" ':.

,
., .

.CHAPTER TEN

DISO RD ER~SPECIFIC
INTERVIEWING:
PERSONALITY DISORDERS

..1. Emotional Withdrawal and Odd Behavior-<::luster A

Suspiciousness in Paranoid Personality Disorder
Withclrawal in Schizoid Pcrsonality Disorder
Irrationality in Schízotypal Personaliry Disorder
2. Exaggerated, Drarnatic' EmoÚonality-<::luster B
Lying in Antisocial Personaliry Disorder
Lability in Borderline Personality Disorder
Phoniness in Histrionic Personality Disorder
Grandiosity in Narcissistic PersonalíryDi~order
3. Anxious, ResistiveSubmissiveness-CIUster e
Hypersensitivity in Avoidant Personaliry Disorder
Submissiveness in Dependent Personaliry Disorder
Circumstantialíty and Perfectionism in Obsessive-Cornpulsíve Personality
Disorder
4. Personality Dísorders Not Otherwise Specífled (NOS)
Resentrnenr in Passive-Aggressive Personality Disorder
.Dernandíng Cruelry in Sadistic Personalíry Disorder
Sacrifice and Self-Destruction in Self-Defeating Personality Disorcler

SUMMARY

Chapter 10 describes how to esiabiish rapport, select your interviewing

techniques, and modify your mental status exarninatíon ro diagnose patienrs
with personalíty disorder:
 404 TIJe Clinical Interuieur Using DSM·/V DISORDER·SPECIFIC INTER\lEW1f\'G PERSO\.-\Un DISORDERS

+ +
It is worse to be sick in soul than in body, for those
afflicted in body only suffer, but those afflicted in soul both
suffer and do ill. u
+ +
_..,.Plutarch,Moralia: Affections of soul, and body, sec, 5,01
'E. about A.D.. 95
+

1 .. .
Psychologists, socialworkers.and psychi'atfisis are intrigued by person- + + + + +
ality disorders. Yet they cannot '~gree which personality disorders have
validity nor how to assess them.
+ + + +
For the assessment, c1iniciansand researchers alike vacillate berween a
dimensional approach-as for instance irsed in the Minnesota Multiphasic
Personality Inventory (MMPi).--,and a topological approach-e-as intended by + + + + +
the DSM·IV. Yet DSM-IV does not presenr rnutually exclusive persona lity
rypes but allows a conglomera te. DSM·IV also allows you .to use criteria
+ + + + +
across several personality disorders and iss'ign a personality disorder not
.. otherwise specified (NOS)~ . '. ..;
To give you an effective approach to Mal. with the 10 persona lity
disorders in DSM-IV, we offer Table 10-:1. -lt .ilists 30 DSM-IV criteria + + + + + + +
characteristic of 10 personaliry disorders of. DSM-IV. For the first eight
criteria the opposites (listed in parenthesés). are-also used. Plus (+) and
minus (-) signs indicate whether a particular, criterion (+) or its opposite, + + + +

respectively (-), applies to a given personalíry disorder. A blanh indicates

that under usual circurnstances this criterion is..not required. +
The first eight criteria characteríze personalíry disorders of more than
one cluster. They are useful ro decide'whether a patient has a personalirv e
disorder or not. 'Critería 9-13 are shared by personaliry disorders belonging
to Cluster A. Criteria 14-26 are specificfor personality disorders in Cluster B.
arid criteria 27-30 for Cluster C.
The 30 criteria in Table 10-1 allow you 10 arrive al a personality profile. 2:
If this profile is consistent with one particular personaliry disorder, assign i
o:
that diagnosis. e
If the profile satisfies criteria for rwo or more perscnality disorders,
make those diagnoses. If the profile Iulfills sorne criteria of one or several
personality disorders without satisfying all the criteria foroany one single
personality disorder, make the diagnosis of.personaliry disorder NOS on
 'lOó loe CUntcaJ Intervtew Ustng IDM-IV LJISOIWEK-SPEUHC IN1EKVIEW1Nli: PEH:;ONAL1TY OISüRDERS 407

u
1~ .
o

AxisJI. Clinicians may álso assign a personalíty dísorder NOS for personalíry

V
JI·
O O
h.l.f·
+ + .. + disorders that are not represented by a set of criteria. Examples are
passive-aggressíve and depressive personality disorders. .

I
.Each of the 10 personality disorders listed in DSM-IV poses speeifie

j +
obstacles to interviewing. For instance, a patient with dependent personality
disorder rnay endorse symptoms that, in faet, he has not experienced but

I feels cornpelled to admit to.in order to please the interviewer, In contrast, a

patient with antisocial personality disorder may falsify his past and deny
problems to írnpress the intervíewer.
It is the interviewer's task to spot sueh deeeptive behavior and traee its
~., I origin (Othmer and Othmer 1994). Such.a pursuit often Ieads right to the
+ + +
I core of personality pathology .. Sinee patients with a personality disorder
have no or only limited insight into their disorder, and therefore cannot
+ + + repon their pathology in terms of symptorns, the observatíon of the patient's
behavior during the interview beeomes an important tool for the diagnosis

I + +
of personality disorders.
To facilita te this process we have highlightedthe pathologieal behavior
of eaeh of the 10 personaliry disorders and 3 personality disorders NOS that

I
+ most likely emerge during and interfere with the diagnostie interview.

l'
I ··1. EMOTIONAL WITHDRAWAL AND ODD
BEHAVIOR-CLUSTER A

Three personality disorders are in Cluster A: paranoid, schízoid, and

schízorypal. The mental status of a patient belonging to Cluster A is
characterized by emotional withdrawal, lack of warmth, and odd or eccen-
trie behavior. Throughout the ulterview he lacks spontaneity, appears eold
and sometimes sarcastic, and seerns even to hide his feelings from you.
.1 Regardless of your techníque, and the type of question you ask, the patient
.. has a tendency to answer with "yes" and "no." It is difficult to induce him to
I
!
talk spontaneously and the interview does not flow. You never get the
feeling that you are truly in touch with him and have established rappon.
The interviewíng process díffers according to the type of personality
disorder, but in all cases you will experience a lack of rapport, If you
analyze the reason for this deficlt, you will find the patíent's coldness is the
culprit. Make it the point of departure for your interview. Explore whether
the patient showed these characteristícs. throughout his Ji fe, resulting in
1 .social isolatíon. After exclusion of the.Axís 1dísorders such as schizophrenía
and delusional disorder, yqu have narrowed down your diagnostic options

I
.-o N rr; ~
N N· ..~ N ro a personality disorder.
 Suspiciousness in Paranoid Personality Disorder Diagnosls: .The patient does not present any difficulry other than having
to interview him with great caution in order not ro trigger his suspiciousness
.Rapport: Rapport with a patient who has paranoid personaliry disorder is and hostiíity. Since his hostiliry is so pervasíve, it emerges early on. To

hampered by his pervasive perception that everybody, absolutely every-· establish a diagnosis of paranoid personaliry disorder, exclude persecutory

body, will harm or exploit him. He screens al! questions for hidden rneaning .delusions and any rype of hallucinatíons: this elimina tes schizophrenia,
and conspiratorial contento He questions your trusrworthiness; your fríendlí-. paranold rype, and brief psychotic disorder. The dementias or psychotic
ness, which he may assume is fake, a c1everly disguised atternpt to take disorders due to ageneral medical condítion, substance abuse; depression;
. advantage of his weaknesses, your lirnit setting, assurning a strategy of . and bipolar, mixed states, may be associated with suspiciousness and ideas
revenge: your offer to help hirn, aTrojan horse. You cannot win beca use he of reference, however this suspiciousness rarely remains 00 a nondelusional

has exposed you. He is nobody's fool because he is nobody's friendo leve!. The Iatter is also tíme-límited, and shows a circumscribed beginning

Genuine openness on your part may persuade hirn to temporarily trust and is associated with other syrnptorns of a specific disorder,
you with sorne of his problems. If you openly tell hirn how suspicious you . If social withdrawal, aloofness, and coldness emerge during the ínter-

find him, he may be impressed by your frankness, or he may interpret your view, and if the patient expresses sorne odd and superstítíous ideas, explore
statements as hostile, criticál, or ínsulting. He may decide to coopera te with . the differentiaI diagnosis of the personaliry disorder of Cluster A. Notice thar
the border berween delusionaI disorder (Axis I) and paranoid personaliry
you, but may, at any mornent, feel betrayed and disappointed,and lash out
disorder (Axis Il) is fluid. While the patient withdelusional disorder sees his
at you with a hostile counterattack,
behavior as the best response to a danger he perceives as real, the patient
with paranoid personaliry disorder, who has an awareness of his increased
Technique: Interviewíng the parlent with paranoid personaliry disorder is
.suspiciousness, usually tries ro keep it to himself but finds reusons to justify
a delícate operation. As he assumes all your questions to have a hidden, and
it. Here is a more severe case:
threatening meaníng, he will scrutinize thern:

1: Hi, would you like 10 come in?

"Why do you ask that?"
P: What do you mean=-líke 10 come in?
1: Didn't you want to talk lO me?
But he resents being scrutinized himself. Smooth trarisitions. are absolutely P: Who gave you that idea?
necessary. Any abruptness will be experienced as an :unjustified switch in 1: Well, you made an appointment, didn't you?
topíc and may lead to anger, counterartack, or abrupt termination of the P: AIe you holding this against me? Maybe 1shouldn't have,
1: Since you are here, why don't you sir clown.
interview, He will confront you but not tolera te .confrontation himself.
P: You think you've got me already. OK. Let's get on with it. 1 will Sil down, bUI
dón't think that 1 will submit to your tricks, 1 have had sorne experience with
Mental status: The mental status of a patient with paranoíd personaliry psychiatrísts. They are basically all the sarne. They trick and outmaneuver
disorder is overshadowed by hypervígilance and suspicíousness, His attire .you'-at least that's what they try to do, but not with me.
may be rneticulous so as not to give anybody .reason for criticism, or show 1: You don't seem to like or trust me.
P: Besides the Washington politicians, 1 have not found anyone 1 trust as litde as a
sorne neglect if he ís depressed. He may then express that he is not
psychiatrist. .
interested in pleasing anybody. Bis speech is usually fluent and goal-
directed. But the content of these goals is .characteristic of his disorder:
checking out your intentions, expressíng thathe looks through your rnaneu- Withdrawal in Schizoid Personality Disorder
vers, and voicing his displeasure about your secret plans. His affect vacil-
Rapporti Rapport with the patient with schizoid personalíry disorder is
lates berween anxiousness ano overt hostílity. Mernory and orientatíon are
hampered by his pervasive emotional withdrawal. There is no affective
intact, but his judgment is ímpaired byhis suspiciousness. He may acknowl-
response at the start of the interview, and none at the end. If you express
edge his suspicíousness but staunchly defend it as justified and not accept it
.empathy-it leaves him cold. He may talk about his depressive feelings, but
as a part of a personaliry disorder.
"., .'(

410 . 17JeCltnic~lInterview Using DSM-1V DISORDER-SPECIFlC Il':TERVlE-V;l:"G: PERSO:-.lAUn' DlSORDERS 411

you don't feel his suffering. Since emotional warmth is rriissing, you cannot pisto Then he usually reports vegetatíve symptoms and depressed mood for
judge wh~ther (he problerns he talks ubout are central to him. YOl! cannot which he seeks treatrnent.
appreciate:whether he likes, trusts. and respects you, or resents you. Itdoes
not' help when you ask him about it, beca use he does not know, and if he Diagnosis: A patient with schizoid personalíry disorder usually comes to
knows, rt, does not manero because he does not care. He is indifferent. your attention when he develops a clinical disorder (Axis 1) such as
Rapport i~ a st~;e where the patient is willing to reveal and discuss hís substance abuse, depression, or a schizophreniforrn disorder, or struggles
symptoms. problems. and Innermost feelings. Since the schizoid personality , with psychosocial stressors (Axis IV).
does not appear to have those feelings, you never get the impression of The cornbination of a c1inical disorder with schizoid personality disor-
having rapport. der ís a source of confusíon, A concornitant depressíon, for instance, may
present in a younger person as a simple schizophrenia beca use of severe
Technique: You notice frorn the beginning that the patient only answers blunting of affect and severe social isolation. Fleeting hallucinaticns, due to
with "yes" and' "no," or with ver)' short, seerningly absent-minded replies. substance abuse such as LSD, rnay rnake you consider incipient schizophre-
You may misinterpret this poverry of words as sensitivity and beco me nia. The accuracy of your diagnosis will however be assured if you routinely
cautious not to hurt his feelings,
but this would be an incorrect assumption, , include in your differential the combination of an Axis 1 disorder with an
Ány strategy seerns to fail. No mane!' whether you invite him ro talk ábout Axis II personality disorder.
any topie 01' his choice, or try to push him with highly structured questions, Usually, it is not so rnuch the chief complaint of the schizoid personal-
Úle fIow ofínforrnatíon remains restrícted. Yo~ will detect that his lirnited ity, but the observeci mental status that will tip you off. With your suspicion
verbal and eruotional expression is not due to self-protection, but te-mental aroused, scrutiniie the patient's social history. His !ife history is marred by
and emotÍorial ernptiness. Therefore, you can start and end where you lone!iness, isolation. and desertion, which seem to be more significant to
want-e-abruptly-e-it does not matter. yOLl than lo hirn. ,
The schizoid personaliry's behavior pattem and lnteractions seem to
Mental status. It is characterized by edgy body movernents, lack of facial correspond ro the syrnptornatology of patients with negative symptorns of
cxpressions, and frozen and clurnsy gestures, His speech is goal-directed but
schizophrenia: the same lack ofinitiative, blunted affect, poverry of gestures,
lacks detaíled elaboratíon. The tone of voice rarely ever chsnges, not even
and verbal productions are seen. However, these patíents are not hallucinat-
when he talks about the most intimate or traurnatic events in his life. Neíther ing, they do not harbor deltisions or show a formal thought disorder, and
the death of his rnother nor the loss ora friend seems to affect him.This lack
their reality testing 15 intact.
of responsiveness underscores his main impairment: affectíve wíthdráwal.
'The tnore intelligent patient with this personalíry disorder sornetimes , The Iollowing segment illustrates rappon and mental status with Mr. Forster,
corriplains about his lack of interest and motívation. He may even name this a patient with schizoid personaliry disorder. '
.i
state "depressíon." but he' usüally does nót 'report associated sadness, guilt,
or anguish. l: Mr. Forster, can you tell me what kind of problerns made you come to our
A patient with schizoid personality disorder does not hallucinate or clinic?
P: My work.
display delusional thinking; he ma{ have sorne ideas of reference and á, '
1: Would you tell me about the problems that you have at work?
feelíng that others don't care for hirn, but if they did, ít wouldburden rather I
P: No interese
tharr please'rhím. His rnemory is lIsually intact, He sees, hirnself as less 1: It rnust feel bad to work all da)' without being really interested.
'1
animated tha~ others but does not consider this lack of interest a distur- ,P: Hmm.
bance, His [udgrnent conceming fu tu re plans is usually adequate; he rarely 1: What kind of work do you do? Tell me more about it!
ove¡-estimate~ his potentíal unless he develops a schízophreniform dísorder.' P: Lab work.
1: What kind of laboratory do you work al?
Only if he is threatened wtrh losing his job orspouse (rnale patients with
P: Animal. '
schizoid personaliry disorder rarely rnarry) wlll he possibly consult a thera- '1: ' Please tell me what you do in your lab?
412 Tbe Cli71icaUntervtew Using DSM:¡V DISORDER-SPECIFIC INTERVIE\'q\'G: PERSONAUn- D!SORDERS 413 '.

