Front Cover Authors and Editors Dedication Preface About the Authors Contents Drugs Used in Psychiatry 1 - The Patient-Doctor Relationship 2 - Human Development Throughout the Life Cycle 2.1 - Normality 2.2 - Embryo, Fetus, Infant, and Child 2.3 - Adolescence 2.4 - Adulthood 2.5 - Late Adulthood 2.6 - Death, Dying, and Bereavement 3 - The Brain and Behavior 3.1 - Functional and Behavioral Neuroanatomy 3.2 - Neurophysiology and Neurochemistry 3.3 - Neuroimaging 3.4 - Electrophysiology 3.5 - Psychoneuroendocrinology, Psychoneuroimmunology, andChronobiology 3.6 - Neurogenetics 4 - Contributions of the Psychosocial Sciences 4.1 - Jean Piaget 4.2 - Attachment Theory 4.3 - Learning Theory 4.4 - Aggression 4.5 - Sociobiology and Ethology

4.6 - Anthropology and Cross-Cultural Psychiatry 4.7 - Epidemiology and Biostatistics 5 - Clinical Neuropsychological Testing 5.1 - Clinical Neuropsychological Testing of Intelligence andPersonality 5.2 - Clinical Neuropsychological Assessment of Adults 6 - Theories of Personality and Psychopathology 6.1 - Sigmund Freud - Founder of Classic Psychoanalysis 6.2 - Erik Erikson 6.3 - Schools Derived from Psychoanalysis and Psychology 7 - Clinical Examination of the Psychiatric Patient 7.1 - Psychiatric History and Mental Status Examination 7.2 - Interviewing Techniques with Special Patient Populations 7.3 - Physical Examination of the Psychiatric Patient 7.4 - Laboratory Tests in Psychiatry 7.5 - Medical Record and Medical Error 8 - Signs and Symptoms in Psychiatry 9 - Classification in Psychiatry and Psychiatric Rating Scales 9.1 - Classification in Psychiatry 9.2 - Psychiatric Rating Scales 10 - Delirium, Dementia, and Amnestic and Other Cognitive Disorders 10.1 - Overview 10.2 - Delirium 10.3 - Dementia 10.4 - Amnestic Disorders 10.5 - Mental Disorders Due to a General Medical Condition 11 - Neuropsychiatric Aspects of HIV Infection and AIDS 12 - Substance-Related Disorders 12.1 - Introduction and Overview 12.2 - Alcohol-Related Disorders 12.3 - Amphetamine

12.4 - Caffeine 12.5 - Cannabis 12.6 - Cocaine 12.7 - Hallucinogen 12.8 - Inhalant 12.9 - Nicotine 12.10 - Opioid 12.11 - Phencyclidine 12.12 - Sedative-, Hypnotic-, or Anxiolytic-Related Disorders 12.13 - Anabolic-Androgenic Steroid Abuse 12.14 - Other Substance-Related Disorders 13 - Schizophrenia 14 - Other Psychotic Disorders 14.1 - Schizophreniform Disorder 14.2 - Schizoaffective Disorder 14.3 - Delusional Disorder and Shared Psychotic Disorder 14.4 - Brief Psychotic Disorder, Psychotic Disorder Not OtherwiseSpecified, and Secondary Psychotic Disorders 14.5 - Culture-Bound Syndromes 15 - Mood Disorders 15.1 - Depression and Bipolar Disorder 15.2 - Dysthymia and Cyclothymia 15.3 - Other Mood Disorders 16 - Anxiety Disorders 16.1 - Overview 16.2 - Panic Disorder and Agoraphobia 16.3 - Specific Phobia and Social Phobia 16.4 - Obsessive-Compulsive Disorder 16.5 - Posttraumatic Stress Disorder and Acute Stress Disorder 16.6 - Generalized Anxiety Disorder 16.7 - Other Anxiety Disorders

17 - Somatoform Disorders 18 - Chronic Fatigue Syndrome 19 - Factitious Disorders 20 - Dissociative Disorders 21 - Human Sexuality 21.1 - Normal Sexuality 21.2 - Abnormal Sexuality and Sexual Dysfunctions 21.3 - Paraphilias and Sexual Disorder Not Otherwise Specified 22 - Gender Identity Disorders 23 - Eating Disorders 23.1 - Anorexia Nervosa 23.2 - Bulimia Nervosa and Eating Disorder Not Otherwise Specified 23.3 - Obesity 24 - Normal Sleep and Sleep Disorders 24.1 - Normal Sleep 24.2 - Sleep Disorders 25 - Impulse-Control Disorders Not Elsewhere Classified 26 - Adjustment Disorders 27 - Personality Disorders 28 - Psychosomatic Medicine 28.1 - Psychological Factors Affecting Physical Conditions 28.2 - Consultation-Liaison Psychiatry 29 - Complementary and Alternative Medicine in Psychiatry 30 - Psychiatry and Reproductive Medicine 31 - Relational Problems 32 - Problems Related to Abuse or Neglect 33 - Additional Conditions That May Be a Focus of Clinical Attention 34 - Emergency Psychiatric Medicine 34.1 - Suicide 34.2 - Psychiatric Emergencies in Adults 34.3 - Psychiatric Emergencies in Children

35 - Psychotherapies 35.1 - Psychoanalysis and Psychoanalytic Psychotherapy 35.2 - Brief Psychodynamic Psychotherapy 35.3 - Group Psychotherapy, Combined Individual and GroupPsychotherapy, and Psychodrama 35.4 - Family Therapy and Couples Therapy 35.5 - Dialectical Behavior Therapy 35.6 - Genetic Counseling 35.7 - Biofeedback 35.8 - Behavior Therapy 35.9 - Cognitive Therapy 35.10 - Hypnosis 35.11 - Interpersonal Therapy 35.12 - Psychiatric Rehabilitation 35.13 - Combined Psychotherapy and Pharmacology 36 - Biological Therapies 36.1 - General Principles of Psychopharmacology 36.2 - Medication-Induced Movement Disorders 36.3 - alpha2-Adrenergic Receptor Agonists - Clonidine and Guanfacine36.4 - beta-Adrenergic Receptor Antagonists 36.5 - Anticholinergics and Amantadine 36.6 - Anticonvulsants - Gabapentin, Pregabalin, Tiagabine,Levetiracetam, Topiramate, and Zonisamide 36.7 - Antihistamines 36.8 - Barbiturates and Similarly Acting Drugs 36.9 - Benzodiazepines and Drugs Acting on Benzodiazepine Receptors36.10 - Bupropion 36.11 - Buspirone 36.12 - Calcium Channel Inhibitors 36.13 - Carbamazepine and Oxcarbazepine 36.14 - Cholinesterase Inhibitors and Memantine

36.15 - Dantrolene 36.16 - Disulfiram and Acamprosate 36.17 - Dopamine Receptor Agonists and Precursors 36.18 - Dopamine Receptor Antagonists - Typical Antipsychotics 36.19 - Lamotrigine 36.20 - Lithium 36.21 - Melatonin Agonists - Ramelteon and Melatonin 36.22 - Mirtazapine 36.23 - Monoamine Oxidase Inhibitors 36.24 - Nefazodone 36.25 - Opioid Receptor Agonists - Methadone, Buprenorphine, andLevomethadyl 36.26 - Opioid Receptor Antagonists - Naltrexone, Nalmefene, andNaloxone 36.27 - Phosphodiesterase-5 Inhibitors 36.28 - Selective Serotonin-Norepinephrine Reuptake Inhibitors 36.29 - Selective Serotonin Reuptake Inhibitors 36.30 - Serotonin-Dopamine Antagonists - Atypical Antipsychotics 36.31 - Sympathomimetics and Related Drugs 36.32 - Thyroid Hormones 36.33 - Trazodone 36.34 - Tricyclics and Tetracyclics 36.35 - Valproate 36.36 - Yohimbine 36.37 - Brain Stimulation Methods 37 - Child Psychiatry - Assessment, Examination, and PsychologicalTesting 38 - Mental Retardation 39 - Learning Disorders 40 - Motor Skills Disorder - Developmental Coordination Disorder 41 - Communication Disorders

42 - Pervasive Developmental Disorders 43 - Attention-Deficit Disorders 44 - Disruptive Behavior Disorders 45 - Feeding and Eating Disorders of Infancy or Early Childhood 46 - Tic Disorders 47 - Elimination Disorders 48 - Other Disorders of Infancy, Childhood, and Adolescence 48.1 - Reactive Attachment Disorder of Infancy or Early Childhood 48.2 - Stereotypic Movement Disorder and Disorder Not OtherwiseSpecified 49 - Mood Disorders and Suicide in Children and Adolescents 49.1 - Depressive Disorders and Suicide in Children and Adolescents 49.2 - Early-Onset Bipolar Disorders 50 - Anxiety Disorders of Infancy, Childhood, and Adolescence 50.1 - Obsessive-Compulsive Disorder 50.2 - Posttraumatic Stress Disorder 50.3 - Separation Anxiety Disorder, Generalized Anxiety Disorder, andSocial Phobia 50.4 - Selective Mutism 51 - Early-Onset Schizophrenia 52 - Adolescent Substance Abuse 53 - Child Psychiatry - Additional Conditions That May Be a Focus ofClinical Attention 54 - Psychiatric Treatment of Children and Adolescents 54.1 - Individual Psychotherapy 54.2 - Group Psychotherapy 54.3 - Residential, Day, and Hospital Treatment 54.4 - Biological Therapies 54.5 - Psychiatric Treatment of Adolescents 55 - Child Psychiatry - Special Areas of Interest 55.1 - Forensic Issues in Child Psychiatry

55.2 - Adoption and Foster Care 55.3 - Child Maltreatment and Abuse 55.4 - Impact of Terrorism on Children 56 - Geriatric Psychiatry 57 - End of Life Care and Palliative Medicine 57.1 - Palliative Medicine and Pain Management 57.2 - Euthanasia and Physician-Assisted Suicide 58 - Clinical-Legal Issues in Psychiatry 59 - Ethics in Psychiatry

Authors: Sadock, Benjamin James; Sadock, Virginia AlcottTitle: Kaplan & Sadock's Synopsis of Psychiatry: BehavioralSciences/Clinical Psychiatry, 10th EditionCopyright 2007 Lippincott Williams & Wilkins> Front of Book > Authors

