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(BQ) Part 2 book “The psychiatric interview in clinical practice” has contents: The traumatized patient, the dissociative identity disorder patient, the antisocial patient, the antisocial patient, the psychotic patient, the psychosomatic patient, the cognitively impaired patient,… and other content.
C H A P T E R THE TRAUMATIZED PATIENT ALESSANDRA SCALMATI, M.D., PH.D Trauma is common in everyday life It can take many forms, from the unexpected loss of a loved one to a serious motor vehicle accident, the diagnosis of a life-threatening illness, or being the victim of an assault Popular attention has focused on the aftermath of severe trauma such as civilian disasters, industrial explosions, natural catastrophes, terrorist attacks, life-threatening combat situations, rape, and childhood sexual abuse Many people respond to a traumatic event with an acute stress reaction or an increase in anxiety of short duration that resolves spontaneously without need for treatment Some people develop a more chronic traumatic stress response that becomes impairing and disabling Being the victim or witness of a traumatic event does not imply a pathological response or enduring psychological trauma In fact, even though close to 90% of people will be exposed to some kind of traumatic event during their lifetime, according to a survey conducted in the early 2000s to establish the prevalence of psychiatric disorders in the population, the lifetime prevalence of posttraumatic stress disorder (PTSD) was 6.8% From the beginning, an essential question of traumatic studies has been what differentiates between people who develop a disabling response to trauma and those who are more resilient in response to similar tragedies Traumatic events and their effect on the human psyche occupy center stage in the current psychiatric landscape, and it is easy to forget that until 1980 PTSD was not an acknowledged diagnosis Even though trauma, war, misfortune, loss, death, illness, and suffering are and have 339 340 • THE PSYCHIATRIC INTERVIEW IN CLINICAL PRACTICE always been common, for many millennia the stories of sorrow and heartbreak, of soul-sickness and madness, caused by life tragedies, fate capriciousness, and human cruelty were mostly the province of poetry and art, not of medicine and science It has been suggested that the interest of science in the psychological effects of trauma only became relevant when life expectancy in Western societies grew to a length that allowed for concerns other than mere physical survival It is possible that a more comfortable lifestyle, afforded by the industrial revolution, the Enlightenment—with its focus on reason—and a decrease in fatalism and the will of God as an explanation for human events, also played a role However, by the middle of the nineteenth century, psychiatrists and neurologists started describing with more interest and consistency symptoms that seemed to have their origins in past traumatic events in the patient’s life What makes the study of the psychological effects of trauma different from the study of any other mental illness is the necessity of an event outside of the human psyche to occur in order for the disorder to exist PTSD (and acute stress disorder) is the only diagnosis that requires the clinician to determine that exposure to “a traumatic event” has taken place Starting with the American Civil War, doctors reported more systematically cases of acute distress experienced by soldiers during and after combat However, military authority and society at large were quick to accuse the sufferer of cowardice, unless a medical explanation could be devised The cultural moral standard expected men to be capable and willing to fight for their country and their cause Soldiers who refused to fight or escaped from the battlefield were accused of desertion and court martialed Although it might be easy for us to scorn the preoccupation with honor of European countries at the beginning of the 1900s that allowed the unspeakable slaughter of the trenches, it is important to remember that similar ideals of masculinity, strength, and heroism still play a role in modern military culture and contribute to the obstacles veterans encounter even today in accessing and receiving care During this era, with the exception of a few studies that investigated the effects of trauma in victims of railway accidents, and in survivors of an earthquake in Southern Italy, outside of military hospitals, the other main area of investigation in the traumatic neurosis was the study of hysteria Patients suffering from hysteria, mostly women, presented with a host of confounding symptoms and many somatic complaints Contrary to war, neither sexual violence nor the abuse of children had been per se the focus of literature However, any superficial reading of fairy tales, legends, and mythology from any culture and tradition cannot fail to detect rather accurate descriptions of early life loss, abandonment, neglect, The Traumatized Patient • 341 and abuse Of course, it is a matter of debate whether this is a representation of the inner fantasies of the child, and a projection of our worse fears, or a fair appraisal of what we know to be all too common The two explanations not need to be mutually exclusive; fantasies can be not only projected but also enacted with tragic consequences At the beginning of the nineteenth century, the Bronte sisters, along with Charles Dickens, offered some interesting descriptions of child abuse and neglect that were quite revolutionary for the time, particularly in a society that considered children the property of their parents and male and religious authority unquestionable However, notwithstanding some sensationalistic reporting in the news of the time, and some increase in the literature of more realistic descriptions of violence and abuse, society was not ready to accept the reality of sexual violence or child abuse as commonly occurring events Controversies surrounded the work of Jean-Martin Charcot, who had suggested that the cause of hysteria in his patients was a traumatic event, most likely a past sexual trauma After Charcot’s death, Joseph Babinski, who took over the directorship at the Salpêtrière Hospital in Paris, declared that the cause of hysteria was a preexisting suggestibility in the patient and that women suffering from hysteria, when forced to, would abandon the symptoms These principles were embraced by French and German physicians and applied with a rather extreme level of cruelty to “treat” French and German soldiers suffering from war neurosis during World War I The “treatment” used involved the application of electric shock and was in general so painful