The Clinician's Subjective Experience during the Interaction with Adolescent Psychiatric Patients: Validity and Reliability of the Assessment of Clinician's Subjective Experience.

INTRODUCTION: The last decade has witnessed a resurgence of interest in the clinician's subjectivity and its role in the diagnostic assessment. Integrating the criteriological, third-person approach to patient evaluation and psychiatric diagnosis with other approaches that take into account the patient's subjective and intersubjective experience may bear particular importance in the assessment of very young patients. The ACSE (Assessment of Clinician's Subjective Experience) instrument may provide a practical way to probe the intersubjective field of the clinical examination; however, its reliability and validity in child and adolescent psychiatrists seeing very young patients is still to be determined. METHODS: Thirty-three clinicians and 278 first-contact patients aged 12-17 years participated in this study. The clinicians completed the ACSE instrument and the Brief Psychiatric Rating Scale after seeing the patient, and the Profile of Mood State (POMS) just before seeing the patient and immediately after. The ACSE was completed again for 45 patients over a short (1-4 days) retest interval. RESULTS: All ACSE scales showed high internal consistency and moderate to high temporal stability. Also, they displayed meaningful correlations with the changes in conceptually related POMS scales during the clinical examination. DISCUSSION: The findings corroborate and extend previous work on adult patients and suggest that the ACSE provides a valid and reliable measure of the clinician's subjective experience in adolescent psychiatric practice, too. The instrument may prove to be useful to help identify patients in the early stages of psychosis, in whom subtle alterations of being with others may be the only detectable sign. Future studies are needed to determine the feasibility and usefulness of integrating the ACSE within current approaches to the evaluation of at-risk mental states.

Relationship Between Gender and Clinician's Subjective Experience during the Interaction with Psychiatric Patients.

INTRODUCTION: The clinician's subjective experience can be a valuable element for diagnosis and treatment. A few factors have been recognized that affect it, such as the patient's personality, the severity of psychopathology, and diagnosis. Other factors, such as patient's and clinician's gender, have not been specifically investigated. The aim of this study is to explore the impact of gender differences on the clinician's subjective experience in a large sample of psychiatric patients. METHODS: The study involved 61 psychiatrists and 960 patients attending several inpatient and outpatient psychiatric settings. The clinicians completed the Assessment of Clinician's Subjective Experience (ACSE) questionnaire after observing each patient for the first time. RESULTS: In multivariate analysis, higher scores on the Difficulty in Attunement (p < 0.001), Engagement (p<0.05), and Impotence (p<0.01) scales were significantly associated with female clinician gender, whereas higher scores on the Tension and Disconfirmation scales were significantly associated with male clinician gender. The scores on all ACSE dimensions were also associated with the severity of psychopathology. CONCLUSION: The findings suggest that clinician's gender might affect a clinician's emotional response toward patients. Specific attention to this issue might be useful in clinical situations, not only in terms of promoting gender-balanced teams but also in terms of enhancing self-observation in clinicians evaluating patients for the first time.

Clinician's Subjective Experience in the Cross-Cultural Psychiatric Encounter.

INTRODUCTION: The clinical encounter is still at the core of the psychiatric evaluation. Since the diagnostic process remains basically clinical in nature, several authors have addressed the complexity of the clinical reasoning process and highlighted the role played by intersubjective phenomena and clinician's feelings. Some recent studies have supported the view of a significant link between the clinician's subjective experience during the assessment and the diagnosis made. In a globalized world, this issue requires a careful reflection, since cultural differences may affect the intersubjective atmosphere of the encounter, which may indirectly influence the clinician's thinking. METHODS: We used a previously validated instrument, named Assessment of Clinician's Subjective Experience (ACSE), to compare the clinician's subjective experience during the evaluation of Italian patients with the subjective experience of the same clinician during the assessment of foreign patients. The 2 patient groups (n = 42 each) were individually matched for known potential confounders (age, sex, categorical diagnosis, and clinical severity). RESULTS: We found no significant differences in mean scores on all ACSE dimensions (tension, difficulty in attune-ment, engagement, disconfirmation, and impotence), which suggests that cultural diversity did not substantially affect the clinician's subjective experience. However, the lack of information about the native country and linguistic proficiency of about a quarter of foreign patients may have limited the possibility to detect subtle or specific differences, especially with regard to the clinician's empathic attunement. CONCLUSIONS: Although further investigation is needed, our preliminary findings may have significant implications for the reflection upon the clinician's empathic experience as well as pragmatic consequences for the act of psychiatric diagnosis in the cross-cultural encounter.