AuthorsBenjamin James Sadock M.D.Menas S. Gregory Professor of Psychiatry and Vice ChairmanDepartment of Psychiatry, New York University School of Medicine;Attending Psychiatrist, Tisch Hospital; Attending Psychiatrist, BellevueHospital Center; Consulting Psychiatrist, Lenox Hill Hospital, New York,New York

Virginia Alcott Sadock M.D.Professor of PsychiatryDepartment of Psychiatry, New York University School of Medicine;Attending Psychiatrist, Tisch Hospital; Attending Psychiatrist, BellevueHospital Center, New York, New York

Contributing EditorsJack A. Grebb M.D.Professor of PsychiatryDepartment of Psychiatry, New York University School of Medicine, NewYork, New York; Vice President, Clinical Design and Evaluations,Neuroscience, Bristol-Myers Squibb, Walingford, Connecticut

Caroly S. Pataki M.D.Clinical Professor of Psychiatry and the Biobehavioral SciencesKeck School of Medicine at the University of Southern California;Director, Child and Adolescent Psychiatry Residency Training Program,University of Southern California, Los Angeles, California

Norman Sussman M.D.Professor of PsychiatryNew York University School of Medicine; Co-director, ContinuingEducation in Psychiatry, Department of Psychiatry; Associate Dean forPostgraduate Programs, NYU Postgraduate Medical School; AttendingPsychiatrist, Tisch Hospital, New York, New York

Secondary EditorsCharles W. MitchellAcquisitions Editor

Katey MilletDevelopmental Editor

Joyce A. MurphyManaging Editor

Bridgett DoughertyProduction Editor

Benjamin RiveraManufacturing Manager

Stephen DrudingDesigner Coordinator

Aptara, Inc.Compositor

Quebecor World-TauntonPrinter

Authors: Sadock, Benjamin James; Sadock, Virginia AlcottTitle: Kaplan & Sadock's Synopsis of Psychiatry: BehavioralSciences/Clinical Psychiatry, 10th EditionCopyright 2007 Lippincott Williams & Wilkins> Front of Book > Dedication

Dedication

To Celia and Emily

Authors: Sadock, Benjamin James; Sadock, Virginia AlcottTitle: Kaplan & Sadock's Synopsis of Psychiatry: BehavioralSciences/Clinical Psychiatry, 10th EditionCopyright 2007 Lippincott Williams & Wilkins> Front of Book > Preface

Preface

This is the tenth edition of Kaplan & Sadock's Synopsis of Psychiatry toappear since its founding over 35 years ago and the second edition tobe published in the 21st century. Since its beginning, the goal of thisbook has been to foster professional competence and ensure the highestquality care to those with mental illness. An eclectic, multidisciplinaryapproach has been its hallmark; thus, biological, psychological, andsociological factors are equitably presented as they affect the person inhealth and disease. Each edition is thoroughly updated and thetextbook has the reputation of being an independent, consistent,accurate, objective, and reliable compendium of new events in the fieldof psychiatry.Synopsis serves the needs of diverse professional groups: psychiatristsand nonpsychiatric physicians, medical students, psychologists, socialworkers, psychiatric nurses, and other mental health professionals,such as occupational and art therapists, among others. Synopsis is alsoused by nonprofessionals as an authoritative guide to help themcollaborate in the care of a family member or friend with mental illness.As authors and editors, we have been extremely gratified by theSynopsis' wide acceptance and use, both in the United States andaround the world.

HistoryThis textbook evolved from our experience editing the ComprehensiveTextbook of Psychiatry. That book is nearly 4,000 double-column pageslong, with more than 400 contributions by outstanding psychiatrists andbehavioral scientists. It serves the needs of those who require anexhaustive, detailed, and encyclopedic survey of the entire field. In aneffort to be as comprehensive as possible, the textbook spans twovolumes to cover the material, clearly rendering it unwieldy for somegroups, especially medical students, who need a brief and morecondensed statement of the field of psychiatry. To accomplish this,sections of the Comprehensive Textbook of Psychiatry were deleted or

condensed, new subjects were introduced, and all sections were broughtup to date, especially certain key areas, such as psychopharmacology.We wish to acknowledge our great and obvious debt to more than 2,000contributors to the current and previous editions of the ComprehensiveTextbook of Psychiatry, all of whom have allowed us to synopsize theirwork. At the same time, we must accept responsibility for themodifications and changes in the new work.

Comprehensive Teaching SystemThe textbook forms one part of a comprehensive system developed byus to facilitate the teaching of psychiatry and the behavioral sciences.At the head of the system is the Comprehensive Textbook of Psychiatry,which is global in depth and scope; it is designed for and used bypsychiatrists, behavioral scientists, and all workers in the mental healthfield. Synopsis of Psychiatry is a relatively brief, highly modified, andcurrent version useful for medical students, psychiatric residents,practicing psychiatrists, and mental health professionals. A specialedition of Synopsis, Concise Textbook of Clinical Psychiatry containsdescriptions of all psychiatric disorders, including their diagnosis andtreatment. It will be useful for clinical clerks and psychiatric residentswho need a succinct overview of the management of clinical problems.Another part of the system, Study Guide and Self-Examination Reviewof Psychiatry, consists of multiple-choice questions and answers; it isdesigned for students of psychiatry and for clinical psychiatrists whorequire a review of the behavioral sciences and general psychiatry inpreparation for a variety of examinations. The questions are modeledafter and consistent with the format used by the American Board ofPsychiatry and Neurology (ABPN), the National Board of MedicalExaminers (NBME), and the United States Medical LicensingExamination (USMLE). Other parts of the system are the pockethandbooks: Pocket Handbook of Clinical Psychiatry, Pocket Handbook ofPsychiatric Drug Treatment, Pocket Handbook of Emergency PsychiatricMedicine, and Pocket Handbook of Primary Care Psychiatry. Those bookscover the diagnosis and treatment of psychiatric disorders,psychopharmacology, psychiatric emergencies, and primary carepsychiatry, respectively, and are designed and written to be carried inthe pocket by clinical clerks and practicing physicians, whatever theirspecialty, to provide a quick reference. Finally, Comprehensive Glossaryof Psychiatry and Psychology provides simply written definitions forpsychiatrists and other physicians, psychologists, students, othermental health professionals, and the general public. Together, thesebooks create a multiple approach to the teaching, study, and learning of

psychiatry.

Classification of DisordersDSM-IV-TRA revision of the fourth edition of the American Psychiatric AssociationDiagnostic and Statistical Manual of Mental Disorders (DSM-IV), calledDSM-IV-TR (TR stands for text revision), was published in 2000. Itcontains the official nomenclature used by psychiatrists and othermental health professionals in the United States; the psychiatricdisorders discussed in the textbook are consistent with and follow thatnosology. Every section dealing with clinical disorders has been updatedthoroughly and completely to include the revisions contained in DSM-IV-TR.

ICD-10Synopsis was the first U.S. textbook to include the definitions anddiagnostic criteria of mental disorders used in the tenth revision of theWorld Health Organization's International Statistical Classification ofDiseases and Related Health Problems (ICD-10). There are textualdifferences between DSM and ICD, but according to treaties betweenthe United States and the World Health Organization, the diagnosticcode numbers must be identical to ensure uniform reporting of nationaland international psychiatric statistics. Currently, both DSM and ICDdiagnoses and numerical codes are accepted by Medicare, Medicaid, andprivate insurance companies for reimbursement purposes in the UnitedStates. Readers can find the DSM-IV-TR classification with theequivalent ICD-10 classification listed in Chapter 9. Color cuesdifferentiate DSM and ICD diagnostic tables as a further aid to thereader.

Cover Art and IllustrationsSynopsis was one of the first modern psychiatric textbooks to use artand photographs to illustrate psychiatric subjects to enrich the learningexperience.The cover art is entitled Melancholy by the Norwegian artist, EdvardMunch (18631943). In this painting, the limp female figure with herhidden face is stooped over and unable to raise her eyes to view thebeautiful landscape of the fjords which normally lighten the mood ofthose who gaze on them. To Munch, the inability to obtain pleasure

coupled with withdrawal and introversion were the hallmarks ofmelancholic depression.Color plates of all psychiatric drugs and their dosage forms, includingall new drugs developed since the last edition was published, are alsoincluded, as in all Kaplan & Sadock books. New illustrations and colorplates have been added to many sections.

Case HistoriesCase histories, which make clinical disorders more vital for the student,are an integral part of Synopsis. All cases in this edition are new,derived from various sources: ICD-10 Casebook, DSM-IV-TR Casebook,DSM-IV-TR Case Studies, contributors to the Comprehensive Textbookof Psychiatry, and the authors' clinical experience at New York'sBellevue Hospital Center. We especially wish to thank the AmericanPsychiatric Press and the World Health Organization for permission touse many of their cases. Cases appear in tinted type to help the readerfind them easily.

