Excerpts from Must Read Books & Articles on Mental Health Topics
Books, Part IXX

Key Concepts in Psychotherapy
Erwin Singer
Chapter 14: The Concept of Termination and Achievement of Identity, pp. 338-358

A number of the processes observable in the course of psychotherapeutic work serve the patient in a dual function: (1) they prevent him from gaining awareness of his nature and maintain dissociated what he desires to keep buried; (2) at the same time the patient's behavior forces him to reveal himself to the therapist, as if asking to be understood, that his human dilemma be grasped so that he in turn may reach higher levels of self-understanding. The patient's cry for help proceeds almost in spite of him and despite his simultaneous desire to remain oblivious. The essential ambivalence in the emotionally disturbed person who seeks help because he has some faint idea that life is not necessarily the way he sees it through his distortions was outlined. Incidents which reveal these obscuring yet self-revealing processes and developments constitute the day-to-day content of the psychotherapeutic encounter and exchange. Their full exploration ultimately results in the growth of insight which represents the essence of psychological well-being, replacing pathological states of repression and dissociation.
    At what point is the therapeutic relationship to halt; when is termination to take place? The answer is deceptively simple: when the therapeutic goals have been achieved. This answer is deceptively simple and deceptively obvious because the definition of well-being is a very complex problem and the meaningful assessment of well-being is even more difficult. Therefore the aims and goals of psychotherapy must be restated briefly, making an inquiry into the operational reflections of their achievement possible. But before the indications for the termination of successful psychotherapy can be outlined, some consideration must be given to the problem of precipitous termination and the dangers attendant on undue prolongation of psychotherapy.
    Premature termination of therapeutic contacts by the patient is not likely to occur if some genuinely curative exchange has been established. Once the patient has experienced any meaningful expansion of his horizons, his resistances and the despair they reflect will diminish and simultaneously curiosity and courage to be inquisitive will grow. The patient will be at least somewhat eager to pursue self-investigation to reach further insights, increased self-awareness, and increased self-actualization. Of course, it would be highly unrealistic to expect that on the basis of fruitful beginnings all resistance will disappear. At any point in the therapeutic progress at which new vistas open up, new resistances must be expected because each advance represents a simultaneous loss of familiar security and is therefore fraught with new anxieties. This increased discomfort is experienced by patients when new insights force themselves on them, heightening their temptation to leave therapy.
    There is another characterological force responsible for premature termination. One frequently meets patients who cannot bear the sense that anybody is useful to them. This inability is often caused by their intense feelings of dependence, which make them feel that the slightest degree of actual need for the analyst will result in their becoming putty in his hands and that their cravings for satisfaction of dependent needs will cause them to lose any outline and definition. In other instances unwillingness to permit the therapist to be helpful is occasioned by another factor. When in his development the patient has felt forced to identify with a highly depriving person, he frequently manifests an eagerness to perpetuate a tradition as if he tried to honor his teacher in deprivation by becoming equally depriving toward others, including the therapist, and he often does this by denying him the satisfaction of being useful and of service. Only patient and persistent analytic investigation of this urgency to perpetuate familial behavior plus constant interpretive and confrontational comments around this issue will lead to insight into this outlook, which seems life-sustaining to the patient. Unfortunately, the inner rage operating simultaneously in such patients often provokes the therapist's anxiety and countertransference reactions. Triggering these reactions may well lead to the therapist's unwitting and unconscious rejection of the patient. Then the patient feels doubly "hurt," and unless the therapist is willing and able to analyze his counter-transference reaction with the patient and by so doing help him see how he invites being hurt, precipitous termination is in the offing. The following example illustrates such an incident:

An artist in her late thirties had been in analytic therapy for about a year. Her character orientation was highly depriving; she was extremely cynical and furious with all other artists, gallery owners, and the world at large. Despite all this she was quite successful and supported herself well in a field notorious for economic hardship. Of course her angry deprecation had also been vented continuously on the therapist.
    One day she announced with a good deal of satisfaction and pride that she was to have a one-man show in a prominent gallery, and she invited the analyst to the private opening of her exhibition. She remarked sarcastically that she knew that he would not come anyhow because this was against the rules laid down by "St. Sigmund," but since she was to say whatever she thought or felt she thought she'd better mention it. Furthermore, she believed "it might do you some good to see serious art and perhaps you could learn something about me by seeing my work."
The opening was to be the next day and the analyst inquired with surprise how long she had been planning her show, only to be informed that negotiations and preparations had been going on for months even though the patient had not mentioned a word of it. The therapist remarked on this, and knowing that he was free at the time of the opening he decided to see for himself some of the patient's work and to accept the invitation.
    The following day, however, he became involved in all kinds of activities connected with other professional commitments and finally arrived at the gallery a few minutes before closing time. During her next session, the patient became even more sarcastic and derogatory with the therapist, and instead of focusing on his own annoyance with her and his unconscious desire to punish her, the therapist started to analyze the patient's "infantile demandingness." Not long thereafter the patient left therapy.