P: Setting up experiments. Empathy for his feelings and thoughts can lure him out of his reserve.
1: For how long have you had a problern with not being ínterested?
When youindicate that you don't releer him, and that you undersrand his
P: From the start.· . .. .. . . ...
1: How long have you been working al yOUJ present job in that laboratory? perceptions and feelings, his confidence in you will grow and he will open
P: Sorne years. up to you the sanctuary of his secret, autistic woi-!d. He will share with you
I: Has your ínterest always been that low? his insights; personal references, sensitivities, and an individualized aware-
P: No. . ness that transcend reality. Unlike your efforts with the patient with schizoid .
1: When did this problern start? personality disorder, you can shape rapport with the schizotypal patient.
P: Lately.
1:. Can you give me a more accurate time frame?
P: Maybe spring of this year. . Technique: The patient answers al! rypes of questions if you have estab-
1: How have you been feeling lately? lished rapport. You frequently have to ask him to specify his impressions
P: Not so good. and give you exarnples. In this darification process you detect that he sees
1: I'm sorry to hear that you.have not been feeling so good. What seems to give relationshíps among events and people that are not obvious to yOU.You can
you the most trouble? Is itthe type of work? o- other people at work? Can you
follow the dírecrion of thinking without being fully able to apprecíate its
give me sorne idea?
p. I'm feeling bad. elements. Any empathic and interested approach to listening together with
1: Can you pinpoint this? conunuation techniques usually suffice to rnake the patient explaín his
P: Not really. experiences. In contrast, doubtíng questíoníng and expressions of rejection
1: How-are things at work? What is it about your work that makes it so uninterest- of his views or confrontation with his reality cause the patient 10 recoi!.
. ing? . A bright patient wíth schízorypal personality disorcler often desires to
P: It's slow.
find out whether you have .experiences similar to his. For him it is not
1: Are you getting your work done in time?
P: Barely, enough that you are interested in his views; he hungers to cornmunicare on
1: Does anyone complain, push you, .or threaten you? the same wavelength. To handle this situation is more a questíon of rapport
P: No. than a problem ofhow 10 formulate questions most effectively.
I: Or does anybody ask you to do moré wqrk?
P: There isn't that much to do.
Mental status: The mental status shows several characteristic fearures.
The .patienes .attire may be sornewhat peculiar; he may carry a talisrnan
No matter how hard you try, no mauer how ernpharic you are, whether
around his neck. He may use words with an unusual meaning, or in -an
you ask short, elaborare, open- or closed-ended questions, his resporises are
unusual context, His sense of humor may strike you as bizarre, and his
monotonous and short. He does not elaborare. Any affective tone ís rníssing.
thoughts rnay be hard to follow. He will make an effort ro cornmunícate his
To establish adifferential lísr you wil! have to review a laundry list of
thougbts and feelings to you, provided he trusts you and believes you are
symptoms using structured questions that perrnit yes andno answers. Such
worthwhile talking too .
an interview will frustrare you but not the patient, who will return for the
The patient's thought content. is indeed rernarkable. It may show
next appointment and will be as .rnonotonous and unínspired as the first
paranoid ideation, suspiciousness, ideas of reference, and magical thinking.
time around.
He rnav claim to have aecess to a fourth dimension, to have out-of-body
experiences, extrasensory 'perception (ESP), telepathy, and premonitions.
lrratíonallty in Schlzotypal Personality Disorder The petuliarities in formulation and thought content give you the irnpres-
sien that the patíent is odd, strange, eccentric, and superstitious. His affect
Rapport: When you try to establish rapport with a patient with schizorypal changes with the thought content, He may appear aloof and cold when you
personality disorder, you wil! be amazed by his unusual formulations, ínvolve him in topies of your choosing, but become lively and even intense
surprising statements, and peculiar ideas. Rapport .is harnpered as long as in his affect when he talks about his telepathic experiences and his
the patient feels that you cannot appredate his experiences. .convictions.
 _.•_._._._,~~-,_-,~_.':"":"" __._:_¡ __ .~~.__ ..:.:.....w....:.._':"""';__ _.'__ :._._. •..

. . ':. . .
l. ' . I D1S0ROEli-Sl'fC1F1C lNTERvtEWJNG: PERSONALITY DISORDERS 415
Tbe ClInical Interuieui Using DSM-IV
414

. The interviewer evades a direct answer and ernphasizes that he wants to

His orientation, memory. and ínformation processing are intact and' his
understand Kevin's feelings ..
speech is coherent. However, his judgment is ínfluenced by thoughts
situated outside ¡he realm of verífíable reality.ínsight, heHe has partial 7.1: .1 want to understa~d how ¡hey bOlhe~ you, how they gel 10 yOU.
knows that others consider him odd, strange, and sometimes hard to P: The way they look at you, [he way they don'[ talk (O you.
understand. But he sees thern as unable to look beyond a simplistic reality 8.1: Have you ever heard thern even when they were far awav?
P: No, not really. . .
and not as critics of his poor reality testing.
9.1: Have you heard any volees ever?
P: ~Y own thoughts.J think thern in words. I imagine how they would sourrd
Diagnosis: The patient's oddities rernind you of a sehizophrenic patient if I were 10 speak thern OUIloud. 'There is the quality of sound .in thoughts,
with positive symptoms. Yet, when you hunt for delusions or hallucinations, Thoughts go beyond people ..They interconnect and survive. .
you find none, neither in his mental status even
nor in his past hístory, 10.1: Do you have access 10 those interconnecríng thoughts? .AI~ ;ou, famili~r with
B~ . .' '.
though his thinking is reminiseent disorder, with overvalued
of a thought
P: I can sense thern, 1 can sense the hostile {houghts of {he character disorders.
ideas and ideas of reference, Serutiny of the patient's past will reveal that Tell me abour these character disordersí Who are they? . ". . . . '.
11. 1:
even as a teenager he was eonsidered odd and strange. Such chronicity .\ p. Those people who i~pose on your thoughts-you meet thern everywhere.
. alerts you to the presence of a personaliry disorder of Cluster A. . These thoughtless, callous mental morons, .
The lack of predorninantly paranoid ideas differentiates the schizotypal iz. 1: Do you think they are like a fra[ernity? Sticking together and conspiring
agamsl you? '.' . . '. . .
patient from the paranoid patient, preoceupation with the oceult and the
P: No, they are not like a conspiracy-e-more here ánd'lhere you know, just like
supernatural from the patient with schizoicl personalíry disorder.
people you meet and don'[ like, 1 don't think they are organized. lt's more
The following ínterview with Kevin illustrates sorne of the characteris- like a rnind garne.
ties of schizorypal personaliry disorder:
Aft~r he found the interviewer receptíve, Kevin cOlnm~nic~tes freely
1. 1: . where shall we begin? about his perceptions. The interviewer's attitude toward Kevi~'s odd views
P: . I mayas well start with thern, the character disorders.
is similar to the position taken toward hallucinations and delusions (se e
2. 1: Tell me about them!
'1': l. thínk the people who gíve you the rnost rrouble-e-that's who they are. Chapter 4)¡ he takes the position as if interviewing an astronaut who has
3. 1: lt sounds as if some people bother you a íot. visited a' remote planet. What the patient reports was certainly his experi-
P: You see, it all depends. 1 ha te me character dísorders who are cruel and who ence even though not immediately verifiable by the listener. .
hurt you. You can feel their aggresslve thoughts, but 1 quít my job so they
can't get at me anymore.
.4. 1: It must feel awful to be harassed by those people. 2 .. EXAGGERATED, DRAMATIC EMOTIONALITY-
P: 1 just have to stay away from them. CLUSTER B
5. 1: Did they try ro harrn or persecute you?
P: It's their thought1essness that hurts you. The four personality disorders in Cluster B are the antisocial, borderlíne,
6. 1: Have they ever tried to follow you, observe your house, tap your phone, ~istrionic, and narcissistic personality. The mental status of a patient be long-
bug your bedroorn, or living room? . . mg to Cluster B irnpresses you by. the erratic, exaggerated, drarnatic, and
P: No, but 1'01 surprised that you ask. Are you in tune with thern?
.' seerningly nongenuine embrional display with colorful affect. Most ¿f the
time the patient is not aware of her affectatíonor inappropriateness. Her
.:Kevln uses formulations such as "who are cruel and who hurt you"
speech is usually fluent but often vague and evasive. Frequently, she gets
rather than "who are cruel and who hurtrne." Such fonnulations:dedare his .
caught in conrradictíons. She intends to impress you by her behavíor rather
experiences as generally true. This interpretation is supported by his direct
than by the revelation of her problems or suffering. , . . .: .
question CA. 6): Supérficially, this type of patient is easy to inrerview. .Open-ended

I "Are you in tune with thern?'

'. questions usually lead ro lengthy, ernotionally colorful answers decorated
·íl(Í Tbe Clinicallnterview Using DSM-IV DISORDEH-SPECIFIC INTER\lE\VJNG: PERSO;'\ALITY DISORDERS 417

. .' . ~
with similes and metaphors. YOI.i have to ask her to specify, lO narrow form a therapeutíc aJliance and becorne cooperative, dependent, trustful,
down; you have to curo the flow and steer her direction. Usually she is not and willing to level wíth the therapist. Then it ís temporarily possible to
irritated by accemuated or abrupt transitions but is easily hurtand angered discuss as part of his.disorder his need to impress, his inability to postpone
by interpretations. " . gratification, his lack of ternper control and dependability, and his tendeney
However, because of her superficially exaggerated emotionality, and to lie, steal, and cheat. However, it is rare for the sociopathic patient to
her desire too impress you, it is diffícult to esrablish rapport during the sincerely atternpt to change his behavior, '
.interview. You do not feel she is leveling with you. She may threaten,
complain, beg, flirt, or tease. It is difficult for you (and for her) lo get in Technlque: His outfit (sec below: Mental Status) may be the starting point
touch with her true feelings, which seem hidden behind the ernotional '' , fora conversatíon. Ask (he patient to discuss his opposition to comply with
display. The mental status and the type of rapport alert you to a personality social rules. Although the patient rnay seek help for his drinking, substance
disorder of Cluster B. 'abuse, or depression, his mental status may serve as an opener.
The patient wíth antisocial personaliry likes attentíon. He uses bragging
Lying in Antisocial Personality Disorder and Hes to get attention, He glows in the limellght, His attentión span is
often short, rewards are strived for without delay. You can make him talk if
Patients with antisocial personality Csociopaths) rarely consult a mental
you encourage him ro bóast, as in: '
health professional for behavior problems. Instead, they come to see you for
alcohol detoxification, to get a certiflcate as excuse from work, to obtain
"You are quite a s~lesman.~"
stirnulants or sedative hypnotics (drugs with street valué), or to avoid prison "What .a con-artist you mus! be."
after committing a crime by claiming a mental disorder.. "You seem lo be able to put anything across ro people."
"Wefe you quite a fighter?"
Rapport: Rapport with such a paticnt is a problern. lt is easy to talk to him
as long as you play along, but he wiII criticize you and be angry when you Such comments will stimulate him to display his accomplishments. The
resist his manipulations. lt ís dífficult ro direct him to focus on deflcíts such tendency of the .person with antisocial personality disorder to líe and cheat
, as his lack of emotional control and his unwillingness to act.responsibly, or will distort his stories. If he talks freely, avoid a judgmental or accusatory
to consider the negatíve consequences of his behavior. This lack ofsincerity tone so as not to lose his cooperatíon. Do not approve of his crimes. Accept
and genuineness prevents rapport. lf he perceives you as an authority his boasting but explore the negative consequences of his deeds at the same
figure, he will protest against you clandestinely or evenopenly. t~e. " , , ,
It has been said that the person with antisocial personality disorder If the patient is uncooperative, notwilling to answer questions, or if he
lacks a sense of suffering. This is only partly accurate. He is usually not adopts a complaining or hosríle posture, withdraw your attention, display
remorseful about his Iying, stealing, angry outbursts, or ~urting others, but indifference, and initiate the terminaríon of the interview:
he can be made aware of the fact that nothing is going ríghtfor him and that
he is ruining his life. You can establish rapport and review the patient's '''You don't seern 10 be in the rnood to discuss your problems now. Maybe
we would hit it off better some other time."
difficulties free of lies and dístortions when you show him empathy for the
consequences of his behavior and his failures..
, Be vague about "sorne other time," maybe several days "clown toe road."
"1 agree that you've had a fair share of trouble. Maybe we can find a way Given the faet that patients with antisocial personalíry ha ve short attention
10 prevent it in the future by finding out where things go wrong." " spans, he may quickly change his attitude.
A similar tactie ís to offer the assistance of someone lower in rank:
When he feels that the interviewer is an ally who does not scold, judge,' or
punish hirn, bur. supports his constructive goals and shows understanding "Maybe you would Iike to talk lo the medical student (or the aide)-she
for his inabilirv to obey rules and regulations=-he rnay occasionally start to can tell 'me later what's troubling you."
____ ._c.,_.,._ ,-,-.,C"-- __ , ,-'--'_.. "'-.~_,_c-r-i-r-+ __ ,
, :.~..;-------..:....:.._-,;---...:---'--------_._-.-_---.::.........:.._------_._._' ---------- •..._-_.: ".