New and Updated SectionsChapter 1, The Patient-Doctor Relationship, has been rewritten toreflect new concepts in the complex relationship between the doctorand his or her patient. A discussion of the narrativethe story thepatient tellsand its effect on that interaction is also included. Chapter2 has been expanded to include a comprehensive survey of normality.Aging is covered in a new section that considers the process not as adisease but as an evolving part of the life cycle and includes a thoroughsurvey of normal aging.Chapter 3, The Brain and Behavior, has been reorganized, revised,updated, and extensively rewritten. The section, FunctionalNeuroanatomy, emphasizes the influence of function rather thanstructure on behavior. The sections, Psychoneuroendocrinology, andPsychneuroimmunology and Chronobiology, have been expanded toreflect the rapid advances in these fields. A newly written section,Neurogenetics, details the important and complex role of genetics inboth normal and abnormal behavior.The chapter End-of-Life Care and Palliative Medicine has been updatedand reflects the important role that psychiatrists play in the clinicalspecialty of palliative care and pain control. Too little timeespeciallyin medical schoolis provided in training students to care for the dyingpatient with sensitivity and compassion. The chapter, Psychiatry and

Reproductive Medicine, was extensively revised both to keep pace withadvances in women's health issues and to clarify the confusionsurrounding antepartum and postpartum events, contraception,abortion, and the role of hormone replacement therapy in women'smental health.The chapter Ethics in Psychiatry was completely revised and updatedand includes an extensive discussion of the role of euthanasia andphysician-assisted suicide and their impact on the practice of medicine.The section Mental Disorders Due to a General Medical Conditioncontains an updated discussion of prion disorders and mad cowdisease. In the last edition, the section Posttraumatic Stress Disorderand Acute Stress Disorder covered the tragic events of September 11,2001, involving the World Trade Center in New York and the Pentagonin Washington. With the passage of time, we are now able to providereliable data on the psychological sequelae of those events. Otherdisasters, however, have occurred since then, such as hurricane Katrinaand the Pakistan earthquake in 2005. The psychological effects of thoseevents are also covered. Two chapters, Anthropology and Cross-CulturalPsychiatry, and Cross-Cultural Syndromes, reflect the global scope ofpsychiatry and the need for clinicians to understand disorders thatappear around the world. A new section called Brain StimulationMethods describes many new advances in stimulating the brain in aneffort to restore health to those patients who have not responded toconventional therapies and who are among the most severely mentallyill.The sections on psychotherapy have been expanded with new, separate,and up-to-date discussions on genetic counseling, cognitive therapy,interpersonal therapy, hypnosis, and dialectical behavior therapy.This edition continues the tradition of speaking out on sociopoliticalissues that affect the delivery of health care. Practitioners have aspecial obligation to know about such issues that inform the physicaland psychological well-being of their patients. Thus, discussions areincluded on the homeless mentally ill, deinstitutionalization, workingconditions and number of hours medical house staff are on duty, therole of managed care in medicine and psychiatry, and the regulation ofmedicine by government agencies, among other areas of controversy.Finally, every section on clinical psychiatry has been updated to includethe latest information about diagnosing and treating mental disorders.The references are also completely up-to-date.

PsychopharmacologyThe authors are committed to classifying drugs used to treat mentaldisorders according to their pharmacological activity and mechanism ofaction rather than using such broad categories as antidepressants,antipsychotics, anxiolytics, and mood stabilizers, which are overly broadand do not reflect, scientifically, the clinical use of psychotropicmedication. For example, many antidepressant drugs are used to treatanxiety disorders; some anxiolytics are used to treat depression andbipolar disorders; and drugs from all categories are used to treat otherclinical problems, such as eating disorders, panic disorders, andimpulse-control disorders. Many drugs are also used to treat a varietyof mental disorders that do not fit into any broad classification.Information about all pharmacological agents used in psychiatry,including pharmacodynamics, pharmacokinetics, dosages, adverseeffects, and drugdrug interactions, was thoroughly updated andincludes all drugs approved since publication of the previous edition.

Childhood DisordersThe chapters, Adolescent Substance Abuse and Forensic Issues in ChildPsychiatry, were revised and expanded to reflect the epidemic of illicitdrug use among youth and the problems of violence and delinquency.Data about posttraumatic stress disorders in children have been added,including the latest data on the psychological effects on childrenexposed to terrorist activities and natural disasters. The section AnxietyDisorders was reorganized and updated thoroughly. Every clinicaldisorder section was updated and revised, especially those that dealwith the use of pharmacological agents in children.

AcknowledgmentsWe deeply appreciate the work of our distinguished group ofcontributing editors, who gave generously of their time and expertise.Caroly Pataki, M.D., was responsible for updating and revising thesection on childhood and adolescent disorders. We thank her for hertremendous help in this area. Norman Sussman, M.D., updated thesection on psychopharmacology, enabling us to provide the reader withthe current material in this ever-changing and rapidly expanding field.We thank Jack Grebb, M.D., who guided us in the neural sciences andwho was co-author of the seventh edition of Synopsis. He has anencyclopedic knowledge of the field from which we benefited immensely.We thank Dorice Viera, Associate Curator of the Frederick L. EhrmanMedical Library at the New York University School of Medicine, for her

valuable assistance in the preparation of this and previous editions inwhich she was so very helpful.Nitza Jones played a key and invaluable role as Project Editor, as shehas for many of our other books. Her vast knowledge of every aspect ofbook publishing was indispensable and she contributed heavily toediting the text. She was ably assisted by Regina Furner who alsoperformed an invaluable service as Picture Editor. Both worked withenthusiasm, alacrity, and intelligence. Among the many others to thankare Ren Robinson, M.D., Caroline Press, M.D., Michael Stanger, M.D.,Rajan Bahl, M.D., Samoon Ahmad, M.D., and Jay K. Kantor, Ph.D., all ofwhom contributed to the text. Seeba Anam, M.D., deserves specialmention for her help in the section on Reproductive Psychiatry.We also wish to acknowledge the contributions of James Sadock, M.D.,and Victoria Gregg, M.D., for their help in their areas of expertise:emergency adult and emergency pediatric medicine, respectively.We want to take this opportunity to acknowledge those who havetranslated this and other Kaplan & Sadock books into foreign languages,including Chinese, Croation, French, German, Greek, Indonesian,Italian, Japanese, Polish, Portuguese, Romanian, Russian, Spanish, andTurkish, in addition to a special Asian and international student edition.The staff at Lippincott Williams & Wilkins was most efficient. We wish tothank Katey Millet for her prodigious efforts. We have been fortunate tohave worked with her for many years on many projects and her helpand support have been invaluable. Bridgett Dougherty at LW&W andJudi Rohrbaugh and Chris Miller at Aptara also deserve our thanks.Joyce Murphy, Managing Editor, and Charley Mitchell, Executive Editor,have been loyal friends over the years and their help and enthusiasmfor our projects have been most welcome.We especially want to acknowledge and thank Alan and Marilyn Zublattfor their generous support of this and other Kaplan & Sadock textbooks.Over the years they have been unselfish benefactors to manyeducational, clinical and research projects at the NYU Medical Center.We are deeply grateful for their help. We thank them not only forourselves but on behalf of all those at NYUstudents, clinicians, andresearcherswho have benefited from their extraordinary humanitarianvision.Finally, we want to express our deep thanks to Robert Cancro, M.D.,who retired after 28 years serving as Chairman of Psychiatry at NewYork University School of Medicine and who gave us his full support. Hewas succeeded as Chair in 2006 by Dolores Malaspina, M.D., to whom

we extend a warm welcome as she leads the Department of Psychiatryat NYU into the 21st century.

B. J. S.

V. A. S.New York University School of Medicine, New York, New York

Authors: Sadock, Benjamin James; Sadock, Virginia AlcottTitle: Kaplan & Sadock's Synopsis of Psychiatry: BehavioralSciences/Clinical Psychiatry, 10th EditionCopyright 2007 Lippincott Williams & Wilkins> Front of Book > About the Authors

About the Authors

Benjamin James Sadock, M.D., is the Menas S. Gregory Professor ofPsychiatry and Vice Chairman of the Department of Psychiatry at theNew York University (NYU) School of Medicine, New York, New York. Heis a graduate of Union College, received his M.D. degree from New YorkMedical College, and completed his internship at Albany Hospital. Afterfinishing his residency at Bellevue Psychiatric Hospital, he enteredmilitary service, serving as Acting Chief of Neuropsychiatry at SheppardAir Force Base, Wichita Falls, Texas. He has held faculty and teachingappointments at Southwestern Medical School and Parkland Hospital inDallas and at New York Medical College, St. Luke's Hospital, the NewYork State Psychiatric Institute, and Metropolitan Hospital in New York.Dr. Sadock joined the faculty of the NYU School of Medicine in 1980 andserved in various positions: Director of Medical Student Education inPsychiatry, Co-Director of the Residency Training Program in Psychiatry,and Director of Graduate Medical Education. Currently, Dr. Sadock isCo-Director of Student Mental Health Services, Psychiatric Consultantto the Admissions Committee, and Co-Director of Continuing Educationin Psychiatry at the NYU School of Medicine. He is on the staff ofBellevue Hospital and Tisch Hospital and is a consulting psychiatrist atLenox Hill Hospital. Dr. Sadock is a Diplomate of the American Board ofPsychiatry and Neurology and served as Associate Examiner for theBoard for more than a decade. He is a Distinguished Life Fellow of theAmerican Psychiatric Association, a Fellow of the American College ofPhysicians, a Fellow of the New York Academy of Medicine, and amember of Alpha Omega Alpha Honor Society. He is active in numerouspsychiatric organizations and is founder and president of the NYU-Bellevue Psychiatric Society. Dr. Sadock was a member of the NationalCommittee in Continuing Education in Psychiatry of the AmericanPsychiatric Association; he served on the Ad Hoc Committee on SexTherapy Clinics of the American Medical Association, was a delegate tothe conference on Recertification of the American Board of MedicalSpecialists, and was a representative of the American PsychiatricAssociation Task Force on the National Board of Medical Examiners and

the American Board of Psychiatry and Neurology. In 1985, he receivedthe Academic Achievement Award from New York Medical College andwas appointed Faculty Scholar at NYU School of Medicine in 2000. He isthe author or editor of more than 100 publications, a book reviewer forpsychiatric journals, and he lectures on a broad range of topics ingeneral psychiatry. Dr. Sadock maintains a private practice fordiagnostic consultations and psychiatric treatment. He has been marriedto Virginia Alcott Sadock, M.D., Professor of Psychiatry at NYU School ofMedicine, since completing his residency. Dr. Sadock enjoys opera, golf,skiing, and traveling, and is an enthusiastic fly fisherman.Virginia Alcott Sadock, M.D., joined the faculty of the New YorkUniversity (NYU) School of Medicine in 1980, where she is currentlyProfessor of Psychiatry and Attending Psychiatrist at the Tisch Hospitaland Bellevue Hospital. She is Director of the Program in HumanSexuality at the NYU Medical Center, one of the largest treatment andtraining programs of its kind in the United States. Dr. Sadock is theauthor of more than 50 articles and chapters on sexual behavior andwas the developmental editor of The Sexual Experience, one of the firstmajor textbooks on human sexuality, published by Williams & Wilkins.She serves as a referee and book reviewer for several medical journals,including the American Journal of Psychiatry and the Journal of theAmerican Medical Association. She has long been interested in the roleof women in medicine and psychiatry and was a founder of theCommittee on Women in Psychiatry of the New York County DistrictBranch of the American Psychiatric Association. She is active inacademic matters, has served as Assistant and Associate Examiner forthe American Board of Psychiatry and Neurology for more than 15years; she was a member of the Test Committee in Psychiatry for boththe American Board of Psychiatry and the Psychiatric Knowledge andSelf-Assessment Program (PKSAP) of the American PsychiatricAssociation. She has chaired the Committee on Public Relations of theNew York County District Branch of the American Psychiatric Associationand has participated in the National Medical Television Network seriesWomen in Medicine and the Emmy Award-winning PBS televisiondocumentary Women and Depression. She has been Vice-President ofthe Society of Sex Therapy and Research and a regional council memberof the American Association of Sex Education Counselors andTherapists; she is currently President of the Alumni Association of SexTherapists. She lectures extensively in the United States and abroad onsexual dysfunction, relational problems, and depression and anxietydisorders. She is a Distinguished Fellow of the American PsychiatricAssociation, a Fellow of the New York Academy of Medicine, and aDiplomate of the American Board of Psychiatry and Neurology. Dr.