[Experience of group art therapy with music improvisation in the integrated treatment at a psychiatric Day Hospital: preliminary results]. / Esperienza di arteterapia di gruppo con improvvisazione musicale nel trattamento integrato riabilitativo presso un Day Hospital psichiatrico: risultati preliminari.

AIM: The study aims at evaluating the resocializing effects of music therapy as add-on therapy in the course of integrated, pharmacological and psychological, treatment. METHODS: During a six months period, 24 patients belonging to a psychiatric Day Hospital were recruited and divided into 2 groups. An accurate music anamnesis was collected for each patient. Group 1 (n=11) received as add-on therapy 14 improvisational music therapy sessions on a weekly basis, while group 2 (n=13) received 7 improvisational music therapy sessions alternated with 7 listening music therapy sessions, on a weekly basis. The response to music therapy was evaluated at the beginning and at the end of the add-on therapeutic process through a music therapy observation form consisting of 9 variables. RESULTS: In both groups there was a good response from patients affected by mood disorders as well as obsessive-compulsive disorder, while schizophrenic patients response was either absent or reduced. The improvement of the variable interaction between the components, sharing of the instrument, facial expressions and tension was significantly higher in the group that received as add-on therapy both improvisational music therapy and listening music therapy. DISCUSSION AND CONCLUSIONS: The findings suggest a significant role of the improvisational music therapy in gaining a re-socializing effect within a therapeutic group. The effectiveness turns out to be greater if the improvisation is combined with a listening therapy, aimed at educating the patient to a greater openness to the expressive aspect of sound. The active-passive music therapy association could then bring a valuable contribution as an add-on rehabilitative treatment.

Attachment in Patients with Bipolar and Unipolar Depression: A Comparison with Clinical and Non-clinical Controls.

BACKGROUND: A link between depression and insecure attachment has long been postulated. Although many studies examined the relationship between depressive symptoms and attachment, relatively few studies were performed on patients diagnosed with depression. Also, research on patients with bipolar disorder is scarce. OBJECTIVE: We aimed at testing the association between attachment insecurity and unipolar and bipolar depression. METHODS: We studied 21 patients with bipolar disorder, current episode depressed, and three age- and sex-matched groups, each consisting of 21 individuals: patients with major depressive disorder, recurrent episode; patients with epilepsy; non-clinical participants. The Experience in Close Relationships questionnaire was used to assess adult attachment style. RESULTS: Patients with both bipolar and unipolar depression displayed significantly higher scores on attachment-related avoidance as compared with patients with epilepsy and non-clinical participants. Also, patients with bipolar depression scored significantly higher on attachment-related anxiety than all other groups. In both psychiatric groups, attachment dimensions were not significantly correlated with global clinical severity or severity of depression. CONCLUSION: Despite some study limitations, our results are consistent with some previous studies and provide support to Bowlby's seminal hypothesis that attachment insecurity may predispose to depression. Attachment theory may provide a valuable theoretical framework for future research and for guiding treatment.

On the Concept of Praecox Feeling.

Despite the development and widespread diffusion of modern nosographic systems, the diagnosis of schizophrenia continues to raise several epistemological issues. To address these issues, a number of researchers are currently pursuing the possibility of an integration between reliable, objective approaches and the intersubjective perspective in the clinical encounter. In the present article, we discuss Rümke's popular concept of praecox feeling, as introduced in 1941 and re-elaborated over the following 20 years. Our aim was to thoroughly analyze the author's original formulation and to identify the connections between his thinking and certain psychopathological developments, epistemological issues, and research perspectives on schizophrenia. The praecox feeling is presented by Rümke as a sensitive diagnostic tool for schizophrenia that is rooted in the peculiar subjective experience of the clinician when encountering a schizophrenic patient. This experience seems to be characterized by two essential dimensions: a subjective one, which reflects the failure of a clinician's empathic effort due to a fundamental alteration of the intersubjective space, a phenomenon related to schizophrenic autism, and a gestaltic, objective one, which is grounded in the clinician's implicit typifying process as a consequence of collecting recurrent clinical observations over the course of his/her professional experience. According to Rümke, the diagnostic use of the praecox feeling should be limited to the acute phases of the schizophrenic process, as the clinician's experience of an intersubjective struggle is attenuated in interactions with older, chronic patients. The multifaceted nature of Rümke's proposal seems to have contributed to some theoretical critiques and to inconclusive results from empirical investigations, leading to a progressive devaluation of the scientific and diagnostic validity of praecox feeling. The present analysis of the original concept suggests that a renewed research interest in the role of the clinician's subjective experience with regard to the schizophrenic patient could be helpful.