4ís ; ~:. :
.: '\ ".~,: . Tbe Clinical1"terview Using J):!lIl1.,-J v DISORDÉR-SPECIFlC Ii\TER\1E\\l:\G: PERSONALlTY DlSOHDEHS 'ÍJ9

If the pátíent is interviewed in fronr uf sraff, offer to release the staff so that The insight of the perseo with aruisocial personality disorder may be
you cantalkto him alone. Usually, rhe loss of audience is painful for him, limited. He may have a tendency to blarne the environment for his failure.
and he J¡ily quickly become cooperative. ":" , However, when you do have rappon with him, he may admit that .he
If the patient with antisocial personality disorder and affective disorder screwed up his life with self-destructive behavior. judgment is often poor as
becornes homicidal or suicidal but is unwíllíng to cooperate with the well, On a superficial basis he mal' be able ro read social expectations
assessment or treatment plan, set limits, forcefully, and right away: accurately, bur he is rarely able ro accepr expectations as justified and is
therefore unable to comply wíth thern, A person with antisocial persona lity
"1 want you (O write a leuer ro the hospital administration right now, so that disorder also lacks rernorse, whichallows him to use unethical shortcuts in
I can start commitment procedures against you." the pursuít of his goals.

Mental status: The sociopathic patient usually tries to rnake a quick

Diagnosis: The díagnostíc process is simple when you suspect antisocial
irnpression through his appearance and behavior. Sorne come close to the
personality disorder. AlI it takes is establishing rapport and collecting a list
following stereorype: The mal e patient rnay try·to look very masculine-
of teenage and early adulthood infractions against social standards and laws
sporting long ha ir, excessive facial ha ir, or an open shirt or V-neck revealing
with questions such as:
chest hair and jewelry. Other clues are tattoos, scars, leather belts with large
bucklcs, kcys on chains, visible knives or flrearrns, tight pants with an
"Did you ha ve disciplinary. problcms in school- Jn thc service? J)iJ you have
apparent penile bulge, and boots. probJems with the [aw? At work?"
The female 'person with antisocial personality disorder may try to
appear seductive and feminine. Here is her stereorype: brash, heavy
Here is an .intervíéw wíth Brewster, a 26-year-old, white male, who
makeup, unusually long or very short hair, tightly fitting clothes, short skirts, was brought to a Veterans Administration hospital by rwo friends. They
skirts with long slits, or transparent blouses. Alternatively, she may wear an had found him with a shotgun in his hand aírned at his mouth filled with
ouifit that is neglectful and sloppy, showing conternpt or lack of interest in water. He w.is pullíng the trigger. Because the safety was on, the gun did
social rules. no! go off and they wrestled the weapon away from him.
Motor behavior, speech, and mood of rhe sociopathic patient reveal
sorne common characteristics. The male socíopathic patient shows an erect L 1': 'I heard from the adrnítting resident what you were up too You rnust have
posture, a forceful walk, and a srrong handshake with a pronounced really meant business.
P: You are darnnrigbt. Thev meant well, but I wish these assholes would have
emphasis on movernenrs=-dependíng on whether he wants to appear cool
let me do iL' ,
and relaxed, strong and masculine, or display an ,"1don't care" attitude. The 2. 1: 'Why do you want ro shoot yourself?
female may try to reveal her upper thighs, stretch out her breasts, and swing P: My best friend got shot in one of the street fíghts that we had in L. He was
her hips in a provocative fashion. , just buried 2 days ago. I feh real bad.
Speech may reveal stiltedness, boisterousness, or-in males_':'_a certain 3. 1: You felt real bad?
hoarseness trying to áppear srnart and impressive with foul language or P: I let him down. I \\"3Sa real ass. 1 betrayed him,
4. 1: In what way did you 'betrav him?
words he' does not quite under~tand. His statements are rarely clear.
P: 1 screwed his old lady. Can you imagine? My best friend ... and 1 take his
, detailed, and informative but instead exaggerated, vague, and contradictory, old lady to ,bed. He trusted me all the way. Th;H'S the jackass I amo
'which suggests Iying. 5. 1': You are really down on vourself, ,,
His rnood may be irritable, depressed, or elated. He may portray a P: You aren't kidding. Jesus. what a smart ass [cursing at the doctor].
special ernotional state such as rnodesry, which you will soon recognize as 6. 1: Okay, let's ger on with it..
P: Listen, doc, I'm tired of talking to yOU. You can shove it.
being merely pretended to get you onhís side and have hls waywith you.
7, 1: Okay. You C3n talk [O the resident. l'll be back on Monday .
. Usually, he shows a lack of ernotional control .when caught lying oc when P: Screw yOU.
asked to follow rules. 8, I: Well"1 can't help you if vou don't talk to me.
 OISORDER-SPECIFIC INTERVlEWIr\G: PERSO:\'AUn- DISORDERS 421
I1Je Clinical Interuieui Using DSM-IV
420

rnove in. \\le grab the manager-he is usually the last lO leave. \'<'e make him
P: . Listen, doc, 1 didn't want lO be here in ihe firsl place. Just let me OUl of this .turn over the cash. B\11 first we let hirn beg. We let him go clown on his
damn [oint. knees and we pull a. pisrol on him, \\le play sorne Russían roulette wuh
9. 1: No way, You tried lO shoot yourself. \'('e have lO evaluare you. him=-clíck-c-clíck [laughsl. '. .
P: I want to sign out. 24.1: You seern like one of those tough guvs,
10. 1: You can write a letter {Q the chief of staff requesting your release, but 1 can. P: You belt~r believe il. Thar's the only thing that gives me a kick, to see a guy
tell you what will happen. prss 10 11Is pants ano beg us. \Ve tell hím that if he plays hís cards right, we
P: What's that? may let him off. Then we let him pay for his life, take his cash, kick him in
11. 1: We'll have {O commit you. In the staffs opinion you are a danger to yourself. the ass, and run off.. . .
You may suffer from a depression and 1 agree with them. So, I'll see you on 25.1: Aren't you afraid that yoo might get c;¡'lIght' .
Monday. I hope you will Icel beucr by then. P: Oh shit. We ~lIt a scare in him. We tell him ir h~ opens hís fucking mouth,
P: Darnn, doc, 1don't want to sit here the whole weekend just waiting until you ?f
sorne us will be back. We tell him we know where he lives. \'V~won't get
come back. Let's get it over with. lust hirn .. We will blow off his whole shiu)' family. He undersrands, The
12. 1: Okay. pol.lCe are busy ~ishing out speeding tickets to car pooling mothers=-they
P: Whal do you want to know? am t doing anythíng. They go where it's easy.
13.1: 1 really don't want to know anything. 26.1: .Is·that how you always got your kicks?
P: Whal kind of shit are you pulling on me' P: Wh;ú do you mean? .
l]. 1: 1 really want to understand how you get vourselfin tllat rness. What mude 27. 1: \'('hal diJo you do in school?
you so upset? P: 'X'ell, my father was a colonel in the army and my mother was a rehabilita-
P: Well. 1 rnessed up rny whole Iucking life. 1 [ust can't lick it. I can't getmyself tion offícer llaughsl, They kicked the shit out of me. . .
to do anything useful. . 28.1: .Did you getin any trouble at school? '. .
15. 1: You're not working? P: No. We lived on base. We moved around a lot.
P: Nope. Well, I'm service connected. I got a medical díscharge. They told me ·29 1: \\'ere you a good fighter in school?
that I have schizophrenia. P: \\'ell, 1 could take and give a good lick.
16. 1: How did thts come about? 30.1: . You could? .
P: I was on this ship. I was alwavs on the shit Iist. They rnade ine scrub the P: Yeso
deck. I tripped, I fell down the steps, must have bumped rny head. I passed 31. 1: Oid you ever do it?
out. After that 1 told thern that I had these bursting headaches. I could not P: 1 kick~d. ~he assistant baseball coach and gave hirn one with my bat, He
concéntrate. They would not let me 80. So I got drunk and ran rny jeep into . woke up 10 the hospital. .
a light post. Then they sent me to a psychiatrisl.·1 told him that I hear the . 32. 1: . What did the school do' .
voice of my dead grandfather and that he le lis meto kili myself. That got me P: No! mucho They suspended me, but mv dad got me back in. Then we moved
sorne action. The shrink said thatI have schizophrenia and that I have no to another base.' .
business in the service. So lm 26 yeurs bid and I already ha ve a riice 33.1: Ever had a problern like this again?
pensiono P: One of the kids was a real smart .aleck. I stralghtened him out. 1 knocked his
17. 1: Can you live off il' teeth out. That taught him sornethlng. .
P: .1 suppose I could. If I take an apartrnent in the ghetto, and líve off fust food. 3-1.. 1: .Did you gel ín trouble for that;
18. 1: How do you Iive? p. His dad triedto start somethíng, but m'y dad put on his uniform and went
P: Do you have to know all that? over to his housc. l le told him to tell his son not to provoke people and that
19. 1: I don't have any feeling for what's really bugging you. he had told me that 1should take care of myselfíf somebody crosses me. So
P: . Well, 1 live wíth a motorcycle gang. They're the only friends I've got, 1 did. The teachers wanted me out, but rny dad straightened them out.
20, 1: You mean you stay with thern all the time? 35.1: How are you getting álong with your dad now?
P: Yeah, We're hanging around in a tráiler park. P:. H.e doesn't wanl to have anything 10 do ~ilh me anymore. 1 got in sorne
21. 1: Really? kmd.oE trouble. and 1finally ran away. I enlisted with the Marines. I lied
P: That's all confidemíal, isn:t ie about my birthday. They shipped me right over to Nam.
22. (: It's confidential. . 36: 1: Howdid you gel along in the service'
P: \X'e go out and get our kicks. P: 1 had a great time in Saigon. \\le had por and speed and heroin.,-everything.
23. 1: Ho~"s that? And you would screw the hell Ollt of tllose little girls. We got hold of sorne
P: \'Ve ~talk shonnin!!' cenlers. \\'e waii till everybody is gone and then \Ve'
 Tbe ClInicallnterolew Using DSM-IV , I, DISORDER-SI'ECIFIC INTERVIEWli\G: PERSO:-.iALlTY DISORDEKS
422
·'i'

stuff from the navy and sold it. No problem. We always had money. BUI. the interviewer. She may show intense emotions, then unexpectedly switch
corning 'bnck was 'Ihe pits, her tone. She scerns to trust artd likc you and tell you that you are the best
37.1: Whal did you try (O do here? .'. doctor she has ever met. Then she will reverse her judgment .when she feels
P: l tried to work as a trucker.T got in an argurnent. 1 tried tOwork as a scuba lack of support and understanding.
diver, bUIeverything bores me. You handle rapport wíth a patient with borderline personality by
38. 1: AnO now?
focusing in an empathic rnanner 0.0 her insrabilíry. You atternpt ro separare
P: And nciw l've had íl.
39. 1: Oíd you really want to pull that trigger? . . . ír as a pathological part that needs to be explored for the patient's benefit.
P: I felt like ít, but 1 put thern on. 1 knew that {he safety was on. Butit put the However, since the Iabílity in feelings, judgrnent, and goals also affects her
scare in them. relationship to you, it is diffieult to rnaíntain her instability as che focus of
40. 1: So you really wanted thern to get you here? me interview. To neutralize the negative influence 0.0 rapport, you may
P: 1 guess, 1 mus! have. . .
have to come back to it many times. When you ·thus demonstrate that you
41. 1: So you really wanted to do sornething about your problems?
recognize the instability, the patient may be more willing ro open up to you,
P: 1 guess.
42. 1: 1 see. .' . thus furthering rapport.
P: l'm messing up my life.1can'[ go on like this. I nave nothing to look forward
too1can't just live for [he kicks. l have.ro grow up. Technique:' It is clifficult to keep the patient on a subject. You have to
43. 1: Ooes that mean you want (O gel more out of Iife? direct her, encourage her pursuit of a topic with rernarks of support, and
P: Yeah,
curb her diversions. She may teH you about .her goals and then renege on
44. 1: . Let's talk ahout it. Will you level with me?
!': .. We'll see. what she just told you. She may talk entbusiastically about a new relation-
45.1: Okay, Let's see. 1 want to know about the voices. ship [ust toodevalue it, mornents later, when some unpleasant experienee in
'. P:' Oh shit, 1 pulled cine over on thisclown: this relationship comes up.
46. 1: . You did? ; . Confront her with her. contradictions but express that you understand
P: 1know enough psychology to give young Freud his hour's worth. 1 rnade it
the nature of her arnbivalent feelings-what appears good and right at one
, up. 1 [ustwanted [Ogel out of there. This shrink couldn't tell a shit.
47.1: Okay. . . time may seem the opposite at another.
P: What do you think is wrong with me? The patient with borderline personality disorder usually talks in a more
48. 1: Well, 1think you don'! care abou! rules, you don't care about lying;you don'! genuíne way if you ask open-ended questions and help her to stick with a
care about cheating. You live 0.0 impulse: lf you gel angry you just gel rnad. subjeet by curbing, rather than trying ro get precise answers with closed-
ended, pointed questions. .
. At the beginning, Brewster appears angry but cooperative. Showing hirn
empathy seems to work. However, he starts to test the interviewer's ability Merital status: The overriding Ieature in mental status is the intense but
to control the situation in A. 5. When the ínterviewer sets firm Iimits (Q. 7, labile affect. It varies from euphcric to depressed, frorn appreciatíve to angry
9-11), Brewster cooperates again. The interviewer expresses interest in him andcritical. The affect shows a close relationship to both the content of the
.and in the way he gets himself into difficulties (Q. 14). The patient becomes patient's story and the way she experiences you, the interviewer. The labile
willing (O discuss hisproblems-at times even sineerely. He finally levels, affed is paralleled by (he description of a labile mood, which you can
gives up his boisterous display of anger, and tells his recent distress starting . abstraet from the patient's reports about life events.
with A. 14. . The excessive intensiry of affect and mood is impressive. Unlike histri-
onie personalíry disorder in whieh the affeet appears more intensely ex-
pressed than felt, the patíent with borderline personality disorder genuinely
LabiUty in Borderllne Personállty Disorder experiences an intense affect and mood. The flair of phoniness is missing.
Investigators have found that the patient with borderline personalíry disor-
Rapport: The patient with borderlinepersonality disorder presents special
der shows a strong relationship ro the patient with bipolar disorder and rnay
resistance to rapport by the instability in her mood, goals, and in: relating. te
424 17Je Cltntcaí Intervíeui Using DSlIf-IV
DISORDER-SPECIFIC INTERVIEWli\G: PERSO:\:\LITY DISORDERS 425