Sadock is a graduate of Bennington College; she received her M.D.degree from New York Medical College, and trained in psychiatry atMetropolitan Hospital. She maintains an active practice that includesindividual psychotherapy, couples and marital therapy, sex therapy,psychiatric consultation, and pharmacotherapy. She lives in Manhattanwith her husband Dr. Benjamin Sadock. They have two children, JamesWilliam Sadock, M.D., and Victoria Anne Gregg, M.D., both emergencyphysicians, and two grandchildren, Emily Alcott and Celia Anne. In herleisure time, Dr. Sadock enjoys theater, film, golf, reading fiction, andtraveling.

TABLE OF CONTENTS

[+] 1 - The PatientDoctor Relationship[-] 2 - Human Development Throughout the Life Cycle[+] 2.1 - Normality[+] 2.2 - Embryo, Fetus, Infant, and Child[+] 2.3 - Adolescence[+] 2.4 - Adulthood[+] 2.5 - Late Adulthood (Old Age)[+] 2.6 - Death, Dying, and Bereavement

[-] 3 - The Brain and Behavior[+] 3.1 - Functional and Behavioral Neuroanatomy[+] 3.2 - Neurophysiology and Neurochemistry[+] 3.3 - Neuroimaging[+] 3.4 - Electrophysiology[+] 3.5 - Psychoneuroendocrinology, Psychoneuroimmunology, andChronobiology[+] 3.6 - Neurogenetics

[-] 4 - Contributions of the Psychosocial Sciences[+] 4.1 - Jean Piaget[+] 4.2 - Attachment Theory[+] 4.3 - Learning Theory[+] 4.4 - Aggression[+] 4.5 - Sociobiology and Ethology[+] 4.6 - Anthropology and Cross-Cultural Psychiatry[+] 4.7 - Epidemiology and Biostatistics

[-] 5 - Clinical Neuropsychological Testing[+] 5.1 - Clinical Neuropsychological Testing of Intelligence and Personality[+] 5.2 - Clinical Neuropsychological Assessment of Adults

[-] 6 - Theories of Personality and Psychopathology[+] 6.1 - Sigmund Freud: Founder of Classic Psychoanalysis[+] 6.2 - Erik Erikson

[+] 6.3 - Schools Derived from Psychoanalysis and Psychology[-] 7 - Clinical Examination of the Psychiatric Patient[+] 7.1 - Psychiatric History and Mental Status Examination[+] 7.2 - Interviewing Techniques with Special Patient Populations[+] 7.3 - Physical Examination of the Psychiatric Patient[+] 7.4 - Laboratory Tests in Psychiatry[+] 7.5 - Medical Record and Medical Error

[+] 8 - Signs and Symptoms in Psychiatry[-] 9 - Classification in Psychiatry and Psychiatric Rating Scales[+] 9.1 - Classification in Psychiatry[+] 9.2 - Psychiatric Rating Scales

[-] 10 - Delirium, Dementia, and Amnestic and Other Cognitive Disorders[+] 10.1 - Overview[+] 10.2 - Delirium[+] 10.3 - Dementia[+] 10.4 - Amnestic Disorders[+] 10.5 - Mental Disorders Due to a General Medical Condition

[+] 11 - Neuropsychiatric Aspects of HIV Infection and AIDS[-] 12 - Substance-Related Disorders[+] 12.1 - Introduction and Overview[+] 12.2 - Alcohol-Related Disorders[+] 12.3 - Amphetamine (or Amphetamine-like)-Related Disorders[+] 12.4 - Caffeine-Related Disorders[+] 12.5 - Cannabis-Related Disorders[+] 12.6 - Cocaine-Related Disorders[+] 12.7 - Hallucinogen-Related Disorders[+] 12.8 - Inhalant-Related Disorders[+] 12.9 - Nicotine-Related Disorders[+] 12.10 - Opioid-Related Disorders[+] 12.11 - Phencyclidine (or Phencyclidine-like)-Related Disorders

[+] 12.12 - Sedative-, Hypnotic-, or Anxiolytic-Related Disorders[+] 12.13 - Anabolic-Androgenic Steroid Abuse[+] 12.14 - Other Substance- Related Disorders

[+] 13 - Schizophrenia[-] 14 - Other Psychotic Disorders[+] 14.1 - Schizophreniform Disorder[+] 14.2 - Schizoaffective Disorder[+] 14.3 - Delusional Disorder and Shared Psychotic Disorder[+] 14.4 - Brief Psychotic Disorder, Psychotic Disorder Not OtherwiseSpecified, and Secondary Psychotic Disorders[+] 14.5 - Culture-Bound Syndromes

[-] 15 - Mood Disorders[+] 15.1 - Depression and Bipolar Disorder[+] 15.2 - Dysthymia and Cyclothymia[+] 15.3 - Other Mood Disorders

[-] 16 - Anxiety Disorders[+] 16.1 - Overview[+] 16.2 - Panic Disorder and Agoraphobia[+] 16.3 - Specific Phobia and Social Phobia[+] 16.4 - Obsessive-Compulsive Disorder[+] 16.5 - Posttraumatic Stress Disorder and Acute Stress Disorder[+] 16.6 - Generalized Anxiety Disorder[+] 16.7 - Other Anxiety Disorders

[+] 17 - Somatoform Disorders[+] 18 - Chronic Fatigue Syndrome[+] 19 - Factitious Disorders[+] 20 - Dissociative Disorders[-] 21 - Human Sexuality[+] 21.1 - Normal Sexuality[+] 21.2 - Abnormal Sexuality and Sexual Dysfunctions

[+] 21.3 - Paraphilias and Sexual Disorder Not Otherwise Specified[+] 22 - Gender Identity Disorders[-] 23 - Eating Disorders[+] 23.1 - Anorexia Nervosa[+] 23.2 - Bulimia Nervosa and Eating Disorder Not Otherwise Specified[+] 23.3 - Obesity

[-] 24 - Normal Sleep and Sleep Disorders[+] 24.1 - Normal Sleep[+] 24.2 - Sleep Disorders

[+] 25 - Impulse-Control Disorders Not Elsewhere Classified[+] 26 - Adjustment Disorders[+] 27 - Personality Disorders[-] 28 - Psychosomatic Medicine[+] 28.1 - Psychological Factors Affecting Physical Conditions[+] 28.2 - Consultation-Liaison Psychiatry

[+] 29 - Complementary and Alternative Medicine in Psychiatry[+] 30 - Psychiatry and Reproductive Medicine[+] 31 - Relational Problems[+] 32 - Problems Related to Abuse or Neglect[+] 33 - Additional Conditions That May Be a Focus of Clinical Attention[-] 34 - Emergency Psychiatric Medicine[+] 34.1 - Suicide[+] 34.2 - Psychiatric Emergencies in Adults[+] 34.3 - Psychiatric Emergencies in Children

[-] 35 - Psychotherapies[+] 35.1 - Psychoanalysis and Psychoanalytic Psychotherapy[+] 35.2 - Brief Psychodynamic Psychotherapy[+] 35.3 - Group Psychotherapy, Combined Individual and GroupPsychotherapy, and Psychodrama[+] 35.4 - Family Therapy and Couples Therapy

[+] 35.5 - Dialectical Behavior Therapy[+] 35.6 - Genetic Counseling[+] 35.7 - Biofeedback[+] 35.8 - Behavior Therapy[+] 35.9 - Cognitive Therapy[+] 35.10 - Hypnosis[+] 35.11 - Interpersonal Therapy[+] 35.12 - Psychiatric Rehabilitation[+] 35.13 - Combined Psychotherapy and Pharmacology

[-] 36 - Biological Therapies[+] 36.1 - General Principles of Psychopharmacology[+] 36.2 - Medication-Induced Movement Disorders[+] 36.3 - 2-Adrenergic Receptor Agonists: Clonidine and Guanfacine[+] 36.4 - -Adrenergic Receptor Antagonists[+] 36.5 - Anticholinergics and Amantadine[+] 36.6 - Anticonvulsants: Gabapentin, Pregabalin, Tiagabine,Levetiracetam, Topiramate, and Zonisamide[+] 36.7 - Antihistamines[+] 36.8 - Barbiturates and Similarly Acting Drugs[+] 36.9 - Benzodiazepines and Drugs Acting on Benzodiazepine Receptors[+] 36.10 - Bupropion[+] 36.11 - Buspirone[+] 36.12 - Calcium Channel Inhibitors[+] 36.13 - Carbamazepine and Oxcarbazepine[+] 36.14 - Cholinesterase Inhibitors and Memantine[+] 36.15 - Dantrolene[+] 36.16 - Disulfiram and Acamprosate[+] 36.17 - Dopamine Receptor Agonists and Precursors: Apomorphine,Bromocriptine, Levodopa, Pergolide, Pramipexole, and Ropinirole[+] 36.18 - Dopamine Receptor Antagonists: Typical Antipsychotics[+] 36.19 - Lamotrigine

