By: Henry Kellerman and
Anthony Burry
A well-formulated, meaningful diagnostic statement summarizes
the patient’s functioning, problems, and strengths in a manner that indicates
the nature of the disorder
and potentials that exist for change. The identification of such possibilities
for change can lead to the purposeful design of intervention strategies that
sensibly and systematically relate to
diagnostic findings.
In addition, a carefully formed diagnostic analysis, along
with its implications for appropriate intervention, present the opportunity to
evaluate the patient’s prognosis. Thus, the diagnosis leads to a
prognostic assessment. Just as the diagnosis presents the patient’s total functioning in
an encapsulated framework, the prognostic statement
indicates what sort of change, growth, repair, or even deterioration may be possible or likely.
Because the prognosis for the patient and the choice of
intervention are so dependent on implications contained in the diagnostic
assessment, a careful analysis of the structure of diagnosis is of primary importance.
Elements of Diagnosis
The formulation of a diagnosis for the patient who has been tested brings together a complex array of several thematic and structural elements that the psychological analysis has served to clarify throughout the report. In addition, these features of the patient’s personality have to be considered along with factors that are implied by the diagnosis itself.
For
example, some diagnostic conditions are chronic, and others tend to be more
transient in their effects. Some diagnostic states involve deeper, more serious
pathology; others reflect superficial disturbances. A
number of diagnostic categories are inherently fluid and changeable while others
tend to be crystallized and rigid. The former are more amenable to modification
and the latter tend to be recalcitrant to efforts toward change.
Similarly,
the presenting problem may be superficial within the personality or it may
represent more profound, long-term ramifications. An additional feature about
the phenomenon of diagnosis is that the reporting of different levels of
pathology may be the most effective way to compose a diagnosis.
As can be seen, diagnosis involves several interconnected features, including the following:
• The potential for shift within any diagnostic formulation; • The relationship between the presenting problem and the overall diagnosis of the personality; • The presenting problem as an onset phenomenon that bears on the acute versus chronic dimension of pathology; • The presence of various levels of pathology and their interconnections; • The impact of these diagnostic features on the development of intervention strategies and prognostic formulations.Diagnosis as a Shifting Phenomenon
It should be noted that the diagnosis is formulated at a specific point in the patient’s life. This raises the implication that, in certain cases, the diagnosis may represent only a temporary or time-limited statement about the patient; thus, it can be a shifting phenomenon. Examples of diagnostic shift are the incipient, emerging psychosis or, conversely, the psychosis proceeding toward remission in which a relatively stable characterology emerges. An additional example is the change in character type that follows psychotherapeutic treatment. This example also reflects the fact that diagnosis may be an evolving phenomenon.There also are instances in which fluidity and shifts in diagnosis are less likely to occur or may not occur at all. The most striking example of this diagnostic inflexibility may be the profoundly organically impaired patient. Even in this case, however, psychological elements related to the patient’s comfort and maximal functioning can be enhanced within the limits of obvious pathology and, thus, be part of interventions involving change.
The
persisting acting-out of some psychopathic or antisocial individuals may also
be relatively unchanging; yet, a deeper analysis of overall personality
functioning may provide opportunities for change. Therefore, reporting the potential for change with respect to the
formulation of any diagnosis is an important contribution that the psychologist
can make.
Connections Between Diagnosis and the Presenting Problem
One consideration the psychologist can make in a diagnostic formulation concerns the manner in which the presenting complaint is embedded in the context of the patient’s overall functioning. The importance of this portion of the diagnostic process results from the fact that the presenting disturbance is a sample of the underlying personality problem and both the symptom and underlying problem have contributed to the test referral.
The
presenting symptom represents an outgrowth of psychological pressure in the
person and may also reflect the difficulty imposed on the individual’s social
network. Inherent vulnerabilities within the individual’s overall personality structure or a shift in an internal aspect of
personality functioning provide the occasion of symptom development. Thus, the
relationship between the presenting complaint and the diagnosis may be
clarified by demonstrating certain linkages. The presenting symptom, the
prognosis, and the choice of intervention may depend on the nature of the
linkage between the structure and functioning of the overall personality and
the outgrowth of the singular or apparently more limited presenting symptom.
For
example, the complaint of sudden hyperactivity in a school-age child requires diagnostic
delineation of the symptom based on its nature, consistency, context in which
it appears, duration, and corresponding signs of disturbance. Clarity about the
nature of the presenting problem is not fully useful, however, unless the
nature of the personality disturbance that generates it is also understood.