and brutal that the soldiers preferred to go back to the trenches Pierre Janet was also a student of Charcot but followed the initial course of research and maintained the belief that hysteria was caused by a past traumatic event that had caused a “vehement emotion” that created a memory that could not be integrated into personal awareness and was split off into a dissociated state This state was not accessible to voluntary control, and the person was not able to make a “narrative of the event.” This state of affairs caused a “phobia of the memory” that failed to be integrated, but it left a trace, or idée fixe (“fixed idea”) These fixed ideas were constantly reoccurring as obsessions, reenactments, nightmares, somatic symptoms, and anxiety reactions Janet also described the patient’s hyperarousal and reactivity to triggers and reminders of the traumatic event The patient was not better until he or she could integrate the traumatic memory into consciousness Sigmund Freud studied with Charcot at the Salpêtrière, and in his early writing he initially agreed with the interpretation of hysteria symptoms as caused by an early seduction or sexual trauma However, as 342 • THE PSYCHIATRIC INTERVIEW IN CLINICAL PRACTICE Freud started focusing on infantile sexuality, he changed his view and reinterpreted hysterical symptoms as being a reaction to the fantasy of a seduction and, therefore, a defensive response to a conflict between an unconscious wish and a prohibition, not the somatic response to a trauma As far as war neurosis was concerned, Freud recognized the similarities between the symptoms of World War I veterans and those of patients with hysteria His hypothesis was that the conflict at the core of war neurosis was between a wish to survive and a wish to act honorably Freud initially hypothesized that the soldiers’ symptoms would improve once the war was over, eliminating the threat to their life and therefore resolving the conflict and rendering the symptoms obsolete Charles Myers and William Rivers are the two psychiatrists best known for their work with World War I soldiers in Britain Myers was the first to use the term shell shock Both were advocates for a more humane treatment of soldiers and a recognition of their suffering as real and not a result of cowardice or a preexisting moral weakness Abram Kardiner, an American psychiatrist, worked with World War I veterans between 1923 and 1940 He carefully described his patients’ symptoms and reported that many of these veterans had been admitted to psychiatric and medical hospitals and had received multiple diagnoses (including malingering) before a connection was made between their symptoms and the history of trauma Kardiner was the first to focus on the physiological hyperreactivity associated with traumatic reactions He described the patients’ chronic state of hypervigilance, irritability, explosive anger, and recurrent nightmares Kardiner’s descriptions include veterans reporting an overwhelming sense of futility; most of them were socially withdrawn, and intent on avoiding any possible recollection of the trauma The work of Kardiner was applied and expanded upon by a group of American and British psychiatrists working with servicemen during World War II John Spiegel, William Menninger, and Roy Grinker confirmed many of Kardiner’s observations about the state of hyperarousal and Janet’s observations about the lack of a narrative memory, even though the patients maintained a very precise somatosensory memory of the trauma that could be easily triggered Hypnosis and narcosynthesis were used to help the patients to abreact the traumatic memories However, it was noted that abreaction without integration did not result in resolution of the symptoms Studies on the psychological symptoms of Holocaust survivors started to appear almost a decade after the end of World War II and were prolific in the 1960s and 1970s The survivors were afflicted with a variety of symptoms: somatic symptoms, nightmares, hyperarousal, irritabil- The Traumatized Patient • 343 ity, social withdrawal, and extreme grief reactions (sometimes associated with the hallucinated images of dead relatives) It is important to note that this last symptom, which has been confused with psychosis as recently as the Vietnam War, is rather common in victims of massive trauma, particularly when the trauma is associated with the traumatic loss of loved ones Holocaust survivors, and veterans, who have lost beloved companions in action will speak of these visions or ghostly visitations, but they will have no other symptoms to indicate a psychotic disorder William Niederland was the first to coin the term survivor syndrome to describe the decline in function and chronic stress reaction of survivors who suffered not only psychologically but physically from a host of stress-induced maladies Henry Krystal, who was himself a survivor, described the experience of the concentration camp victim and the victim of massive trauma as one of “giving up”: in a situation of inescapable terror, when any attempt to activate the flight or fight response is futile, the mind response “is initiated by surrender to inevitable danger consisting of a numbing of self reflective functions, followed by a paralysis of all cognitive and self preserving mental functions.” Krystal also described alexithymia as a consequence of protracted trauma During this same period Robert Lifton conducted a remarkable study interviewing survivors of the atomic bomb devastation in Japan, recognizing in them a very similar preoccupation with death themes and a numbing of capacity for enjoyment and intimacy Lifton compared the reaction of the Japanese survivors with those of Holocaust survivors Meanwhile, in the United States, Burgess and Holstrom termed the symptoms of their patients who were victims of rape—and who reported nightmares, flashbacks, and hyperarousal—as rape trauma syndrome; they found these symptoms to be similar to those in many other syndromes already described Andreasen et al described the stress reaction of a burn victim Herman and Hirschman worked with victims of incest and domestic violence Kempe and Kempe published the first well-documented account of the pervasive problem of child abuse Shatan and Lifton started “rap groups” with Vietnam veterans who were tormented by nightmares, flashbacks, rage, and a growing sense of alienation Horowitz described the alternating states of reexperiencing and numbing common in trauma survivors By the time the committee for the American Psychiatric Association’s DSM-III was discussing which disorders to include, there were groups lobbying for the inclusion of a “Holocaust survivors syndrome,” a “war neurosis,” a “rape trauma