be a variant. Mood and affect in bipolar disorder again are intense by nature
but not by the patient's intent. .
The lability in ernotions persists also in the patient's social attitude.
Intense ambivalence to close friends leads to contradictory reports about
their characreristics: they are either overidealized or devaluated, Since a
patient with borderline personality has no distance from her íntense feel-
ings, she has no insight into the source of her difficulties.
Diagnosis: The diagnostic process is fueled by the patíent's report of a
string of intense interpersonal conflicts, possibly suicidal or self-mutílatlng
behavior, and by your mental status observations. AlI you have to do is
collect the pieces that complete the set of DSM-IV criteria. Unless you
disrupt your interview by critical, rejecting remarks, you will have no
problems with the diagnosis.
P: . You hit itright on the SpOL [sarcastioallv] You must really be a pretty good
psychlatrist.
-. A suicidal gesture or suicide attempt in a young fernale suggests
borderline personallry disorder to be included in the differential, This
diagnostic impression is substantiated for janet when the reason for her
suicide attempt is not depressed mood and delusional guilt but anger and
revenge CA. 2).
Despite the. evidence of a borderline personality diagnosis, the ínter-
viewer makes a mistake in technique in Q. 3. Rather than beíng supportive
and understanding and tellirig her:
"This fellow must have really hurt you that you were pushed so far as ro
overdose,"

she asks a rational and criticalquestion-e-andjanet lashes out in response.

This is an interview with]anet. a 29-year-old, white female dernonstrating
this ínstabílíry. . When the interviewer tries ro correct her místake (A. 4) by expressing her
empathy, Janet remains .sarcastic.
When the. interviewer restrains herself from supportive staternents and
1. 1: What brought you here today? . focuses on the facts instead, janet provides them freely. While she recon-
P: They sen! me up here from the emergency room. I had taken too much structs her last argument with her boyfriend that led ro the overdose,
Parnate and too much cold medication. They gave me an infusión, because
surprisingIy, she changes herIeelings about the event. The expression of her
my blood pressure went so high.
2. 1: Whar rnade you take so much medicatíon? anger seemed ro have freed her posítive feelings about her boyfriend, and
P: 1 had an argument wíth my boyfriend-I wanted to teach that bastard a she shows a bout of guilt (A.7). When the intervíewer pursues her insight
lesson, and makes an irnplicit interpretation that it seems díffícult for her to sort out
3. 1: How would it teach hlrn a lesson, if you end up in the emergency room? her feelíngs, she abandons the ínsight track. She rejects the interviewer's
P: I really don't like your questions. They're really durnb, reminds me of my
interpretation with sarcasm, dernonstrating her defensiveness against facing
boyfriend.
4. 1: So you rnust have felt really desperate, . a core syrnptorn of her personaliry dísorder.
P: [sarcastically]Mustnt I?Why else would 1 take an overdose?
5.1: Can you tell me a línle bit about what brought on thatargument with your .
boyfriend? Phonlness in Hlstrlonlc Personallty Disorder
P: Oh, just hís stupidíry,
6. 1: How is rhar? Histríoríic personaliry disorder is more frequently diagnosed in fernales than
P: It really tears me to pieces. But he can be so nice at other times. We bought in males.
a house real cheap and fixed it up together to live there ... [after a pause! 1
really think I should call him. He probably wonders what's going on. Rapport: When you atternpt to esrablísh rapport, you deaI with exagger-
7. 1: You just told me that you have these bad arguments with him and that you
ated ernotionality and lack of depth. Together with frequent contradictions
were ready to teach him a lesson..
P: Maybe it's all my faultand 1shouldn't have been so impulsive. in her story, she gíves you the impression that she Iacks sincerity; she
8. 1: Are you impulsive ofren? appears "phony." It is a cornmon response by novices ro dislike and
P: He brings out the worst in me. But 1still love him a lot. disrespect such a .patient, . .
9. 1: It seems dífficultfor you to sort out these feelings: With a rnale interviewer the female histrionic patienr likes to flirt, to
 tu« cumcat tncerotew Using DSM-1V DISORDER-Sl'ECIFIC INTERVIE\X''L'\G: l'EI~SONALlTY DISORDERS 427
-126

"It seerns to me that you have a hard time' making people understand what
impress hirn with stories of sexual advenrures, and to 'display h.er physical
you are going through. You tell them about your problems and they just
attributes scductivcly. With feinale interviewers, she rnay initiate. rlvalry or a dont scem to careo 1think we should try to understand why this happens."
power contest. Since the histrionic patient seems to be more interested in
approval and admiration than in a professional relationship, '(apport is If pursued, the patient mal' cornplain about being rejeeted and ridiculed
harnpered .. even by her farnily. She rnay admit that she wants to be loved, praised, and
admired. Those adrnissions bríng you closer to her true feelings and allow
Te~hnique: You have to ovércorne the patíent's vagueness a¡nf~r~inatic you to overcome her strategy.
exaggerations to obtain specific information for a diagnosis. UnstructUred; The next step is to induce the patient ro. tell you the reasons why she is
. open-ended questions usually do not work, beca use the patient bécornes. .' criticized. This may lead to a confession of her weakness·es. At this point,
sidetracked and gets lost in reproducing stories in which she was victimized. you ha ve ternporarily helped {he patient to overcome her phonlness=-at
Therefore, settle on a rnain therne, like a marriage problern, a conflict at least for the momento .

work, or JI. fight with her children, and keep her focused on this theme with
curbing and specification, Get concrete exarnples. Even then you rnay not Mental status: The mental status of a histrionic patient is dorninated by a
get a .clear picture beca use the patient contradicts herself. Confrontation display of. emotionality: vivid facial expressions, drama tic gestures, and a'
witl, hcr comradictions oftcn resuhs in anger aod a 105S of rapport. Te) get highly modulated voice: However, she can he ínterrupted :1I1c1 redírectcd ro
her .to reflect on her behavior, you have to express understanding and a different topic, whích she will take up in the same drarnatic fashion. Her
encouragcrncnt. Use phrases like: ,'," ". . ,~
distractibiliry cliffers from mania. since there is no push of speech or flíght of
,1'
., ~:- ideas (see Glossary). The constant drama gives you the impression that she
"You seern robe a sensitive person." does not realIy experience any intense feelings. Her strong show of emo-
"You scem 'te) feel rhat other pecplc can't appreci:lle. w~i;lt you went tions is for your bendito not a catharsis for her. In spite of excessive facial
through." expressions and abundant gesruring, she appears uninvolved in her story,
The terrn la belle indifférence has been eoined for this internal emotional
i
.Wheo [he. patient expresses that she feels und úsióó8 by you,' you may ask. distance .
. her: ".
Diagnosis: As for rnost personality disorders, it is the patient's mental
"How do you think your husband would repon the .~ame event?''
status that will alert you. When vou suspect a histrionic personality disorder,
invite the patient to rell you how she is getting along with people close to
By comparing his aod her perceptioo you may help her to develop a better her. Since the histrionic patient usually has conflícts, for exarnple, with
understanding of her conflicts and give her some insight. Such ínsight, parents, children, or spouses, she will report lifelong conflícts with them.
however, is usually short-líved. .' ,:-;" . She often divides her relatives into "the good and the bad guys." Besides the
You ..can sometimes help her to developtnsight into her behavior by exaggeration typical of the patient with histrionic personality, you will also
asking ernphatic questions. \,<;'hen you si de with .her, the patient may be often encounter passíve-aggressive features and in tense arnbivalent feeliogs
encouraged to admit at times so me of her deficiencies. Assoon as she feels typical for the patient with borderline personality disorder.
that your support, understanding, and empathy are slipping away, she will
return to drarnatization. A histrionie female patieot has often experienced This is an interview with jane, a middle-aged, white, married fernale who
has chroníc marital conflicts ..
rejection that she does not understand. She tries to overcorne it by exag-
gerating her pain and this tactic often eams her conternpt rather than 1. 1: Wha¡ kind of problems brought you here?
empathy. P: . Before we begin let me tell you something. I undersrand that you wanted

I
Another approach is to address the exaggerated drarnatic behavior from me' 10 be seen by sorne other doctor in the clinic, but 1 wanted the best..
That's whv 1 insisted on seeíngyou.
the patient's poínr of view, such as:
 Tbe Cllnlcal Interview Using DSM-¡Y DISORDER-SPECIFIC INTER\lEW1i\G: PERSO:\AUn: DISORDERS 429
·Wl

P: .I stilllove him, 1 enjoy the closeness when we have sexo

2. 1: Thank you. But what makes you say l'rn the best?
17.1: Wt:;ll,as.you said, that has not happened for a long time.
P: Well, you are the director of the c1inic, aren't you? And Dr. T., who referred
me here, said you specíalíze in sleep problems.
P: Oh, it was just last Friday. And sorne hours later he was tearing me apart.
18. 1: I thought you had not been intimare with him for quite sorne time.
3. i: Tell me about your sleep problems. .
P: Why do you use whatever I say against me? Can't you understand? I meant
P: Oh, u's terrible. There are whole nights when 1 can't sleep at all. I toss and
(he lime befo re last time.
tum, and 1 get up in the moming without having closed rny eyes for even a
second.
4. I: This happens only some nights? Even though jane talks freely,it is difficult to get precise informatíon. At
P: It happens when 1 have these terrible, terrible fights ~vith my husband, He .. first, she does not describe the circumstances of the fights with her husband,
just tears me to píeces [rolls her eyes dramatically upward]. .
nor does she agree to have him intervlewed. She expresses her suffering in
S. I: Does he or anybody else notice what you are going through? .
an exaggerated way but she is reluctant to furnish the facts, She wants the
P: They don't have the foggiest idea [shakes head vigorouslyl. 1 can scream and
yell and they still don't understand [shrugs shouklersl .: intcrviewer to feel sorry for her, the mere fact that she suffers should be
6. I: When you have these fights, is your mood affected? . . reason enough for the interviewer to side with her.
P: I gel these devastating depressions [looking up to the ceílíngl and 1 have to . Her vagueness is ternporarily overcome when the interviewer asks her
cry the whole time. to project what the husband would report about her. But when he tries to
7. 1: 'Wnat are these fights about? . explore whether .the husband's staternents are to sorne extent justified, she
P: l'm not sure. just anything. We have not had sex for the last 4 rnonths. I can't
protests. She prefers to indulge in suffering rather than to analyze her
understand how a rnan can be so cruel and hateful,
8. 1: 1 ha ve a hard time understanding what your fights with your husband are all underlying problerns. .
about. . . When the interviewer explores whether she considers a divorce, her
P: He criticizes me and puts me down: H~ has lefr me more than 30 times in dependency needs surface. She has aha~d time fending for herself, She starts
the last few years, to ernphasize her husbands positive features. Thus, it appears that the patient
9.1: Maybe you can gíve me an example?
is more interested in complaíning about her problerns than solving thern.
P: Well, he comes back from his trips and rips me all aparto
10. 1: So his criticism is the main part of your problems? .
P: 1 suffer so terríbly mucho A nice man like you probably cannot understand Grandiosity in Narclsslstíc Personality Dlsorder
how a man can be as mean as my husband.
11. 1: . Maybe 1 should have a chance 'to talk toboth of yOU. Throughout the inrerview, the parient with narcíssistic personality gives you
P: l'd rather not do that. He tells his side of the story in such a way that it Iools the feeling that you are. there 'to endorse his self-promoted importance. As
everyone, long as you play along, you will be ídolized as a wonderful interviewer.
12. 1: \\ñat do you think he would say? However, ifyou support bis grandiose self-perception, you will not help
P: Just the same old thing, that I'm abad housekeeper. that I haven't done
anything, that l'm just sitting on my fanny while he has to do all the work.
him to test his grandiosiry agairist the reality of everyday life. Yet, helping
He'll just carry on like that. .. the patient recognize his lirnits shatters his self-ínflated ego.
13: 1: So he talks about your shortcornings, Does he ever ask you how you feel To you (he grandiosiry is in gIaring contrast with reality, but the patíent
and why you are having trouble getting things done? . has 00 insight to tell the difference between his healthy, critical self and his
P: He has no understanding whatsoever. It's like he 's made of wood and he pathologícal tendencies. Aliiance between you aod the patíent's healthy part
looks so cold. I'm getting tired easily and when I resr and watch television,
.is not possible. His lack of insight prevents rapport.
the time is gone and I can't get thíngs done ..
14. 1: I see. Do you think then that he has a point?
P: Are you taking his side? I thought l'm your patient, I'rn the one who's Here is an intervíew with Henry, a childpsychiatrist at an eastern pediatric
.department:
suffering. I thought you understood that, .
15. I: Okay. Let's start to talk about your problems and talk with him later.
P: \vell, when you talk to him you will notbelteve how nasry and mean he can L 1: Hello, Henry.
be. P: . Beforeyou say anything, let me give you the background of rny visit, 1 arn
1 r.; t. ~"hi~ "ninl <lo vou see a future for your marriage? . hereto discuss with vou, as a srnart and knowledgeable insider, sorne of the
 .' ...,'
. DISORDER-SPECIFIC INTER\'1EWT:\G¡; PERSO:\AUn' DISORDERS

