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

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

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

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