syndrome,” a “child abuse syndrome,” and so on As Kardiner had written with some frustration in 1947, 344 • THE PSYCHIATRIC INTERVIEW IN CLINICAL PRACTICE “[The traumatic neuroses] have been submitted to a good deal of capriciousness in public interest The public does not sustain its interest, and neither does psychiatry Hence these conditions are not subject to continuous study, but only to periodic efforts which cannot be characterized as very diligent Though not true in psychiatry generally, it is a deplorable fact that each investigator who undertakes to study these conditions considers it his sacred obligation to start from scratch and work at the problem as if no one had ever done anything with it before In fact, the fragmentation in the field had not yet reached a level of integration with the incorporation of PTSD as an official diagnosis in the DSM system PTSD was grouped with the anxiety disorders (because of the high anxiety and hyperarousal state), even though research suggested the important role of dissociation in the disorder Disputes about the appropriate placement continued for decades; field studies and evidence suggested different criteria to be included in the manual, and controversies continued to surround the diagnosis It was suggested that a second diagnosis could be introduced, that of “Complex PTSD,” to account for the more pervasive disruption in the system of meaning and personality structure observed in survivors of massive trauma It was also suggested that PTSD be moved to the dissociative disorder category In DSM-5, the trauma-related disorders occupy a separate category, between the anxiety and dissociative disorders There is a new criterion, which specifically addresses “a negative alteration in cognition and mood,” and there is an option to specify whether the disorder presents with dissociative symptoms Controversy most likely will always surround the field of trauma studies, because neither society at large nor the field of psychiatry will ever feel completely comfortable to fully address the problem of responsibility (causality/blame) for the consequences of violence However, having a diagnostic category legitimized the field, and it provided a language to standardize research and to compare results PSYCHOPATHOLOGY AND PSYCHODYNAMICS Diagnosis The DSM-5 diagnostic criteria for PTSD appear in Box 10–1 Table 10–1 summarizes the differences between the diagnostic criteria for PTSD in DSM-IV-TR and DSM-5 The Traumatized Patient BOX 10–1 • 345 DSM-5 Criteria for Posttraumatic Stress Disorder Posttraumatic Stress Disorder Note: The following criteria apply to adults, adolescents, and children older than years For children years and younger, see corresponding criteria below A Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: Directly experiencing the traumatic event(s) Witnessing, in person, the event(s) as it occurred to others Learning that the traumatic event(s) occurred to a close family member or close friend In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse) Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related B Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s) Note: In children older than years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s) Note: In children, there may be frightening dreams without recognizable content Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children, trauma-specific reenactment may occur in play Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s) Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s) C Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following: Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s) 346 • THE PSYCHIATRIC INTERVIEW IN CLINICAL PRACTICE Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s) D Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs) Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”) Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame) Markedly diminished interest or participation in significant activities Feelings of detachment or estrangement from others Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings) E Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects Reckless or self-destructive behavior Hypervigilance Exaggerated startle response Problems with concentration Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep) F Duration of the disturbance (Criteria B, C, D, and E) is more than month G The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning H The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition Specify whether: With dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic stress disorder, and in addition, in response to the stressor, the individual experiences persistent or recurrent symptoms of either of the following: The Traumatized Patient • 347 Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly) Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted) Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts, behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures) Specify if: With delayed expression: If the full diagnostic criteria are not met until at least months after the event (although the onset and expression of some symptoms may be immediate) Posttraumatic Stress Disorder for Children Years and Younger A In children years and younger, exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: Directly experiencing the traumatic event(s) Witnessing, in person, the event(s) as it occurred to others, especially primary caregivers Note: Witnessing does not include events that are witnessed only in electronic media, television, movies, or pictures Learning that the traumatic event(s) occurred to a parent or caregiving figure B Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s) Note: Spontaneous and intrusive memories may not necessarily appear distressing and may be expressed as play reenactment Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s) Note: It may not be possible to ascertain that the frightening content is related to the traumatic event Dissociative reactions (e.g., flashbacks) in which the child feels or acts as if the traumatic event(s) were recurring (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Such trauma-specific reenactment may occur in play 348 • THE PSYCHIATRIC INTERVIEW IN CLINICAL PRACTICE Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s) Marked physiological reactions to reminders of the traumatic event(s) C One (or more) of the following symptoms, representing either persistent avoidance of stimuli associated with the traumatic event(s) or negative alterations in cognitions and mood associated with the traumatic event(s), must be present, beginning after the event(s) or worsening after the