próblerns that ¡"-ha\'·(:· dealing with íncornpeteru diagnostic moroos.· One

shouldcall them rnedical technicians: they ha ve no graspof the essence of
the problems they deal with. We ha ve a long-standing conflict that is now
corning lO a head. Even after I published my book, they doubt my expertise
. ir{ the neldo I have lO make a decision whether I should quit this clinic that
!J 'suppons those morons or try to get thern fired: .
I¡ 2. 1: . Whar does Dr. L. lthe clinic director] think about it?
P: '. I have been over that one with her several times. i have pushed her toward an
ultímatum, I had her crying, butshe is íncapable of ?king the necessary actioos:
12.1: . Come on Henry, we have been fricnds. I want ro helpyou to finó out wl!;\I',
. golng wrong! Do you want to show thern.how ignoraru they are, or d•• you
want to get.your diagnostic reasoning across-
P: Bull .. , l'rn not enjoying this conversation, Lets forget it.
13.1: \Vell, Henry. you seem to Ieel insulted and misundersrood,
P: The hell, Ido. They think beeause they are pediatricians, they have one up
on me, And you seern to be 00 their side too, just beca use they think they
are real docrors just like you seem to think, Maybe you did the right thing

! 3. 1: Who are the doctors that you have á conflíct with?

P: Sever~l pediatricians at my c1inic. They have no clinical savvy whatsoever.
Their judgment with regard to the trustworthiness of rnolesred children is
by going into neurology: Next time around I would do the same [his eyes fil!
with téarsl. You don't believe how rnuch 1 have suffered in thís department.
By the 'way. do you know Rick D., the surgeon? We have the same little
nursing student in' the works. She really is a eute ass. Are you still. giving

I 4. 1:
PO.
just horrendously impaired.
How's thaé
As a forensic child and adolescent psychiatrist, I have the experience that
~liows me to decide' whether or not a child is lying. But al! they are
concerned about is the evidence: did the child have a conduct disorder, or
did he abuse drugs? Intuition. recognition of defenses, aod understanding of
talks?
14. 1: A few of thern. Why do you ask? . .
P: If you know anyone who needs a speaker, 1 would be willing , , , you can
recomrnend me. .
, .

the family dyoamics escape thern completely. . This interview shows howa patient with narclssistic personalitydisórder
5. 1: Well, Henrv, 1'11\ not up on the field. rnaybe you can tell me on what kind tries to ~laintain his serf~iinportance in light of an adverse reality. The
of criteria \'OlI base a child's rrusrworthíness. íntervíewer's atternpts" ib: make' 'Henry review his behavior are overrun.'
P: That's so ~bviolls. I'm surprised that you ask such a question, Haven't Y0l! When the interviewerexpresses empathy foro his repercussions (dueto his
read my book? l did semi you a copy. Do yOll really expect me to teach you
grandiosc distortion), the patlcnrcolíapses hriefly but atternpts to regain his
the basics here? '. . .
6. 1: Well, since one of your discussions with your colleagues centers around
posture by bragging about his-arnorous success: .
uustworthíness of witnesses. I would like ro koow how you approach the . As with other persclD,;ility. disorclers, an ernpathic addressing of the
questioo. . narcissistic goal such as:
P: Let me tell you what, I'll give you six criteria: experience, experience,
experience, knowledge, understanding, and [udgment. How does rhat strike "You only feel worthwhlle Vihen.you convinceyourself and others that you
you? I guess that. does not sit well with your obsessiveness, are tops," '. . ,-.." ,.. .. . ,.".<:" " , .: .. . . . .

'7.1: tome on. Henry: You can do better than that,

~ P: You have really lost your c1inical touch since you have been away from

I
or .ernpathy. for the consequences of the narcíssistic behavior such as:
psychoanalysis. Your neurology traíning has gotten the better ofyou, 1 guess
there is no sense in talking ro you any longer!
. :·"1see you are hurting. Let's find out how you gel. hurt. and how we can
8,1: Okay, Henry, 1 think I'm not helping you. It seems t~e pediatricians really
do not grasp .your contributíons, stop it,' .'¡

p, Now we're getting sornewhere. .. , ~

;

9.1: I'd like ro know why you think they misunderstand you! may only ternporarily enable the patient to"!=onsjder.hi$J')a(cis~istic behavior
P: . I told you: It's their intellectual flat-footedness! as the cause of his problerns. Usually, each .in~ight)~ followed .by, a
10. 1: Okay, if that's right, is there anything you could do to írnprove rnatters? . I grandíose repair of hís shattered image. ,. , .
P: Listen, don't put it on me! Who do you think I am? You know I have dealt
with al! kinds of people who were nor the smartest, but at leasr they had .. 1
intuition, and esprit. You don't really expect me to get down to theirlevel 3 .. ANXIOUS, RESISTIVE SUBMISSIVENESS_;_
and worry about what pediatricians think!
CLUSTER e
11. 1: Well, it depends on your goals.
:.' . ' ;
P: What do you mean? I am noton trial here, YOu always point at me, thanks
Three personaliry disorders fall into Cluster <;:: the ay'?id~n,!,l~e clepen~e~\,
anyway-thanks, but no thanks!
and [he' obsessive-compulsive personality disorder, The mental status <?(a
 432 roe Clinical/nterview UsingDSM·/V DISORDER_SPECIFIC INTERV1E',';l:'\G: PERSONALITY DISORDERS 433

patient in Cluster C is dominated by an anxious, tense; and dysphoric affect. being ernbarrassed as silly and express this. However, if you identify with
. She worries whether you accept her. Her speech appears overcontrolled, this position, she may fee! ridicu!ed and criticized and withdraw again .
. .
and she weighs each word to avoíd mistakes. Cluster C personality disorder . . . '. '... ." . . "

patients have more insight into their behavior than patíents in Clusters A and
ll--anxiety produces self-awareness and self-consciousness.
Rapport develops along a specific pattern. The patíent watches you
closely lo find out what you think of her. If she finds you supportive;
receptíve, nurturing, and nondemanding, she strives to overcorne her anxi-
ery by paying reverence to your authoriry. She rnay flatter you, ask your .
advice, laud you as an expert, and tell you .what she thinks you. wani to
hear. She clings to you, and expects you to take charge. Rapport beco mes
!opsided.
One of the personality disorders of Cluster C is more difficult to
interview: the obsessive-compulsive personalíty. As the interview with her
progresses, you may find it was onIy a token reverence that the patient paid
you. After you respond with empathy and act protective of her, her interna!
resentment creeps up. Gestures and rernarks slip out that indicate reluctance
to cooperate. She may ask probing questions and let you know your
inadequacies. She feels that you were not really worthwhile or powerful
enough to [ustify her initial anxíery, she may resent her submissiveness and
may shut you out. Special techniques will be discussed for the interview
with the obsessive-cornpulsíve personality disorder patíent.
Mental status: The' avoidant personalíry initially shows withdrawaí and
this feature dominates her mental status. She is monosyllabic, vague, and
circumstantial. Initial!y she mar appear suspicious and paranoid, or anxious
and phobic, but voíd of clear-cut syrnptoms of DSM-IV clinical disorders.
After she feels cornfortable with you and develops trust; she may reveal her
sensitivítyto being inisun&rstood and be easily hurt by critícism or disap-
proval. She rnay then discuss her fear of rejection and inappropriate
behavior.
Diagnosis; The patient's anxiousness and restricted affect at the beginning
ofthe intervíew usually attract [he interviewer's attention-early clues. If she
opens up, the diagnostic interview follows the standard phases '(see Chap-
ter 7).
Donna, a 27-year-old, white, single female, had never been in treatrnent.
When she entered the office, she sat down and put her hands in her lap,
· and thenhung her head down glumly. She refused to ha ve corree by shaking
her head and mumbling no. She appeared unusuaIly tense. The ínterviewer
decided-since small talk seemed to rnake her more uncomfortable=-to ask
for her chief cornplaint.