Delusional Themes Across Affective and Non-Affective Psychoses.

The current debate about the diagnostic significance of delusion revolves around two positions. The neurocognitive position conceives delusion as a non-specific, though polymorphic, symptom. The psychopathological position views features of delusion such as content and structure as having meaningful connections with diagnostic entities. This study aims at contributing to this debate by examining the association between delusional themes and diagnosis in a sample of 830 adult psychotic patients. All diagnoses were made by experienced psychiatrists according to DSM-IV or ICD-10 criteria, and in 348 patients were established with the SCID-I. All patients were administered the Brief Psychiatric Rating Scale (BPRS). In each patient, the presence of somatic delusions and delusions of guilt, grandiosity, and persecution was determined by examining the scores on relevant BPRS items. Delusions of guilt were almost pathognomonic for a psychotic depressive condition (psychotic major depression 40%; psychotic bipolar depression 30%; depressed schizoaffective disorder 8%; bipolar and schizoaffective mixed states 6 and 7%, respectively). Only 1% of patients with schizophrenia and no patient with delusional disorder or bipolar or schizoaffective manic state showed such delusions. The difference between unipolar and bipolar depression and the other diagnostic groups was highly significant. Delusions of grandiosity characterized mostly patients with manic symptoms (bipolar mania 20%; bipolar mixed states 19%; manic schizoaffective disorder 10%). They were observed significantly more often in bipolar mania than in schizophrenia (7%). Persecutory delusions were broadly distributed across diagnostic categories. However, they were significantly more frequent among patients with schizophrenia and delusional disorder compared with depressed and manic patients. Somatic delusions were also observed in all diagnostic groups, with no group standing out as distinct from the others in terms of an increased prevalence of somatic delusions. Our findings suggest a middle position in the debate between the neurocognitive and the psychopathological approaches. On the one hand, the widespread observation of persecutory delusions suggests the usefulness of searching for non-specific pathogenic mechanisms. On the other hand, the association between some delusional contents and psychiatric diagnosis suggests that a phenomenological analysis of the delusional experience may be a helpful tool for the clinician in the diagnostic process.

Relational variables in short-term psychodynamic psychotherapy: an effectiveness study.

This study examined associations between specific elements of therapeutic relationships and short-term psychodynamic psychotherapy (STPP) outcomes. Notably, we focused on therapists' subjective experiences during their first clinical interaction with patients, countertransference patterns and therapeutic alliance evaluated early in treatment, in relation to patient symptom changes at the end of STPP. Twenty clinicians completed the Comprehensive Psychopathological Rating Scale to evaluate patients' (N=32) symptom severity at the beginning and end of STPP. They also completed the Assessment of Clinicians' Subjective Experience (ACSE) to assess their subjective experiences of their patients at the first clinical interview and the Therapist Response Questionnaire (TRQ) and Working Alliance Inventory to evaluate their countertransference reactions and therapeutic alliance at the sixth therapy session. The findings showed that the TRQ and ACSE scales correlated in a coherent way, with the exception of the TRQ helpless/inadequate pattern and ACSE impotence. Strong and more negative TRQ countertransference patterns and ACSE dimensions were significantly associated with lower quality of the therapeutic alliance. Finally, better STPP outcomes were positively associated with a good therapeutic alliance and negatively correlated with greater difficulty in attunement at the beginning of clinical assessment and therapists' stronger responses of helplessness, frustration, and disengagement during therapy. These results confirm the precious value of the clinical relationship, which represents a useful source of information for therapists when planning therapeutic interventions.

Psychopathological dimensions and the clinician's subjective experience.

Classical psychopathology highly valued the interaction between clinician and patient, and recent findings have provided preliminary evidence of an association between categorical psychiatric diagnosis and the clinician's subjective experience during the first clinical assessment. To extend these findings, the present study examined the relationship between psychopathological dimensions and clinicians' subjective experiences. The study involved 45 clinicians and 783 patients in several psychiatric inpatient and outpatient units. When they saw a new patient, the clinicians completed the Assessment of Clinician's Subjective Experience questionnaire (ACSE) and the 24-item Brief Psychiatric Rating Scale (BPRS). Scores on five core psychopathological dimensions supported by meta-analytic evidence (Affect, Positive Symptoms, Negative Symptoms, Activation, Disorganization) were derived from the BPRS. Multivariate analysis revealed that each psychopathological dimension was characterized by a distinct pattern of independent associations with certain aspects of Clinician's Subjective Experience, as measured by the ACSE. This study provided preliminary evidence of significant and theoretically consistent relationships between major psychopathological dimensions and the psychiatrist's subjective experience during the first clinical evaluation. Improving the understanding of intersubjective processes may have important implications for theory, practice, research, and training.