event(s): Persistent Avoidance of Stimuli Avoidance of or efforts to avoid activities, places, or physical reminders that arouse recollections of the traumatic event(s) Avoidance of or efforts to avoid people, conversations, or interpersonal situations that arouse recollections of the traumatic event(s) Negative Alterations in Cognitions Substantially increased frequency of negative emotional states (e.g., fear, guilt, sadness, shame, confusion) Markedly diminished interest or participation in significant activities, including constriction of play Socially withdrawn behavior Persistent reduction in expression of positive emotions D Alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects (including extreme temper tantrums) Hypervigilance Exaggerated startle response Problems with concentration Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep) E The duration of the disturbance is more than month F The disturbance causes clinically significant distress or impairment in relationships with parents, siblings, peers, or other caregivers or with school behavior G The disturbance is not attributable to the physiological effects of a substance (e.g., medication or alcohol) or another medical condition Specify whether: With dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic stress disorder, and the individual experiences persistent or recurrent symptoms of either of the following: Index psychopathology and psychodynamics of, 344–357 risk factors for, 352–353 transference and countertransference issues in, 366–372 trauma and the life cycle, 355–356 Power struggles, 22, 31, 49 obsessive-compulsive patient and, 113, 114, 115, 117, 119, 124, 128, 131, 132 paranoid patient and, 447 patient of different background and, 592, 597 Precipitating factors for present illness, 45 Preconscious, 94 Premature termination of interview, 73 Prenatal history, 48 Preoedipal conflicts, 49 See also Oedipal conflicts histrionic patient and, 145 obsessive-compulsive patient and, 108 Previous psychiatric illnesses, 47 Pride of patient, 9, 10 Primary process thinking, 97 Privacy See also Confidentiality disclosure of information and, 72 of interview setting, 60 of medical records, Process of interview, Procrastination, 105, 108, 109, 114, 121, 187 Prognosis, patient’s questions about, 73 Projection, use of, 88, 92 by antisocial patient, 416, 417 by constricted patient, 583 by depressed patient, 230–231, 244, 261 by hospitalized patient, 566 by manic patient, 243 by narcissistic patient, 192, 194, 323 • 693 by paranoid patient, 438, 444, 445, 446, 450, 451, 453, 454, 468 by phobic patient, 286–287, 298, 307 by psychosomatic patient, 501, 510, 511 by psychotic patient, 478, 479 Pseudodementia, depressive, 231 Psoriasis, 500 Psychiatric emergencies See Emergency patient Psychiatric examination, 39–63 mental status, 39, 56–57, 523–526 psychiatric history, 39–56 therapeutic formulation based on, 57 Psychiatric history, 39–56 organization of data for, 42–55 chief complaint, 43–44 history of present illness, 44–46 personal history, 47–55 preliminary identification, 42–43 previous psychiatric illnesses, 47 psychiatric review of systems, 46–47 purpose of, 39–40 techniques for obtaining, 40–42 with psychotic patient, 42 questionnaires, 41 training in, 42 Psychiatric interview, 5–6 chance meeting of patient outside of, 62–63 closing phase of, 70–73 confidentiality of, 5, 66, 5, 66, 425, 428, 429, 470, 520, 589, 607, 633 content of, 7–8 data of, 7–39 diagnostic and therapeutic interviews, 6–7, 71 694 • THE PSYCHIATRIC INTERVIEW IN CLINICAL PRACTICE Psychiatric interview (continued) differences from general clinical interview, fees for, 60–62 importance of, 77 initial, 7, 64–73 later, 7, 74–75 management of, 63–75 middle phase of, 67–70 opening phase of, 64–66 patient disclosure or concealment in, 5, pre-interview expectations for, 63–64 interviewer, 63–64 patient, 63 premature termination of, 73 privacy of, 60 process of, seating arrangements for, 60 via telephone, 626–628 time factors for, 58–60 using first names with patients, 14, 15–16, 64, 333, 521 voluntariness of, Psychiatric review of systems, 46–47, 48 Psychic determinism, 79–80 “Psychic energy,” 78 Psychic reality, 84, 98 Psychoanalysis, 78 basic assumptions of, 78–85 Psychoanalytic models of mental functioning, 94–101 Psychodynamic formulation, 4, 57, 77–78 object relations theory and, 100 Psychodynamics, xi, 3, 10, 77–101 of antisocial patient, 410–411, 418–420 basic assumptions of psychoanalysis and, 78–85 dynamic unconscious, 79 emotions, 82 fantasies of danger, 82 fixation and regression, 81 motivation, 78–79 objects, 83–85 psychic determinism, 79–80 regulatory principles, 80–81 representations, 82–83 of borderline patient, 323–326 of depressed patient, 247–249 of dissociative identity disorder, 379–382 of histrionic patient, 148–152 of hospitalized patient, 558–562 patient factors, 558–560 staff factors, 560–562 of masochistic patient, 210–212 of narcissistic patient, 189–193 of paranoid patient, 444–448, 452–456 of phobic and panic disorder patients, 292–294 psychoanalytic models of mental functioning, 94–101 object relations models, 99–100 self psychological model, 100–101 structural model and ego psychology, 94–99 of psychopathology, 85–94 neurosis and psychosis, 91–94 normality and pathology, 85–86 structure of neurotic pathology, 86–89 symptom and character, 89–91 of psychosomatic patient, 501–502 of traumatized patient, 354–355 Psychological tests, 77, 327 Psychologically unsophisticated patient, 583–589 description of problem, 583–585 management of interview with, 585–589 closing phase, 588–589 countertransference issues, 586–587 Index modification of interview, 587–588 opening phase, 585–586 Psychopath, 405–406 See also Antisocial patient Psychopathia Sexualis, 201 Psychopathology, 9–10 normality and, 85–86 psychodynamics of, 85–94 Psychopathology and psychodynamics of antisocial patient, 410–421 of borderline patient, 314–326 of cognitively impaired patient, 514–519 of depressed patient, 228–249 of dissociative identity disorder, 375–382 of masochistic patient, 204–213 of paranoid patient, 439–456 of psychosomatic patient, 500–502 of psychotic patient, 475–487 of traumatized patient, 344–357 Psychosexual history, 51–52 See also Sexual behavior/functioning Psychosis, bipolar disorder and, 476, 477–478, 486, 488 as “brain disease,” xii, 474 depression and, 230–231, 235–236 intensive care unit, 513 paranoid, 449–452 posttraumatic stress disorder and, 357 Psychosomatic patient, 499–512 “doctor shopping” by, 509 management of interview with, 502–511 closing phase, 510–511 countertransference responses, 509–510 exploration of presenting symptoms, 503–506 exploration of psychological problems, 506–508 • 695 opening