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.

1.
APA: Diagnostic and Statistical Manual of Mental Disorders, ed 3 (DSM-III). Washington, American Psychiatric Publishing, 1980.
2.
APA: Diagnostic and Statistical Manual of Mental Disorders, ed 3, rev (DSM-III-R). Washington, American Psychiatric Publishing, 1987.
3.
APA: Diagnostic and Statistical Manual of Mental Disorders, ed 4 (DSM-IV). Washington, American Psychiatric Publishing, 1994.
4.
APA: Diagnostic and Statistical Manual of Mental Disorders, ed 4, rev (DSM-IV-TR). Washington, American Psychiatric Publishing, 2000.
5.
APA: Diagnostic and Statistical Manual of Mental Disorders, ed 5 (DSM-V). Washington, American Psychiatric Publishing, 2013.
6.
World Health Organization: International Classification of Mental Health, ed 9, rev (ICD-9). Geneva, World Health Organization, 1978.
7.
World Health Organization: The ICD-10 Classification of Mental and Behavioural Disorders. Clinical Descriptions and Diagnostic Guidelines. Geneva, World Health Organization, 1992.
8.
Blashfield RK, Keeley JW, Flanagan EH, Miles SR: The cycle of classification: DSM-I through DSM-V. Annu Rev Clin Psychol 2014;10:25-51.
9.
Maj M, Gaebel W, López-Ibor JJ, Sartorius N (eds): Psychiatric Diagnosis and Classification. Chichester, Wiley & Sons, 2002.
10.
McGorry P: The next stage for diagnosis: validity through utility. World Psychiatry 2013;12:213-215.
11.
Parnas J: Differential diagnosis and current polythetic classification. World Psychiatry 2015;14:284-287.
12.
Jansson L, Handest P, Nielsen J, Sæbye D, Parnas J: Exploring boundaries of schizophrenia: a comparison of ICD-10 with other diagnostic systems in first-admitted patients. World Psychiatry 2002;1:109-114.
13.
Jakobsen KD, Frederiksen JN, Parnas J, Werge T: Diagnostic agreement of schizophrenia spectrum disorders among chronic patients with functional psychoses. Psychopathology 2006;39:269-276.
14.
Andreasen NC: DSM and the death of phenomenology in America: an example of unintended consequences. Schizophr Bull 2007;33:108-112.
15.
Parnas J: A disappearing heritage. The clinical core of schizophrenia. Schizophr Bull 2011;37:1121-1130.
16.
Parnas J, Sass LA, Zahavi D: Rediscovering psychopathology: the epistemology and phenomenology of the psychiatric object. Schizophr Bull 2013;39:270-277.
17.
Parnas J, Zahavi D: The role of phenomenology in psychiatric diagnosis and classification; in Maj M, Gaebel W, López-Ibor JJ, Sartorius N (eds): Psychiatric Diagnosis and Classification. Chichester, Wiley and Sons, 2002, pp 137-162.
18.
Van Os J: The dynamics of subthreshold psychopathology: implication for diagnosis and treatment. Am J Psychiatry 2013;170:695-698.
19.
Spitzer RL, First MB, Shedler J, Westen D, Skodol AE: Clinical utility of five dimensional systems for personality diagnosis: a ‘consumer preference' study. J Nerv Ment Dis 2008;196:356-374.
20.
Westen D: Prototype diagnosis of psychiatric syndromes. World Psychiatry 2012;11:16-21.
21.
DeFife JA, Peart J, Bradley B, Ressler K, Drill R, Westen D: Validity of prototype diagnosis for mood and anxiety disorders. JAMA Psychiatry 2013;70:140-148.
22.
PDM Task Force: Psychodynamic Diagnostic Manual (PDM). Silver Springs, Alliance of Psychoanalytic Organizations, 2006.
23.
OPD Task-Force (ed): Operationalized Psychodynamic Diagnosis (OPD-2). Manual of Diagnosis and Treatment Planning. Kirkland, Hogrefe & Huber, 2008.
24.
Kraus A: How can the phenomenological-anthropological approach contribute to diagnosis and classification in psychiatry?; in Fulford KW, Morris KJ, Sadler JZ (eds): Nature and Narrative. Oxford, Oxford University Press, 2003, pp 199-216.
25.
Gross G, Huber G, Klosterkötter J, Linz M: Bonner Skala für die Beurteilung von Basissymptomen. Berlin, Springer, 1987.
26.
Parnas J, Møller P, Kircher T, Thalbitzer J, Jansson L, Handest P, Zahavi D: EASE: Examination of Anomalous Self-Experience. Psychopathology 2005;38:236-258.
27.
Nelson B, Thompson A, Chanen AM, Amminger GP, Yung AR: Is basic self-disturbance in ultra-high risk for psychosis (‘prodromal') patients associated with borderline personality pathology? Early Interv Psychiatry 2013;7:306-310.