Autism Spectrum Disorders and Schizophrenia Spectrum Disorders: Excitation/Inhibition Imbalance and Developmental Trajectories.

Autism spectrum disorders (ASD) and schizophrenia spectrum disorders (SSD) share clinical and genetic components that have long been recognized. The two disorders co-occur more frequently than would be predicted by their respective prevalence, suggesting that a complex, multifactor association is involved. However, DSM-5 maintains the distinction between ASD, with core social and communication impairments, and SSD, including schizophrenia (SCZ), with hallucinations, delusions, and thought disorder as essential features. ASD and SSD have common biological underpinnings that may emerge early in development and unfold over time. One of the hypotheses supporting the similarities in the social and cognitive disturbances of ASD and SSD relates to abnormalities in the ratio of excitatory to inhibitory cortical activity (E/I imbalance). E/I imbalance in neurodevelopmental disorders could be the consequence of abnormalities in genes coding for glutamatergic and GABAergic receptors or synaptic proteins followed by system derangements. SSD and ASD have been characterized as polygenic disorders in which to the onset and progression of disease is triggered by interactions among multiple genes. Mammalian target of rapamycin signaling is under intense investigation as a convergent altered pathway in the two spectrum disorders. Current understanding of shared and divergent patterns between ASD and SSD from molecular to clinical aspects is still incomplete and may be implemented by the research domain criteria approach.

Association between Clinician's Subjective Experience during Patient Evaluation and Psychiatric Diagnosis.

BACKGROUND: Classical psychopathology greatly valued the interaction between clinician and patient, and assigned to the clinician's subjective experience a significant role in the diagnostic process. Psychoanalysis, too, ascribed a privileged position to the clinician's feelings and empathic participation in the assessment and deep understanding of the patient. This study aimed at testing the traditional, though still relatively unexplored empirically, tenet that particular diagnostic groups elicit distinct and diagnostically useful reactions from clinicians. SAMPLING AND METHODS: The study was performed in several psychiatric inpatient and outpatient units in Rome, Italy. The clinicians completed the Assessment of Clinician's Subjective Experience (ACSE) questionnaire and other standardized assessment instruments when they evaluated a previously unknown patient. All adult patients diagnosed with schizophrenia (n = 119), cluster B personality disorder (n = 114), manic or mixed bipolar I episode (n = 59), and unipolar depression or anxiety disorder (n = 130) were included in the study, for a total of 422 patients evaluated by 35 clinicians. RESULTS: We found a significant and theoretically consistent relationship between the clinicians' pattern of subjective experience during the first visit and patients' clinical diagnoses. Patients with unipolar depression/anxiety showed significantly lower scores than the other groups on all ACSE scales except engagement; patients with schizophrenia displayed significantly higher scores than the other groups on difficulty in attunement, and significantly higher scores than patients with cluster B personality disorder on impotence. Compared with the other groups, the patients with cluster B personality disorder displayed significantly lower scores on engagement, and significantly higher scores on disconfirmation. In multivariate models controlling for patient's age and education, symptom severity, clinician's sex, duration of visit and setting, diagnosis remained a significant predictor of scores on all ACSE scales except for impotence. CONCLUSIONS: The main limitations of the study are its reliance on clinical diagnoses and the non-independence of assessments. Further studies based on diagnoses made by a third observer through standardized instruments are needed to provide a most stringent test of the hypothesis that different diagnoses are associated with distinct profiles of clinicians' subjective experience. This study provided intriguing, though preliminary, evidence that the clinician's subjective experience may play a useful role in the diagnostic process. Time may have come to reintroduce the concept of intersubjectivity at the core of the diagnostic process.

Assessing clinician's subjective experience during interaction with patients.