phase, 502–503 patient’s expectations of consultant, 508–509 psychodynamics of, 501–502 range of psychopathology of, 500–501 therapeutic alliance with, 500, 503, 504, 506, 507 Psychotic patient, 83, 473–498 acutely psychotic patient, 475–480 acute schizophrenia, 478 delusions and hallucinations, 479–480 disturbances of thought and affect, 477–479 manic patient, 477–478 positive and negative symptoms, 475–477 antipsychotics for, 474, 475 case example of, 94 comorbidities of, 487 e-mail communications from, 633 fantasies of, 478, 483–484, 496 initial telephone call from, 612 management of interview with, 42, 93–94, 487–494 acutely psychotic patient, 489–491 therapeutic alliance, 42, 475, 485, 491–494, 497 neurotic conflicts of, 91–94, 474 paranoid, 94, 438, 455, 456, 457, 460, 464, 466, 467 psychopathology and psychodynamics of, 475–487 response to clinician’s note taking, 608 role of clinician with, 494–497 ancillary and ongoing treatment, 497 interpretations of defensive pattern, 495–497 696 • THE PSYCHIATRIC INTERVIEW IN CLINICAL PRACTICE Psychotic patient (continued) schizophrenia patient presenting in nonacute phase, 480–487 assertion, aggression, and struggle for power and control, 486 disturbances in interpersonal relations, 92–93, 485 disturbances of affect, 480–482 disturbances of behavior, 484–485 disturbances of thought, 482–484 suicide and violence, 486–487 use of object relations models for, 100 PTSD See Posttraumatic stress disorder Puberty, 52 antisocial patient and, 420 borderline patient and, 325 histrionic patient and, 150 narcissistic patient and, 193 paranoid patient and, 455 Punishment of antisocial patient, 415 masochism and, 218 patient’s unconscious need for, 17 symbolic, symptoms as, 89 Pygmalion fantasies, 31 Questionnaires, 41 Race, defined, 575 Racism, 576–577 Rado, Sandor, 17n Rage See also Anger/hostility of patient of antisocial patient, 413, 414, 421 of borderline patient, 314, 317, 323, 330, 338, 633 childhood fear of, 293 of depressed patient, 246, 267, 268, 551 of dissociative identity disorder patient, 381 due to telephone interruptions, 620 of erotomanic patient, 451 of histrionic patient, 140, 142, 150, 153 of masochistic patient, 209, 210, 217, 220, 221, 223 of narcissistic patient, 174, 177, 184, 194, 198, 207, 323 of obsessive-compulsive patient, 109, 112–113, 116, 117–118, 127 of paranoid patient, 440, 442, 443, 446, 447, 454 anabolic steroids and, 452 of psychosomatic patient, 499, 510 of psychotic patient, 486 of suicidal patient, 246 suppression of, 86 of traumatized patient, 343, 361, 363, 365 Rape trauma syndrome, 343 Rapport with patient, 64–66 See also Clinician–patient relationship; Therapeutic alliance Rating scales, 56, 77 Rationalization, use of, 630 by antisocial patient, 407, 416, 426–427 by anxiety disorder patient, 287, 307 by depressed patient, 241 by narcissistic patient, 201 by obsessive-compulsive patient, 110, 116, 130, 132, 185 by paranoid patient, 444, 461 by suicidal patient, 260 Reaction formation, use of, 59 by depressed patient, 261 by obsessive-compulsive patient, 108, 132 by paranoid patient, 444, 445, 446, 450, 454 Index Reality, psychic, 84, 98 Reality principle, 81 Reality testing of antisocial patient, 421 of borderline patient, 314, 323 of cognitively impaired patient, 523 of paranoid patient, 622 of phobic patient, 287 of psychotic patient, 91–92, 484, 489 telephone calls and, 617–618 Reassurance, 6, 10, 19, 24, 28, 35, 69, 73 of antisocial patient, 416 of anxiety disorder patient, 285, 294, 295, 296, 301, 304–305, 307, 310, 615 of borderline patient, 315, 321 of cognitively impaired patient, 520, 521, 527 of depressed patient, 230, 255, 263, 265, 266 of dissociative identity disorder patient, 381, 386, 387, 401 of emergency patient, 544, 545, 546, 549, 551 of hospitalized patient, 562, 568, 569 of paranoid patient, 457, 461, 466–467 of psychosomatic patient, 507, 508, 509, 511 of psychotic patient, 496 via telephone, 615, 626 Reenactment, traumatic, 341, 345, 347, 350, 361, 366, 367, 369, 371, 372 Referral for interview, 63, 64, 612–613 of emergency patient, 541–542 by homosexual clinician, 595 of hospitalized patient, 563, 568, 569 of paranoid patient, 464 • 697 of psychosomatic patient, 502–503 of traumatized patient, 358, 362 Regression, 81 adaptive, 81 by histrionic patient, 147–148, 150, 164–165 by hospitalized patient, 558, 566, 567 medical illness–induced, 501 by obsessive-compulsive patient, 108 by panic disorder patient, 294 by paranoid patient, 444, 446–447, 450, 453, 455 Rejection sensitivity of borderline patient, 319 of depressed patient, 235 Relational psychology, Religious advisors, 550, 576 Religious beliefs, 43, 52, 108, 211, 299, 309, 543, 582 culture, ethnicity and, 575, 576, 580 of depressed patient, 241 dissociative states and, 373 about life after death, 246, 260 of paranoid patient, 441 of psychotic patient, 476, 484, 490 about sexuality, 551 of traumatized patient, 366, 369 Reminiscences, 84 Repetition compulsion, 25, 354 Representations, 82–83 object relations model of, 99–100 Repression, use of, 16, 59, 96 by depressed patient, 261 by dissociative identity disorder patient, 380, 394 by histrionic patient, 142, 143, 146 by obsessive-compulsive patient, 117 by phobic patient, 280, 292 by psychotic patient, 495 of sexual wishes, 88, 147 undoing of, 17, 35–36 698 • THE PSYCHIATRIC INTERVIEW IN CLINICAL PRACTICE Resentment, 18 of depressed patient, 254, 272 of disabled patient, 590 of histrionic patient, 137, 149 of masochistic patient, 204, 210, 212, 213, 215, 222 of obsessive-compulsive patient, 130, 185, 607 of paranoid patient, 439–440, 446, 463, 469 of phobic patient, 300 of psychotic patient, 492 related to note taking, 607, 609 related to telephone interruptions, 620, 621 Reserpine, 474 Resistance, 16–25, 42, 75, 101 acting out as, 22–25, 429 affective display as, 21 of antisocial patient, 429, 431 of anxiety disorder patient, 295, 296, 303 clinical examples of, 17–25 concentrating on trivial details as, 21 definition of, 16 delaying important subject until final minutes of interview as, 58 of depressed patient, 268, 273 of dissociative identity disorder patient, 385, 387, 389, 390, 397 expressed by communication patterns, 16, 18–21 generalization as, 20–21 of histrionic patient, 160 of hospitalized patient, 568 intellectualization as, 19–20 interpretation of, 36–38 timing of, 37–38, 45 lateness as, 58 of obsessive-compulsive patient, 118, 121 of psychotic patient, 483 related to telephone calls, 619, 626, 629 reluctance to participate in treatment as, 25 seductive, 23–24 transference used as, 16, 38 traumatic transference, 397 uncovering of, 71 Retirement, 591, 592–593 Review of systems, psychiatric, 46–47, 48 Rhetorical questions, 20, 162, 