28.
Nordgaard J, Parnas J: Self-disorders and the schizophrenia spectrum: a study of 100 first hospital admissions. Schizophr Bull 2014;40:1300-1307.
29.
Klosterkötter J, Hellmich M, Steinmeyer EM, Schultze-Lutter F: Diagnosing schizophrenia in the initial prodromal phase. Arch Gen Psychiatry 2001;58:158-164.
30.
Parnas J, Handest P, Sæbye D, Jansson L: Anomalies of subjective experience in schizophrenia and psychotic bipolar disorder. Acta Psychiatr Scand 2003;108:126-133.
31.
Vollmer-Larsen A, Handest P, Parnas J: Reliability of measuring anomalous experience: the Bonn Scale for the Assessment of Basic Symptoms. Psychopathology 2007;40:345-348
32.
Nordgaard J, Parnas J: A semi structured, phenomenologically-oriented psychiatric interview: descriptive congruence in assessing anomalous subjective experience and mental status. Clinical Neuropsychiatry 2012;9:123-128.
33.
Nordgaard J, Sass LA, Parnas J: The psychiatric interview: validity, structure, and subjectivity. Eur Arch Psychiatry Clin Neurosci 2013;263:353-364.
34.
Stanghellini G: The grammar of the psychiatric interview. A plea for the second-person mode of understanding. Psychopathology 2007;40:69-74.
35.
Fuchs T: Subjectivity and intersubjectivity in psychiatric diagnosis. Psychopathology 2010;43:268-274.
36.
Jaspers K: Allgemeine Psychopathologie. Berlin, Springer, 1913.
37.
Blankenburg W: Der Verlust der natürlichen Selbstverständlichkeit: Ein Beitrag zur Psychopathologie symptomarmer Schizophrenien. Stuttgart, Enke, 1971.
38.
Kraus A: The significance of intuition for the diagnosis of schizophrenia; in Maj M, Sartorius N (eds): Schizophrenia. Chichester, Wiley, 1999.
39.
Srivastava A, Grube M: Does intuition have a role in psychiatric diagnosis? Psychiatr Q 2009;80:99-106.
40.
Varga S: Vulnerability to psychosis, I-thou intersubjectivity and the praecox feeling. Phenomenol Cogn Sci 2013;12:131-143.
41.
Wyrsch J: Über die Intuition bei der Erkennung der Schizophrenen. Schweiz Med Wochenschr 1946;46:1173-1176.
42.
Minkowski E: La schizophrénie. Psychopathologie des schizoïdes et des schizophrènes. Paris, Payot, 1927.
43.
Minkowski E: Le temps vécu. Etudes phénoménologiques et psychopathologiques. Paris, Collection de l'Evolution Psychiatrique, 1933.
44.
Binswanger L: Welche Aufgaben ergeben sich für die Psychiatrie aus den Fortschritten der neueren Psychologie? Zeitschr Gesamte Neurol Psychiatr 1924;91:402-436.
45.
Binswanger L: Drei Formen missglückten Daseins. Verstiegenheit, Verschrobenheit, Manieriertheit. Tübingen, Niemeyer, 1956.
46.
Tellenbach H: Geschmack und Atmosphäre. Medien menschlichen Elementarkontaktes. Salzburg, Müller, 1968.
47.
Winnicott DW: Hate in the countertransference. Int J Psychoanal 1949;30:69-74.
48.
Heimann P: On countertransference. Int Journal Psychoanal 1950;31:81-84.
49.
Racker H: The meanings and uses of countertransference. Psychoanal Q 1957;26:303-357.
50.
Searles HF: Countertransference and related subjects; selected papers. New York, International Universities Press, 1979.
51.
Gabbard GO: Countertransference issues in psychiatric treatment. Washington, American Psychiatric Press, 1999.
52.
Kernberg O: Notes on countertransference. J Am Psychoanal Assoc 1965;13:38-56.
53.
Kohut H: Forms and transformations of narcissism. J Am Psychoanal Assoc 1966;14:243-272.
54.
Klein M: Notes on some schizoid mechanisms. Int J Psychoanal 1946;27:99-110.
55.
Ogden T: Reverie and Interpretation. New York, Aronson, 1997.
56.
Irle G: Das ‘Praecoxgefuhl' in der Diagnostik der Schizophrenie. Arch Psychiatr Nervenkr Z Gesamte Neurol Psychiatr 1962;203:385-406.
57.
Sagi GA, Schwartz MA: The ‘praecox feeling' in the diagnosis of schizophrenia: a survey of Manhattan psychiatrists. Schizophr Res 1989;2:35.
58.
Rümke HC: Das Kernsymptom der Schizophrenie und das ‘Praecox Gefühl'. Z Gesamte Neurol Psychiatr 1941;102:168-175.
59.