The therapist had not addressed himself to what really mattered. He had not helped the patient gain knowledge of her self-defeating ways, and in failing to do this he had failed her. Her resistance and its unpleasant manifestations were originally heightened by increased feelings of dependence and then increased further by her conviction that she had evidence that any efforts to seek contact led to fewer rather than more satisfactions in living. Only when the therapist's active interpretations help the patient see that satisfactions in living follow the progressive diminution of withdrawal tendencies will resistances decrease in intensity.
    A patient's desire to perpetuate therapy even though the therapist can see no good reason for continuation must also be taken seriously and cannot be dismissed readily as an expression of what is commonly called separation anxiety (Rank, 1945). Not infrequently one meets patients who seem addicted to psychotherapy and yet do not grow significantly, almost as if they tried to avoid termination. This type of addiction, like any other, must be thought of as reflecting an inner state of emotional disturbance and therefore needs investigation and "working through" in its own right. It expresses itself in an extreme reluctance to terminate therapeutic contacts, but it must not be confused with the patient's and the therapist's realistic hesitance to end a relationship which was deeply meaningful to both. There is inevitably a sense of sadness in the parting of two people who have gained and shared knowledge--and the therapist-patient relationship should be one of profound gaining and sharing. This sadness is tempered provided the relationship has been rational and constructive by their gratifying knowledge that new and productive experiences lie ahead for both. But just as the child will be reluctant to do what he must do--leave the parents--if he has the silent conviction that they will be lost and will not know what to do with themselves once he is gone, so will the patient hesitate in leaving the therapist if he suspects that a sense of bewilderment about his own future well-being will overcome the therapist once the patient has left.
    The patient's suspicions, whether conscious or out of awareness, may of course stem from transference distortions--or they may be realistic perceptions of a problem in the therapist's life, may represent a correct appreciation of counter-transference problems. A combination of transference distortions and realistic gleaning of counter-transference difficulties may occur, making for a stubborn prolongation of the therapeutic relationship to which both patient and therapist contribute for their own neurotic ends. Only when the therapist is capable of dealing with certain psychological problems easily triggered by termination can a fruitful dissolution of the relationship ensue. Because termination with a patient is often psychologically analogous to termination of parenthood, it potentially forces upon the therapist some awareness of his own aging. Therefore his rational acceptance and realistic dealing with the problems aging inevitably brings--a tall order indeed--are demanded. This maturity will prevent or remove counter-transference difficulties which often lead to undue prolongation. Only such maturity will prove to the patient that this "bind" is truly fictitious and a reflection of transference distortions which then are in need of being understood and dealt with as one would any other transference manifestations.
    But dealing with the problem of one's aging is an extremely difficult undertaking for most human beings, including psychotherapists, and therefore troublesome and intricate combinations of transference-counter-transference binds produced by the problems outlined here are more frequent than one may think. The likelihood of their developing and making for prolongation of therapy is marked because the therapist's own extensive self-investigation usually occurred at a time in his life when aging was not an immediate problem for him and hence his reactions in this area were either not investigated at all or in only minimal and tangential fashion. Jung (1926b) has repeatedly suggested that the problems human beings face before forty revolve around issues markedly different from those of later years (and that therefore the focus of therapy before and after this admittedly arbitrary landmark cannot be the same). If this is true of all human beings, so much more is it true for the psychotherapist whose professional activity centers primarily on the preparation of others for future living while he has usually passed the prime of life. It is entirely possible that Freud (1937) had some such issues in mind when late in life he reiterated his conviction that the analyst must periodically re-enter analytic self-investigation.
    Just as unduly prolonged therapy is a manifestation of unresolved counter-transference difficulties, so does the danger of therapy being terminated (by the therapist) before the therapeutic goals are achieved derive from similar sources. If therapy has been protracted and very slow in moving, the therapist may come to question his professional ability; in order to dispel his doubts and convince himself that he does a creditable job he may delude himself that important changes have taken place. Hopefully, the needs of the therapist will not demand the irrational satisfaction of being able to induce curative results faster than the patient is prepared to move. Hopefully, his self-esteem will rest on firmer grounds, but it must be admitted that under the best of circumstances these are potential human weaknesses in the most mature of therapists which he must reckon with and guard against. Closely associated with his eagerness to insist that therapeutic results have been achieved when this is not so is of course the therapist's sense of guilt about perchance not having done as well as he might have had he been more attentive, and about having wasted his and the patient's time here and there. Burdened by such secret and perhaps even justified self-recriminations (conscious or unconscious), he is eager to stop his own wastefulness and at the same time convince himself that his work has been fully fruitful by terminating the relationship precipitously.
    The therapist who has labored long and hard and with little results on behalf of a patient, and who experiences his self-esteem shaken by the slow progress, may come to resent the patient whose minuscule progress frustrates him. Such disappointments can lead to at least covert and unconscious hostility, overtly expressed in premature termination. When this happens it is not only an indication that the therapist has lost confidence in the patient's capacity to grow beyond an often rather minimal point and that he tries to convince himself that this is as far as the patient is capable of going, at least at this moment in his life, but it reflects more: rather than face his own disappointment and his "narcissistic injury" he turns against the patient and abandons him halfway with covert anger. There are instances when new personal growth cannot take place because the patient needs a period of consolidation and therefore a patient may need "time out," a period during which he can simply live with insights he has seen in dim outlines so that he may absorb and assimilate them. This is a period in which the patient can become more conversant with himself than he has been heretofore. It may well be that such periods demand a decrease in frequency of sessions or even a temporary interruption of therapy. This possibility must be faced by therapist and patient, but such a decrease or interruption of therapy represents an entirely different situation than outright premature termination.
    It is also possible that a therapist may come with his patient to the realistic conclusion that their collaboration has gone as far as it can go and that the interests of both would be served best were the patient to see another therapist for additional help. Such a transfer does not imply that the patient cannot go further; it clearly indicates that in the therapist's opinion the patient can progress. It simply represents recognition by the therapist that, for whatever reasons, he is incapable of helping the patient advance and that another therapist may yet render valuable service to the patient.
    The general statement that suggests itself is obvious: premature termination and unduly prolonged therapy are essentially reflections of uninvestigated counter-transference difficulties which interfere with the therapist's effectiveness. To keep the number of such failures to a minimum, therapists who find it impossible to resolve their personal difficulties with some patients suggest to them that they work with other practitioners. While this step may strike the patient as a rejection, it is a course infinitely more desirable than a laborious prolongation of a relationship which brings both participants nothing but anguish, boredom, and disappointment.
    Now let us turn to those indications which are genuinely convincing that the therapeutic relationship can be terminated. Obviously termination seems indicated when those symptoms which brought the patient to the therapist have disappeared. This conclusion appears reasonable enough, but the issue is actually more complicated. Even though the basic model of psychotherapeutic cure suggests that harmful and bothersome symptoms and the conflicts and anxieties underlying them disappear when genuine insight occurs, various authors have observed and reported on a phenomenon which is often referred to as "flight into health." The dynamics described by this somewhat awkward term were discussed by Alexander: ". . . 'flights into health' [are] sometimes observed in psychoanalyses when, because of some clear and successful reconstruction of repressed tendencies, the patient reacts by losing his symptoms in order to save himself from further unpleasant truths." [1946b, p. 153].
    Many analysts believe that some patients lose their symptoms in order to maintain their character pathology. (Alexander does not seem to share the orientation he describes.) Fundamental to postulating such a process is the notion that insight is noxious to human beings and that they don't "really" want to learn anything about themselves, though it might be more accurate to suggest that some patients have not bothered to become conversant with the expectations of certain psychoanalytic theoreticians. Why should one assume that "some clear and successful reconstruction of repressed tendencies," indications to the patient that he has been understood, move him to flight from his therapist, who in hearing him has rendered invaluable service? It is more reasonable to expect that after he has been heard and understood genuine relief will set in and the patient will grow without the dubious benefit of gaining familiarity with fanciful constructs. It is more likely that he has learned something real though in nonintellectualized terms.
    French commented upon a related topic:

The term "transference cure" was given ... quick relief of symptoms to signify "apparent cure" as a result of the satisfaction the patient received from his emotional relationship to the therapist and not of any more permanent modification of his personality such as new insight would have brought. In the early days of psychoanalysis, we looked upon such "transference cures" as exceedingly superficial and felt it our duty to urge the patient, in spite of his relief, to face his more deep-seated problems in order to achieve a more radical and 'permanent' mastery of his difficulties. Sometimes, however,"'transference cures" become permanent. Such a permanent improvement is usually to be explained by the fact that the relief the patient gets from unburdening his difficulties to the therapist makes possible a better adjustment in his real life situation; this, in turn, so improves the situation that the patient may, after a time, find he no longer needs the support of the therapist [1946b, p. 133].

