Finally, a patient may signal suffering by deceiving you.

Such a patient does not accept the interviewer as a supportive person. He does not share his
symptoms and, at times, misleads the interviewer.

For these difficult patients, we have used interviewing techniques that differ from both descriptive,
criteria-oriented interviewing and open-ended, psychodynamic interviewing. We have collected the
histories of those difficult patients for whom these not-so-common interviewing techniques were
helpful. This inductive process led us to four groups of difficulties and their matching interviewing
techniques.

The first type of difficulty is the displaying of signs and symptoms of illness that are in fact
medically inexplicable; these signs and symptoms involve a patient's consciousness, identity,
memory, sensory and motor nervous systems, and bodily functions (Part I of this volume). Patients in
this group show conversion, dissociative, avoidance, or somatic symptoms; frequently, patients
experience these symptoms simultaneously.

The DSM-IV disorders characterized by these symptoms are conversion disorder; dissociative
disorders; posttraumatic stress disorder, and somatoform disorders, especially somatization
disorder. All these disorders are judged to be associated with psychological factors-factors that may
represent a history of physical and sexual abuse, life-threatening traumatic events, or stressors

often associated with the onset, maintenance, and exacerbation of the symptoms. Clinical
experience indicates that a group of uncovering techniques may help to explore these psychological
factors: hypnosis, free association, active listening, and symptom validation.

The second type of difficulty is a patient's impaired reality testing, resulting from delusional
and hallucinatory experiences (Part II). With such patients, it is difficult to establish and maintain
rapport. They act on hallucinations and delusional thoughts as if they were real. They may

encapsulate themselves in mute stupor while attending to their internal world, or attack the
interviewer as an enemy. All DSM-IV disorders that are associated with psychotic symptoms belong
in this category. We describe several techniques useful for such patients: amobarbital and lorazepam
interviewing, tranquilization with retrospective interviewing for delusional and hallucinatory
experiences, and empathizing with patients' acceptable goals while diffusing their socially
destructive behaviors.

The third type of difficulty is cognitive impairment, which causes patients to provide
incomplete information or inappropriate feedback about their problems (Part III). Such cognitive
impairment may be overlooked and misinterpreted as symptoms of major depression,
schizophrenia, or an anxiety disorder. The three major categories of DSM-IV cognitive disorders
dementia, amnestic disorders, and delirium- belong to this group.

However, some disorders, usually first diagnosed in infancy, childhood, or adolescence, complement
this group-namely, mental retardation, learning disorders, and attention-deficit disorders. We
discuss methods to alert the interviewer to the presence of a cognitive disorder and present specific

examination techniques that can quickly identify the impairment.

The fourth type of difficulty is deception and self-deception (Part IV). In DSM-IV, deception is
recognized in conduct disorder and antisocial personality disorder within the criteria of lying and
using aliases. It is seen in the self-deceptive, dissimulating behavior that is an associated feature of
substance use and eating disorders. Deceptive behavior is also addressed as a characteristic of
borderline personality disorder and pedophilia. False information received from a patient can lead to
misdiagnosis. Interviewers may be fooled because they may not notice deceptive behavior. In this
book, we present techniques to help the interviewer detect deceptive behavior and enable the
patient to replace that behavior with the openness necessary for a successful therapeutic alliance.
These techniques include cross-examination, voice-stress analysis, and cognitive techniques.

The Clinical Interview Using DSM-IV, Volume 2: The Difficult Patient builds on our first interview
book, The Clinical Interview Using DSM-IV,

Volume 1: Fundamentals (Othmer and Othmer 1994). The four-dimensional interviewing approach
outlined in Volume 1 is now applied to the difficult patient. This approach focuses on the
interviewer's rapport with the patient, on the techniques that elicit information, on the patient's
mental status during the interview, and on the diagnostic decision process. However, this four-prong
approach is not sufficient for interviewing the difficult patient successfully. The interviewing
strategies presented here enhance the symptom and sign-oriented interviewing style by employing
specialized techniques that address the difficulties encountered by clinicians.

Volume 2: The Difficult Patient draws from many sources. It integrates interviewing techniques
developed by different schools of thinking in psychiatry and psychology, such as psychodynamic,
cognitive, and neuropsychiatric approaches, as well as the legal system's methods of cross-
examination and voice stress analysis. It shows how these different approaches help the interviewer
elicit reliable information from patients normally tough to interview and solve their diagnostic
puzzles. We discuss the effectiveness of these methods and, in those instances where they could

be improved on, point this out too.

The organization of each chapter shows the following outline: First, we describe the nature of a
specific difficulty in interviewing and its appearance in patients' mental status. Then we discuss
interviewing techniques that might be most helpful with patients showing that difficulty, and how a
given technique can best be integrated into the interview. We recommend a progression in five
steps:

Step 1: Listen. This step allows the interviewer to recognize the patient's mental status and identify
his exact type of difficulty.

Step 2: Tag. In this step, the patient is made aware that the interviewer is noticing a difficulty.

Step 3: Confront. During this step, the interviewer signals to the patient that there is a difficulty that
needs to be discussed.

Step 4: Solve. During this step, the interviewer implements a technique thought to be the most
effective for resolving the patient's difficulty.

Step 5: Approve. In this step, the interviewer makes the patient realize the advantage of having
overcome his difficulty.

We demonstrate each technique in patient interviews. We highlight the interviewing strategy and
not the authenticity of the individual case. Our cases are prototypes of psychiatric pathology.
We have found that gender influences the course of interviews; thus, because the cases that appear
in this book are to some extent real cases, and the dialogue, actual dialogue, we have been careful
about retaining the original gender of the interviewer. Most of the interviews were conducted

by E. Othmer, in these cases we therefore have kept the male gender for the interviewer. However,
we have taught and observed female interviewers in situations that resemble some of our own
cases; therefore, in those cases in which we have drawn on these interviews, we have used the
female gender for the interviewer. For the patients, the gender of the patient in the original

interview has been retained. However, to ensure the noninterview portion of the text reads
smoothly, we have chosen to switch genders as each new topic is introduced in the text.

We hope this introduction gives you a framework from which to consider the interviews with various
types of difficult patients