disorder (n=3), adjustment disorder
(n=1), schizophrenia (n=6), schizotypal disorder (n=4)
and personality disorder not otherwise specified (n=3).
The interrater agreements appear in tables 1 and
2. The interrater kappa value was 0.94 for the total
EASE. For the five domains of the EASE, the interrater
agreements were also high (kappa values between 0.89
and 0.95). For the individual EASE-items the agreement
was perfect to complete with kappa values above 0.81
except for two items: Inability to discriminate
Clinical Neuropsychiatry (2012) 9, 3
modalities of intentionality (kappa 0.73) and Dimi-
nished presence (kappa 0.77).
For MSE, the interrater-agreement was perfect to
complete, with kappa values above 0.81, except for 4
items where the agreement was substantial: Withdrawn/
shy (kappa .77), Suspicious, guarded and hostile
(kappa 0.76), Raport insecure and anxious (kappa
0.76) and Restless (kappa 0.64).
Although the samples become very small if
partitioned into subgroups, we did not observe major
changes in kappa levels as a function of the sex of the
patient or of which one of the two raters that was
interviewing.
Discussion
The results of this study are in line with previous
reports on the reliability of psychometric measures of
subjective experience: the BSABS scale by our own
group (Vollmer-Larsen et al. 2007) and the EASE scale
by a Norwegian study (Moller et al. 2011) We have,
however, chosen not to present our result as a standard
reliability study. Given the fact of the raters (JN and
JP) have been involved together in studying
schizophrenia for several years, our results are not
directly applicable to a setting of a standard reliability-
study.
The EASE-kappa values in the present study are
therefore higher than those reported in the study by
Mller et al. (Moller et al. 2011) In addition, this
difference may have been amplified by two other factors:
1) the joint presence of the raters during the live
interview provides a better access to paraverbal and
interactive information that increases reliability. For
example, such joint presence amplified reliability in the
studies of bizarre delusions (Cermolacce et al. 2010).
2) The observers possibility of making a couple
of supplementary or clarifying questions at the end of
the session increases the clarity of potentially vague
initial descriptions.
On the whole, our study demonstrates that it is
possible to achieve high agreements in the assessment
of single psychopathological items in a conversational,
phenomenologically oriented interview. In such a type
of interview, the primary source of information is the
patients narrative with self-description of experience
and behaviour. The raters task is to identify, from the
conversational flow, the chunks of information that are
psychopathologically relevant and eventually serve to
individuate those chunks as signifying as this or that
particular experience. This is a more demanding
situation than a rating of the symptom-presence on the
basis of observing an interview with a question-answer
structured sequence. Second, reliability studies often
use ratings of video-clips, a procedure in which the very
selection of the clips prefigures in advance what seems
be a relevant symptom.
This study also shows excellent congruence in the
assessments of subtle disorders of expression, such
as qualities of rapport, thinking, gesture, and ap-
pearance, all highly pertinent to diagnosis of the
schizophrenia spectrum disorders.
Notably, there was a perfect agreement on the
suspicion of autism, i.e. a sense that the patient lives
125
 Julie Norgaard and Josef Parnas