Although French's willingness to consider the value of therapeutic procedures which were once frowned upon reflects a significant departure from traditional psychoanalytic thinking, he may have underestimated the profound transformation that can occur in patients even after relatively few contacts if the therapist's work is genuinely incisive. There is really nothing wrong with "supportive therapy" if "supportive" means taking the other person seriously and addressing oneself fully to the core of the patient's life situation and inner experience. Analysis to be fruitful must always be "supportive" in this sense of the term.
    This growth often influences the patient to engage in a more far-reaching reappraisal of his life and the basic assumptions which govern his relations with his fellow men. He may even proceed to a serious investigation of those historical circumstances in his life which moved him to adopt a reality-distorting outlook and orientation and address himself to a searching examination of the origins of his life style. It is difficult to understand why a serious search brought about by the patient's convincing sense that his premises for living are faulty is deemed "superficial" by some unless he also develops intellectual adherence to certain constructs.
    Of course, it is true that some patients flee from therapy as if it were poison and in order to make this flight effective and yet reasonable they lose their symptoms, at least temporarily. But this usually happens when they have the uncomfortable suspicion that nobody is genuinely willing to understand their inner situation and/or that the therapist's intellectual appreciation of their emotional life will be used by him to their detriment. Unfortunately, such suspicions may be valid. Even the most able and empathic of therapists may not grasp the particular idiosyncratic expressions of a given patient's experience, and such failure results in termination leaving patient and therapist in a state once described by Sullivan (1953) as "mutual exhaustion" (p. 11). In other instances uninvestigated counter-transference reactions give the patient the painful though accurate impression that he is confronted with hostility and rather than expose himself to more of the same he "reforms" --mends his ways and departs gracefully.
    Finally, there are those moments in which the patient sees with terror that his whole world system is challenged fundamentally by the therapist's precise understanding and his own growing awareness of the nature of this system. This happens, indeed must happen, when the investigation of the transference premises is accurate. Then patients are tempted to leave but will actually terminate only when again some uninvestigated counter-transference difficulty prevents the analyst from a full and persistent investigation of the patient's belief that the analyst will not appreciate the agony caused by personal transformation and reorientation. This is of course what human beings dread most: that they will dare to institute basic changes and that they will be abandoned while engaged in this process because they will reveal something that they fear will revolt and terrify the other person; or because the analyst really "does not mean it"; or for some similar reasons.
    They dread that then they will be left with nothing without the identity (or rather the pseudo-identity) of their defensive world system and without any new sense of self. This deep fear of troubled human beings requires investigation in itself, this profound distrust and terrifying sense that one will be abandoned helpless and unprotected demands careful exploration in its own right. The more disturbed the patient, the more likely is his distrust to play a vital role in his life and it is well to recall that Erikson (1959) insisted that the development of trust is the first and most basic task in the growth of identity. "Flight into health" and "transference cures" truly reflecting avoidance of further and basic self-knowledge rather than the avoidance of intellectualized insight occur precisely at moments when the therapist for his own reasons fails to investigate the patient's basic feelings of distrust.
    The reduction of troublesome and self-destructive symptomatology represents, then, the most obvious criterion for therapeutic termination. But it will be remembered that symptoms have been defined as merely overt and dramatic communications of inner states and orientations. Genuine disappearance of symptoms implies the resolution of underlying attitudes and the development of new orientations. To illustrate with obvious and familiar examples: when a patient with potency disturbances becomes genuinely potent with his partner, this represents not only the disappearance of a symptom but it also indicates that he has abandoned some of his orientation which underlies the impotence; if the compulsive patient stops his hand-washing rituals, this once again implies a changed outlook; and if a child starts to learn those basic skills which he seemed incapable of acquiring despite his biological and physiological ability to do so, this, too, reflects a reorientation and not just the disappearance of a symptom. Of course, questions about the nature of this reorientation immediately arise. Impotence can be exchanged for potency because the individual has grown into readiness to share with others, because he values life, experience, and generativity, and because it gives him joy to bring joy to his partner; or this exchange can be effected because the patient now feels that he has found a more effective way of hurting or humiliating his partner. Hand-washing rituals may be abandoned because the person does not feel as dirty inwardly as he used to; indeed, he may have reason to feel clean because in a meaningful sense of the word he is clean, or because he is less troubled about besmirching the surrounding world, is not frightened any longer of the consequences of his dirty work, is less afraid of being caught than he had been previously. Finally, a child may start to learn because the expansion of the universe is a joyous experience, because the flame of inherent or "epistemic" curiosity has been rekindled, and because he has grown convinced that his identity can be developed through self-expansion; or the youngster may start to learn because it has occurred to him that the learning of certain skills places him in a better position eventually to give vent to his hatred. The former possibilities reflect genuine changes from essential inactivity and/or pseudo-activity to genuine activity; the latter possibilities merely reflect the exchange of one form of inactivity or pseudo-activity for another. If the hegemony of pseudo-activity as the supreme value persists one cannot possibly talk of health or cure even though the symptom has disappeared. Only continued inquiry into the value system of the patient will reveal whether genuine transformation has taken place.
    Even though most theorists--despite their divergent assumptions about the nature of man--agree that the patient's ability to engage in activity and to assume responsibility are the indicators that therapy can stop, the pertinent literature describes pathetically few specifics revealing that the patient has reached such a level of development. Freud offered a formulation describing the point at which therapy can be terminated with the knowledge that therapeutic goals have been achieved.

The other meaning of the "end" of an analysis is much more ambitious. In this sense of it, what we are asking is whether the analyst has had such a far-reaching influence on the patient that no further change could be expected to take place in him if his analysis were continued. It is as though it were possible by means of analysis to attain to a level of absolute psychical normality--a level, moreover, which we could feel confident would be able to remain stable, as though, perhaps, we had succeeded in resolving every one of the patient's repressions and in filling in all the gaps in his memory [1937, pp. 219-20].

Even if one were to agree with Freud's definition of wellbeing, and regardless of one's belief whether its attainment is possible--something apparently doubted by Freud himself--it is clear that he did not offer any criteria which make the analyst reasonably certain that these goals have been reached, either fully or at least approximately. Turning to Nunberg, one of Freud's devoted and respected students, one finds that specificity is no more prominent than in the writings of his teacher:

The ego becomes stronger since it does not have to expend its energy for defenses; it controls the instincts and acquires the ability to master and tame them. "Fantastic" thinking, subject to the primary process, is now replaced by realist thinking, subject to the secondary process. The ego is enriched through the assimilation of repressed material. The severity of the superego is mitigated; it tolerates the repressed instinctual strivings better. The chaotic, disorderly neurotic ego, so full of contradictions, is replaced by an orderly, unifying, and mediating ego. In other words, the ego regains its synthetic function, its capacity to mediate between superego and id, as well as between id and external world [1955, p. 359].

The writings of a whole array of theorists and practitioners in psychotherapy reveal a similar paucity of specifics indicating cure. Adler (1927), for instance, gave the impression that the disappearance of what he called "disjunctive affects" such as anger, disgust, fear, and anxiety and their replacement by "conjunctive affects" such as joy and sympathy, to his mind reflections of social feelings, were his therapeutic goals (pp. 265-78). The patient's ability to engage in genuine cooperative inter-relatedness indicated to him that therapy was to be terminated. How he assessed the attainment of this state he did not say. And in accordance with his own theoretical formulations Jung (1933) suggested that termination was indicated when therapy had progressed to the point where the patient was able to enjoy the benefits of his unconscious, its wisdom, and its creative powers. But here too specifics are sorely lacking.
    Because Sullivan (1947) was most eager to define a state of well-being in strictly operational terms, he was also much more specific in outlining the criteria for termination than other, less operational theoreticians. When he defined mental health by saying "One achieves mental health to the extent to which one becomes aware of one's interpersonal relations . . ." (p. 102), he established bases for defining the conditions for termination more succinctly and directly than most other authors. Imbued with the spirit of logical positivism (logical empiricism would be more correct), a fact highlighted by Tauber (1960 ), Sullivan was prepared to spell out what he meant by mental health and in doing this he avoided postulating inner reorientations: ". . . insight into the actual fact of illusory, parataxis distortions as a factor that complicates the patient's interpersonal relations . . . constitutes the first therapeutic milestone ..." [1947, p. 116].
    Thus Sullivan came quite close to a basic concern with overt and symptomatic aspects of the patient's life, and in doing so he sidestepped cumbersome constructs. If the patient exhibits behavior which reflects the achievement of satisfactions and securities and if this achievement is based on awareness of his relationships with others then, Sullivan insisted, one may assume that there operates within the patient whatever is necessary to make effective living possible. Of course, it is also evident that Sullivan, no matter how much he may have tried to take a pure positivistic stance, at least by implication suggested that this overt picture required a specific inner situation. He suggested that the absence of crippling anxiety was necessary, for he had always insisted that distortions were actually attempts to reduce the experience of anxiety (1953).
    It would be belaboring an abundantly clear picture to proceed in further examination of the position of various authors on the question of termination. As already stated, they all considered the achievement of a state characterized by eagerness to engage in productive and creative activity in various spheres of living as the central criterion of well-being making termination of psychotherapy possible. This generalization encompasses Sullivan's position, too, if those mental processes which bring about greater awareness of one's relationships with others are included in "creative and productive activity."
    The attainment of a maturity characterized by childlikeness and reflected in man's willingness to become familiar with the new (within or without) was equated there with psychological well-being. This willingness and eagerness reflects itself in the way an individual listens to inner and outer voices, in his persistence in striving for deeper knowledge, and in his dissatisfaction with stereotyped and schematized formulations. This leads to the obvious conclusion that the readiness to engage in a genuine search and to shoulder its burdens is the hallmark of therapeutic success and therefore the ultimate criterion for termination of therapy. Paradoxical as it may sound, the moment the patient enters therapy fully and genuinely, the therapeutic task has been fulfilled.
    Psychotherapy is then primarily concerned with preparing the patient for searching and persistent self-investigation and self-awareness by removing those obstacles the patient employs in preventing his becoming his own therapist through reducing those encumbrances which interfere with the creative growth implied in self-investigation. With the development of the patient's intense desire to break the chains of self-alienation and its attending alienation from others and with the initiation of this self-expanding process, formal therapy may terminate. For at that moment the patient has arrived at a point where his individuality is not overwhelmingly frightening to him any longer, a point where he can endure the aloneness implied in individuality and where he can say with Shaw's (1951) Joan: ". . . I will dare, and dare, and dare, until I die" (p. 134).
    The eventual outcome of psychotherapy, then, is not the achievement of ultimate insight and understanding of self but the willingness to engage in never-ending striving for such insight, a willingness characteristic of well-being and therapeutic success. It would be folly to believe that psychotherapy will activate the patient's total capacity to love and care and to use his powers fully and productively. All that one may hope for is that he will become engaged in a never-ending effort to love, to care, and to use his abilities fully and creatively. Belief in the perfectibility of man is not synonymous with belief in a perfect man. Perfectibility is rather defined as a capacity for continuous driving toward growth despite the full realization that the achievement of some absolute end state is a childish illusion.
    The man struggling along this road to greater self-use and intimate relatedness to others, the man dedicated to this course, is already a man who has achieved a remarkable degree of well-being and perfectibility, provided his search is a genuine and serious dedication to effort and struggle. The illusions that blind him and prevent him from facing the road he must travel are the symptoms of pathological man and, as Fromm (1955, 1962) has pointed out so well, the symptoms of a pathological society. Psychotherapy is dedicated to a reduction of these "chains of illusion" in the individual and through him in the society in which he lives. This commitment, if it is a true one, cannot stop at some arbitrary point in life or in a formalized self-examination.
    Focused a bit differently, one may say that formal therapy can terminate when the patient genuinely accepts his unique individuality and has become dedicated to a continuous refinement of his personal identity. But the growth of this identity cannot be achieved through identification, the basic instrumentality proposed by Freud (1914b, 1927a, 1933, 1951) as effecting maturity. Erikson (1950), even though he tried to reject the supreme value of identification, talked of individual identity as a "successful variant of a group identity" (p. 208), and in effect spoke of identification.
    Nor can identity be achieved by stubborn negativism, a process somewhat akin to what Erikson (1962) called "negative identity." Much more does the development of genuine identity demand the capacity to say "No"--not in any isolating and oppositional terms but as an expression of the realization "I am I and not you; I am separate," a development well described by Spitz (1957). Only from this positive "No," the "No" of identity and the ultimate assertive "No" of Joyce's heroine, can the "Yes" of meaningful human solidarity arise. For only if one recognizes and accepts his separateness and aloneness can he possibly reach others and unite with them. Thus neither negativism and isolation nor self-destroying identification represent the road to well-being and the outcomes of the psychotherapeutic process but such outcomes are expressed in continuous heightening of identity and the interminable growth of human solidarity.
    In 1937, with the specter of horrible events to come clearly in view, Freud wrote Analysis Terminable and Interminable. There he indicated that he did not think that analysis was a terminable process. Two years before his death, a year before his forced exile, Freud returned again to an examination of Thanatos and a reassertion of what he believed was a justification for postulating this tendency in human beings. He took delight in making reference to the thinking of Empedocles and his system of thought which suggested the never-ceasing alternation between love and strife (Freud, 1937, pp. 347-50). Two and a half millennia ago a leading mind had outlined a world picture similar to his own biopsychical thinking, Freud exclaimed. And should not this constantly ongoing conflict between love and strife be held responsible for so much of the resistances observable in the analyst's work with his patients?
    Freud enumerated several examples typifying large groups of patients with whom analysts' work seemed in vain, patients who constantly returned to neurotic patterns or showed a total unwillingness to abandon old roads even though "new paths are pointed out for the instinctual impulses":

