Excerpts from Must Read Books & Articles on Mental Health
Books, Part IXX
Key Concepts in Psychotherapy
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
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
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
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 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
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.
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
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
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
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
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
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.
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
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
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
|| Anxiety disorders
|| Affective Disorders
|| Somatization disorder
|| Antisocial personality
|| Chemical dependence
|| 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
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
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
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
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
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
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
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,
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
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
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
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
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
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
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
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
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
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
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
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
Focus of the presentation
Review of systems
Appearance and behavior
Form and content of thought
Affect and mood
Memory and intellectual functioning
Insight and judgment
1. Goodwin. D. W., Alderson, P., and Rosenthal. R. Clinical significance
of hallucinations in psychiatric disorders. Arch. Gen. Psychiat. 24:76-80.
2. Jaspers. K. General Psychopathology. Chicago: Univ. of Chicago
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:
& Sons, Danielson, 1922.