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Reliability and validity may also be threatened. For example, if two or more interviewers conduct independent interviews with a patient, they may or may not end up with the same diagnosis, hypotheses, conclusions, or treatment plans. Furthermore, patients may not report the same information when questioned by several different interviewers (Hubert, Wachs, Peters-Martin, & Gandour, 1982). Interviewer gender, race, age, and skill level are some of the factors that may affect patient response during an interview (Grantham, 1973). Emotional level may also have an impact on reporting of information (Kolko, Kazdin, & Meyer, 1985). For example, personal questions regarding sexual behavior, alcohol use, child abuse, or other sensitive issues may elicit varying responses from patients under different circumstances. Reliability and validity may be enhanced by using structured interviews, asking similar questions in different ways, using multiple interviewers, and supplementing interview information from other sources (e.g., medical records, observers, questionnaires).

whom they enter in conflict continues to be realistic and cognizant of the complexity of the interactions To the contrary, in the case of identity diffusion, the descriptions of the most important persons in his or her life on the part of an adolescent with borderline personality organization are vague and chaotic, and so is his or her description of the self, in addition to the emergence of significant discrepancies in the description of the adolescent s present psychosocial interactions, on the one hand, and the interaction with the interviewer, on the other It is also typical for severe identity diffusion in adolescence that there exists a breakdown in the normal development of ideals and aspirations The adolescent with identity diffusion may display a severe lack of internalized value systems, or a chaotic and contradictory attitude toward such value systems.

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In contrast to the diagnostic value of exploring identity and internalized value systems, other aspects of the mental status examination are less important in the case of adolescents Thus, particularly, the dominance of primitive defensive operations is less important than it would be in adult patients The reason is that, with a reactivation of oedipal conflicts, and conflicts about sexuality in general, primitive defensive operations may emerge, particularly in the area of conflicts with the parents Severe conflicts with intimate members of the family are diagnostically much less important than they would be later on Chaotic experiences in the sexual realm, manifestations of polymorphous perverse infantile sexuality, rather extreme oscillations between inhibited, puritanical attitudes and impulsive sexual behavior also are not necessarily indicative of identity diffusion at this time.

The nature of adolescent school failure also includes a broad spectrum of diagnostic possibilities and does not reflect directly the syndrome of identity diffusion: depressive reactions, attention-deficit-hyperactivity disorder, physical, sexual or emotional abuse, significant inhibitions of many origins, the characteristic pattern of narcissistic personalities of being the best student in some courses and the worst in others, and generalized breakdown in the functioning at school as a reflection of identity diffusion have to be differentiated from each other The capacity to fall in love and to maintain a stable love relation, in general, is related to normal identity, but some adolescents may be delayed in their capacity to establish sexual intimacy out of inhibition, and the absence of that capacity is not necessarily diagnostic Sexual promiscuity, on the other hand, may or may not reflect identity diffusion in adolescence.

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Significant changes in mood and emotional lability are also less important in the diagnosis of identity diffusion in adolescence than in adults Finally, the relationship of an adolescent with his or her particular psychosocial group may provide important clues to both identity and superego developments The capacity for a harmonious participation in group structures needs to be differentiated from the blind adherence to an isolated social subgroup, and from the incapacity to function outside the protective structure of such a group Chronic social isolation, in contrast to the capacity to adjust to group situations also may point to significant character pathology The relationship to groups permits us to clarify the potential presence of a negative identity.

The most typical manifestations of the syndrome of identity diffusion, that is, a clear lack of integration of the concept of self and of the concept of significant others can be found in patients with borderline personality disorder, and, to a somewhat lesser degree, in patients with histrionic or infantile personality disorder In contrast, in the case of the narcissistic personality disorder, what is most characteristic is the presence of an apparently integrated, but pathological, grandiose self, contrasting sharply with a severe incapacity to develop an integrated view of significant others: the lack of the capacity for grasping the personality of significant others is most dramatically illustrated.

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