Hypersensitivity in Avoidant Personality Disorder 1. 1: Maybe you can tell me what kind of problems bríng you here ... [pause],
What would you like ro talk about?
P: lsilent, looking down at her hands with a tense expression on her face, then .
Rapport: In a patient wíth avoidant personality disorder anxious guarded- .Iooking back at the interviewerl
ness and reticence can be approached with reassurance and empathy. Avoid . .2.1:· How do you think 1 can help you?
confrontation that she may interpret as criticismo Instead, express ernpathic P: I don't know .
understanding for her suffering, which may encourage her to share her past .3. 1: Maybe you can tell me what's bothering yOU.
·P: llooks down and shakes her headl People, I guess.
tortures and her present anticipatory fears. If the patient feels that you
4. l: Isilent, looking at herJ
understand her sensitivity and are protective of her, she will trust you and P: . [getting tenser andstill looking down at her lap]
cooperare with you. The result is rapport. After she feels acceptecl and safe, 5. 1: [in a soft, soothing voícel People? \V'hat is it.about people?
the character of the interview may change dramatically, She may become ·P: 1 can't really tell.
explicitly detailed, may give you examples of social insults she has endured, . 6. í: You seem to be scared of people.
P: lnodsl .
and report to you the reliving and resuffering of her traumata.
·7. 1: What rnakes you 'scared -of them?
P: l. don't. know. I Ieel like they are closing in on me.
Technique: After you have rapport, the patient is easy to interview. She 8. 1: '{olÍ Ieel they are out to harrn you? .
feels relieved when she can describe her social fears of being criti~ized and P: No, not really out ·to harrn me. They are so loud and pushy; they shut me
rf'if'rtf'rl h("(';:¡n~f' she ff'f'1.~VOIIr emnarhv, She mav exoerience these fears of up.
r~-'--' Tbe Clinical Interuieui Using DSM-IV
I undersiand. You teel that they can run over you any time; the'y close in on
. you and crush you ... lrernains sÚer\[) ... ls this close to how you feel?
Pretry' close. .
15'there anyone' in panicular?
My father's brother. He comes in. pushes me aside, laughs at me. 1 hear ít al!
.the time: "Come on Donna, come off it, Donna, that's crazy, Donna, you're
so impractícal, Oonna, damn, get your shit together, Oonna, and put your
foot down." [shakes her whole body] 1 can't stand it. Iwould like to hide in
my room.
You must go through a 16l.
(sighs) Yeah ... yeah, really. [for the fírst time looks at.the ínterviewer and
establishes eye contact)
How long has this bothered you?
As far back as 1 can think. My past is full of hurts.
School must have been hell for you. .
as. ¡. rernember when 1 had written a .poern and the teacher made
Oh, it \.••.
me read it to :the class. . . abrupt transitions, and allows you ro probe very personal feelings. What she
What happened?
1 did no¡ wunt to do it. I was .ashamed of having written a poem.
Oid the teacher understand and help you out? .
She told me 1 could stay i~ my seat and read itthe¡e-it was awful.
What was awful? '.
When I started to read.: the kids in the front yelled: "Read louder, we can'!
hear you!" 1 staned ro swallow--flnaüy, the teacher took the poem and read
it. The whole class laughed. 1 swore .that '1would 'never wríte a poern again.
You have thin skin. Everything seeins to get right through 'to you.
I have no skin at all. 1 seem to be much too sensitive.
That makes it hard for you to speak up, '. . .
1'11die before 1 open m}' rnouth in front of a whole bunch of people again ..
It takes the interviewer eight questions ro piece together Donna's chief
complaint. Rapportís established with Q. 9 and 11; Q. 9 expresses cogníiive
understanding and Q. 11 ernpathy. In Q. 9 (he interviewer sumrnarizes what
was learned. He focuses then on the person Donna most dreads. For the first
time the patient gives a sornewhat longer and emotionally laden account of
a person she fears and ha tes at. the same time. The interviewer expresses
ernpathíc understandíng in Q. 11. The patient relaxes and the i~terviewer is
I
now able to follow the standard interview and get the patient's history
(Q. l2-'18). ..
Submisslveness in Dependent Personality Disorder
Rapport: It is easy to establish rapport with a patient with a dependent
personality¡ after she loses her initial anxiery, she puts her trust in you. As
1
OISOROER-SPECIFIC INTERvlE\V1NG: PERSO;-;ALlTY DISORDERS 435
long as you give pleasant advice, show ernpathy for her indecisiveness and
failures, and are supportíve. the interview flows easily.
However, if you try to explore the background of the patíent's submis-
siveness, she becomes uncornfortable and tries to persuade you not to be
too harsh 00 her. If you pursue exploring her dependency, and if you do
this from your own, rather than from th~ patient's poinr of view, .she will
show you how much she suffers. If you don't soothe the pain, the patient
. wíll change therapists [O find a more sympathetic ear.
Tec~que: lnterviewing the patientwith dependent persori~lity disorder
is easy. She coopera tes and tries to meet your expectatíons. She answers
questions to the point. She clarífies her answers on demand, so you can
easily steer che direction of the interview. She tolera tes accenruated and
cannot tolerare is confrontati6n with and interpretations of her dependency.
. .
Mental status: The mental status is colored by the assocíated disorders
that bring her into therapy in' the first place. The overriding features,
however, are her dependency, subrnissíveness, anxiousness, and her need
to please you. She tries to giveyou answers that she thinks you willlike. Her
affecrstrikes you often as anxious and depressed with sorne obsessive
fearures.
The thought content mirrors themes of low self-esteem, desertion, and
anxíery of doing the wrong thíng. The patient with dependent personality
dísorder is oriented to her surroundíngs and has good mernory but fails to
apprecíate the degree bf her lack of initiative and írs eff~ct on her life. Her
judgrnent is hampered by her dependency.
Diagnosis: Severa! features of the Interview tell you that you are dealing
with a patient with a dependent personaliry. From the very beginning the .
patient eleva tes you to a position of authority.
i . Her social history ShO'l\'5that she always seemed to share quarters with
.'!
a person who took charge of her lífé. The cornbinatíon of these features
rather than any ene alone will suggest to you that the patient has a
I
I dependent personality disorder. After you have included this diagnosis jn
I your differential, tWQtasks rernain: you haveto show, first, that the pattern
I of dependency is lifelong, and second, that her dependency can be sepa-
rated frorn the symptoms of a disabling clinícal dísorder, or from justifiable
responses [Osuch a disorder.
 Susan, a \.••.
hite, divorced female in her late 305 has been attending a
Most long-terrn patients have a chronic disorder=one of the Axis 1
psychlatric: outpauent c1inic regularly for rnany years .. During the first
disorders that is, such as schízophrenla, rapid cycling, nonresponding
interview with a new psychiatrist, she demonstrates sorne characterístic
features of the dependent personality, bipolar disorder: or nonresponsive major depressíve disorder. If such a
disorder ís missing, yet the patient visits the clinic over rnany years, a
1. 1: I'm taking overfor Dr. v. I understand that you have been coming ro thís personaliry disorder of Cluster C is Iikely, especially dependent personality.
c1inic for quite sorne time. . . This may surprise the reader since by definition all personality disorders
P: Oh yes, at least me last 15 years.
2.1: What seems to be the problem?
are chronic, However, not all result in long-term therapy as the Cluster C
.' disorders do.' Therefore, a patient who is psychologically minded, with
1': [pauses] I don't know how to answer that qucstion, Maybe you can tell me
what's going on. deep, nonresolvíng dependency needs, is a prime candidate for long-term
3. 1: Hmm. Maybe you can help me by telling me what you've been struggling . psychotherapy. Theintervíew with Su san bears it out. .
with lately, . From the beginning of the interview Susan attempts to put the inter-
P: 1 really need your guidance. You can probably sort it all. out. Thát's why L viewer in charge (A..2, 3).He does nOI confront her with this tendency but
am eoming here. 1 need your help and advice,
4.1: You.have a hard lime 10 get along?
.
!
\
assesses her Jife circumstances Insread. She describes a situation typical of
the dependent personalíry.
P: Yes, since my husband deserted and divorced me, people have been taking
sdvantage of me,' says Dr. V. I'd. been better off if rny husband hadn't In Q. 10 theinterviev.:er artempts to address her ability/inability to rely
divorced me. But he always saíd J clíng 10 hÚll too mucho And so he 'Ieft me, I on her resources, Susan rnisunderstands thís exploratíon as an irnplicit
and J had done everythlng for him. criticism and responds with tears and a plea for not wanting to be criticized.
5. 1: Ir seems you still miss him.
P: I still see him once in a while. He's married again. They ha ve three children.
I Ihis response shows that you should not confront the patient wíth her
pathological dependency in the first interview. lnstead, explore the patient's
It gives me a pain in the chest when I see them and how happy they are,
.and I'm so miserable. Maybe you can help me .. view of her .'dependency . and then make her gradually aware of the
6. 1: Are you living alone now? . consequences of her behavior, Chances are that, in spite of your interview-
P: No, I moved baek in with my mother, She neverIiked my husband, Now I'm ing skills, you will end up with an eternal patient rather than a stable adult
not dating at all. I don't even go out. I don't want to hurt my mother. who faces and solves herproblems.
f 1: Have you ever thought of marrying again? .
P: My mother wouldn't like it, lt would be like .desertíng her a second time.
Sometimes 1 think it would be niee to find aman who would love me and CircUmstantiality and Perfectionism in
would Iíke to take care of me. Maybe an older mano
Obsesslve-Compulsíve Personality Disorder
8. 1: Why don't you want to find aman your own age?
P: They are so demanding; they want you like a partner and not as a wife, I'm
pretty traditional when it comes to marriage. I think the husband should be Rapport: The obsessive patient is blind to the situation beca use he is fixed
a gentleman and show you love and care for you.
on details, Therefore, in the interview you will be involved in an endless
9.1: Being a partner in a marriage seems lO betough foryou.
P: I think with reallove men wlll be understanding. 1 feel that you understand. struggle about words, issues, and who is in charge without being able to
10. 1: Jt sounds 10 me that you have 10 find out how much you have 10 be on your .develop an atmosphere ofcooperation and understanding.
own, how rnuch responsibiliry to take. If you show ernpathy you will have a problern, He is proud that he
P: You sound like Dr. R. He did not seem to like me. He was not like Dr. V., . doesn't have any feelirigs, that he is objective. Therefore, he is perturbed
who was always on my side., . .
when you express ernpathy for hts suffering and 'rejects.it as irrelevant. Not
11. 1: I feel J have touehed on something very paínful for )'00.
his suffering but .his problems are important; however, they are unsolvable.
P: (silentl
12. 1: I think it may be helpful for you if we can discuss ir. This struggle rriay prevent you from establíshing the split between the
P: My mother criticizes me all the time ... but I don't make enough money to healthy and the diseased part of his personaliry.
líve by myself (her eyes fill with. tearsl, I'm really trapped. Please don't You may overcome this struggle by continually trying ro get and keep
eriticize me, 1 can't take it, 1.want you to help me. thé patient in touch wíth his anger.: This rnay work as lorig as he believes !hat
 r ---_--"-
I .
->----- ----------,-----' -_' ------------------------------------------------- ----
- --
..
----
-------
..
--
.--
...
-----------.----
..
-.-------.-.--
..

17JeCllnlcallnterview Uslng DSM·IV DISOROER-SI'ECIFIC INTERV1ÉWI:'\d: Pf.RC,Q;-¡ALITY DISORDERS 439 .

j you feel his anger is [ustlfied. But if you auernpt 10make me anger me objeet
of the intervíew. he wíll.defend or deny it. He will put forth more obstructive
obsessive thinking, actively.preventing.a split between me healthy and me siek
2. 1: \'Vnat was the letter about?
P: I don'tknow whetherI should discuss this here, You may know her.
3.1: .Areyou concerned that sornething may Ieak out?
P: Obviously ... But rnaybe ¡ can tell vou if you can assure me of complete
pan of rus personaliry: To form an allianee is difficult, and the interview often confidentiality.' ..
~ consists of aborted atternpts, struggles, and frustrations. 4·.1: How can I help you if you can't talk abour jI? .
P: Maybe the content of the letter is not the problern, but her reaction,
. 5.1: What is it about her reaction that corícerns you?
Technique: Your posuion as interviewer is precarious because the
P: I'rn jusr thinking that you can't really understand her reaction if you don't
patient's ambívalence is hard to overcorne. He doubts yourassurances, Your know about the letter. .
open-ended questíons lead to confusion. He wants more' circumscribed 6. 1: Let's look at the whole package.
questions, but if you eomply he interprets them as too narrow. P: . You are pushing me. Maybe 1 should think more about what 1 should tell
you.
7.1: Alright, .
Mental status: The mental status of the patient with obsessive-compulsive
p. If 1 break off now; you couldnt really charge me for that short a visit,
personalíry is overshadowed by one difflculry-c-making decísíons, Thís ·because it isn't me who can't guaramee confidentialiry. .
shows in his ambivalenee and [he way he keeps you in limbo when 8. 1; I'm sorry, this hour iras reserved for you, 1 ~ill charge you for my time.
answcring.questions, Should he opcn IIp to you, or would he he mísunder- P: You really have a way with words. OK, if you charge me anyway, 1 rnay as
stood? He rnay decide nOI to open up, but wij¡ wonder, is that right? Should ·well use the time. My coauthor agreed with one of the harshest crities who
reviewed our paper. .This really incensed me, because she's not really an
he spend his rnoney on seeing y~ll ,. and then risk not getting a true
.
reading
expert in (he area. .
of his problems? How can he gel your best opinión if he holds baek? Are
9.1: So you beca me angry.
you really the right person to talk to? Probably nOL He has to fínd out from P: Not angry. i am very rarely distracted by my feelings. I ·con.sider therú
you what's wrong. He should ask the questions: you should provide the ·irraliona!.
. .
Wh~t 1 basically
.' .
did is ask her 10 change
.
the
. .
paper according
." .
10
.

I answers. Who is in eharge? Him?Or should you be in charge, sínceyou are her criticismo .

; supposed to be the expert?

The obsessíve-cornpulsíve patient perceives himself as being neutral, a
a
quite dístorted view. You sense low-grade, ehronic anger that can flare up
10. 1: Could she do it if she is nót an expert in the area?
P: I cannot understand how someone can criticize work if they can't change iE.
Then she shouldn't have criticized it in ¡he first place.
11. 1: Bu! wasn't her intention ...

I
í
into tenacious, persistent, bothersome questíoning that cannot be satisfied
by any answer. His anger will becorne overt when .his obsessive expeeta- .'
. tions are not met, when he feels shortchanged in interviewing time, over-
P: I don't really care about intentions.Tm looking al facts. The facts are that she
criticized the paper without being able to irnprove il. It's as simple as' thar.
12. 1: But don't you 'miss. the point, when you look at the facts without including

I
the intentions? .
charged for his visit, or not rewarded wíth useful answers to his questions.
P: 1 don't think you have ah)' appreciaiion for the facts, You are unable to see
the facts, You have a hang-up on (he emocional sitie. You are obviously
Diagnosis: The mental status gives the patient's diagnosis away; noseeret I biased.
here. The problern is to get the details of the associated disorders, if any. If 13. I: l'vIystaternents seern to make you angry.
sueh a patient presents ar a c1inie, obsessive-cornpulsíve disorder ítself, ·P: I'rn nor an erriotional person, i ¡US( want to get the facts straight. But you
wori't let me do that.
depression, phobic disorder, and sornetimes. delusional disorder are corn-
mon concomitants.
The interviewer dernonstrates a struggle that frequently evolves with á
Here is an example of an obsessive-compulsive personaliry found in Wynn. patient suffering from obsessive-compulsíve personaliry disorder. Since he
a 35-year-old scientist: questions everything that he does and that you pro pose by considering the
1. 1: How can 1 help you? opposite, no resolution is forthcorning. However, the patient with obsessive-
P: I'm concerned about a letter I wrote to my coauthor. She did not take it well cornpulsive persona lity disorder has a speciflc sensitiviry that allows you to
at all. .'. channel [he lntervíew-e-he wants tO be considered logica!. He cannot stand

440 Tbe Clinical Intéruieui Using DSM·IV
ro give up sornething for nothing. He is stingy with ernotion, time, money,
and control and does not want to lose out to anyone, Therefore he
continues with the interview when he hears that he may get charged
anyway if he breaks it off. Thus the interviewer can motiva te him to
complete the interview even though ir appears that the interviewer is not in
charge when indeed he ís. Progress will not be straightforward but will
rnove three steps ahead and two sreps back.
4. PERSONALlTY DISORDER NOS
Three other personality disorders were classífied in DSM-lII-R: passíve-
aggressíve personality disorder, sadistic personaliry disorder, and self- ..
defeating personality disorder. The latter rwo were considered under those
disorders that need further study. Since you are likely ro encounter these
disorders when you interview patients, we have included them here. In
DSM-IV, they are c1assified as "Personaliry Disorders NOS."
Resentment in Passíve-Aggressíve
. Personality Disorder
Rapport: Like the patient with dependent personalíry disorder, the patient
wíth passive-aggressive personaliry disorder establishes and maintains rap-
port as long as you agree with him and take his side. When you challenge
his view, you trigger his anger. He is especially sensitive to demands put on
him, he resists them with tardiness, sulking, evasíveness, arguments, and
occasionally open anger. ' ' work.
lf you address his resentment toward dernands, he becomes guarded,
monosyllabic, and often hostile, If you fail to appreciate·this sensitiviry to
dernands, or even syrnpathize with the demanding person, you lose rapport.
You regain ít only if you return to the patíent's point of view,
Technique: ' Slowly and carefully. explore the patient's deep aversión to '
demands. The skillful interviewer expresses that she .understands the
patient's needs for leniency but points out at the same time that the
unfulfilled expectations cause disappointrnent and resentrnent and poíson
all relationships, She knows that if she temporarily sympathízes with the
patient's resentment about dernands, the patient may coopera te and allow
her to explore the superimposed disorder (se e below: Diagnosis),
lJ.J..)Vl\ULl\-.)r CA..•
II·I ••.....•.
II~.l Ll\ "'L" 1."V. l J.....n.J'-'.·. u ..._, •• ~.v.._,.,_L. ..•" .•
Mental status: ,During the interview the patient may not show much
, psychoparhology.His affect appears tobewell adjusted and pleasant except
when he starts ro talk about situations where he was asked otoperforrn. Then
he shows sígns of resentrnent, irritability, 01' anger: If you fail to identify
these trigger situations, you may miss his underlying personality disorder.
': .' '.'
Diagnosis: A patient with passive-aggressive personality disorder rarely
•consults you [or problems related to his disorder. His associated Axis 1
disorders bring him to see )'ou. such as alcoholism, mood disorder, or an
.anxiety disordee',
His story becornes transparent when he talks about social disappoint-
rnents, interpersonal conflicts, and bad breaks. Typicálly, the patient does
not openly oppose dernands but accepts commitments and rnakes promises
even when he knows he will not keep therri.He says "yes" but acts "no."
I This .characterisric leads ro disappointrnents and rejection by colleagues,
Iriends, and family rnernbers. And the patient cornplaíns bitterly about being
I1, rejected without understanding how he sets it off.
If you hit upon the "say yes/act no" attirude, explore whether it is
limited to certain people, situations, oc certain life periods when the patíent
was depressed. If this attitude tints alI relationships lifelong, your patient has
passíve-aggressive personality disorder.
Andy is a 34~year·old businessrnan with a farnily history of bipolar disorder,
but without a psychiatric historv of his own,
, 1, 1: How can I help )'OI.I?
P: I. [ust have toralk ro sornebody about the things that happened toome' at
,2, 1: -01(, Andy. ,
P:' It will probably upset you as rnuch as me,
3.,1: You.must ha ve gone through some rough times,
P: " Have I. ever . , . boyo ir I could tell yOU. This friend of mine accepted a [ob
downhere and when I talked otohim he asked me if I wouldn't like to join
him.
.4. .1:' So you did? ,',' " ,
P:' \X'~H,I did because I trusted ,him. So I went to work with him, and 1 thought
, we'd have a good time, because the guy seemed to be a lot of fun.
5. 1: \Vas he?, " ' , - ,
I P: Let me tell you:_the first thing he did was start with staff rneetings in the
rnornlng=-did 1 ever resent them. That was his sneaky "'{IYof forcing us to
be on time.'
6.1: \X/as there a problern with that?
 '------------------,----- ,

::¡ ..
: ..•.