Table 1. Interrater congruens for the EASE items

% agree-
Rater 1 Rater 2 ment on
n Frequ- n Frequ- indivi-
scored ency in scored ency in Cohens dual
present % present % Kappa level
Item no. And designation
1.1 Thought interference 4 24% 4 24% 1 100%
1.2 Loss of thought ipseity 3 18% 3 18% 1 100%
1.3 Thought pressure 10 59% 10 59% 1 100%
1.4 Thought block 4 24% 4 24% 1 100%
1.5 Silent thought echo 0 0% 0 0% n.c 100%
1.6 Ruminations - obessions 13 76% 13 76% 1 100%
1.7 Perceptualization of inner speech or thought 9 53% 8 47% 0,89 94%
1.8 Spatialization of experience 3 18% 4 24% 0,87 94%
1.9 Ambivalence 7 41% 7 41% 1 100%
1.10 Inability to discriminate modalities of intentionality 5 29% 3 18% 0,73 88%
1.11 Disturbance of thought initiative or intentionality 5 29% 4 24% 0,89 94%
1.12 Attentional disturbances 3 18% 3 18% 1 100%
1.13 Disorder of short-term memory 6 35% 6 35% 0,9 100%
1.14 Disturbance of time experience 2 12% 3 18% 0,83 94%
1.15 Discontinous awareness of own actions 2 12% 2 12% 0,87 100%
1.16 Disconrdance between expression and expressed 4 24% 4 24% 1 100%
1.17 Disturbance expressive language function 4 24% 4 24% 1 100%
Domain 1 0,94 98%
2.1 Diminished sense of basic self 6 35% 7 41% 0,9 94%
2.2 Distorted first-person perspective 2 12% 2 12% 1 100%
2.3 Other states of depersonalization (self-alienation) 1 6% 2 12% 1 94%
2.4 Diminished presence 5 29% 4 24% 0,77 94%
2.5 Derealization 5 29% 5 29% 1 100%
2.6 Hyperreflectivity; increased reflectivity 10 59% 10 59% 1 100%
2.7 I-split 2 12% 2 12% 1 100%
2.8 Dissociative depersonalization 1 6% 1 6% n.c 100%
2.9 Identity confusion 2 12% 1 6% 0,9 94%
2.10 sense of change in relation to chronological age 1 6% 1 6% n.c 100%
2.11 Sense of change in relation to age 4 24% 3 18% 0,89 94%
2.12 Loss of common sense/natural evidence/perplexity 4 24% 4 24% 1 100%
2.13 Anxiety 10 59% 10 59% 1 100%
2.14 Ontological anxiety 0 0% 1 6% n.c 94%
2.15 Diminished transparency of conciousness 1 6% 1 6% n.c 100%
2.16 Diminished initiative 8 47% 8 47% 1 100%
17 Hypohedonia 10 59% 10 59% 1 100%
2.18 Diminised vitality 4 24% 5 29% 0,89 94%
Domain 2 0,95 98%
3.1 Morphological change 0 0% 0 0% n.c 100%
3.2 Mirror-related phenomena 6 35% 6 35% 1 100%
3.3 Somatic depersonalization 2 12% 2 12% 1 100%
3.4 Psychophysical misfit 1 6% 1 6% n.c 100%
3.5 Body disintegration 0 0% 0 0% n.c 100%
3.6 Spatialization 2 12% 1 6% 0,83 94%
3.7 Cenesthetic experiences 7 41% 6 35% 0,9 94%
3.8 Motor disturbances 2 12% 2 12% 1 100%
3.9 Mimetic experinces 0 0% 0 0% n.c 100%
Domain 3 0,95 99%
4.1 Confusion with the other 0 0% 0 0% n.c 100%
4.2 Confusion with ones own specular image 0 0% 0 0% n.c 100%
4.3 Threatening bodily contact 2 12% 3 18% 0,83 94%
4.4 Passivity mood 2 12% 2 12% 1 100%
4.5 Mimetic experiences 2 12% 2 12% 0,83 100%
Domain 4 0,89 99%
5.1 Primary self-reference phenomena 6 35% 6 35% 1 100%
5.2 Feeling of centrality 3 18% 3 18% 1 100%
5.3 Feeling as if subjects exp. Field is only extant reality 2 12% 2 12% 1 100%
5.4 Feelings of extraordinary creative power or insights 2 12% 2 12% 1 100%
5.5 Feelings that the experienced world is not real 3 18% 2 12% 0,83 94%
5.6 Magical ideas linked to the subjects way of experiencing 3 18% 2 12% 0,83 94%
5.7 Existential or intellectual change 1 6% 1 6% n.c 100%
5.8 Solipsistic grandiosity 2 12% 2 12% 1 100%
Domain 5 0,95 99%