251 Rigidity of cognitively impaired patient, 518 of obsessive-compulsive patient, 105, 106, 108, 109, 110, 111, 112, 116, 130, 132, 440 of paranoid patient, 440, 441, 450 of psychotic patient, 495 Risk taking, 50, 292 Ritualized behaviors, 25, 81 of obsessive-compulsive patient, 80, 107, 110, 121, 130, 186 of phobic patient, 302 Rivers, William, 342 Role of interviewer, 34–39 reaching maturity in, 26 Sadism, 30.95, 202 of antisocial patient, 412 masochism and, 202, 204, 207–208, 209, 220, 222, 224 of narcissistic patient, 152, 181, 187 of obsessive-compulsive patient, 108, 109, 111, 113, 120, 122 of parents of paranoid patient, 441, 453, 454, 455 traumatized patient’s history of, 369, 372 Sadness, 9, 225, 228, 229 Same-sex marriage, 54 Index Schizophrenia, xii, 92 See also Psychotic patient acute phase of, 478 course of, 480 vs dissociative identity disorder, 382–383 hypochondriasis and, 448 nonacute phase of, 480–487 assertion, aggression, and struggle for power and control, 486 disturbances of affect, 480–482 disturbances of behavior, 484–485 disturbances of interpersonal relations, 485 disturbances of thought, 482–484 suicide and violence, 486–487 paranoid, 94, 449, 455 positive and negative symptoms of, 476–477 delusions and hallucinations, 479 pseudo-neurotic, 311, 312 use of humor in, 243 use of intellectualization in, 19 School experiences, 50–51, 53 School phobia, 294 Searles, Harold, 474 Seating arrangements for interview, 60 Secondary gains, 36, 46, 89 case examples of, 37, 46 factitious dissociative identity disorder and, 384 histrionic patient and, 141, 147, 148, 160, 164 phobic patient and, 283, 289, 302–303, 307 psychosomatic patient and, 499, 505–506, 508, 510 psychotic patient and, 483, 485 Secondary loss from symptoms, 46, 88, 142, 160, 203 • 699 Secondary process thinking, 97 Seductive behavior, 7, 8, 15, 23–24 of borderline patient, 333, 337 of histrionic patient, 53, 134, 135, 137, 138, 139, 140, 141, 144, 148, 149, 150, 152, 156–157, 170 of mother of paranoid patient, 454 of phobic patient, 284 Seizures, 85, 384, 391, 392 in conversion disorder, 500 hysterical, 79, 146, 374 Selective serotonin reuptake inhibitors, 515 Self childhood development of sense of, 292 vs personality and character, 108 Self-confidence of interviewer, 24 Self-confidence of patient, 19 depressed patient, 239, 243, 248, 262, 266, 534 histrionic patient, 136, 151 narcissistic patient, 176 obsessive-compulsive patient, 118 phobic patient, 284, 293, 294 Self-defeating behavior, 80, 121 of cognitively impaired patient, 519 of masochistic patient, 201, 203, 212, 219, 224 Self-destructive behavior See also Suicidality of borderline patient, 212, 311, 313, 319, 320–321, 322, 325, 330, 331, 335, 338 of cognitively impaired patient, 523 of depressed patient, 228, 245, 261–262, 272 of histrionic patient, 153 of masochistic patient, 218 of traumatized patient, 346, 364, 365, 366 substance abuse and, 356 700 • THE PSYCHIATRIC INTERVIEW IN CLINICAL PRACTICE Self-doubt, 161, 186, 221, 391 Self-dramatization, 134, 136, 143, 144, 150, 152, 156–158, 159 Self-esteem of clinician, 29, 272 Self-esteem of patient antisocial patient, 410, 412, 417–418 borderline patient, 321 cognitively impaired patient, 522, 527 depressed patient, 227, 237, 239, 240, 242, 244, 245, 248, 249, 535 emergency patient, 551, 555 histrionic patient, 141, 149, 150, 162, 164 hospitalized patient, 565 masochistic patient, 212, 214, 215, 224 narcissistic patient, 174, 182, 191 object relations model of, 100 obsessive-compulsive patient, 109, 111, 114, 118, 213 paranoid patient, 444, 454, 455, 458, 467 psychotic patient, 498 telephone calls and, 615, 620 Self-fragmentation, fear of, 190.198 Self-image of interviewer, 28 Self-image of patient, 51 borderline patient, 313 depressed patient, 239, 240, 241, 244, 247 histrionic patient, 136, 145, 163 paranoid patient, 244, 437, 447 Self-indulgence, 139 Self-injury See Self-destructive behavior; Suicidality Self-mutilative behavior See also Self-destructive behavior of borderline patient, 313, 320–321, 325, 331 Self-perception of patient, 69 Self-preoccupation of depressed patient, 230, 233 of narcissistic patient, 178, 196 Self psychology, 3, 100–101 Self-representation, 239 Self-righteousness, 169 of borderline patient, 318 of masochistic patient, 214, 222 of paranoid patient, 438 Self-sacrifice of depressed patient, 233 of masochistic patient, 203, 204, 205, 214 of paranoid patient, 442 Self–object differentiation, 189 Separation anxiety, 49, 135, 278, 291, 292, 293–294 Separation anxiety disorder, 278–279 Serotonin syndrome, 515 Sexual abuse/assault dissociative identity disorder and, 379, 381, 382, 396 posttraumatic stress disorder and, 339, 352, 354, 356, 357, 360, 367 Sexual behavior/functioning See also Homosexuality adult, 53–54 of borderline patient, 317–318, 333–334 of elderly patient, 591 frigidity, 54, 88, 139, 140, 154 of histrionic patient, 139–141 infantile, 51, 79 of masochistic patient, 201 of obsessive-compulsive patient, 116–117 psychosexual history of, 51–52 sexual drive, 78–79 Sexual bondage, 202 Sexual ecstasy, 202 Sexual fantasies, 54, 81, 87, 577, 591 adolescent, 52 of borderline patient, 327, 334, 336 of histrionic patient, 167 homosexuality and, 595, 597 of masochistic patient, 203, 204, 206–208, 212–213 Index of obsessive-compulsive patient, 109 Sexual feelings toward patient, 32 Sexual impulses anxiety and guilt about, 95 homosexual, 444 inhibition of, 87 panic attack and, 546 projection of, 88, 286–87, 444 at puberty, paranoid behavior and, 455 repression of, 88 Sexual inhibitions, 79, 87, 88 of obsessive-compulsive patient, 116–117 Sexual orientation, 573, 593–598 See also Homosexuality of borderline patient, 318 gay clinician and gay patient, 595–598 transference and countertransference issues related to, 594–595 Sexual proposition of clinician, 24 Shallowness of antisocial patient, 406, 410, 411, 413, 415 of conduct disorder patient, 409 of histrionic patient, 134 of narcissistic patient, 318 of psychotic patient, 92, 93 Shame, 9, 18, 82 of antisocial patient, 413 of depressed patient, 242, 257, 259, 272 of dissociative identity disorder patient, 385, 395, 402 of homosexual patient, 593 of masochistic patient, 206, 211, 220, 222 of narcissistic patient, 177, 178.179, 180, 182–183, 186, 191–192, 193, 196, 197, 199 of obsessive-compulsive patient, 113, 118, 120, 127, 138 • 701 of paranoid patient, 441, 446, 456, 467 of phobic patient, 282, 295, 299 of psychosomatic patient, 507, 508 of psychotic patient, 491 of suicidal patient, 259 of traumatized patient, 346, 348, 358 Shatan, C., 343 Shell shock, 342 Shyness, 69 in childhood, 50, 52, 292, 297 masochism and, 213, 214, 216 narcissism and, 177–180, 189, 192 Sibling(s) childhood