At this point, however, we must guard against a misconception. I am not intending to assert that analysis is altogether an endless business. Whatever one's theoretical attitude to the question may be, the termination of an analysis is, I think a practical matter. Every experienced analyst will be able to recall a number of cases in which he has bidden his patient a permanent farewell rebus bene gestis [1937, pp. 249-50].

He then proceeded to outline a type of "minimal program" for analytic work:

Our aim will not be to rub off every peculiarity of human character for the sake of a schematic "normality", nor yet to demand that the person who has been "thoroughly analysed" shall feel no passion and develop no internal conflicts. The business of the analysis is to secure the best possible psychological conditions for the functions of the ego; with that it has discharged its task [1937, p. 250].

But these words were in strange contradiction to the thought Freud had expressed in the same paper immediately preceding the paragraph just quoted: "So not only the patient's analysis but that of the analyst himself has ceased to be terminable and become an interminable task." [p. 250].   These contradictory thoughts can be reconciled only by defining "the best possible psychological conditions for the functioning of the ego" as tendencies which further and encourage interminable analysis--perpetual self-examination. But this view does not require postulating Thanatos or any other force which ceaselessly exerts regressive pulls and requires constant vigilant counteraction. In its stead this position requires the acknowledgment of man's finiteness and incompleteness and at the same time his inherent tendency to expansion. There is ample evidence supporting the assertion that such a tendency exists. And the acknowledgment of finiteness and incompleteness, the condition for expansive efforts, also brings about the sense of individuality, uniqueness, and separateness: the feeling of aloneness and responsibility. Once again it must be realized that, paradoxically, man's awareness and acceptance of aloneness is his ultimate guarantee against loneliness.
    It would be foolish to insist that man's behavior in general and the reactions of neurotics in particular do not suggest directions proposed by Freud. Freud's "nihilism and pessimism," to use Burchard's (1958) phrase, seem justified to many. But, contrary to Burchard's assertion, these qualities in Freud's thinking derive not from his "very high level of therapeutic aspiration" (1958, p. 356) but from Freud's general orientation to life, which was characterized by a deeply ingrained and grim conservatism only slightly tempered by a benevolent paternalistic attitude. He had to see regressive tendencies as inherent in human nature rather than as man's reactions to and within a restrictive social and economic order. This conservatism and reluctance to examine the social and economic setting in which his patients lived and to notice its destructiveness is amply illustrated by a revealing comment made by Freud. At a time when the bankruptcy of the order in which Freud had grown up was only all too apparent; when the once-powerful Austrian Empire had collapsed and Europe in general and Germany and Austria in particular were in ferment looking for new ways of social and economic organization; when men no matter how ineffectually and often for selfish motives advanced bold dreams to help humanity to its feet; at that moment in September 1918 Freud mused:

We shall probably discover that the poor are even less ready to part with their neuroses than the rich, because the hard life that awaits them if they recover offers them no attraction, and illness gives them one more claim to social help. Often, perhaps, we may only be able to achieve anything by combining mental assistance with some material support in the manner of the Emperor Joseph [1919, p. 167].

The picture is devastating. "Claim to social help" is essentially what Freud envisioned as the inherently infantile and regressive striving in man. As Freud saw it, the inherent drive is not toward dignity, identity, and genuine independence, it is much more toward the "I kiss your hand, merciful sir." of the Viennese mendicant. Freud could not let himself see that there are other forces operating in man and that as Fromm (1955) has put it, "Destructiveness is a secondary potentiality . . . ," that there exists also a "primary potentiality for love and reason . . ." (p. 37). The "terminable" task of psychotherapy is to help man get on his way in search of this "primary potentiality"; the "interminable" aspect of psychotherapy is man's pursuit of this road and his everlasting quest for ways of making the journey meaningful.

Summary
1. Concepts such as "flight into health," "transference cure," and "supportive therapy" are employed to explain premature termination. Failures in therapy are to be understood as outcomes of unexamined counter-transference reactions and not as manifestations of the patient's inherent opposition to change.
2. Unduly prolonged therapy reflects the analyst's reluctance to examine the patient's transference beliefs; this reluctance is the result of the analyst's unexamined counter-transference difficulties.
3. Various conditions can be considered indices for fruitful termination of the therapist-patient relationship.
4. The formal aspects of therapy are terminable but strenuous self-examination is a life-long process and hence "interminable."

