CHAPTER EIGHT

A DIFFICULT PATIENT
SUMMARY

This interview deals witha patient who initially seemed minimally moti- vated to
talk. The patient's short answers do not help the interviewer clarify the
psychopathology. He fails to recognize the source of the difficulty and to
approach it with fitting techniques. Yet his -persistence and empathy do ultimately
elicit the source of her suffering and help him to establish rapport. He garners
enough information to make a meaningful differential without being able to
convincingly arrive at the principal diagnosis.
A A A A A
In the United States, man does not feel that he has been torn from the
center of creation and suspended between hostile forces. He has built
his own world and it is built in his own image: it is his mirror. But
now he cannot recognize himself in his inhumane objects, nor in his
fellows. His creations, like those of an inept sorcerer, no longer obey
him. He is alone among his works, lost ... in a wilderness of mirrors.
--Octavio Paz, The Labyrinth of Solitude, 1985

V V V V V
The previous chapter showed an interview with a cooperative patient whose
symptoms, signs, and behaviors did not obstruct the interview process. The vast
majority of outpatients who seek your help fall into this category. In a Board of
Psychiatry and Neurology Examination, you will most likely encounter a
cooperative patient (the organizers of the examination request cooperative patients
from the various participating sites). However, throughout your career as a mental
health professional you will also encounter many difficult patients. You find them
in the emergency room, on the consultation service, or in your office when a
colleague requests a second opinion. We chose the patient represented in this
chapter to show you some of the pitfalls with difficult patients.
Difficultie
'
s,.in interviewing patients stem from four sources. First, the
patient's' ioms and signs may have a direct impact on the interviewing symp
process and induce the patient to distort the information you seek. Such a patient
may somatize _dissociate right in front of you. His high avoidance anxiety may
make him shy away from reporting his pathology, or he may befuddle you with
dramatic conversion symptoms that appear to be irreversible, at least during the
interview.
Second, a psychotic process may dictate the patient's behavior. He presents as
.

stuporous and mute, or attacks you because he has identified you as one of his
persecutors.
Third, a cognitive impairment may be developing in the patient. This
impairment and his lack of insight conceal his true pathology, Unless you are
consciously testing for it, you may be unable to detect it. Even if you Identify
signs of cognitive impairment, you might assume they emerge from a different
clinical disorder and not explore them further.
Fourth, the patient may intentionally want to deceive you. He conceals,
falsifies, or fabricates information essential to his pathology, or he tries to enlist
you
.
to take part in his deceptive strategies.
This book is not designed to familiarize .you with how to approach difficult
patients. Such advanced challenges are addressed in The Clinical Interview (Icing
DSM-IV, Volume 2: The Difficult Patient (Othmer and Othmer 1994).
In the following, we present an unmotivated patient whose pathology interferes
with the interview. Basic interviewing strategies do not elucidate fully the nature
of her psychopathology. Through the first two-thirds of the interview, the
interviewer faces the patient's superficial answers. Only when he opens up to
berque
l
stions and gives her feedback about his observations does his approach
become more effective. Now he arouses the patient's interest in the interviewing
process and engages her in the diagnostic puzzle.
This' interview is with Kelly Jasmin, a 19-year-old, white, slender female. She
was referred for a diagnostic evaluation by another psychiatrist.
The patient sits slumped over her crossed legs in the waiting area and does, not
look up when the interviewer enters. She wears a long-sleeved blouse over A
intight pants tucked into boots--all black, Necklaces with big pendants and
oversized rings adorn her. Her black hair is spiked, colored red at the tips, and
shaved around the ears.
She looks up only after the interviewer addresses her. Her face is pasty white
and thick with makeup; her eyebrows are plucked to a thin line.

Phase : Warm-Up and Screening of the Problem
1. I: Hi, Miss Jasmin. My name is Dr. 0. I'm glad you came over this morning.
P: Hi.
2. I: (while walking with the patient to the interviewing room) You are still over
in the inpatient unit, Miss jasmia7
P: No.
3. I: Oh?
P: [gives a hostile look]
4. I: I thought you were still on the inpatient unit and came over here
o
n a pass.
P: No.
5. I: So Dr. A. must have discharged you after I talked to him last.
P: He discharged me last Saturday.
6. I: [entering the interviewing room] Please come in and have a seat.
P: (sits down without a word)
7. I: Can I get you anything, a coffee maybe?
P: No. (at this point the interviewer notices that the patient has placed an open
cola can on his desk that she must have held in her left hand when he
approached her from the right in the waiting room) May I smoke?
8. I : Sure, go right ahead. Here is an ashtray.
P: Thanks.
9. I: Before we start, what would you like me to tall you?
P: Kelly is fine.
10. I: Has Dr. A. told you what this visit with me is all about?
P: Yeah Booking at the interviewer with a blank facial expression).
11. I: What did he tell you?
P: Just what you think about me [blank look].
12. 1: Think about ... [waiting)? Think about what?
P: (answers quickly without a change in tone) About me cutting myself.
13. 1: Yes, he told me he was puzzled.
P: [shrugs her shoulders and looks down at her knees)
14. 1: What do you think about 10
P: [with a blank facial expression) Nothing.
15. 1: Would you like to talk about it?
P: [shrugs her shoulders) It's OK, I guess.
16. 1: When was the last time that you did it?
P: looks up at the interviewer) Wednesday, the day before I came to the
hospital.
17. I: Why don't you tell me all that happened during the day when you cut
yourself?
P: I got mad at myself (no change in facial expression, posture, gestures, or
intonation). I was angry.
18. I: Angry:,.?
P: Yeah.
19.1: Angry about what?
P: Abput'ddt getting anywhere.
20. I: Hi-hm Sounds like (pause) ... you felt stuck?
P. Yeah [looks bored].
21. I: 1: Can you tell nipin gre about it?
P: I don't know, just with my grades in college.
22. I: Your grades in college ... which college do you attend?
P: The XXX community college.
23. I: Hmm . - . What's your major?
P: I haven't declared one.
24. I: What do you take?
P: Sculpture (pause]... painting (pause) ... writing .. .
25. I: And what kind of grades do you get?
P: A's and B's.
26. I: Sounds pretty good to me.
P: I got 'a C in weaving (draws down the corners of her mouth).
27. I: How did you feel about that?
P: Fine, I guess (shrugs her shoulders).
28. I: [displaying surprise in his voice and facial expression) What did you
expect to get?
P: At the beginning; a C is fine. There's a lot of technique involved [in
weaving]. 29. I: So you are really doing all right?
P: [silence]
30. I: Then what made you cut yourself?
P:
.
just in general.
31. I: I don't understand. Can you explain?
P: no change in voice or facial expression] I was just mad.

Rapport: The interviewer quickly notices the patient's inattention and
indifference when he enters the waiting room. He decides not to confront her with
her lack of interest by asking her, for instance:
"How did you feel about Dr. A. asking you to come over here this morning?"
but to wait until he can decide whether the patient's indifference results from
being initially uncomfortable with him, from having a negative transference to
him, or from a clinical or personality disorder. Instead of a
confrontation, he attempts to warm up the patient by reviewing the circumstances
of the referral. Unfortunately, lie is not up to date, prompting the patient to correct
him, which she does with a minimum of words. Rapportb is not improved when
the'interviewer offers her a beverage because he had