relationships with, 49–50 death of, 49–50 Sick role, 500, 501 Signal anxiety, 88, 278 Silence of interviewer, 23 with depressed patient, 252 with histrionic patient, 157 with masochistic patient, 217 with obsessive-compulsive patient, 122, 129 with patient of different background, 586 with psychosomatic patient, 504 Silence of patient, 16, 18, 36 anxiety disorder patient, 295 histrionic patient, 148 obsessive-compulsive patient, 126 paranoid patient, 456–457 psychotic patient, 496, 497 during telephone interview, 628 “Silly” questions, 56–57 “Sitting duck syndrome,” 398 Sleep patterns/disturbances, 46–47 in childhood, 49 parent–child struggles about, 113, 115, 149 of delirious patient, 515 antipsychotics for, 527 of dementia patient, 518 702 • THE PSYCHIATRIC INTERVIEW IN CLINICAL PRACTICE Sleep patterns/disturbances (continued) of depressed patient, 232, 254–255 atypical depression, 234, 235 melancholia, 234 of grieving patient, 535 of hospitalized patient, 558 of manic patient, 477 of separation anxiety disorder patient, 278 of traumatized patient, 346, 348, 351, 354, 356, 359, 363 Sleeping pills, suicidality and, 246, 272–273, 367, 628 Social ataxia, 111, 450 Social media, 611–612 Social withdrawal See also Emotional isolation; Isolation of depressed patient, 229–230, 232, 233, 235 of paranoid patient, 448–449, 450 of psychotic patient, 92, 480 of traumatized patient, 342, 343, 347 Socioeconomic status/social class, 55, 581–582, 584, 585 posttraumatic stress disorder and, 352 Sociopath, 405 See also Antisocial patient Somatic complaints, 23 See also Hypochondriasis of antisocial patient, 427 of anxiety disorder patient, 299–300 during panic attack, 289, 290, 546 of cognitively impaired patient, 523 of conversion disorder patient, 500, 502 of depressed patient, 229, 232, 242, 254–255, 502 differential diagnosis of, 502 of emergency patient, 537–538 evaluating psychological components of, 499–500 of histrionic patient, 141, 145–147, 160 of paranoid patient, 448–449 of psychosomatic patient, 499–512 of psychotic patient, 502 of substance-abusing patient, 502 Somatic delusions, 452, 479, 502, 538 Somatization, 23, 146, 502, 507 Somatoform disorders, 374–375, 500–501, 509, 510 Special patient, 29, 33–34 Spiegel, John, 342 Splitting, use of by bipolar patient, 384 by borderline patient, 336, 453 by dissociative identity disorder patient, 374, 377, 379–380, 382, 384, 399 by histrionic patient, 135 by hospitalized patient, 561 Stern, Adolph, 312 Stone, M.H., 313, 405–406 Stranger anxiety, 49, 278, 292, 293 Structural model of the mind, 94–99 Stubbornness, 565 of obsessive-compulsive patient, 106, 108, 110, 121, 132 Studies on Hysteria, 291, 379 Subcultures, 582–583 Submissiveness, 16, 61 of antisocial patient, 414 of masochistic patient, 201, 205, 206, 207, 209, 210 of obsessive-compulsive patient, 109, 112, 118, 129, 131, 186, 421 of paranoid patient, 445, 447, 454, 455, 456, 463, 466 Substance abuse, 547, 584 by antisocial patient, 406, 411, 415, 418, 420 attention-deficit/hyperactivity disorder and, 406 Index by borderline patient, 313, 314, 320, 323, 325, 330, 331 delirium due to, 514–515 by depressed patient, 225, 255 by dissociative identity disorder patient, 377, 378, 383, 384 interview of hospitalized patients about, 570–571 interview of intoxicated patient, 546–547 malingering pain to obtain narcotics, 547 parental, 382 by psychosomatic patient, 499, 502 by psychotic patient, 487 by traumatized patient, 356, 366 Suggestibility, 134, 139, 341 Suicidality, 535 ambivalence about, 260, 544 of borderline patient, 320–321, 323 of depressed patient, 225, 244–247, 535, 544–545 discussing with patient, 247, 257–261, 544–545 of dissociative identity disorder patient, 378, 379 hospitalization for, 257, 545 impulsivity and, 247 motivations for, 245 of paranoid patient, 442 providing clinician’s home telephone number to patient, 615 psychological meaning of dying, 246 of psychotic patient, 486–487 risk and prohibitive factors for, 246 unconscious meaning of, 246, 258–259 Sullivan, Harry Stack, 5, 81, 473 Sundowning, 513 Superego, 95–96, 97, 241 of antisocial patient, 406, 410, 419 • 703 of anxiety disorder patient, 278, 293 of borderline patient, 326 of depressed patient, 241, 243, 249 of histrionic patient, 134, 135, 151 of manic patient, 243–244 of masochistic patient, 208 of narcissistic patient, 176, 184, 191 of paranoid patient, 446–447 of psychotic patient, 479 role in behavior, 98 of traumatized patient, 355 Superego lacunae, 419 Supervision of interview, 4, 24, 26, 27, 101 mental status evaluation, 57 note taking, 603–609 psychiatric history taking, 42 related to handling of fees, 61 with specific types of patients borderline patient, 337 dissociative identity disorder patient, 400, 401 psychotic patient, 475 traumatized patient, 371 young interviewer’s emulation of supervisor, 28 Supportive psychotherapy, for depression, 261–264 Survivor syndrome, 343 Survivor’s guilt, 355, 365 Suspiciousness, 11, 64, 90, 607 of antisocial patient, 433 of obsessive-compulsive patient, 117 of paranoid patient, 80, 437, 438, 439, 443, 459, 465, 466 of psychotic patient, 473 Symbolization, use of, 97 by depressed patient, 231 by phobic patient, 283, 286, 287, 307 by psychosomatic patient, 502 704 • THE PSYCHIATRIC INTERVIEW IN CLINICAL PRACTICE Sympathetic responses of clinician, 5, 28, 34, 65 See also Empathy of clinician to antisocial patient, 427 to anxiety disorder patient, 302, 303 to borderline patient, 314, 315, 320 to cognitively impaired patient, 529 to depressed patient, 229, 252, 271 to dissociative identity disorder patient, 399, 400 to histrionic patient, 136, 152, 159, 160, 161, 163, 166, 168, 169 to manic patient, 243 to masochistic patient, 205 to obsessive-compulsive patient, 115, 122 to paranoid patient, 457, 465 to patient with an interpersonal crisis, 548 to psychotic patient, 482, 492 secondary gain and, 17, 37, 46 to traumatized patient, 359 Sympathetic responses of patient, elicited by telephone interruptions, 622–623 Systems review, psychiatric, 46–47, 48 Tangentiality, 477, 482 Teasing of gay patient, 596 by histrionic patient, 148 by masochistic patient, 208 by obsessive-compulsive patient, 108, 111–112, 120 Telephone calls, 4, 611–631 cellular phones, 624, 629–631 after the first interview, 614–616 initial telephone contact from patient, 611, 612–614 with patient’s relatives, 428, 625 patient’s request to use clinician’s telephone, 624 providing clinician’s home telephone number to patients, 615 between sessions, 60, 616 sessions conducted by, 611, 625–629 telephone emergencies, 625–626 telephone interviews, 626–628 telephone treatment sessions, 628–629 telephone interruptions during the interview, 611, 616–624 deciding whether to