 

The Psychiatric Examination
Donald W. Goodwin & Samuel B. Guze

Such is man that if he has the name for something. it ceases to be a riddle.
Isaac Bashevis Singer


The purpose of a psychiatric examination is to evaluate psychological function and to diagnose psychiatric disorders. To elicit enough information about the disorders in order to diagnose them, one must know their signs and symptoms. course and complications. That is why this chapter ends the book.
     There is an art to eliciting clinical information. It can be learned in a formal way, but only in part. To establish the trust and rapport between doctor and patient that brings out reliable information, empathy, intuition, and common sense are essential. These cannot be learned from books. Here we will give advice on interviewing, provide a logical framework for organizing observations, and suggest how case histories should be presented. But first a few words about terminology and time.
     A mental status examination is the part of the physical examination that deals with the patient's thoughts. feelings, and behavior at a particular point in time. This term is often used as a synonym for a psychiatric examination, but mental status refers to one part of the psychiatric examination: the current thoughts, feelings, and behavior of the patient. Psychiatric examination in-
eludes the past history of the patient as well. The distinction between the two terms is somewhat artificial. As with liver status or cardiac status, what exists now is inseparable from what came before; a certain amount of historical background is unavoidable in describing the current mental status of a patient. Still, the term "mental status" is used when the primary focus of the questioning is on current functioning.
     Internists, family practitioners, and other nonpsychiatrists generally have little time to conduct a physical examination: often no more than fifteen or twenty minutes. If the examination is "complete," it will include some attention to the mental status of the patient. This may be limited to a few minutes.
     Later we will provide some screening questions that will help nonpsychiatrists decide quickly whether the mental state of the patient is abnormal. For now, we will assume the mental status examination is being conducted by a psychiatrist, a student or a resident in psychiatry who has the luxury of being able to spend a fair amount of time with the patient, observing him or her and asking questions.


ADVICE ON INTERVIEWING

Here are four rules for conducting a psychiatric examination.
1. Start open ended. Unless the patient is uncooperative or incapable of free expression (perhaps because of physical disability), let the patient tell his or her story with little or no interruption during the first five to fifteen minutes. After exchanging friendly greetings with the patient and attempting to set a relaxed tone, the interviewer should ask an openended question such as, "What is the problem that brings you here?" "What can I do for you?"
     The patient is often tense early in the interview and this tension may indeed stimulate the information flow. A patient with a formal thought disorder (where the thoughts do not connect coherently) will reveal this quickly. Much of the information needed for the diagnosis is often provided in the first few minutes if the patient proceeds uninterruptedly. By steering the questions along certain lines, one may miss important material.
     On the other hand, for a particularly tense patient, more structure at the beginning of the interview may lead to easier communication. With such a patient, the interviewer can ask specific questions that are emotionally neutral. Questions about the patient's background-where the patient grew up and went to school, marital status, job. other physicians seen-usually are not difficult to answer and provide a comfortable transition into asking about the presenting problems.
2. Ask specific questions later. One purpose of the mental status examination is to make a diagnosis, if possible. This requires specific questions if merely to rule out remote possibilities. For example, patients often avoid volunteering information about hallucinations. "Do you hear voices or see things that others do not hear or see?" or some variation on this query is often necessary to determine whether the patient is psychotic. "Do you feel in danger?" may elicit persecutory delusions. "Do you have a special mission in life?" may bring out grandiose delusions. "What are your plans after leaving the hospital?" may bring out unrealistic thinking, raising questions about judgment.
     Even with the advantage of a long interview, the psychiatric examiner must ask specific questions bearing on a reasonable differential diagnosis. There is usually no point, for example. in going through a complete review of systems if the patient experiences excellent health and presents with symptoms of a psychiatric condition in which physical symptoms do not usually play a role.
     Details about early life experiences rarely bear on the problem of making a differential diagnosis in adults. School and social history are often important but not always, particularly in dealing with elderly people.
3. Establish the chronology of the illness. Kraepelin (3) noted that the course of a psychiatric illness is as important as the symptoms. Sydenham (5) said that "true" illnesses should have common symptoms and a common course. Few, if any, pathognomonic symptoms exist in psychiatry. We agree with Kraepelin that establishing the course of an illness is as important as recognizing current symptoms.
     When did the symptoms begin? Was the patient ever free of psychiatric symptoms? When? Age of onset is an important clue to diagnosis as many conditions typically begin at particular times in life. Has the illness been continual, always present with fluctuations, or episodic in the sense that symptoms sometimes go away entirely? How rapid was the onset? (Psychotic illnesses with abrupt onsets generally have a better prognosis than those with a gradual onset.) Have professional interventions (medications, psychotherapy) altered the course of illness? In general. has the patient tended to improve or get worse?
     "Diagnosis is prognosis" is an old saying in medicine, and knowledge of the course of illness as well as the symptoms forms the basis for determining prognosis.
4. Be friendly, sympathetic, respectful. Examiners should never insult patients. They should never make fun of them. This may seem obvious, but there are subtle ways of betraying disrespect. Adult patients should be called "Mr." or "Mrs." or "Ms.." at least until the examiner knows them well.
Be sensitive to the emotional state of the patient. If certain questioning makes the patient angry, anxious, depressed, or tearful, this may offer an opportunity to enhance the patient's ability to communicate, though sometimes a return to more neutral ground is indicated so that the patient is not overwhelmed by the emotion.
     A word about the uncooperative patient: To say. "1 can't help you unless you help me" sometime works, but usually it does not. Asking specific questions such as "What led to your coming
here?" or "Whose idea was it that You come here?" may help lower resistance. Sometimes the interview must be postponed until another time when the patient may be more helpful. Anger toward the uncooperative patient is never appropriate.
     Psychiatry, probably more than any other specialty, benefits greatly from' informants-friends and family who will tell what the patient will not (or cannot). Although caution should be exercised in judging the merit of such information, it can be very helpful in making a diagnosis.


THE DECISION TREE

Except for open-ended questions at the beginning and specific questions toward the end, history taking should flow easily and casually, as in a conversation. Patients should be permitted to talk about what they want to talk about, but they should be gently guided back into channels that provide information the examiner requires for a diagnosis. From the minute a patient walks into the examination room, however, the examiner's mental "computer" starts making decisions. How is the patient dressed and groomed? Does the patient have a normal gait and range of motion? Is the patient hostile or friendly? How old does the patient appear to be?
     Based on these first impressions, the interviewer starts narrowing the diagnostic range. The examiner's choices about probable diagnoses will determine which areas to emphasize and which to skip over lightly or omit entirely. The examiner's mind, indeed, functions as a computer. By the end of the interview-if it is successful-the choices will have narrowed to one or a few.
     Table 12.1 shows a highly simplified branching process for approaching the diagnosis of psychiatric disorders. The first decision concerns memory. If the patient has a normal memory, move to the right of the line in Table 12.1. The second decision concerns psychosis. Is the patient psychotic or nonpsychotic? Psychosis can be both broadly or narrowly defined. Broadly defined, it refers to the gravity or seriousness of the condition; a suicidal patient might be called psychotic because suicide is serious. Narrowly defined, as here, psychosis means the presence of persistent hallucinations and/or delusions and/or disordered thoughts.

