A.

DIFFICULT PATIENT
Overlooked the patient's cola can on his desk. Thus, his offer appears to be routine
rather than a genuine concern for her comfort.
Not being current on the patient's status and the oversight of the opened cola
would not matter if the patient is eager to talk about her problems. However, this
is not the case. It remains the interviewer's task to establish rapport by addressing
her suffering (Q. 1-9).
The interviewer probes whether the patient has been adequately informed
about the reasons for the referral (Q. 10-12), but this topic does not establish
rapport. At this point the interviewer could have asked the patient whether she
agreed with Dr. A.'s request to seek a second opinion. This might have caused her
to ventilate her feelings about the present interview and to possibly open up.
Instead, the interviewer assumes that the patient's cutting is her chief complaint
and the center of her suffering. Therefore, he focuses on the emotions that may
underlie her self-mutilation. He echoes her emotion (Q. 19) and gives a
summarizing interpretation (Q. 20). However, the patient's affect remains
restricted and her verbal elaborations scarce.
The interviewer tries to identify frustrating situations that may result in the
patient cutting herself, but he draws a blank. No emotional response occurs.
Instead, she gives some longer but mainly factual answers. He attempts positive
feedback by telling her that he thinks her grades are good (Q. 26). But the praise
yields merely the report of a C in weaving. Overall, her answers express
reluctance, without overt resistance or refusal to answer.

Technique: The interviewer goes through the formalities of introduction. He
reviews the circumstances of the referral and asks the patient how she wants to be
addressed (Q. 1-9). He uses four open-ended questions (Q. 11, 12, 14, 17), which
are all answered with a short sentence or a single word. When the patient
expresses a feeling (A. 17), he echoes this feeling in a client-centered manner (Q.
18, 19) and attempts an interpretation. These techniques do not initiate a
spontaneous free flow of information.
Open-ended Q. 21 produces only a vague answer, Follow-up results in answers
that do not explain her arm and wrist cutting. Thus, the fact-oriented questions
produce diagnostically useless results, yet the interviewer pursues them in the
expectation of hitting on a topic that might help to initiate a more spontaneous and
productive flow of information. Positive feedback (Q. 26) and two open-ended
questions (Q. 27, 28) directed at assessing her feelings about a mediocre grade In
school, followed by a summary of her feelings, do not improve upon her one-
sentence answers. Probing for the reasons of her cutting (Q. 30, 31) do not full
circle, the interviewer returns to the topic of cutting without having learned
anything significant about her psychopathology.

Mental status: Observation of the patient's attire suggests that she attempts to set
herself apart through her fashion statement, and may be searching for her identity.
This may indicate that her social judgment is impaired, or that she belongs to a
subculture where this look is the accepted uniform.
Her psychomotor movements appear normal except for the lack of a reactive
movementsuch as looking up--when the interviewer enters the waiting area.
During the brief conversation it becomes apparent that she understands all
questions, and answers them appropriately, showing adequate information
processing, and no indication of a thought disorder.
Her affect, as expressed in face, gestures, and intonation (Q. 10-20) appears to
be restricted. She is indifferent to the interviewer and the topic of the interview,
merely going through the motions without being engaged.
She comes for the appointment unescorted and recalls her discharge day, both
of which show absence of severe anxiety, gross uncontrolled psychotic
excitement, and disorientation to time and place (list no. 3).,
The patient is cooperative enough to talk about herself, which allows a
progression from conversation to exploration of her current and past problems.
Her verbal production shows poverty of response without prolonged latency.
The patient shows ambivalence; she expresses concern about her college
grades, but then contradicts herself and reports good grades and satisfaction with a
C. This ambivalence reveals an illogical aspect of her judgment.

Diagnosis: The patient's attire, together with her lack of a reactive movement
when the interviewer enters the waiting room and her emotionally restricted
response during the warm-up period, suggest several psychiatric disorders for list-
no. 1.
Clinical disorders:
substance intoxication or withdrawal
schizophrenia,
bipolar 11 disorder, depressed
major, depressive disorder
adjustment disorder with depressed
,
mood

Personality disorders:
paranoid
schizoid
schizotypal
antisocial
avoidant
borderline

Her reluctance to volunteer information may suggest the presence of passive-
aggressive personality disorder. Her ambivalence about her
-
grades underscores as
diagnostic options schizophrenia, and/or any of the personality disorders of
Cluster A in DSM-IV.
It excludes (list no. 2) possibly:
bipolar I disorder, manic
adjustment disorder with depressed mood .0 dependent
personality disorder
The patient's answers do not point to any stressor necessary for the diagnosis of
adjustment disorder.

Phase 2: Follow-Up of Diagnostic Impressions
32. I: Any other feelings?
P: No.
33. I: Did you feel, in any way, down?
P: No.
34. I: Any other problems?
P: I don't know.
35. I: How was your sleep during that time?
P: Okay.
36. I: And your appetite?
P: Fine.
37. I: Any problems with eating at all?
P: Sometimes.
38. I: What kind of problems?
P: Sometimes I eat too much.
39. L: Do you do anything about it?
P: Like what?
40. L: Did you ever try to starve yourself?
P : Maybe for a day or so
41. L: Did you ever do anything elselike trying to vomit?
P: Yeah, a couple of times but it didn't work.
42. L: What types of things do you eat when you eat too much?
P; Pretty good food. Lots of fruits and vegetables.
43. L: So you ate all right and slept fine when you cut yourself.
P; I guess...
44. L: Was anything else going on?
P: just looks at the interviewer, then takes out a cigarette and lights it
45. L: Anything with your friends? Or your boyfriend?
P: No, we were fine,
46. L: What were you thinking then when you were cutting yourself?
P: I was just mad [no change in tone of voice or facial expression],
47. L: Mad? Mad enough to die?
P: No. Just to cut myself.
48. L: Do you have any idea why you did it?
P: I was angry.
49. L: About. ?
P: Myself.
50. L: So you cut yourself when you are angry about yourself?
P: Yeah, and about others too.
Rapport: The interviewer assesses symptoms of clinical disorders that could
explain the cutting. Neither reviewing the topics of depressive and eating disorder
symptoms nor using open-ended questions enhance rapport and induce more
spontaneity,
Technique: The interviewer checks out whether depressive symptoms were
associated with the arm cutting. If he keeps the symptom-oriented questions open,
the patient makes him specify (Q. and A. 39), or answers them with yes or no as if
they were closed-ended (A. 32, 35, 36, 45). His two summary statements (Q. 43,
50) are met with vague consent, which leaves it doubtful whether these summaries
establish any facts.
Mental status: The patient reports her arm cutting in a matter-of-fact way. Her
affect appears blunted; she displays an inappropriate distance to her maladjusted
behavior. She indicates overeating and an attempt to induce vomiting. However,
unlike a patient with bulimia, she is not eating junk food but "lots of fruits and
vegetables." Overeating those appears to be bizarre and points toward an
ambivalence about her eating habits.
Diagnosis: The patient is only reluctantly cooperative and shows no spontaneity.
The interviewer
,
decides to verify or exclude some diagnostic options possibly
associated with the self-mutilation.