answer calls, 617–618 interviewers reactions to, 623–624 patient’s reactions to, 618–623 anger, 619–620 curiosity, 622 denial, 620 distraction, 619 envy or competition, 621 fright, 623 guilt or feelings of inadequacy, 620–621 paranoid responses, 621–622 pleasure, 623 relief, 618–619 sympathy, 622–623 Theoretical foundation, Theoretical orientation, 3, 66 Theory of the mind, 100 Therapeutic alliance, xi See also Clinician–patient relationship with borderline patient, 320, 327, 328, 329, 338 with cognitively impaired patient, 519, 520, 523, 525 with depressed patient, 261 with dissociative identity disorder patient, 391, 393 with emergency patient, 551 with histrionic patient, 137, 169 Index with homosexual clinician, 597 with hospitalized patient, 558, 562, 564, 565–566, 567 impact of interpretations on, 38 intellectualization and, 19 investigating Facebook postings and, 612 with masochistic patient, 216 with obsessive-compulsive patient, 110, 127–129 with paranoid patient, 461, 462–467 with patient of different background, 577, 587 with phobic patient, 303 with psychosomatic patient, 500, 503, 504, 506, 507 with psychotic patient, 42, 475, 485, 491–494, 497 transference and, 11, 12 with traumatized patient, 357, 358, 361 Therapeutic formulation, 57–58 Therapeutic interview, 6–7, 71 Therapeutic use of self, 26 Thought(s), 8, avoidance of, by traumatized patient, 345, 346, 351 censoring or editing of, 18–19 of cognitively impaired patient, 516, 525, 526 of confused patient, 536 constricted, 9, 229, 251 delusional (See Delusions) of depressed patient, 226, 229, 230–231, 236, 251, 252, 266, 544 disturbances of, in psychotic patient, 92, 93, 94, 476, 477–478, 479, 482–484, 493–494 emotions and, 82 of histrionic patient, 146, 153 magical (See Magical thinking) of manic patient, 243, 476, 477 • 705 motives and, 78 of obsessive-compulsive patient, 106, 108, 115, 116, 118 of phobic patient, 280, 282, 292, 295, 308 primary process and secondary process thinking, 97 of suicidal patient, 244, 247, 250, 257–260, 535, 544–545 suppression or avoidance of, 16 Time factors changing time of appointment, 22–23, 615–616 clinician-related, 32, 59, 464 duration of interviews, 7, 58, 114, 124 duration of treatment, 62, 73 patient-related, 22–23, 58–59 arriving late or forgetting appointments, 23, 58–59, 614 histrionic patient’s lack of concern with punctuality, 134, 138 punctuality of obsessivecompulsive patient, 90–91, 108, 111, 112 transition between interviews, 60 Toddler development, 49–50 Toilet training, 48, 49, 113, 115 Topographic model of the mind, 94–95 Trance states, 373 Transference(s), xii, 11–16 See also Countertransference age-related, 15 of antisocial patient, 25, 431–433 of borderline patient, 311, 335–336 of cognitively impaired patient, 521 common patterns of, 12–16 competitive, 14–15, 16, 20, 23 definition of, 11 dependent, 12–13, 20 of depressed patient, 271–273 706 • THE PSYCHIATRIC INTERVIEW IN CLINICAL PRACTICE Transference(s) (continued) of dissociative identity disorder patient, 395–398 flashback, 395 of gay and lesbian patients, 594–595 of histrionic patient, 166–171 idealizing, 194, 195, 197–198 of masochistic patient, 217, 222–223 mirroring, 174, 197 of narcissistic patient, 194, 195–200 negative, 11, 12, 16 displaced to other authority figures, 22 of dissociative identity disorder patient, 395, 397 of paranoid patient, 11 of obsessive-compulsive patient, 129–132 omnipotent, 11, 13, 16, 271, 309, 468 of paranoid patient, 468–469 positive, 11, 12, 14, 15, 16 of anxiety disorder patient, 301 pre-interview, 63 related to note taking, 609 related to use of interpreter, 579–580 therapeutic alliance and, 11 traumatic, 395–397 of traumatized patient, 366–372 used as resistance, 16 Transference neurosis, 11–12, 32 Transgender patients, xi Transition between interviews, 60 Traumatic transference, 395–397 Traumatized patient, 339–372 combat exposure, 339, 340, 341, 342, 343, 352, 354, 355, 356, 363 comorbidities of, 356–357 DSM-5 diagnostic criteria for acute stress disorder, 349–352 for posttraumatic stress disorder, 344–349 epidemiology of, 352–353 epidemiology of posttraumatic stress disorder, 352–353 fantasies of, 341, 342, 355, 358, 361, 366, 370–371, 374 historical studies of, 340–343 Holocaust survivors, 342–343, 354, 355, 356, 357, 358, 365, 369, 370, 526 management of interview with, 357–365 protective factors and resilience of, 338, 353, 367 psychological response to traumatic exposure, 339–340 psychopathology and psychodynamics of, 344–357 rape trauma syndrome, 343 therapeutic alliance with, 357, 358, 361 transference and countertransference issues with, 366–372 trauma and the life cycle, 355–356 Treatment plan, 56, 62 for cognitively impaired patient, 526–528 discussing with patient, 70, 71, 72 for emergency patient, 537, 541, 553, 554–555 for paranoid patient, 463–464 psychotic patient’s noncompliance with, 488 for symptom relief, 90 Treatment sessions via telephone, 628–629 Trust in clinician, 8, 11 Unconscious, 94, 95, 96 dynamic, 79 Undoing, 17, 108, 116, 186 Index Using first names with patients, 14, 15–16, 64, 333, 521 Vacation of clinician, 273, 302, 319, 429, 465 Video recordings of interview, 606–607 Violence See also Aggression; Dangerousness; Homicidality of antisocial patient, 405, 406, 414, 421, 430 behavioral regulation of, 80 of borderline patient, 314, 317, 330 of depressed patient, 246, 256 of dissociative identity disorder patient alters, 377 management of interview with assaultive patient, 548–549 of narcissistic patient, 183, 184 of paranoid patient, 443, 470 of phobic patient, 293 • 707 of psychotic patient, 486, 489 sexual, 340, 341, 345, 356, 360 of suicidal patient, 246, 486–487 traumatized patient’s exposure to, 340, 341, 343, 344, 345, 350, 352, 356, 360, 366, 367 War neurosis, 341, 342, 343, 355 See also Traumatized patient Weiss, R.W., 447 Wheelchair patient, 590 Winnicott, D.W., 83 Worthless feelings of depressed patient, 226, 244, 267 of dissociative identity disorder patient, 391 of masochistic patient, 210 of narcissistic patient, 183, 186 of paranoid patient, 446, 447, 453, 458, 469 of suicidal patient, 486 ... INTERVIEW IN CLINICAL PRACTICE distressed during the interview The counselor put his arm on the young boy’s shoulder, probably to comfort him Mr A left the interview feeling confused about the intentions... more engaged when speaking about them He expressed much regret at not having been 360 • THE PSYCHIATRIC INTERVIEW IN CLINICAL PRACTICE more involved in their life during their formative years;... chance—to be exhilarating and liberating However, it is not up to the interviewer to attribute this uplifting meaning to the experience 366 • THE PSYCHIATRIC INTERVIEW IN CLINICAL PRACTICE TRANSFERENCE