Ungvari GS, Chiu HFK, Leung HCM, Chow LY, Hong Y, So EMP, Lum FCK: Conceptual issues in the diagnosis of schizophrenic psychoses. Hong Kong J Psychiatry 1997;7:4-8.
60.
Grube M: Towards an empirically based validation of intuitive diagnostic: Rümke's ‘Praecox feeling' across the schizophrenia spectrum: preliminary results. Psychopathology 2006;39:209-217.
61.
Ungvari GS, Xiang Y, Hong Y, Leung HCM, Chiu HFK: Diagnosis of schizophrenia: reliability of an operationalized approach to ‘Praecox-Feeling'. Psychopathology 2010;43:292-299.
62.
Brody EM, Farber BA: The effects of therapist experience and patient diagnosis on countertransference. Psychotherapy 1996;33:372-380.
63.
McIntyre SM, Schwartz RC: Therapists' differential countertransference reactions toward clients with major depression or borderline personality disorder. J Clin Psychol 1998;54:923-931.
64.
Holmqvist R: Staff feelings and patient diagnosis. Can J Psychiatry 2000;45:349-356.
65.
Schwartz RC, Smith SD, Chopko B: Psychotherapists' countertransference reactions toward clients with antisocial personality disorder and schizophrenia: an empirical test of theory. Am J Psychother 2007;61:375-393.
66.
Thylstrup B, Hesse M: Substance abusers' personality disorders and staff members' emotional reactions. BMC Psychiatry 2008;8:21.
67.
Røssberg JI, Karterud S, Pedersen G, Friis S: Psychiatric symptoms and countertransference feelings: an empirical investigation. Psychiatry Res 2010;178:191-195.
68.
Betan E, Heim AK, Conklin CZ, Westen D: Countertransference phenomena and personality pathology in clinical practice: an empirical investigation. Am J Psychiatry 2005;162:890-898.
69.
Røssberg JI, Karterud S, Pedersen G, Friis S: An empirical study of countertransference reactions toward patients with personality disorders. Compr Psychiatry 2007;48:225-230.
70.
Colli A, Tanzilli A, Di Maggio G, Lingiardi V: Patient personality and therapist response: an empirical investigation. Am J Psychiatry 2014;171:102-108.
71.
Tanzilli A, Colli A, Muzi L, Lingiardi V: Clinician emotional response toward narcissistic patients: a preliminary report. Res Psychother Psychopathol Process Outcome 2015;18:1-9.
72.
Gazzillo F, Lingiardi V, Del Corno F, Genova F, Bornstein RF, Gordon RM, McWilliams N: Clinicians' emotional responses and Psychodynamic Diagnostic Manual adult personality disorders: a clinically relevant empirical investigation. Psychotherapy 2015;52:238-246.
73.
Lingiardi V, Tanzilli A, Colli A: Does the severity of psychopathological symptoms mediate the relationship between patient personality and therapist response? Psychotherapy 2015;52:228-237.
74.
Pallagrosi M, Fonzi L, Picardi A, Biondi M: Assessing clinician's subjective experience during interaction with patients. Psychopathology 2014;47:111-118.
75.
Kernberg OF: Borderline Conditions and Pathological Narcissism. New York, Aronson, 1975.
76.
Ventura MA, Green MF, Shaner A, Liberman RP: Training and quality assurance with the Brief Psychiatric Rating Scale: ‘The drift buster'. Int J Methods Psychiatr Res 1993;3:221-244.
77.
Ventura J, Lukoff D, Nuechterlein KH, Liberman RP, Green M, Shaner A: Appendix 1: Brief Psychiatric Rating Scale (BPRS) expanded version (4.0) scales, anchor points and administration manual. Int J Methods Psychiatr Res 1993;3:227-244.
78.
Morosini P, Roncone R, Impallomeni M, Marola V, Casacchia M: Presentazione dell'adattamento italiano della Brief Psychiatric Rating Scale, versione 4.0 ampliata (BPRS 4.0). Riv Riabil Psichiatr Psicosoc 1995;3:195-198.
79.
Roncone R, Ventura J, Impallomeni M, Falloon IR, Morosini PL, Chiaravalle E, Casacchia M: Reliability of an Italian standardized and expanded Brief Psychiatric Rating Scale (BPRS 4.0) in raters with high versus low clinical experience. Acta Psychiatr Scand 1999;100:229-236.
80.
Stanghellini G: Philosophical resources for the psychiatric interview; in Fulford KW, Davies M, Gipps R, Graham G, Sadler J, Stanghellini G, Thornton T (eds): The Oxford Handbook of Philosophy and Psychiatry. New York, Oxford University Press, 2013, pp 321-356.
81.
Chang H: Inventing Temperature: Measurement and Scientific Progress. New York, Oxford University Press, 2004.
82.
Schwartz MA, Wiggins OP: Typifications. The first step for clinical diagnosis in psychiatry. J Nerv Ment Dis 1987;175:65-77.
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