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

Abstract

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.

Patient personality and psychotherapist reactions in individual psychotherapy setting: a systematic review

“…These results are in accordance with the clinical literature suggesting that clusters A and B PDs patients evoke more troublesome emotional reactions among therapists than cluster C PDs patients (Gabbard, 2014;McWilliams, 2011). Furthermore, empirical studies excluded from this review and involving group therapists (Rossberg et al, 2008), psychiatrists (Pallagrosi, Fonzi, Picardi, & Biondi, 2016) and various mental health workers (Eren & Şahin, 2016;Thylstrup & Hesse, 2008) confirmed these results in relation to the clinicians' patterns of reactions to Cluster B patients, but show contradictory results about the clinicians' reaction toward Cluster A and Cluster C patients.…”

“…These results are in accordance with the clinical literature suggesting that clusters A and B PDs patients evoke more troublesome emotional reactions among therapists than cluster C PDs patients (Gabbard, 2014; McWilliams, 2011). Furthermore, empirical studies excluded from this review and involving group therapists (Rossberg et al, 2008), psychiatrists (Pallagrosi, Fonzi, Picardi, & Biondi, 2016) and various mental health workers (Eren & Şahin, 2016; Thylstrup & Hesse, 2008) confirmed these results in relation to the clinicians' patterns of reactions to Cluster B patients, but show contradictory results about the clinicians' reaction toward Cluster A and Cluster C patients. Our findings align with a review of empirical studies focused on clinician reactions to patients with eating disorders (Thompson‐Brenner, Satir, Franko, & Herzog, 2012), suggesting that clinicians' negative reactions toward patients with eating disorders usually reflected frustration, hopelessness, lack of competence, and worry.…”

Determinants and Predictive Value of Clinician Assessment of Short‐Term Suicide Risk

“…In particular, clinicians' emotional responses to their patients, which may represent both the integration of experience (De Gelder, Morris, & Dolan, ; Meeren, van Heijnsbergen, & de Gelder, ) and factors biasing clinical judgment (Bermúdez, ; Garb, ), may be important contributors to their impression of suicide risk. Indeed, the psychodynamic literature has long recognized the value and utility of therapists' emotional reactions to their patients (Betan, Heim, Zittel Conklin, & Westen, ; Gazzillo et al., ; Pallagrosi, Fonzi, Picardi, & Biondi, ), particularly when those reactions are used to develop a deeper understanding of the patient (Hayes, ).…”

Clinician’s Subjective Experience in the Cross-Cultural Psychiatric Encounter

“…In fact, even though cultural diversity may entail a substantial variation in the interpersonal exchange, especially when there is a linguistic barrier, it is still unclear how profoundly it could affect the prereflective emotional and perceptual experience of the psychiatrist. Indeed, in our previous studies with the ACSE [25, 26, 59], the patient’s psychopathological condition emerged as the variable most strongly correlated with the clinician’s experience, while a number of aspects which contribute to the “cultural” dimension of the interaction (i.e., sex, age, education, and clinician’s expertise) seemed to play a minor role.…”

“…A small number of studies have empirically explored how the interpersonal climate of the psychiatric encounter may affect the diagnostic reasoning [21][22][23], and only recently an instrument for the standardized quantitative evaluation of the psychiatrist's subjective experience during patient assessment has been developed [24]. This instrument, named Assessment of Clinician's Subjective Experience (ACSE), describes and quantifies the clinician's experience along 5 dimensions (tension, difficulty in attunement, engagement, disconfirmation, and impotence), and has been successfully used in 2 studies exploring the relationship between the clinician's feelings and the patient's categorical [25] or dimensional diagnosis [26]. These studies have corroborated the above-mentioned considerations about the connection between the clinician's subjective experience and his or her diagnostic orientation, especially concerning patients with schizophrenia and cluster B personality disorder.…”