[+] 36.20 - Lithium[+] 36.21 - Melatonin Agonists: Ramelteon and Melatonin[+] 36.22 - Mirtazapine[+] 36.23 - Monoamine Oxidase Inhibitors[+] 36.24 - Nefazodone[+] 36.25 - Opioid Receptor Agonists: Methadone, Buprenorphine, andLevomethadyl[+] 36.26 - Opioid Receptor Antagonists: Naltrexone, Nalmefene, andNaloxone[+] 36.27 - Phosphodiesterase-5 Inhibitors[+] 36.28 - Selective SerotoninNorepinephrine Reuptake Inhibitors[+] 36.29 - Selective Serotonin Reuptake Inhibitors[+] 36.30 - SerotoninDopamine Antagonists: Atypical Antipsychotics[+] 36.31 - Sympathomimetics and Related Drugs[+] 36.32 - Thyroid Hormones[+] 36.33 - Trazodone[+] 36.34 - Tricyclics and Tetracyclics[+] 36.35 - Valproate[+] 36.36 - Yohimbine[+] 36.37 - Brain Stimulation Methods

[+] 37 - Child Psychiatry: Assessment, Examination, and PsychologicalTesting[+] 38 - Mental Retardation[+] 39 - Learning Disorders[+] 40 - Motor Skills Disorder: Developmental Coordination Disorder[+] 41 - Communication Disorders[+] 42 - Pervasive Developmental Disorders[+] 43 - Attention-Deficit Disorders[+] 44 - Disruptive Behavior Disorders[+] 45 - Feeding and Eating Disorders of Infancy or Early Childhood[+] 46 - Tic Disorders

[+] 47 - Elimination Disorders[-] 48 - Other Disorders of Infancy, Childhood, and Adolescence[+] 48.1 - Reactive Attachment Disorder of Infancy or Early Childhood[+] 48.2 - Stereotypic Movement Disorder and Disorder of Infancy,Childhood, or Adolescence Not Otherwise Specified

[-] 49 - Mood Disorders and Suicide in Children and Adolescents[+] 49.1 - Depressive Disorders and Suicide in Children and Adolescents[+] 49.2 - Early-Onset Bipolar Disorders

[-] 50 - Anxiety Disorders of Infancy, Childhood, and Adolescence[+] 50.1 - Obsessive-Compulsive Disorder of Infancy, Childhood, andAdolescence[+] 50.2 - Posttraumatic Stress Disorder of Infancy, Childhood, andAdolescence[+] 50.3 - Separation Anxiety Disorder, Generalized Anxiety Disorder, andSocial Phobia[+] 50.4 - Selective Mutism

[+] 51 - Early-Onset Schizophrenia[+] 52 - Adolescent Substance Abuse[+] 53 - Child Psychiatry: Additional Conditions That May Be a Focus ofClinical Attention[-] 54 - Psychiatric Treatment of Children and Adolescents[+] 54.1 - Individual Psychotherapy[+] 54.2 - Group Psychotherapy[+] 54.3 - Residential, Day, and Hospital Treatment[+] 54.4 - Biological Therapies[+] 54.5 - Psychiatric Treatment of Adolescents

[-] 55 - Child Psychiatry: Special Areas of Interest[+] 55.1 - Forensic Issues in Child Psychiatry[+] 55.2 - Adoption and Foster Care[+] 55.3 - Child Maltreatment and Abuse[+] 55.4 - Impact of Terrorism on Children

[+] 56 - Geriatric Psychiatry[-] 57 - End of Life Care and Palliative Medicine[+] 57.1 - Palliative Medicine and Pain Management[+] 57.2 - Euthanasia and Physician-Assisted Suicide

[+] 58 - Clinical-Legal Issues in Psychiatry[+] 59 - Ethics in Psychiatry

Authors: Sadock, Benjamin James; Sadock, Virginia AlcottTitle: Kaplan & Sadock's Synopsis of Psychiatry: BehavioralSciences/Clinical Psychiatry, 10th EditionCopyright 2007 Lippincott Williams & Wilkins> Front of Book > Drugs Used in Psychiatry

Drugs Used in Psychiatry

This guide contains color reproductions of some commonly prescribedpsychotherapeutic drugs. This guide illustrates proprietary forms oftablets and capsules. A symbol preceding the name of a drug indicatesthat other doses are available. Check directly with the manufacturer.(Although the photos are intended as accurate reproductions of thedrug, this guide should be used only as a quick identification aid.)

Authors: Sadock, Benjamin James; Sadock, Virginia AlcottTitle: Kaplan & Sadock's Synopsis of Psychiatry: BehavioralSciences/Clinical Psychiatry, 10th EditionCopyright 2007 Lippincott Williams & Wilkins> Table of Contents > 1 - The PatientDoctor Relationship

1The PatientDoctor Relationship

The quality of patientdoctor or patienttherapist relationship is crucialto the practice of medicine and psychiatry. The capacity to develop aneffective relationship requires a solid appreciation of the complexities ofhuman behavior and a rigorous education in the techniques of talkingand listening to people. To diagnose, manage, and treat an ill person,doctors and therapists must learn to listen. They need the skills ofactive listening, which means listening both to what they and thepatient are saying and to the undercurrents of the unspoken feelingsbetween them (Fig. 1-1). A physician who monitors both the content ofthe interaction (what the patient and the doctor actually say) and theprocess (what the patient or the doctor mean to say) realizes thatcommunication between two people occurs on several levels at once:what the person believes about himself or herself; what he or shewants others to believe about them; and finally who the person reallyis.An effective relationship is characterized by good rapport. Rapport isthe spontaneous, conscious feeling of harmonious responsiveness thatpromotes the development of a constructive therapeutic alliance. Itimplies an understanding and trust between the doctor and the patient.Frequently, the doctor is the only person to whom the patients can talkabout things that they cannot tell anyone else. Most patients trust theirdoctors to keep secrets, and this confidence must not be betrayed.Patients who feel that someone knows them, understands them, andaccepts them find that a source of strength. In his essay, Caring forthe Patient Francis Peabody, M.D. (18811927), a talented teacher andclinician (Fig. 1-2), wrote:The good physician knows his patients through and through, and hisknowledge is bought dearly. Time, sympathy, and understanding mustbe lavishly dispensed, but the reward is to be found in that personalbond which forms the greatest satisfaction of the practice of medicine.

One of the essential qualities of the clinician is interest in humanity, forthe secret of the care of the patient is in caring for the patient.

Establishing RapportEkkehard Othmer and Sieglinde Othmer defined the development ofrapport as encompassing six strategies: (1) putting patients andinterviewers at ease; (2) finding patients' pain and expressingcompassion; (3) evaluating patients' insight and becoming an ally; (4)showing expertise; (5) establishing authority as physicians andtherapists; and (6) balancing the roles of empathic listener, expert, andauthority. As part of a strategy for increasing rapport, they developed achecklist (Table 1-1) that enables interviewers to recognize problemsand refine their skills in establishing rapport.In one survey of 700 patients, patients substantially agreed that manyphysicians do not have the time or inclination to listen and considertheir feelings, that physicians do not have enough knowledge of theemotional problems and socioeconomic background of their families,and that physicians increase their fear by giving explanations intechnical language.Evaluating the pressures in patients' early lives helps psychiatristsbetter understand patients. Emotional reactions, healthy or unhealthy,are the result of a constant interplay of biological, sociological, andpsychological forces. Each stress leaves behind a trace of its influenceand continues to manifest itself throughout life in proportion to theintensity of its effects and the susceptibility of the human beinginvolved. Past and current stresses should be determined to the fullestextent possible.

EmpathyEmpathy is a way of increasing rapport. It is an essential characteristicof psychiatrists, but it is not a universal human capacity. An incapacityfor normal understanding of what other people are feeling appears to becentral to certain personality disturbances, such as antisocial andnarcissistic personality disorders. Although empathy probably cannot becreated, it can be focused and deepened through training, observation,and self-reflection. It manifests in clinical work in a variety of ways. Anempathic psychiatrist may anticipate what is felt before it is spoken andcan often help patients articulate what they are feeling. Nonverbalcues, such as body posture and facial expression, are noted. Patients'reactions to the psychiatrist can be understood and clarified.

Patients sometimes say, How can you understand me if you haven'tgone through what I'm going through? Clinical psychiatry, however, ispredicated on the belief that it is not necessary to have other people'sliteral experiences to understand them. The shared experience of beinghuman is often sufficient. Whether in an initial diagnostic setting or inongoing therapy, patients draw comfort from knowing that psychiatristsare not mystified by their suffering.

TransferenceTransference is generally defined as the set of expectations, beliefs,and emotional responses that a patient brings to the patientdoctorrelationship. They are based not necessarily on who the doctor is orhow the doctor acts in reality but, rather, on repeated experiences thepatient has had with other important authority figures throughout life.

Transferential AttitudesThe patient's attitude toward the physician is apt to be a repetition ofthe attitude he or she has had toward authority figures. The patient'sattitude can range from one of realistic basic trust, with an expectationthat the doctor has

the patient's best interest at heart, through one of overidealization andeven eroticized fantasy to one of basic mistrust, with an expectationthat the doctor will be contemptuous and potentially abusive.

FIGURE 1-1 The active listening described in the text is illustratedby the therapist's expression of concern for what the patient is

experiencing. The psychiatrist Harry Stack Sullivan referred to thetherapist as a participant observer in the patient's life. (Courtesy ofCorbis).

Role of the Psychiatrist versus theNonpsychiatric PhysicianIn many respects, the role of a psychiatrist differs from that of anonpsychiatric physician, yet many patients expect the same from thepsychiatrist as they do from other physicians. If they expect a doctor totake action, give advice, and prescribe medication to cure an illness,they may well expect the same interaction with a psychiatrist and bedisappointed or angry if it does not occur. Transferential reactions canbe strongest with psychiatrists for a number of reasons. For example, inintensive insight-oriented psychotherapy the encouragement oftransference feelings is an integral part of treatment. In some types oftherapy, a psychiatrist is more or less neutral. The more neutral or lessknown the psychiatrist is, the more a patient's transferential fantasiesand concerns are mobilized and projected onto the doctor. Once thefantasies are stimulated and projected, the psychiatrist can helppatients gain insight into how those fantasies and concerns affect allthe important relationships in their lives. Although a nonpsychiatristdoes not use or even need to understand transference attitudes in thatintensive way, a solid understanding of the power and themanifestations of transference is necessary for optimal treatmentresults in any patientdoctor relationship.