Table 12.1 Major branches in diagnosis making Impaired Memory Normal Memory

Impaired Memory
Normal Memory
Acute
Chronic
Psychotic Nonpsychotic
Delirium Dementia Retardation     Schizophrenia     Anxiety disorders
              Acute         Panic
              Chronic         Obsessional
          Affective Disorders         Phobic
              Depression     Somatization disorder
              Mania     Antisocial personality
              Both     Chemical dependence
          Drugs     Affective disorders
            "Personality disorders"
         

     As shown in Table 12.1, a psychotic person with a normal memory may suffer from schizophrenia. an affective disorder, or drug intoxication. Hallucinogens. amphetamines, and phencyclidine (PCP) are commonly associated with psychosis in the presence of a normal memory.
     If the patient has a normal memory and is not psychotic, diagnostic possibilities include the anxiety disorders (there are eight in DSM-III-R), somatization disorder (hysteria), antisocial personality, drug (chemical) dependence. affective disorders, and other personality disorders. Thus, in some conditions such as affective disorders and drug dependence, the patient may or may not be psychotic. The term "personality disorders" is included for purposes of completeness, but these conditions are still either too vaguely defined or too poorly studied to be useful diagnostic categories.
     In most hospitals, about one-fifth of the patients who clearly have psychiatric abnormalities do not fit any of the categories in Table 12.1. The suitable label for these people is undiagnosed. One advantage of this term is that physicians who deal with the patient in the future will not be biased by having a poorly grounded diagnosis in the chart. Another advantage is the sense of modesty it correctly implies.
     A disadvantage is that many insurance companies require a diagnosis. In this case, one can include the most likely diagnosis or diagnoses prefaced by the term "rule out." Most insurance companies will accept this practice.
     Outside of hospitals, many patients who consult psychiatrists do not have a diagnosable illness. They even lack symptoms of sufficient severity to justify being called "undiagnosed." One diagnosis for these more or less normal people who see psychiatrists is "problem of living," which suggests, if nothing else, that no conventional diagnosis seems to fit them.
     Left of the center line in Table 12.1 are conditions associated with impaired memory. Acute refers to those of recent onset (less than a month); chronic to those of longer duration. "Organic brain disorder" or "organic brain syndrome" are commonly used terms for patients with impaired memories. An acute brain disorder includes delirium. Dementia is a chronic brain disorder that represents a deterioration from a previous level of normal cognitive function.
     As noted earlier, the first and in some ways most important decision concerns whether the patient has an impaired or normal memory. Although IQ tests measure more than memory, performance depends to a large extent on what persons have learned and how well they can recall it, that is, memory. Though memory loss may affect some functions more than others, gross memory disturbance usually affects intellectual functioning across the board.
     To be "Impaired" the patient's memory must be really impaired, in contradistinction to "normal forgetting." (Sometimes, admittedly, the distinction is not easy to make.) Disorientation is a form of memory impairment. Inability to do simple arithmetic reflects a bad memory, assuming the person once knew how to do arithmetic.
     Diagnosing dementia is best done by estimating what the patient should know. If patients are interested in sports, they should be able to name sports figures. If interested in gardening, they should be able to name plants. Patients are often asked to do "serial sevens," whereby they subtract seven from one hundred and then continue subtracting sevens in a descending scale. In fact, normal people with little talent in arithmetic have trouble with serial sevens and their failure to do them may not be clinically significant. (Serial sevens tests attention and concentration as well as memory.) On the other hand, if certified public accountants cannot do serial sevens, dementia is likely, although their performance may have faltered because they were anxious or distracted.
     Delirium is usually accompanied by agitation and autonomic hyperactivity as well as hallucinations and delusions (perhaps more often illusions: misinterpretation of stimuli). Sometimes delirious patients lie quietly in bed but still misidentify people and cannot remember the year or where they are. Delirious people may be dangerous. To escape their delusional persecutors they may jump out of hospital windows or attack those around them. They must be watched closely.
     Poor intellectual functioning is associated with, and often indistinguishable from, bad memory. Impaired memory produces impaired intellectual functioning. As noted, "intelligence" encompasses more than memory, but even those skills not normally associated with memory (e.g., reasoning ability) often suffer when memory is impaired.
     Depressed patients sometimes have bad memories and this is called "pseudodementia." Their memory improves as their depression improves. Stroke patients and patients with Alzheimer's disease also experience depression, but their memory usually does not improve as the depression improves.
     Here is the important point about gross memory impairment (as distinguished from absentmindedness, normal forgetting, or "not paying attention"): Patients with organic brain disorders may display any psychiatric symptom associated with disorders on the right side of Table 12. 1, but organic brain disorders still take precedence as the diagnosis unless the other disorders clearly ante
dated the brain disorder. Anxiety, depression, delusions, hallucinations, mania, incoherence, obsessions, phobias may all occur in organic brain disorders. Diagnosing organic brain disorders is one of the most important things a psychiatrist can do. It initiates a search for the cause of the disorder and the cause may be treatable. Physicians are uniquely qualified to identify the organic disease. Knowing anatomy, physiology, and biochemistry and aided by modern imaging and laboratory techniques, physicians can evaluate the entire range of causes of organic brain disorders, including brain tumor, endocrine and metabolic disorders, and infections.


THE MENTAL STATUS FORMAT

The purpose of the mental status format is to help the interviewer organize and communicate his or her observations about a patient. Minor deviations occur in the format from expert to expert, but some framework for observations is necessary to facilitate thinking and communication. The format presented here is commonly used and includes the following categories:
Appearance and behavior
Form and content of thought Affect and mood
Memory and intellectual functioning Insight and judgment

Appearance and Behavior
The patient's appearance is often relevant to the diagnosis. Schizophrenics, for example, are often poorly groomed and sometimes dirty. Depressives also are often negligent about their dress and grooming. A manic may wear a funny hat. Sunglasses worn indoors may suggest paranoia; tattoos often suggest antisocial personality; a puffy face and red palms are suggestive of, but not diagnostic of, alcoholism.
     If the patients look older than their stated age, this may suggest depression or long-term substance abuse. If this is the case, they may begin to look younger as they recover.
     The patient's attitude toward the interviewer may be significant. Paranoids are often suspicious, guarded, or hostile. Hysterics sometimes try to flatter interviewers by comparing them favorably with previous doctors; they are often dramatic, friendly-sometimes seductive. Manics may crack jokes and occasionally are quite funny-when they are not irritable or obnoxious. Sociopaths may seem like con men-and sometimes are.
     The patient may be agitated--unable to sit still, moving constantly. Others are retarded, slumping in their seats, slow in movement and speech. Talking may seem an effort.
     Agitation and retardation can have several causes. Neuroleptic drugs may produce a restlessness called "akathisia," in which the patient cannot sit still and feels compelled to walk. Neuroleptics also may produce Parkinson-type symptoms, including tremor and an expressionless face. Pacing and handwringing may be expressions of depression; joviality and volubility may portray mania.
     Neuroleptic drugs are given so commonly that it is often impossible to determine whether abnormal movements are drug induced or are catatonic symptoms. In fact, similar involuntary movements were observed in schizophrenics years ago before drugs were introduced. It is said that catatonic symptoms are disappearing, but what previously was called catatonic may now be interpreted as drug induced without knowing whether drugs are responsible or not.
     Schizophrenia also may involve psychomotor disturbances such as mannerisms, posturing, stereotypical movements, and negativism (doing the opposite of what is requested). Also seen is echopraxia, in which movements of another person are imitated, and waxy flexibility, in which awkward positions are maintained for long periods without apparent discomfort. Some patients say nothing. This is called "mutism"; it may be seen in schizophrenia, depression, brain syndrome, and drug intoxication.