442 Tbe CÚnicallt,terview Using DSM-lV DISORDER-5PECIFIC I'\TERVIE\'\lNG: PERsoNALrri' Dl50RDER5 443

J.,

P: ,~prohlem? \\fe \Vere" fricnds and he kn'<.:wI had good ideas," but they don't out irisr~ad criticizes the friend as a workaholic. Andy responds wíth anger
'necessadlv come at 8 o'clock in the rnorning.
when his friend hurnors hirn for missing work because of a splinter in his
7,1: \\'<;11",
, fóot CA, 10),
P: \\'hcn 1 carne late, when 1 had ca~'lroubl¿, or when ,1 had to run an errand,
, he didi;'t '5a);anything, but I could feel that he didn't like it. ", ' When (he interviewer confronts Andy with his expectation of receiving
8, .1: \\,'as he ever late himself? " ' privileges, he .beco mes hostíle, His response that he is more ínter-
shows
P: Are you kidding? That guy is a workaholic. He was there in the morning ami ested in mustering support for .hís 'position--2if he indeed discusses his
, he' stayed late 'in the evening. If I'd known that he was such .a slave driver, 1 conflict=-rather than facing hts distorted expectatíon.
would not have come here in (he first' place, But i got back at him when i
had that accident. 1 don'[ know whether he believed me, but I brought the
To stay engaged in (he interview with a patient sufferíng fr~m passive-
splinter frorn rnyfoor wíth me backto work to showit. ' aggressíve personaliry disorder, explore bis point of view. Use bis angle to
9, 1: Did your friend see it? l~ok at his co~f1ícts, The ln((~~'iewer started thís in Q, 15, Over rnany future
P: I showed it to sorne colleagues when he was passing by in rhe hall. sessions, the patient would have to becorne aware of his perspecríve and
l O, 1: Did he see il?' , ' ,
, learn to detect why that perspective causes friction and resentrnent wíth
P: You know whatthat bastard said? "lf you don't believe Andy's story today,
'others, For instance, Andy .has to experíence how colleagues resent the
hell bring a bigger splinter in tomorrow!" Boy, was I miffed. "
11. 1,: So you 'expected him to treat you more as a friend ¡han as an ernployee. ' privilege that he demands by his overt behavior.Tíe has to experience that
P: That's exactly riglu. What's the use ofworking for a friend, if you have to granting him these privileges would be an unfair practice that erodes morale
slave ulong anyway? ' at the workplace. To apply these techniques exceeds the scope of a
12, 1: So he should have given vou some privileges and leeway. diagnostíc interview. For the purpose of the diagnosrlc interview, you only
"P: lsn't that obvious? You don't suppose that 1 should run like clockwork for
that' guy.: ','
need -to be abre to. identify the patient's perspective and use' it for data
collectíon.
1,~,1: \Vell, you said hes at work al H o'clock. '

I
P: Listen, 1 Ihink Irnade a rnistake talkíng toyou about ít, You seein robe , '

just like him. i want you ro know there is more to life than work, work, Dernanding Cruelty in Sadistic
, , work.
14, 1: Let's go back, Andy, and explore sorne more of your feelings about your
Personallty Dlsorder

I
friend's dernands.
What are the characterístics of the patient with sadistic personaliry disorder?
P: Listen, mv friend, 1 have to explore nothing with you any more, I'm here of
rny own free will, ,1resent your domineering attitude. The -physiCal and mental cruelty that such a patíent
and lack of ernpathy
15, 1: l'm sorry. 1 rnust have missed the point cornpletely. i failed to see how your shows forhis victirns will impress you each time you encounter one. He is
.friéncl's pertiness has COSI him yourfrieridship and devotion. quite capable offinding victíms-cusually he chooses sornebody under his
P: [sarcastic] What a suelden rurn in your view. cOntrol, such as a child, wife, student, ernployee, or elderly person. If his
16, 1: Iignoring the sarcasml You're right, lfaíled ro see things frorn your vantage
rank does not assure him superioriry, he will pick on sornebody physically
point. Your friend knew you before you went to work for him-he should
weáker,
have told you what to expect. '
P: Thar's right. 1 would never have worked for him if he'd told me that it's He finds pleasure in dornínating, torturíng, and inflicting pain on his
worse to work for a friend than for just any other ernployer. victirn. Not only is he interesred in the dominance and the ensuing increase
in self-esteern, but in the pain that he can unnecessarilyand deliberately
cause,
The patient makes the underlyíng assumption that everybody who
M~ans that can enhance both dominance over and torture of others
worksfor a friend can expect privileges such as being tardy, taking ii easy,
have a rnagíc fascination for :him. Therefore,' he líkes weapons, the rnartial
and extra time off. Wnen the iriterviewer addresses these expectations
arts, and professions that allow him to use thern,
indirectly <Q, 8). Andy avoids a response such as:
A patient with sadistic personaliry disorder does not seek treatment 'to
.have his sadisrn díffused, Sometimes, you may encounter sadistíc features in
"You are right, he sets a good exarnple, why shouldn't 1'do the samt!?" patíents who suffer from other problems such as persecutory delusions or
'1qq rne Cnntcat tnteroteuiustng U~M-JV
alcohol or substance abuse, and you diagnose the sadistic personalíry
disorder as a eomorbid eondition. Usually, however, you meet hirn through
his victirn.
When you interview sueh a person, he may atternpr io intirnidate, bluff,
and make you, too, suffer. He will use his ways to impose his will upon you.
The following interview takes place between a psychiatrist and the husband
(H) of a patient who dernands his wife's release from the hospital. Mr.
Mambrino is a pale, 5'8", thin man wíth dark, slightly disheveled hair. He
síts stiftly and straight up on a chair with his fists pressed against the
armrests, white knuckles protruding. Out of narrowed eyes he sta res
picrcingly at the interviewer without blinking. ' 13. 1: linterruptinglwhy
J. 1: Hi, Mr. Mambrino. I'm Dr. O., the attending physician here, Our nurse, Mrs.
]., jl.ist called me and told me that you would Iike to talk to me. '
H: [stands up, walks toward the interviewer and positions hirnself in front of
him, with legs spread and with a low, pressed voícel' You got that right, 1
want to sign out Irene [his wife]. She just took off [rom horne and [he next
thing I know is that the social worker calls me and tells me that she has
eheeked into this hospital here.
2. I: Hmm ...
H:, And she tells me that [rene doesn't .even want to talk to me. '
3. 1: [frownsl I don't understand ... [with a puzzled look on hís Iacel and you
want to check her out? ' 17.1: 'That ,is what you did? What did you expect to gel out of that?
H: [with suppressed excitement in his volee] You can't hold her here.
4. 1: [stretching out his right hand nearly touchíng Mr, Marnbrino's chest) Wait a
moment ... What did the social worker tell you?
H: She told me that Irene has checked in here and that Irene wanted her to ler
me know that she's here, but that she doesn't want to talk ro me.
5.1: Hmm ... ,
H: She didn't even want lo come to the phone when 1 called b:i¿k.'
6.1: [shruggingl Well. . . ' There was a newly wed güy and after a few rnonths ofmarriage he rnet
H: [protrudíng his chínl Well . ; . what?
7.1: "Ishrugglng sorne more and leaning slightly backwardsl Seerns like your wife
has made her wishes clear;
H: lsteps forward half a footl I don't believe that. That's a bunch of crap. She
wouldn't dare do that! It's the social worker who put her up ro that. 1 know
.those bitches. They put their noses into everythíng. ' The friend laughed and said: "Yoú forgot to rip the cat apart."
8.1: [raises his eyebrows] You say your wife. wouldn't dare? lpuzzledl I don't
understand. ,
H: [with ernphasis] She wouldn't! She knows better than that! We have a kind
of old-fashioned marriage. She knows what I expect frorn her. But you
liberals wouldn't understand that.
9. 1: lwith a very low voícel Maybe you're right 1 don't understand.
H: [loud but less pressedl In our marríage my wífe is the wife and I'm the mano
She wouldn't go against me.
DISQRDfR~SPECIFI<: INTERvlEWING: PERSO\'ALlTY DISOROERS 445
10. I: Jleaning his head ro the side with. ,3 thin slightly provoking smile] What
rnakes you so convinced? '
H: [with open anger in his voice] Listen. I don'rowe you any explanation
lcondescendíngl but 1'11tell you anyway.
n.t. [turns his back to the husband, walks to a chair, and sits down, stretching
out his feet and looking the husband straíght in the faee but nor saying
anythingl
H: Whe~ we got rnarried my wife was quite immature. Whenevef we had an
argument she was on the phone to tell her mother. 1 put a stop to that shit.
12, 1: [with mild interest] How did you do that? .Ór
H: lwalking toward the intervlewer and standing in front of himl I guess you
'don'l believe me. Let me tell you what. 1'11give you an exampIe.
don't you sít clown? ,
H: [insecure, looking .around the waiting room, and finally taking a seat but
sltting stiffly and bent forwardl Okay, I told rny wife not to call her mother
anyrnore, The next thing I know she's writing her a letter. That was it for me.
14,1: What do you mean "Tha! was ir?" ,
H: I grabbed that bitch by the neck and gave her a good shake and then ...
15: 1: And then what? "
H: And then 1 let her.eat her words.
16. I: [raises his eyebrowsl What do you mean? , '
H: I let her read the letter to me aloud and 1just looked at her. When she was
, , through, I told her: "Eat it!" She looked ai me and knew that I rneant it, I had
, hertear up the letter in pieces and eat ír.
H· Exactly what I got. She quit doing that crap. And now she has the rules
down pat.
18.1: Hrnrn.
H: 'Le! me rell you a [oke that my father used to tell. He was from Italy, the old
country, you know,
19 . .l: Alrighr, go ahead if you have too Why don't you sil down!
P: [MI:.Marnbrino rakes a seat bu! sits just 00 its edgel
hís friend and his friend asked hírn.
"How's it going with your rnarriage?" ,
"Bad," the newly wed ,guy sald. "My wife ís doing as she pleases and I
feeJ líke a clown. She talks about me to her family and friends and rnakes
fun of me." ,
When the newly wed guy said that he didn't gel it, his friend said: "You
, 'see when I got rnarried, I carne horne, grabbed the cal by its legs and ripped
it aparto The cat was my bride's peto She understood who's the master."
"\Vell," the newly wed guy said,"my wife has a cat too." ,
Afew days later, the.newly wed guy me! his friend again. The friend was ,
surprised because the newly wed guy had a black eye and wore a bandage
around his neck, ' ,
"What,happened?" he asked hírn. "
 .J.~
•. __,___. " ......:_......__~•....•.
~__ •.~ ._n' '-M_..... _. _--"-_._ "._. _._. __ " _.. __ O_._._._ .•. :_. '--~
-_._---------_: .•..•_---_ ..._. _-_......__ .. -;::.~:.:,;,:.::....-
: >.. ' .. __•._--' ._" _:...:....._,._--_....:_~. _ .._',. o __ ',.

. ,,~.: .
446 Tbe Clint~ai Interuteu: U$wg U::,M.-ll' .