FIGURE 1-2 Francis W. Peabody, M.D. (18811927). (Courtesy ofthe National Library of Medicine.)

The doctor's words and deeds have a power far beyond thecommonplace because of his or her unique authority and the patient'sdependence on the doctor. How a particular physician behaves has adirect bearing on the patient's emotional and even physical reactions.One patient repeatedly had high blood pressure readings whenexamined by a physician he considered cold, aloof, and stern. He hadnormal blood pressure readings, however, when seen by a doctor heregarded as warm, understanding, and sympathetic.

CountertransferenceJust as the patient brings transferential attitudes to the patientdoctorrelationship, doctors themselves often have countertransferentialreactions to their patients. Countertransference can take the form ofnegative feelings that are disruptive to the patientdoctor relationship,but it can also encompass disproportionately positive, idealizing, oreven eroticized reactions to patients. Just as patients have expectationsfor physiciansfor example, competence, lack of exploitation,

objectivity, comfort, and reliefphysicians often have unconscious orunspoken expectations of patients. Most commonly, patients are

thought of as good patients if their expressed severity of symptomscorrelates with an overtly diagnosable biological disorder, if they arecompliant with treatment, if they are emotionally controlled, and if theyare grateful. If those expectations are not met, the patient may bedisapproved of and experienced as unlikable, unworkable, or bad.

Table 1-1 Checklist for Clinicians

The following checklist allows clinicians to ratetheir skills in establishing and maintainingrapport. It helps them detect and eliminateweaknesses in interviews that failed in somesignificant way. Each item is rated yes, no, ornot applicable.

Yes No N/A

1. I put the patient at ease.

2. I recognized the patient'sstate of mind.

3. I addressed the patient'sdistress.

4. I helped the patient warmup.

5. I helped the patientovercome suspiciousness.

6. I curbed the patient's

intrusiveness.

7. I stimulated the patient'sverbal production.

8. I curbed the patient'srambling.

9. I understood the patient'ssuffering.

10. I expressed empathy forthe patient's suffering.

11. I tuned in on the patient'saffect.

12. I addressed the patient'saffect.

13. I became aware of thepatient's level of insight.

14. I assumed the patient'sview of the disorder.

15.I had a clear perception ofthe overt and thetherapeutic goals oftreatment.

I stated the overt goal of

16. treatment to the patient.

17.I communicated to thepatient that I am familiarwith the illness.

18.My questions convinced thepatient that I am familiarwith the symptoms of thedisorder.

19.I let the patient know thathe or she is not alone withthe illness.

20. I expressed my intent tohelp the patient.

21. The patient recognized myexpertise.

22. The patient respected myauthority.

23. The patient appeared fullycooperative.

24. I recognized the patient'sattitude toward the illness.

25. The patient viewed the

illness with distance.

26. The patient presented as asympathy-craving sufferer.

27. The patient presented as avery important patient.

28. The patient competed withme for authority.

29. The patient was submissive.

30. I adjusted my role to thepatient's role.

31. The patient thanked me andmade another appointment.

Reprinted with permission from Othmer E,Othmer SC. The Clinical Interview Using DSM-IV.Washington, DC: American Psychiatric Press;1994.

Disliking a PatientA physician who actively dislikes a patient is apt to be ineffective indealing with him or her. Emotion breeds counteremotion. For example,if the physician is hostile, the patient becomes hostile; the physicianthen becomes even angrier than before, and the relationshipdeteriorates rapidly. If the physician can rise above such emotions andhandle a difficult patient with equanimity, the interpersonal relationshipmay shift from one of mutual overt antagonism to one of at leastincreased acceptance and grudging respect. Rising above such emotions

involves being able to step back from the intense countertransferentialreactions and dispassionately explore why the patient is reacting to thedoctor in such an apparently self-defeating way. The patient needs thedoctor, and hostility ensures that the needed help will occur in a lesseffective context. If the doctor can understand that the patient'santagonism is in some ways defensive or self-protective and most likelyreflects transferential fears of disrespect, abuse, and disappointment,the doctor may be less angry and more empathic than otherwise.Doctors who have strong unconscious needs to be all-knowing and all-powerful may have particular problems with certain types of patients.These patients may be difficult for most physicians to handle, butifthe physician is as aware as possible of his or her own needs,capabilities, and limitationsthe patients will not be threatening. Suchpatients include the following: those who repeatedly appear to defeatattempts to help themselves (for example, patients with severe heartdisease who continue to smoke or drink); those who are perceived asuncooperative (for example, patients who question or refusetreatment); those who request a second opinion; those who fail torecover in response to treatment; those who use physical or somaticcomplaints to mask emotional problems (for example, patients withsomatization disorder, pain disorder, hypochondriasis, or factitiousdisorders); those with chronic cognitive disorders (for example, patientswith dementia of the Alzheimer's type); and patients who represent aprofessional failure and, thus, are a threat to the physician's identityand self-esteem (for example, those who are dying or in chronic pain).

Sexuality and the PhysicianPhysicians are bound to like some patients more than others. However,if the physician feels a strong attraction to a patient and is tempted toact on the attraction, stepping back and assessing the situation areessential. In some medical specialties in which the patientdoctorrelationship is not particularly intimate or intense, the prohibitionagainst romantic involvement with patients may not be strong.

In other specialties, however, especially psychiatry, the ethical andeven legal prohibition is important. The doctor is a powerful figure inthe United States culture and may trigger many unconscious fantasiesof being rescued, taken care of, and loved. Doctors themselves mayhave their own unconscious fantasies of being and needing to be all-powerful, rescuing, and loving. Those fantasies are inherentlyunrealistic and are inevitably disappointed. The disappointments, ifrealized in a romantic relationship between the doctor and the patient,

can be destructive, especially for the patient. Patienttherapist sex isdiscussed further in Chapter 59.Another aspect of sexuality as it pertains to countertransference issuesrelates to asking patients about sexual issues and obtaining a sexualhistory. A reluctance to do so may reflect the physician's own anxietyabout sexuality or even an unconscious attraction toward the patient.Moreover, the omission of those questions generally tells patients thatthe doctor is uncomfortable with the subject, thus leading to aninhibition about discussing any number of other sensitive subjects.

Self-Monitoring of CountertransferenceFeelingsCountertransference feelings do not always have to be perceived innegative terms. They also have the potential, if recognized andanalyzed, to help the doctor better understand the patient who hasstimulated the feelings. For instance, if a doctor feels bored andrestless when with a particular patient and has ascertained that theboredom is not secondary to his or her own preoccupations, the doctormay surmise that the patient is speaking about trivial or insignificantconcerns to avoid real and potentially disturbing concerns.

Physicians as PatientsA special example of countertransference issues occurs when thepatient being treated is a physician. Problems that can arise in thatsituation include an expectation that the physician-patient will takecare of his or her own medications and treatment and the treatingphysician's fear of criticism of his or her skills or competence.Physicians are notoriously poor patients, most likely because physiciansare trained to be in control of medical situations and to be the mastersof the patientdoctor relationship. For a physician, being a patient maymean giving up control, becoming dependent, and appearing vulnerableand frightenedbehaviors that most physicians are professionallytrained to suppress. Physician-patients may be reluctant to becomewhat they perceive as burdens to overworked colleagues, or they maybe embarrassed to ask pertinent questions for fear of appearingignorant or incompetent. Physician-patients may stimulate fear in thetreating physicians who see themselves in the patient, an attitude thatcan lead to denial and avoidance on the part of the treating physician.

Models of Interaction Between Doctor and

PatientThe interactions between a doctor and patientthe questions a patientasks, the way in which news is conveyed and treatmentrecommendations are madecan take different shapes. It is helpful inthinking about the relationship to formulate models of interaction.These are fluid concepts, however. A talented, sensitive physician willhave different approaches with different patients and indeed may havedifferent approaches with the same patient as time and medicalcircumstances vary.

1. The paternalistic model. In a paternalistic relationship between thedoctor and patient, it is assumed that the doctor knows best. He orshe will prescribe treatment, and the patient is expected to complywithout questioning. Moreover, the doctor may decide to withholdinformation when it is believed to be in the patient's best interests.In this model, also called the autocratic model, the physician asksmost of the questions and generally dominates the interview.Circumstances arise in which a paternalistic approach is desirable.In emergency situations the doctor needs to take control and makepotentially life-saving decisions without long deliberation. Inaddition, some patients feel overwhelmed by their illness and arecomforted by a doctor who can take charge. In general, however,the paternalistic approach risks a clash of values. A paternalisticobstetrician, for example, might insist on spinal anesthesia fordelivery when the patient wants to experience natural childbirth.

2. The informative model. The doctor in this model dispensesinformation. All available data are freely given, but the choice is leftwholly up to the patient. For example, doctors may quote 5-yearsurvival statistics for various treatments of breast cancer andexpect women to make up their own minds without suggestion orinterference from them. This model may be appropriate for certainone-time consultations where no established relationship exists andthe patient will be returning to the regular care of a knownphysician. At other times, the informative model places the patientin an unrealistically autonomous role and leaves him or her feelingthe doctor is cold and uncaring.

3. The interpretive model. Doctors who have come to know theirpatients better and understand something of the circumstances oftheir lives, their families, their values, and their hopes andaspirations, are better able to make recommendations that take intoaccount the unique characteristics of an individual patient. A sense

of shared decision-making is established as the doctor presents anddiscusses alternatives, with the patient's participation, to find theone that is best for that particular person. The doctor in this modeldoes not abrogate the responsibility for making decisions, but isflexible, and is willing to consider question and alternativesuggestions.

4. The deliberative model. The physician in this model acts as a friendor counselor to the patient, not just by presenting information, butin actively advocating a particular course of action. The deliberativeapproach is commonly used by doctors hoping to modify injuriousbehavior, for example, in trying to get their patients to stop smokingor lose weight.