BACKGROUND: While psychiatric literature has shown renewed interest in fine psychopathological investigation, little study has been devoted to the clinician's subjective experience with the patient, which is highly valued by the phenomenological and psychodynamic traditions. We aimed at developing a valid and reliable instrument to measure such experience. SAMPLING AND METHODS: First, 104 self-report items were developed, based on daily clinical practice and references from the literature on clinician's subjective experience. Of these, 46 were retained after pilot testing and exclusion of items with poor psychometric properties. Thirteen psychiatrists and 527 first-contact patients participated in the validation study. Psychiatrists completed the 'Assessment of Clinician's Subjective Experience' (ACSE) instrument and the Brief Psychiatric Rating Scale (BPRS) after the visit and the Profile of Mood State (POMS) before and after it. The ACSE was completed again for 60 patients with stable BPRS scores over a short retest interval. Principal component analysis with orthogonal rotation was performed. The internal consistency and test-retest stability of ACSE factorially derived scales were calculated. Convergent validity was tested by examining the correlations between ACSE scores and change in POMS scores during the visit. RESULTS: Five factors (interpreted as tension, difficulty of attunement, engagement, disconfirmation, impotence) accounting for 57% of total variance were extracted. All ACSE scales showed high internal consistency and stability, and correlated with conceptually related POMS scales. CONCLUSIONS: The pattern of subjective experience identified by the ACSE is consistent with classical psychopathological descriptions and previous related studies. Despite limitations such as the relatively small number of psychiatrists studied and the exclusively self-report nature of the instrument, this study supports the validity and reliability of the ACSE and suggests that it may be a valuable tool for training, research and possibly diagnostic purposes.

Acute psychiatric presentation of steroid-responsive encephalopathy: the under recognized side of autoimmune thyroiditis.

Steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT), also known as Hashimoto encephalopathy, represents a rare disorder of presumed autoimmune origins that can be diagnosed when a protean variety of psychiatric symptoms are present in association with elevated titers of anti-thyroid antibodies. Symptoms can have a rapid and complete remission with corticosteroid treatment. A 19-year-old girl, with clinical history of Basedow-Graves disease, has been admitted to our department after presenting acute psychiatric symptomatology. Clinical and serological findings were used to formulate the diagnosis of SREAT, confirmed by subsequent positive response to corticosteroid treatment. SREAT can mimic an acute psychiatric symptomatology, thus it seems extremely relevant for psychiatrists to consider this syndrome in differential diagnosis algorithm, especially in those patients presenting a history of autoimmune thyroid disorder, in order to ensure adequate diagnosis and treatment.

[Sensitive delusion of reference, rivisitation of a concept: clinical accounts on onset paranoid psychosis]. / Rivisitazione del concetto di delirio sensitivo: osservazioni cliniche su scompensi paranoicali all'esordio.

AIM: In this work it is discussed whether and how Kretchmer's psychopathological reflections about sensitive delusion of reference can offer a relevant interpretative key for clinicians who face cases of acute persecutory psychosis. It is argued the utility and topicality of those psychopathological concepts that aren't commonly investigated, especially in the evaluation and management of onset paranoid psychosis in an emergency ward. METHODS: We provide clinical vignettes of two young patients, admitted in the emergency psychiatry ward, who represent a concrete example of the dynamic-affective comprehension of delusional elaboration, through its embodiment in the individual biographical development. RESULTS: An interpretative key, based on this specific conceptual frame, seems to provide an integrated intervention tool that aims both to a causal comprehension and demolition of the delusional solution in onset psychotic cases. CONCLUSIONS: The rediscovery of classical psychopathological concepts appears to be a necessary process, especially in the clinical management of onset psychotic disorders. Further and more accurate researches are, in any case, needed.

[Clinician' emotional resonance as investigation tool: development and preliminary validation of a questionnaire]. / Il sentire del clinico come strumento di conoscenza: sviluppo e validazione preliminare di una scala di valutazione.

AIMS: A robust psychopathological and psychotherapeutic tradition underscores the importance of the clinician's feelings in the assessment and therapeutic process. Our aim is to develop an instrument to evaluate psychiatrist' experience induced by each patient. This paper describes the development and preliminary validation of this instrument. METHODS: Based on the relevant literature and our clinical experience, we developed a self-completed questionnaire consisting of 65 items covering various aspects of the clinician' emotional resonance. Ten psychiatrists completed our questionnaire immediately after first clinical interviews involving a total of 125 patients with various psychiatric diagnoses. Also, they completed the Profile of Mood State (POMS) immediately before and after these interviews. The factor structure and convergent validity of the questionnaire was examined. RESULTS: We identified a six-factor structure. The factors showed acceptable internal consistency and were interpretable as different aspects of the clinician-patient interaction as experienced by the clinician. There was a consistent pattern of correlations between factor scores and changes in POMS scale scores during the clinical interviews. DISCUSSION: The study results, though preliminary, suggest that clinicians' subjective reactions during their interactions with patients can be validly and reliably measured. Quantitative measurement of clinician's subjectivity is potentially useful in both clinical and research settings.