. interviewer "indirectly." That way. Mr. Marnbrino 1': pl.iced ín a posirion

··\X-ell,1 followed your advice, 1 cune: home, I grabbed rile cal and killed
it. My wífe took a big wooden spoon, hít me in the face, and took the kettle comparable to a flasher who gets deflated whcn 1,1·: intendcd víctim asks
with boiling water and threw it al me." .. .. him.
The friend laughed and coukln't SIOp laughing. "You fool, now i¡':s too
late. You should have killed the Ca! on your wedding night." "Is that all you've got? \'('hy do you show it off?"
I never forgot that story. It stuck with me. And I thought when I gel
rnarried I make sure that 1 wear the pants, And 1 do.
Second, when the patient with sadistic personalu y disorder spells out
20. 1: So ... that kind of kids' sruff irnpresses you?
his threats, the interviewer shows no ernotion, especially not disgust, horror,
H: Okay. let's just stop beating around the bush, 1 will take my wife horne, and
1 mean now. . . or intimídatíon. Instead, he indicares his lack of uudcrstanding for the
21. 1: BUI ~Ir. Marnbrino, I don't understand you. You just heard from the social patii::nt's fascination .with violerice. He shows him a neutral, unímpressed,
worker that your wife doesn't even want to talk (o you. Why do you think "professional" side. .
she wants ro ·go home wilh you now? Third, the ínterviewer doesnot give way to the Ihn.:at nordoes he tey to
H: Listen, buddy, I tell you what. I want her {Q tell me that !O my face, and then
rnake a counterthreat, Insread, he confronts Me. Marnbríno wíth his aggres-
we'llsee. .
22. 1: Your wife doesn't want to see you. Mr. Marnbrino, you just heard that your sion and tells him that nothíng can be accornplished with it.
wife doesn't want to talk !O you face 10 face. Is that so hard lO understand? . Fourth, he sidesteps the .affront and focuses on a legitimate topíc of
!
I
H: That's enough of that [he [urnps up from his chair] 1 considér thís a case of conversátion, namely the husband as the Informant for the patient's psychi-
I kidnapping. lf my wife is no! down hcre .in 2 minutes, you will hear frorn atric problerns.
1
my lawyers.
23. 1: lrernains seared] Mr. Mambrino, that is [ust fine. If I can be of any 'help, he re I
ís thc telephone, . .1 Sacrifice and Self-Destructlonin
H: Your kindreally gets {Q me. I want {Q tell you something in confidence. I've
Self-Defeating Personality Dlsorder
.been a hit man for the Mafia. Ji doesn't mean a thing to me to blow anyone
away. . You encoumer a patienr with self-defeating personaliry disorder (once
24. 1: Mr. .Mambrino, I realize you are angry. There is no reason for threats. You
called rnasochistic 'personality dísorder) under one of rwo sets of circurn-
can't tear apart any cat here. 1 would prefer you sit down and answer a few
questions about your wife. 1 believe you ha ve sorne conceen for her, even stances:
though you have a hell of a way of expressing it.
[stares al
the inrerviewer; after a few secondsl Ha ... let's see whatyou can 1. The patient has a clinical disorder. At the begínriíng of the treatment you
come up with, often notice some social problerns that you think can be interpr~ted as
Th¡1Iall dependa how much you can tell me to .make me understand what's
resulting from the major psychiatric disorder. Typical problems are
going on between you and your wife. You already gave me a líttle taste of
relatedto work andto relational problems in the farnily. Since the patíent
it.
Damned, that was exactly what 1 was afraid of. often suffers eirher from rnajor depressíve or an anxíery disorder, you
I guess you're right. If you díd not get mad about all this. nothing on earth see her problern as the consequence of her coping deficit or her guilt
would have gonen you here to talk to us. So since you're here, we mayas feelings. However, you notice during treatrnent that many of the
well make use of ii. relatíonal problerns persist and that new problems surface that the patient
H: Holy cow _.. I don't believe this _ .. but.let's get on with ir.
had hidden from you previously. Thus, your view of the patient's disorder
can change drárnatlcally during treatrnent, íncreasingly, you notice that
This encounter shows sorne of the key features of sadístic personaliry
her copíng deficits are due ro her personalíry dísorder.
disorder as described above. The íntervíewer uses a set of strategies that
2. ·A patient consults you with syrnptoms that superficially fit criteria for
seem toowork for this mano
adjustment disorder with depressed, or anxious mood, or mixed erno-
First, whenever Me. Mambrino makes an ímplied threat, the ínterviewer
tional features, or with withdrawal or disturbance of conduct. However,
tells him that he does not understand, ro force M¡-. Marnbrino to spell out the .
at closer examination you detect that similar adjustrnent reactions under
threat. That gives Me. Mambrino the message that 'he cannot íntímídate the
448 Tbe Clinical Interuieui Using DSM-IV
DISORÚER-SI'ECIFIC II\TERV1E\Xl:-'<G: PERSONA,LlTY DISORDERS 449

similar circumstances have occurred before. You notice that her prob- 3. 1: That's what they say in the staff meetings, ~rid also the recreational and the
lems are less specific to stress than to a coping·deficit. The patient seerns occupational therapíst sa}' that you're doing so much better.
to arrange Sorne of the failures, reminding you of Freud's norion that . P: J arn, at least for the last week or so:
-4. 1: lsurprised and slightly irritated] \\'hy didn't you tell me? 1 talked to you every
sorne patients seem to have a compulsion to repeat their mistakes ..
day.. . .
Behind the adjustment problem, the self-defeating personality disorder P: 1 thought you would tell me when I'rn ready.
emerges. 5.1: [puzzledl.Hmm, you said you felt overpowered by all your problerns.
P: lsltting up] Yeah, but 1 wasn't depressed anymore .
Under both sets of círcumstances the characteristics that the patient . 6. 1: [with doubt] But YoU isolated yourself and stayed in hedo and ... you're still
displays are the same. She sacrifices her own ínterests for others. She gives back here in your room.
P: . Because 1 don't want to bother others wíth m)' problerns, they have enough
IIp her pleasure and her professional opportunities in favor of sornebody
to worry about thernselves. Reallv, 1 think 1 should be with my kids now.
else's. Her sacrifice is often not solicited, and therefore a bother to others 7. 1: \'í!ho takes care of them now? .
and not appreciated, which can cause. rejection. Typically, she misinterprets P: .'Vlysister and her husband. But thats nor right. They shouldn't be doing that
the reason for this rejection. She believes that she has not gíven enough and jus; for me. I'm really lerting them down so much ... ltears well up in her
eyes]. .
thus she increases contempt rather than ameliorates rejedion. Dysphoric
8. 1: Mary, you were pretry depressed, I think it's best Eor al! of you that the Eamily .
feelings and hopelessness result. ..
helps out. .
If you explore her needs and confront her with her denial oE those
P: lshakes her headl No, 1 ha ve ro go back to 'work ro make sorne money for
needs, she will indicare that they are egotistical and that ir is repulsive to her Iood and the rent.
to pursue those needs. She seems to consider it a sin to even talk about 9.·1: \'íIhat about your husbandr
them. Ifyou point out how her self-denial contributes 'lo her misery, she .. P: He left.
10. 1:. He Ieft? ... Why didn't you evertell me about it?
may reject you as materialistic and nonunderstanding, and lose interest in
P: I was asharned ... but we are sull rnarried ...
you.
1L 1: rOl sorry to hear he left ... How long ago did he leave?
You will find this pattern more often in physícally, sexually, or psycho- }>: Nearly ayear now.
logically abused females, and in passive men who often serve loyally in 12. 1: What happened?
underpaid, dependent positions (Spitzer et al. 1989; Kass et al. 1989). P: \Vell, 1 guess it becarne too much for hirn.
. . 13. 1: What"do you mean' .
P: Wel!, whenhe carne horne there were aJways the children, always a lot of
This is an interview with Mary, a 38-year-old, white, separated female. She
cornrnotíon, they were all.over the.place, Iguess he just couldn't take it.
has been hospitalized and was treated with fluoxetine (Prozac): all vegeta- . 1( 1: [surprised] Couldn't take il? .
tive symptoms of her majar depressive disorder had irnproved. She could
P: You know, he had a lot ofpressure at his iob and he couldn't get along with
concéntrate better in.recreational therapy, signs of psychomotor retardation
his foreman anyway and then he carne home and there was sorne more
were gone and she deníed depressed mood, but she still stayed by herself
pressure.
in her room Iying on her bed. When the interviewer enters her roorri, she
15. 1:· Butthey are his kids, aren't they>
is in bed. She has a thin smile on her Iips. When he walks up ro her, she .
P: Well-yeah, of course, we had a good marriage and il lasted for 15 years:
sinks back into her bed. She looks several years older than her stated age.
but then when 1 was pregnant wuh John, he just couldn't take it anymore.
16.1: Couldn'ttake it? .
1. 1: lwith a soft voicel Mary, you have been wíjh us here for a while; you sleep P: He had the problern.before, andonce in a whíle when it got too much for
well now, you eat well, you seern to get around the hospital fine, but you 'bim,. he would just sta y out. .
look like you carry a big cross. You seem sad most of the time. 17. 1: Stayout?
P: Yes, I'm here in the hospital when 1 should be at horne taking ca re of rny P: With a lady friend ofhis or just wirh the guys from work.
kids [patient has eleven children]. 18. 1: How did you handle that?
2. 1: Well, I'm concemed beca use you stay so much by yourself; that's why 1 P: Well, he told me thereis no discipline with ¡he kids, they are all over the
thought you should stay a little while Ionger: place. He said it was rny [ault ¡hat I couldn't control thern any better.
P: But 1 really feel better. 19.1: But what about hirn? Couldnt he help out?
r----·-- -,. ~~~~-" ,'."~'-"'~' "-
i 450
Tbe Clinicallnterview Using DSM-IV DI50RDER-SPECIFIC INTERVIEWING: PERSO:'\ALlTY DISORDERS 451

I
ti
20. [:
P: Well, he was al work and not around mucho
And what abOUI you>
P: l worked lOO mOSI of the lime. because we couldn't pay the bills on one
P: They reallv want ro be with their high sehool friends, you know, go out with
thern and have a good time-I [ust have 'lo gel through wirh it by rnyself. I'm
irapped, 1 jusi have to do it. There's no way out. I have !O get through it.
38. 1:' Are you living alone with your children nowr
~ paycheck; but he didnt like ii. He liked rneto be home when he carne back
, a! night from his jobo ' " P: \v'ell, kind of .. , There is a fricnd of mine who stays with me rnost of the
lime. '
21. 1: Hrnrn.
39: 1: Oh, 1 see. Does he help out)
P: We argued a lot and there was a 101 of fighting.
P: \Ve 11, George has enough problerns of nis .o\\'n, Hes a veteran, he gOl
22. 1: {surprisedl Fighting? You never rnentioned that before.
P: l guess lfelt guilty. ' injured 'in Vietnam, they had [O amputare his foot. and he.still has pain in (he
23.1: , What were the fights about? , , foot even though .it's off. 11 really got to him mentally. He just gOl out of rhe
state hospital; they said he had schizophrenía. .
P: Oh, about anvthing, but often about me working.
24.1: y ou worklng? 40.1: How .dc you Ieel about tha¡)
P: Yeah , .. He said I rub it in, , , When we went bowling, I let-everybody , P: l feel bad about it because I'm Catholic and l think it's a sin. Because as a
know that I had [O work. It rnade hirnrnad and he started ñghting. Catholic I'm not really divorced,
Physically? 41. 1: That's not what l rneant. 1 mean how you feel about George.
25.1:
P: Physically and rnentally. When he was drlnking, he could get pretty upset. P: 1 feel sorry for him, because he's not able ro work and he has only the VA
26.1: He was drinking? Thats news. ,,' ' , ,', pensión. ,
Well, I'm sorry. l didnt know you and l didn't want to tattle on hirn. 42, 1: So you took on an additional burden ...
P:
27.1: Hrnm. P: I can'[ help him as much as I should because sincc l IU~11\\)' jub at the plant
P: I must have angered him a 101. beeause of my bad vision, 1have to work as a, \\'ailrt.:~sund that doesn't pay
28. 1: Angered him? enough toreally help him out.
P: Yeah, he got pretty mad, l got him SO angry one time that he hit me in the 43.1: It appears ro me th;u you have a hard time thinking about yourself a~d your
face and hroke my nose. own.needs. '
29.1: Hmm, ,'P: 'I don't think onc shoulcl jUMlhi~k about oneself.: 1 cant ¡USIred sorry Ior
P: Another time he hit me in the eve and my retina came off. That's when l lost mvself. And it wouldn't help anyway. .
my job, because I couldn't see well enough any more ro put the chips in the .44, 1: We should try to find out, why you can't think about yourself .. ,
holes and do the soldering. ' l'rn not that kind of a person.
1 30.1:
P:
Mary, it sounds like you too k a lot of abuse,
But it was rny fault, he told me, l brought it on. It is easy tO get apparent rapport with the patient, And that is the first
31. 1: What did your kids say .when there was so much fighting? ,
difficulty. She seems to open up and ís ready to talk about her failures in
P: They got mad at him and then he got rnad at me; because he said l put thern
up ro it. So l tried !O hide it frorn them because he's stilltheir father and l spite of all of her efforts. That is where the interviewer can get trapped. It
don't want thern ro be caughl berween us. ' might escape him-as in Mary's case-that the patient carefully edits what
32.1: Where, is your husband now? she reports so that she appears as a victim.
P: He's around sornewhere. Another díffículry arises when you atternpt to discuss her problems and
33.1: Does he not pay child support? rnake her recognize her behavior as self-defeating. If rhe interviewer focuses
P: He's supposed to, but he dont.
on the underlying self-sacrifícing behavior, the patient feels criticized with-
34.1: Don't you want to take him ro eourt?
P: No, he was my husband, and I don't believe in suing him. And l don't want out beíng able to see its pathological nature. .
[O do it because of me kids , . ' so l'm stuck. ' , ., Self-defeating personaliry disorder is ene of the few conditions in which
35,1: Stuck? BUI he let you clown", Can't you get any other kind af child express ion of ernpathy does not work because it devalues the patienr's
support? ' '
,self-sacrifice as a symptorn. The patient still suffers from the nagging feeling

I
P: If l apply for that, those agencies wÜI go after hirn and l don't want that ro
of not investing enough. If you suggest that she is overburdened, you
happen.
But Mary, your husband ran away and let you hold the bago threaten her ídentíry, which she cannot comprehend as pathological. If you
36. l:
P: 1 have ro get through it. There is no need to talk aboutit. l just have ,to, suggest to her that she dentes her needs and forgoes assertivenéss ro gain
~ Do your older ehildren help out? love arid protectíon through sacrifice, she wilI be appalled by ybur misun-
37.1: I
~ i
 .......

Tbe Clinical lnterview Using DSM-IV

derstanding of her motives. Since the patient cannot be helped without

gaining insight into her behavíoral traits. her personaliry disorder defeats
effective help.

. ¡