These models are only guides for thinking about the doctorpatientrelationship. One is not intrinsically superior to any other, and aphysician may use all four approaches with a patient during a singlevisit. Difficulties are most likely to arise not from the use of one oranother of the models, but with the physician who is rigidly fixed in oneapproach and cannot switch strategies, even when indicated anddesirable. The models do not, moreover, describe the presence orabsence of interpersonal warmth. It is entirely possible for patients tosee a paternalistic or autocratic physician as personable, caring, andconcerned. In fact, a common image of the small town or country doctorin the early part of the 20th century was a man (seldom a woman)totally committed to the welfare of his patients, who would come in themiddle of the night and sit at the bedside holding the patient's hand,who would be invited to Sunday dinner, and who expected hisinstructions to be followed exactly and without question.

Illness BehaviorThe term illness behavior describes patients' reactions to the experienceof being sick. Aspects of illness behavior have sometimes been termedthe sick role, the role that society ascribes to people when they are ill.The sick role can include being excused from responsibilities and theexpectation of wanting to

obtain help to get well. Illness behavior and the sick role are affectedby people's previous experiences with illness and by their culturalbeliefs about disease. The influence of culture on reporting andmanifestation of symptoms must be evaluated. For some disorders, thisvaries little among cultures, whereas for others, the cultural mores maystrongly shape the way the patient presents the condition. The relation

of illness to family processes, class status, and ethnic identity is alsoimportant. The attitudes of peoples and cultures about dependency andhelplessness greatly influence whether and how a person asks for help,as do such psychological factors as personality type and the personalmeaning the person attributes to being ill. Some people experienceillness as overwhelming loss; others see in the same illness a challengethey must overcome or a punishment they deserve. Table 1-2 listsessential areas to be addressed in assessing illness behavior and helpfulquestions for making the assessment.

Table 1-2 Assessment of Individual IllnessBehavior

Prior illness episodes, especially illnesses ofstandard severity (childbirth, renal stones,surgery)Cultural degree of stoicismCultural beliefs concerning the specific problemPersonal meaning of or beliefs about the specificproblemParticular questions to ask to elicit the patient'sexplanatory model:

1. What do you call your problem? What namedoes it have?

2. What do you think caused your problem?3. Why do you think it started when it did?4. What does your sickness do to you?5. What do you fear most about your sickness?6. What are the chief problems that your

sickness has caused you?7. What are the most important results you hope

to receive from treatment?

8. What have you done so far to treat yourillness?

Courtesy of Mack Lipkin, Jr., M.D.

Psychiatric versus Medical-Surgical InterviewsMack Lipkin, Jr., described three functions of medical interviews: toassess the nature of the problem, to develop and maintain a therapeuticrelationship, and to communicate information and implement atreatment plan (Table 1-3). These functions are exactly the same inpsychiatric and surgical interviews. Also universal are the predominantcoping mechanisms used in illness, both adaptive and maladaptive.These mechanisms include such reactions as anxiety, depression,regression, denial, anger, and dependency (Table 1-4). Physicians mustanticipate, recognize, and address such reactions if treatment andintervention are to be effective.Psychiatric interviews have two major technical goals: (1) recognitionof the psychological determinants of behavior and (2) symptomclassification. These goals are reflected in two styles of interviewing:the insight-oriented, or psychodynamic, style and the symptom-oriented, or descriptive, style. Insight-oriented interviewing attempts toelicit unconscious conflicts, anxieties, and defenses. The symptom-oriented approach emphasizes the classification of patients' complaintsand dysfunctions as defined by specific diagnostic categories. Theapproaches are not mutually exclusive and, in fact, can be compatible.A diagnosis can be described as precisely as possible by eliciting suchdetails as symptoms, course of illness, and family history and byunderstanding a patient's personality, developmental history, andunconscious conflicts.Psychiatric patients often contend with stresses and pressures thatdiffer from those of patients who do not have a psychiatric disorder.These stresses include the stigma attached to being a psychiatricpatient (it is more acceptable to have a medical or surgical problemthan a mental problem); communication difficulty because of disordersof thinking; oddities of behavior; and impairments of insight andjudgment that might make compliance with treatment difficult. Becausepsychiatric patients often find it difficult to describe fully what is going

on in their lives, physicians must be prepared to obtain informationfrom other sources. Family members, friends, and spouses can providecritical data such as previous psychiatric history, responses tomedication, and precipitating stresses that patients may not be able todescribe themselves.Psychiatric patients may not be able to tolerate a traditional interviewformat, especially in the acute stages of a disorder. For instance, apatient who has increased agitation or depression may not be able to sitfor 30 to 45 minutes of discussion or questioning. In such cases,physicians must be prepared to conduct multiple brief interactions overtime, for as long as the patient is able, stopping and returning when thepatient appears able to tolerate more.Studies show that about 60 percent of all patients with mental disordersvisit a nonpsychiatric physician during any 6-month period and thatpatients with mental disorders are twice as likely to visit a primary carephysician as are other patients. Nonpsychiatric physicians should beknowledgeable about the special problems of psychiatric patients andthe specific techniques used to treat them.

Biopsychosocial ModelIn 1977, George Engel at the University of Rochester, published aseminal paper that described the biopsychosocial model of disease,which stressed an integrated systems approach to human behavior anddisease. The biopsychosocial model is derived from general systemstheory. The biological system emphasizes the anatomical, structural,and molecular substrate of disease and its effects on the patient'sbiological functioning; the psychological system emphasizes the effectsof psychodynamic factors, motivation, and personality on theexperience of illness and the reaction to it; and the social systememphasizes cultural, environmental, and familial influences on theexpression and the experience of illness. Engel postulated that eachsystem affects, and is affected by, every other system. Engel's modeldoes not assert that medical illness is a direct result of a person'spsychological or sociocultural makeup but, rather, encourages acomprehensive understanding of disease and treatment.A dramatic example of Engel's conception of the biopsychosocial modelwas a 1971 study of the relation between sudden death andpsychological factors. After investigating 170 sudden deaths over about6 years, he observed that serious illness or even death can beassociated with psychological stress or trauma. Among the potentialtriggering events Engel listed are the following: the death of a close

friend, grief, anniversary reactions, loss of self-esteem, personal dangeror threat and the letdown after the threat has passed, and reunion ortriumphs.

Table 1-3 Three Functions of the Medical Interview

Functions Objectives Skills

1. To enable theclinician to

1. Knowledge baseof diseases,disorders,problems, andclinicalhypothesesfrom multipleconceptualdomains:biomedical,sociocultural,psychodynamic,and behavioral

2. Ability to elicitdata for theaboveconceptualdomains(encouragingthe patient totell his or herstory:

I. Determiningthe nature ofthe problem

establish adiagnosis orrecommendfurtherdiagnosticprocedures,suggest acourse oftreatment,and predictthe nature ofthe illness

organizing theflow of theinterview, theform ofquestions, thecharacterizationof symptoms,the mentalstatusexamination)

3. Ability toperceive datafrom multiplesources(history, mentalstatusexamination,physician'ssubjectiveresponse to thepatient,nonverbal cues,listening atmultiple levels)

4. Hypothesisgeneration andtesting

5. Developing atherapeuticrelationship(function II)

II. Developingandmaintaining atherapeuticrelationship

1. The patient'swillingness toprovidediagnosticinformation

2. Relief ofphysical andpsychologicaldistress

3. Willingness toaccept atreatmentplan or aprocess ofnegotiation

4. Patientsatisfaction

5. Physiciansatisfaction

1. Defining thenature of therelationship

2. Allowing thepatient to tellhis or her story

3. Hearing,bearing, andtolerating thepatient'sexpression ofpainful feelings

4. Appropriate andgenuineinterest,empathy,support, andcognitiveunderstanding

5. Attending tocommon patientconcerns overembarrassment,shame, andhumiliation

6. Eliciting thepatient'sperspective

7. Determining thenature of theproblem

8. Communicatinginformation andrecommendingtreatment(function III)

III.Communicatinginformationandimplementinga treatmentplan

1. Patient'sunderstandingof the illness

2. Patient'sunderstandingof thesuggesteddiagnosticprocedures

3. Patient'sunderstandingof thetreatmentpossibilities

4. Consensusbetweenphysician andpatient aboutthe aboveitems 1 to 3

5. Informedconsent

6. Improvecopingmechanisms

1. Determining thenature of theproblem(function I)

2. Developing atherapeuticrelationship(function II)

3. Establishing thedifferences inperspectivebetweenphysician andpatient

4. Educationalstrategies

5. Clinicalnegotiations forconflictresolution

7. Lifestylechanges

Reprinted with permission from Lazare A, Bird J, LipkinM Jr, Putnam S. Three functions of the medicalinterview: An integrative conceptual framework. In:Lipkin Jr M, Putnam S, Lazare A, eds. The MedicalInterview. New York: Springer; 1989:103.

The patientdoctor relationship is a critical component of thebiopsychosocial model. Physicians must have both a working knowledgeof the patient's medical status and be familiar with how the patient'sindividual psychology and sociocultural milieu affect the medicalcondition.

Table 1-4 Predictable Reactions to Illness

Intrapsychic Clinical

Lowered self image loss grief

Anxiety ordepression

Threat to homeostasis fear Denial oranxiety

Failure of (self ) care helplessness, hopelessness

DepressionBargainingand blaming

Sense of loss of control RegressionIsolation

shame (guilt) DependencyAngerAcceptance

Courtesy of Mack Lipkin, Jr, M.D.

SpiritualityThe role of spirituality and religion in sickness and health has gainedascendancy in recent years, with some suggesting that it become partof the biopsychosocial model. Some evidence suggests that strongreligious beliefs, spiritual yearnings, prayer, and devotional acts havepositive influences on a person's mental and physical health. Theseissues are better attended to by theologians than by physicians;however, doctors need to be aware of spirituality in their patients' livesand sensitive to their patients' religious beliefs. In some instances,beliefs can impede medical care, such as the refusal of some religiousgroups to accept blood transfusions. In most cases, however, whentreating patients with strong religious beliefs, the wise physician willwelcome the collaboration of the pastoral counselor.