Form and Content of Thought
Form refers to intelligibility related to associations: Does the patient have "loose associations" in the sense of being circumstantial, tangential, or incoherent? Elderly people are often circumstantial. They return to the subject but only after providing excessive detail. Tangentiality is a flow of thought directed away from the subject being inquired about, with no return to the point of departure. Schizophrenics are often tangential. Pressure of speech and flight of ideas are seen in mania and in drug intoxication. With pressure of speech, the patient seems compelled to talk. Manic speech flits from idea to idea, sometimes linked by only the most tenuous connections. Unlike tangentiality, however, manic speech frequently has connections that can be surmised. Manics often rhyme or pun and make "clang" associations, using one word after another because they sound similar. Manics tend to be overinclusive, including irrelevant and extraneous details.
     Derailment, often seen in schizophrenia, is a form of speech in which it is impossible to follow the logic of the associations. Sometimes schizophrenics invent new words (neologisms) that presumably have a private meaning. Sometimes schizophrenics display poverty of thought, conveying little information with their words. Echolalia refers to occasions when the patient repeats words back to the interviewer. Other abnormal speech patterns associated with schizophrenia (as well as dementia) are perseveration, in which the patient seems incapable of changing topics, and blocking, in which the flow of thought is suddenly stopped, often followed by a new and unrelated thought.
     When patients persistently display any of these symptoms (excluding poverty of thought), they are said to have a formal thought disorder, meaning that the structure or form of thinking is disordered.
     Content of thought refers to what the patient thinks and talks about. Under this category come hallucinations, delusions. obsessions, compulsions, phobias, and preoccupations deemed relevant to the psychiatric problem.
     Delusions are fixed false ideas neither amenable to logic or social pressure nor congruent with the patient's culture. They should be distinguished from overvalued ideas; fixed notions that most people consider false but that are not entirely unreasonable or that cannot be disproven, such as certain superstitions. Delusions occur in organic brain disorders, schizophrenia, affective disorders, and various intoxications.
     Jaspers (2) believed the subject of the delusion had diagnostic significance. If the delusional ideas were "understandable," they more likely occurred in depressed patients. Understandable delusions included those in which persons were convinced they had a serious life-threatening illness such as cancer, were impoverished, or were being persecuted because they were bad persons. Jaspers pointed out that healthy, prosperous, and likable people often worry about their health, finances, and approval by others. Such delusions are thus understandable.
     Delusions that are not understandable are seen in schizophrenia, according to Jaspers. Schizophrenic delusions tend to be bizarre; for example, one's acts are controlled by outside forces (delusions of control or influence) or one believes that one is Jesus or Napoleon. Schizophrenia-like delusions occur often in amphetamine psychosis and, less commonly, in other intoxicated states (e.g., from cocaine or cannabis). The delusions of schizophrenia fall outside the ordinary person's experience: The examiner finds it difficult to identify with the schizophrenic's private world; hence the term "autism," derived from "auto," is often applied to schizophrenic thinking.
     Religious delusions are sometimes hard to interpret. Religious beliefs often seem delusional to those who do not accept the beliefs but normal to those who do. Among fundamentalist religious people, truly pathological delusions are usually identified without difficulty by others in the congregation.
     Content also encompasses perceptual disturbances. In illusions, real stimuli are mistaken for something else (a belt for a snake). Hallucinations are perceptions without an external stimulus. Auditory hallucinations may consist of voices or noises. They are associated primarily with schizophrenia but occur in other conditions such as chronic alcoholic hallucinosis and affective disorders (1). Visual hallucinations are most characteristic of organic brain disorders, especially delirious states. They also occur with psychedelic drug use and in schizophrenia. (Certain hallucinations are more common in some conditions, but no type of hallucination is found exclusively in any illness.) Hypnagogic hallucinations arise in the period between sleep and wakefulness, especially when falling asleep. Their occurrence is normal except when they are a symptom of narcolepsy (1).
     Olfactory hallucinations are sometimes associated with complex partial seizures that involve the temporal lobes. Haptic (tactile) hallucinations occur in schizophrenia and also in cocaine intoxication and delirium tremens. The sensation of insects crawling in or under one's skin (formication) is particularly common in cocaine intoxication, but it also happens in delirium tremens.
     In extracampine hallucinations, the patient sees objects outside the sensory field (e.g., behind his head). In autoscopic hallucinations, the patient visualizes himself projected into space. The patient occasionally has a doppelganger (sees his double).
     Other perceptual distortions include depersonalization (the feeling that one has changed in some bizarre way), derealization (the feeling that the environment has changed), and deja vu (a sense of familiarity with a new perception).
     In one study of nonpsychiatric patients, 40 percent reported hallucinations, particularly seeing dead relatives. They had no other psychiatric symptoms and the hallucinations were not judged to be clinically important. Thus a history of transient hallucinations or other perceptual disturbances, which occur occasionally during exhaustion or grief, does not necessarily signify the presence of psychosis. They must be interpreted in the context of the overall clinical picture.

Affect and Mood
Affect refers to a patient's outwardly (externally) expressed emotion, which may or may not be appropriate to her reported mood and content of thought. For example, if a person smiles happily while telling of people trying to poison her, the affect would be described as inappropriate. If one describes unbearable pain but looks as if she were discussing the weather, the affect again would be inappropriate.
     Affect is sometimes referred to as "flat," meaning that the usual fine modulation in facial expression is absent. Schizophrenics sometimes have a flat affect, but so do patients taking neuroleptic drugs, and a depressed patient may show little change of expression while speaking.
     "Flat affect" is probably the most overused and misused term in the psychiatric examination. It should only be used if the affect is extremely "flat" or "blunted." Inappropriate and flat affects are especially associated with schizophrenia.
     Sometimes hysterics have an inappropriate affect in that they describe excruciating pain and other extreme distress with the same indifference or good cheer with which they would describe a morning of shopping. (The French call this la belle indifference.)
     Mood refers to what the patient says about his internal emotional state. "I am sad," "I am happy," "I am angry" are examples. Mood and affect are sometimes labile, meaning that there is rapid fluctuation between manifestations of happiness, sadness, anger, and so on. Labile affect is often seen in patients with organic brain disorders.

Memory and Intellectual Functioning
Subsumed under memory is orientation, meaning orientation for person. place, and time. To be disoriented for time, the patient should be more than one day off the correct day of the week and more than several days off the current date. Misidentifying people (thinking the nurse is one's aunt) is a clear case of disorientation, as is giving the wrong year or the wrong city and wrong hospital where one is currently residing. This part of the mental status is exceedingly important because, if a patient has a gross memory impairment (and is not malingering), he or she almost always has an organic brain disorder and all other psychiatric symptoms may be explainable in this context. (The pseudodementia of depression is one exception.)
     There are many tests for memory and intellectual functioning. Memory can be subdivided into immediate, short-term, recent. and remote memory. Serially subtracting seven from one hundred is a test of immediate memory (assuming the person's arithmetic was ever adequate for the task) as well as a test of attention and concentration. Short-term-memory loss can be tested by asking patients to remember three easy words you have spoken or by showing them three objects and then, five to fifteen minutes later, asking them to repeat what they heard or saw. A short-term memory deficit is the sine qua non of Korsakoff's syndrome. Recent memory refers to recall of events occurring in recent days, weeks, or months; remote memory involves recall of events occurring many years before, such as the winner of a long-ago presidential election. In dementia, recent memory is usually more severely impaired than remote memory.
     As noted earlier, tests of intellectual functioning should be interpreted with the patient's background, education, cooperativeness, and mood state in mind. A history major should be able to name seven presidents, but a "normal" person with a third-grade education may not be able to do so. Depressed patients maybe too slowed down or distractible to concentrate. One approach is to ask patients about their interests and then test their fund of information in those areas.

Insight and Judgment
A person who has insight will know whether he is (or was) psychiatrically ill. If he says, for example, that the voices are "real." he lacks insight. If he says it was simply his imagination playing tricks on him, he has insight. If he says there is nothing wrong with him but that his evil uncle has arranged for his hospitalization because of a Communist conspiracy, he may or may not have insight. (Even paranoids, as the saying goes, sometimes have real enemies.) Psychosis and organic brain disorders are both associated with lack of insight; so-called "neurotics" usually realize they have something wrong with them.
     The term "judgment" is used here in the same sense as "competence" is used in civil court: A competent person is able to understand the nature of the charges and to cooperate with counsel. It implies that a person is realistic about his limitations and life circumstances. A good question to ask is. "What are your plans when you leave the hospital?" If the patient says that he plans to start a chain of restaurants and has no money, this displays impaired judgment. Severe impairment of judgment is seen most often in dementia and psychotic disorders.


