96 CHAPTER 3
interview. In any case, the clinician must keep in mind that “unusual” behav-
ior should perhaps be interpreted differently for patients from different cultural
backgrounds. For instance, Japanese people, as a rule, express less emotion in
their faces (Ekman, 1984). A clinician should not necessarily interpret a Japanese
immigrant’s reduced emotional expression as indicating fl at affect. Conversely,
should a Japanese immigrant display anger that would seem “normal” for an
American, the clinician might inquire further about the patient’s anger and abil-
ity to control his or her emotions. Moreover, the same principle applies to differ-
ent age groups; for example, what is usual for a middle-aged adult might not be
usual for an older adult (Baden & Wong, 2008).Patient’s Self-Report
Some symptoms cannot be observed directly, such as the hallucinations that charac-
terize schizophrenia, or the worries and fears that characterize some anxiety disor-
ders. Thus, the patient’s own report of his or her experiences becomes a crucial part
of the clinical assessment.
At some point in the interview process, the clinician will ask about the
patient’s history—past factors or events that may illuminate the current diffi cul-
ties. For example, the clinician will ask about current and past psychiatric or
medical problems and about how the patient understands these problems and
possible solutions to them. The clinician will inquire about substance use, sexual
or physical abuse or other traumatic experiences, economic hardships, and rela-
tionships with family members and others. This information helps the clinician
put the patient’s current diffi culties in context and determine whether his or her
psychological functioning is maladaptive or adaptive, given the environmental
circumstances (Kirk & Hsieh, 2004).
Some patients, however, intentionally report having symptoms that they don’t
actually have or exaggerate symptoms they do have, either for material gain or to
avoid unwanted events (such as criminal prosecution)—such behavior is the hall-
mark of malingering. For instance, a malingering soldier may exaggerate his or her
anxiety symptoms and claim to have posttraumatic stress disorder in order to avoid
further combat. Malingering contrasts with factitious disorder, which occurs when
someone intentionally pretends to have symptoms or even induces symptoms so that
he or she can assume a “sick” role and receive attention. A soldier with factitious
disorder might exaggerate or invent anxiety symptoms not to avoid combat, but for
the attention he or she might receive from other soldiers or from clinicians. Whereas
both malingering and factitious disorder involve deception—inventing or exaggerat-
ing symptoms—the motivations are different. Unlike those with malingering, people
with factitious disorder do not deceive others about their symptoms for material
gain or to avoid negative events.
Most patients intend to report their current problems and history as accu-
rately as possible. Nevertheless, even honest self-reports are subject to various
biases. Most fundamentally, patients may accurately report what they remember,
but their memory of the frequency, intensity, or duration of their symptoms may
not be entirely accurate. As we noted in Chapter 2, emotion can bias what we no-
tice, perceive, and remember.
Another bias that can affect what patients say about their symptoms is report-
ing bias—inaccuracies or distortions in a patient’s report because of a desire to
appear in a particular way (Meyer, 2002). In some cases, patients may not really
know the answer to a question asked in a clinical interview. For instance, when
asked, “Why did you do that?” they may not have thought about their motivation
before and may not really be aware of what it was, but instead create an answer
on the spot (Westen & Weinberger, 2004).
In other cases, people’s psychological functioning is suffi ciently impaired that they
confuse their internal world—their memories, fears, beliefs, fantasies, or dreams—
with reality, which leads to inaccuracies in self-reports; delusions are such an impair-
ment. For instance, Rex Walls frequently told stories about his past, including hisMalingering
Intentional false reporting of symptoms or
exaggeration of existing symptoms, either for
material gain or to avoid unwanted events.
Factitious disorder
A psychological disorder marked by the
false reporting or inducing of medical or
psychological symptoms in order to assume
a “sick” role and receive attention.