Interviewing EffectivelyOne of the physician's most important tools is the ability to intervieweffectively. Through a skilled interview, physicians can gather the datanecessary to understand and treat patients

and, in the process, to increase patients' understanding of, andcompliance with, the physicians' advice.Many factors influence both the content and the process of interviews.Patients' personalities and character styles significantly influencereactions as well as the emotional context in which interviews unfold.Various clinical situationsincluding whether patients are seen on ageneral hospital ward, on a psychiatric ward, in an emergency room, oras outpatientsshape the questions asked and the recommendationsoffered. Technical factors such as telephone interruptions, the use of aninterpreter, note taking, and the patient's illness itselfwhether in anacute stage or in remissioninfluence the content and process of theinterview. Interviewers' styles, experiences, and theoreticalorientations also have a significant impact. Even the timing of

interjections such as uh huh can influence when patients speak andwhat they do or do not say as they unconsciously try to follow thesubtle leads and cues provided by the doctor.

Beginning the InterviewHow a physician begins an interview provides a powerful firstimpression to patients, which can affect the way the remainder of theinterview proceeds. Patients are often anxious on first encounters withphysicians and feel both vulnerable and intimidated. A physician whocan establish rapport quickly, put the patient at ease, and show respectis well on the way to conducting a productive exchange of information.This exchange is critical to making a correct diagnosis and toestablishing treatment goals.Physicians should initially make sure that they know a patient's nameand that the patient knows the physician's name. Physicians shouldintroduce themselves to other people who have come with the patientand should find out if the patient wants another person present duringthe initial interview. The request for the presence of another personshould be granted, but the physician should also attempt to speak withpatients privately to determine if there is anything that they want thedoctor to know but would be reluctant to say in front of someone else.Patients have a right to know the position and professional status ofpersons involved in their care. For example, medical students shouldintroduce themselves as such and not as doctors, and physicians shouldmake it clear whether they are consultants (called in by anotherphysician to see the patient), are covering for another physician, or areinvolved in the interview to teach students rather than to treat thepatient.After the introductions and other initial assessments have been made,useful and appropriate opening remarks are as follows: Can you tellme about the troubles that bring you in today? or Tell me about theproblems you have been having. Following up with a second one suchas What other problems have you been experiencing? often elicitsinformation that patients were reluctant to give initially. It alsoindicates to the patient that the doctor is interested in hearing as muchas a patient wants to say.A less directive approach is to ask a patient Where shall we start? orWhere would you prefer to begin? If a patient has been referred byanother doctor for consultation, the initial remarks can indicate thatthe consulting doctor already knows something about the patient. Forinstance, the consulting doctor might say, Your doctor has told me

something about what has been troubling you but I'd like to hear fromyou in your own words what you've been experiencing.Most patients do not speak freely unless they have privacy and are surethat their conversations cannot be overheard. Physicians who haveattended to such factors as privacy, quiet, and a lack of interruptionsbefore the interview convey to patients that what they say is importantand worthy of serious consideration.Sometimes a patient will appear frightened at the beginning of aninterview and may not want to answer questions. If this seems to bethe case, the physician may comment on this impression directly in agentle and supportive way and encourage the patient to talk about hisor her feelings about the interview itself. Acknowledging a patient'sanxiety is the first step in understanding and reducing it. An example ofwhat could be said is I notice that you seem to be feeling anxiousabout talking with me. Is there anything I can do or any questions I cananswer that will make it easier? or I know it can be frightening to talkto a doctor, especially one you've never met before, but I'd like to makeit as comfortable for you as possible. Is there anything you can putyour finger on that's making it tough for you to talk with me?Another important initial question is Why now? A physician should beclear about why a patient has chosen that particular time to ask forhelp. The reason may be as simple as that it was the first availableappointment hour. Very often, however, people seek out doctors as theresult of particular events that have increased stress. These stressfulevents may be thought of as precipitants, and they often contributesignificantly to patients' current problems. Examples of stressfulprecipitants include real or symbolic losses, such as deaths orseparations; milestone events (for example, birthdays oranniversaries); and physical changes, such as the presence orintensification of symptoms.

The Interview ProperIn the interview proper, physicians discover in detail what is troublingpatients. They must do so in a systematic way that facilitates theidentification of relevant problems in the context of an ongoingempathic working alliance with patients.The content of an interview is literally what is said between doctor andpatient: the topics discussed, the subjects mentioned. The process ofthe interview is what occurs nonverbally between doctor and patient,that is, what is happening in the interview beneath the surface. Processinvolves feelings and reactions that are unacknowledged or

unconscious. Patients may use body language to express feelings theycannot express verbally, for example, a clenched fist or nervous tearingat a tissue by a patient with an apparently calm outward demeanor.Patients may shift the interview away from an anxiety-provokingsubject onto a neutral topic without realizing that they are doing so.Patients may return again and again to a particular topic, regardless ofwhat direction the interview appears to be taking. Trivial remarks andapparently casual asides can reveal serious underlying concerns, forexample, Oh, by the way, a neighbor of mine tells me that he knowssomeone with the same symptoms as my son, and that person hascancer.

Specific TechniquesTable 1-5 lists some common interview techniques. Others are discussedbelow with examples.

Table 1-5 Common Interview Techniques

1. Establish rapport as early in the interview aspossible.

2. Determine the patient's chief complaint.3. Use the chief complaint to develop a

provisional differential diagnosis.4. Rule the various diagnostic possibilities out or

in by using focused and detailed questions.5. Follow up on vague or obscure replies with

enough persistence to accurately determinethe answer to the question.

6. Let the patient talk freely enough to observehow tightly the thoughts are connected.

7. Use a mixture of open-ended and closed-ended questions.

8. Don't be afraid to ask about topics that you orthe patient may find difficult or embarrassing.

9. Ask about suicidal thoughts.10. Give the patient a chance to ask questions at

the end of the interview.11. Conclude the initial interview by conveying a

sense of confidence and, if possible, of hope.

Reprinted with permission from Andreasen NC,Black DW. Introduction Textbook of Psychiatry.Washington, DC: American PsychiatricAssociation, 1991.

Open-Ended Versus Closed-Ended QuestionsInterviewing any patient involves a fine balance between allowing thepatient's story to unfold at will and obtaining the necessary data fordiagnosis and treatment. Most experts agree that an ideal interviewbegins with broad, open-ended questioning, continues by becomingspecific, and closes with detailed direct questioning.An example of an open-ended question is Can you tell me more aboutthat? A closed-ended question would be How long have you beentaking the medication? Closed-ended questions can be effective ingenerating specific and quick responses about a clearly delineated topic.Closed-ended questions have also been found effective in assessingsuch factors as the presence or absence, frequency, severity, andduration of symptoms. Table 1-6 summarizes some of the pros and consof open- and closed-ended questions.

ReflectionIn the technique of reflection, a doctor repeats to a patient, in asupportive manner, something that the patient has said. The goal ofreflection is twofold: to assure the doctor that he or she has correctlyunderstood what the patient is trying to say and to let the patient knowthat the doctor is perceiving what is being said. The response is meantto let the patient know that the doctor is both listening to the patient's

concerns and understanding them. For example, if a patient is speakingabout fears of dying and the effects of talking about these fears with hisor her family, the doctor might say, It seems that you are concernedwith becoming a burden to your family. This reflection is not an exactrepetition of what the patient has said, but rather a paraphrase thatindicates the doctor has perceived the essential meaning.

Table 1-6 Pros and Cons of Open-Ended andClosed-Ended Questions

AspectBroad, Open-EndedQuestions

Narrow,Closed-EndedQuestions

GenuinenessHighThey producespontaneousformulations.

LowThey lead thepatient.

Reliability

LowThey may leadtononreproducibleanswers.

HighNarrow focus,but they maysuggestanswers.

PrecisionLowIntent ofquestion isvague.

HighIntent ofquestion isclear.

TimeLowCircumstantial

HighMay invite yes

efficiency elaborations. or no answers.

Completenessof diagnosticcoverage

LowPatient selectstopic.

HighInterviewerselects topic.

Acceptanceby patient

VariesMost patientspreferexpressingthemselvesfreely; othersfeel guardedand insecure.

VariesSome patientsenjoy clear-cutchecks; othershate to bepressed into ayes or noformat.

Reprinted with permission from Othmer E,Othmer SC. The Clinical Interview Using DSM-IV.Washington, DC: American Psychiatric Press;1994.

FacilitationDoctors help patients continue in the interview by providing both verbaland nonverbal cues that encourage patients to keep talking. Noddingone's head, leaning forward in the chair, and saying, Yes, and then ?or Uh-huh, go on, are all examples of facilitation.

SilenceSilence can be used in many ways in normal conversations, even toindicate disapproval or disinterest. In the doctorpatient relationship,however, silence can be constructive and, in certain situations, allowpatients to contemplate, to cry, or just to sit in an accepting, supportiveenvironment in which the doctor makes it clear that not every momentmust be filled with talk.

ConfrontationThe technique of confrontation is meant to point out to a patientsomething to which the doctor thinks the patient is not payingattention, is missing, or is in some way denying. The confrontation ismeant to help patients face whatever needs to be faced in a direct butrespectful way. For example, a patient who has just made a suicidalgesture but is telling the doctor that it was not serious may beconfronted with the following statement: What you have done may nothave killed you, but it's telling me that you are in serious trouble rightnow and that you need help so that you don't try suicide again.

ClarificationIn clarification, doctors attempt to get details from patients about whatthey have already said. For example, a doctor may say, You are feelingdepressed. When do you feel most depressed?

InterpretationThe technique of interpretation is most often used when a doctor statessomething about a patient's behavior or thinking of which the patientmay not be aware. The technique requires the doctor's careful listeningfor underlying themes and patterns in the patient's story.Interpretations usually help clarify interrelationships that the patientmay not see. It is a sophisticated technique and should generally beused only after the doctor has established some rapport with thepatient and has a reasonably good idea of what some interrelationshipsare. For example, a doctor may say, When you talk about how angryyou are that your family has not been supportive, I think you're alsotelling me how worried you are that I won't be there for you either.What do you think?

SummationPeriodically during the interview, a doctor can take a moment andbriefly summarize what a patient has said thus far. Doing so assuresboth the patient and doctor that the doctor has heard the sameinformation that the patient has actually conveyed. For example, thedoctor may say, OK, I just want to make sure that I've got everythingright up to this point.

ExplanationDoctors explain treatment plans to patients in easily understandablelanguage and allow patients t