Total EASE scale 0,94

All kappas p<0.001

126 Clinical Neuropsychiatry (2012) 9, 3

 Agreement in a phenomenological inerview

Table 2. Interrater congruens for the Mental Status Examnination

%
agree-
Rater 1 Rater 2 ment on
n scores Frequ- n scores Frequ- Cohens individu-
present ency present ency kappa al level
Language and thougths
Speech difficult to understand 5 29% 6 35% 0,87 94%
Quiet, mumling voice 4 24% 3 18% 0,82 94%
Derailment or semantic disturbances 4 24% 5 29% 0,85 94%
Vagueness 9 53% 8 47% 0,88 94%
Poverty of speech 2 12% 2 12% 1 100%
Rapport
Autism suspected 9 53% 9 53% 1 100%
One-way emotional contact 12 71% 13 76% 0,85 94%
Withdrawn/shy 2 12% 3 18% 0,77 94%
Suspecious, guardedt and hostile 7 41% 7 41% 0,76 100%
Rapport disturbed by psychotic symptoms
or thought disorders 8 47% 7 41% 0,88 94%
Rapport insecure and anxious 9 53% 9 53% 0,76 100%
Rapport silly and inadequate 4 24% 5 29% 0,85 94%
Indifferent rapport 2 12% 2 12% 1 100%
Evasive eye contact 4 24% 5 29% 0,85 94%
Gesturing
Frozen 0 0% 2 12% 88%
Lack of gesture 6 35% 6 35% 1 100%
Parakinesia 3 18% 3 18% 1 100%
Lack of variation in facial expression 5 29% 5 29% 1 100%
Limp handshake 2 12% 2 12% 1 100%
Voice unmodulated 6 35% 5 29% 0,87 94%
Appearance and behaviour
Tense and anxious 11 65% 11 65% 1 100%
Cooperating badly 5 29% 5 29% 1 100%
Hostile 1 6% 2 12% 1 94%
Restless 1 6% 2 12% 0,64 94%
Strange/eccentric
behaviour/clothes/appearance 4 24% 4 24% 1 100%
Do not relax during the interview 9 53% 8 47% 0,88 94%
Increasinly tense during the interview 2 12% 2 12% 1 100%

All kappas p<0.001

in a private universe of fundamentally altered
subjectivity (or frame of reference), which only partially
overlaps the shared, intersubjective, world. In a
previous, poly-diagnostic study from our group, a
judgment on the suspicion of autism, based on a
review of the case-summaries, achieved interrater kappa
of 0.6 (Parnas et al. 2005a). The higher agreement
obtained in the current study probably reflects the
methodological issues addressed above, but also the fact
that EASE inquiry provides a unique access into the
patients modes of experience, and alterations in these
modes of experience define the concept of autism
(Arnfred et al. 2008, Parnas et al. 2002).
It is beyond the scope of this paper to discuss its
wider epistemological implications. Suffice to say that
the current drive towards the structured interviews, must
presuppose that the symptoms and signs have a nature
and a mode of being akin to that of physical, thing-like
entities, which unproblematically announce their ready-
made presence in response to a predesigned stimulus-
question. Such epistemology is inadequate for the
psychiatric inquiry (Stanghellini 2004). The psychiatric
interview is a second person approach, guided by
phenomenological distinctions, a process through which
we extract, represent and individuate from the flow of
the patients subjective life, certain repeatable
constellations of experience, certain meaningful wholes.
A psychiatric symptom or sign only emerges as an
individuated entity (as this or that symptom) in a context
of other, simultaneous, preceding and succeeding,
experiences.
Our study shows that high agreement between
clinicians can be achieved for the assessment of anomalous
self-experience and mental status in a phenomenologically
oriented semi-structured interview. This is an important
finding because the subjective dimension of descriptive
psychopathology is often considered unreliable, and
therefore unfit for empirical study.
Acknowledgements: The study was supported by the
Danish National Research Foundation and by a PhD-
grant from the University of Copenhagen (Dr Nordgaard)

Clinical Neuropsychiatry (2012) 9, 3 127

 Julie Norgaard and Josef Parnas
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