EXCLUDING PSYCHIATRIC DISORDERS

Sometimes for all physicians and often for nonpsychiatric physicians, examination of the "mind" must be accomplished quickly. lest the liver, lungs, heart, and deep tendon reflexes be slighted. For the dozen disorders described in this book. a single question may suffice to exclude the possibility the patient has a given disorder. Some disorders will be missed, but one or two questions will identify the great majority of patients who do not have a particular psychiatric illness:
Depression: Ask if the patient sleeps well. If she sleeps well without medication, the chances of a serious depression are slight. (Oversleeping represents "not sleeping well" as much as undersleeping.)
Mania: Ask if the patient has ever gone on a spending spree. Most manics have, even manics who cannot afford it.
Schizophrenia: Ask if the patient has ever heard or seen things that other people did not hear or see. Ask if he has ever been afraid of being poisoned or controlled by external forces. Hallucinations sometimes occur in normal people, but the presence of both hallucinations and delusions in a person with more or less normal mood suggests schizophrenia.
Panic disorder (anxiety neurosis): Has the patient ever thought she was having a heart attack that did not occur? Does she ever become intensely apprehensive for no apparent reason? Anxiety neurotics report both. At church. does she find a seat on the aisle close to the back? Anxiety neurotics almost always do. They feel the need to make a quick exit if a panic attack seems impending.
Hysteria (somatization disorder): Hysterics are mostly women. Get a menstrual history. If the woman denies having problems with her menstrual periods-if she has never missed work or school because of dysmenorrhea-hysteria is unlikely. If she has reached the age of thirty-five without having her appendix removed, plus some other elective operation, she is probably not hysteric.
Obsessive compulsive disorder: Does the patient, sitting in a waiting room, count things, such as the number of tiles on the floor? Does the patient repeatedly check a door to see if it is locked or an oven to see if it is turned off? Counting and checking are so common in this disorder that, if absent, the diagnosis should be questioned.
Phobic disorders: Does the patient avoid certain situations because they frighten him? Is the fear unreasonable?
Alcoholism: Has the patient ever stopped drinking for a period of time? If so, and the reason is not medical or a desire to lose weight, the patient probably stopped because he was worried about his drinking. At this point, the clinician can ask why he was worried, and this may break down the denial that is characteristic of alcoholism. Almost every alcoholic has stopped, or tried to stop, at some time in his life. This is a better approach than asking, "Do you drink too much?"
Drug dependence: "Have you ever worried about a drug habit?" is probably as good an opener as any.
Antisocial personality (sociopathy): Ask if the patient was frequently truant in grade and high school. Rare is the sociopath who did not cut classes and get in trouble with school authorities as a teenager.
Dementia: Ask if the patient forgets where she parks her car. If this happens often, there should be some concern about her memory. Or simply ask. "How is your memory?" Many people with memory problems are relieved to have the chance to talk about them.
Anorexia nervosa: If the person is intelligent, ask her (and it is usually a her) if she has ever been told she had anorexia nervosa. Anorectics usually know their diagnosis; the press is full of it. Does the patient stuff herself (or himself) with food and then induce vomiting? This practice, called "bulimia," often goes with anorexia in both sexes. Another question: "Are you the right weight?" If the patient is five foot seven inches, weighs ninety-two pounds, is not a model, and says, "I'm too fat," the diagnosis is made.
Sexual problems: "Do you have a sex problem?" is usually sufficient. Since the Sexual Revolution, people are not as reticent about sexual matters as they once were.
     These questions when answered in the negative will eliminate most people who have the above disorders. There will be few false negatives. There will be many false positives. (Many people sleep poorly and sit at the back of churches who do not have depression or anxiety disorders.) But for the physician trying to rule out disorders. false positives are unimportant. They simply mean probing is required. Probing takes time and referral to a psychiatrist may be in order.


SUGGESTIONS FOR PRESENTING CASES

There is obviously a good deal of latitude in presenting case histories for teaching purposes. Different institutions and different teachers within the institutions will have their own advice on the subject. However, discussions with these teachers reveal some agreement about certain points. Here are some general rules for presenting patients.
1. Don't read the history.
2. Don't exceed ten to fifteen minutes (allowing for interruptions).
3. Start with identifying data: name, age, race, marital status, vocation.
4. Provide a clue to the problem you will highlight, e.g., "This patient presents a diagnostic problem," "He has not responded to standard treatments," "She comes from an unusual family." Such clues offer a framework for your audience into which the rest of the presentation will fit.
5. Avoid dates. Open with "Patient was admitted to [hospital] (days.. weeks, months) ago. Do not refer to events occurring on December 3, 1937, but say, "At the age of 15. the patient ."Instead of saying "Between November and January of 1955 and 1956," say, "For a three-month
period when the patient was twenty years old, he _____." It may be easier for patients to remember events by dates, but the listener has to translate dates into ages and, for the unmathematically inclined, this may be difficult while concentrating on the presentation.
6. Begin with the psychiatric history. A good way to begin is, "The patient had no psychiatric problems until age (or days, weeks, or months ago) when he (slowly or rapidly) developed the following symptoms "; then list the symptoms in order of severity. Tell how long the symptoms persisted (for weeks, months. years, or to the present) and what happened as a result (hospitalization, other treatment, full or partial recovery). Often. of course, establishing time of onset is difficult or impossible, particularly when dealing with a poor historian or a complicated case. The onset of illness in a mentally retarded person would be "from birth," which does not help much. But an attempt to establish onset can be of considerable help because different illnesses characteristically begin at different ages.
7. It is important to know whether the illness has been chronic, perhaps with fluctuations, or episodic with full remissions between episodes. If the patient has had more than one episode, describe subsequent episodes, briefly giving the same information that was given for the first episode. Symptoms and life events obviously are interrelated, but emphasize the symptoms rather than the life events unless the life events appear to be causally related to the symptoms.
8. A brief family history should include the following: whether a close blood relative of the patient had a serious psychiatric illness requiring treatment (and what the treatment was, if known). pertinent medical illnesses, and suicide. alcohol or drug problems.
9. Social history should include (very briefly) circumstances of upbringing, particularly whether the parents were divorced or separated or whether the patient was brought up by both parents: parental vocation; siblings; years of education and how well the patient did in school from the standpoint of grades and adjustment; military and job history; marital history: and number and ages of children.
10. Review the medical history only as it is pertinent to the psychiatric problems. The same applies to the review of systems, physical findings, and laboratory results.
11. Give the mental status as it was obtained either on admission or at the first opportunity to fully examine the patient. The mental status findings should be presented in the order provided in the previous section.
12. End the presentation with course in hospital. Tell how the
patient has been doing, whether he has improved, what treatment he is receiving. In other words, bring the patient up to the present moment.
13. With rare exceptions, all this can be presented in ten to fifteen minutes. The trick is to keep in mind at all times the goal of the presentation. If it is diagnostic, the differential diagnosis and the points for and against each of the reasonably likely diagnoses should be given. If you start out by saving the patient was psychiatrically well until the age of sixty, dwelling on such diagnoses as mental retardation, schizophrenia, somatization disorder, or panic disorder is unlikely to be useful. Assuming the history is correct (though, granted, this is often a dubious assumption), people who are well until the age of sixty and then develop major psychiatric problems generally have either an affective disorder or an organic brain syndrome.
14. The reasons for presenting the history and mental status according to the above sequence are to avoid leaving out important information and to make it easier for the listeners to follow the narration. There are many variations on this format, none perfect. (People's lives are much more complicated than formats.) Unlike written psychiatric histories, however, oral presentations should not attempt to be comprehensive. They should touch on the following categories, but not all with equal emphasis.

HISTORY
Identifying data
Focus of the presentation
Psychiatric history
Family history
Social history
Medical history
Review of systems
Physical findings
Laboratory results

MENTAL STATUS
Appearance and behavior
Form and content of thought
Affect and mood
Memory and intellectual functioning
Insight and judgment


REFERENCES

1. Goodwin. D. W., Alderson, P., and Rosenthal. R. Clinical significance of hallucinations in psychiatric disorders. Arch. Gen. Psychiat. 24:76-80. 1971.
2. Jaspers. K. General Psychopathology. Chicago: Univ. of Chicago Press. 1963.
3. Kraepelin, E. Dementia Praecox and Paraphrenia (Barclay, R. M., Robert
son. G. M., tran.). Edinburgh: E. S. Livingstone, 1919.
4. Othmer. E.. and Othmer, S. C. The Clinical Interview Using DSM-I V: II. The
Difficult Patient. Washington D.C.: American Psychiatric Press, 1994.
5. Sydenham, T. Selected Works of Thomas Sydenham, M.D. London: John Bales
& Sons, Danielson, 1922.