Consequently, the diagnosis is most useful when connected to the context of the
presenting complaint. In the instance of a hyperactive student, the
intervention and prognosis will mainly depend on the underlying personality
problem to which the original symptom is tied and that it reflects in
microcosm.
As
one possibility, the hyperactivity may develop from a recent organic trauma such
as one emanating from a head injury; it may stem from the crystallization of symptomatology
deriving from underlying minimal brain damage that suddenly surfaces in
response to increased demands for concentration and learning in school; it may
be generated by an upset—a neurotic child’s silently furious and fearful
reaction to a recent parental separation; or it may be a sign of an emerging psychosis
in a child whose vulnerabilities have been stimulated by an increase in social
pressure.
These
examples are presented to alert the psychologist to the complexity and intricacy
of any approach to diagnosis. A clearly understood link between the original,
overt symptom at the behavioral or experiential level and the current diagnosis
can create a more effective focus to the meaning of the symptoms, their purpose,
the person’s potential for change, and an appropriate intervention. In a similar way, the choice of intervention strategy and consequent prognosis,
which can include or combine medication, psychotherapy, or special educational
placement, necessarily depends on clarification of the symptom’s connection to
its underlying source.
Acute Versus Chronic Pathology
Another
element that contributes to the formulation of the diagnosis is the duration of
the symptom complaint. A determination needs to be made with respect to onset
of the disturbing behavior, which then enables an assessment of the length of
the individual’s difficulty and whether any precursors to this particular
disturbance have previously appeared.
The
importance of the duration of patterns of pathology is often tied to the
seriousness of the diagnosis as well as to the prognostic optimism or
guardedness. Generally speaking, the estimate of prognosis and depth of
pathology in clinical disorders follows the same rule as in general medicine:
acute disorders have better prognoses, and chronic disorders are more
problematic and, therefore, more resistant to change.
For
example, endogenous depression, in which a
historically long-standing depressive mood exists without an obvious external
precipitant, can suggest a poor prognosis. In contrast, the diagnosis of reactive
depression—incorporated in DSM-IV as
dysthymic disorder—indicates a depressive mood of relatively recent onset in
which the symptom is directly tied to a specific traumatic event such as loss or injury. In such cases of recent onset, the depression is a reaction
within the personality that is designed to allay panic and anxiety and allow
the individual to gain time to cope with the problem. Under these circumstances
of acute onset, prognosis is generally positive. When the traumatic event is
not dealt with adaptively, however, the acute reaction can potentially develop
into a more protracted depressive state.
Because,
in the majority of instances, acute onset cases have a positive prognosis, the
psychologist should be aware that when reactive depressions become chronic, a
character structure that fosters crystallization of depressive features is sure
to have existed beneath the surface. The underlying characterology may, for example,
relate to needs for affection and dependency. The psychologist is, therefore,
in a unique position to evaluate an acute symptom as well as long-term
character trends which may complicate diagnosis of the acute problem. The coexistence
of acute or reactive disturbances along with more enduring, underlying
disorders reveals that there are various levels of functioning within the
personality, and that the diagnostic formulation needs to reflect them.
Levels of Diagnosis
Usually,
references to preliminary diagnosis were defined in broad terms as a fourfold
system consisting of neurosis or anxiety disorder, character or personality
disorder, psychosis, and organicity. This classification system should be
considered a heuristic device that is empirically based; it permits
conceptualizations appropriate to the formation of preliminary diagnostic
hypotheses. As additional findings are further analyzed, refinements in
diagnostic hypotheses are possible because more complex possibilities and
combinations become apparent.
Once
finer diagnostic considerations are reached, the fourfold classification model
becomes a basis for a more complex diagnostic statement. This classification
model is founded on clinical distinctions between the four major diagnostic categories.
The
neurotic diagnoses or anxiety disorders are determined by the predominance of
anxiety and symptoms related to anxiety.
The
character or personality disorder diagnoses are based on the relative absence
of anxiety and the prominent role of enduring maladaptive trait patterns.
The
diagnoses involving psychoses are based on profound thinking or
mood aberrations that interfere with fundamental reality testing.
Finally,
the organic disorders are based on physical or neurophysiological traumas that
underlie disturbances in personality functioning.
In
addition to sorting diagnoses into categories, the psychologist can establish a
theoretical and integrative network on the basis of the conventional and
pragmatic catalogue of discrete diagnostic entities. One way to provide an
integrative approach to diagnostic formulation is to consider pathology or
aberration as a reflection of three levels of diagnosis.
The
first of these diagnostic levels may take relatively external forms such as
behavioral manifestations.
The
second level of diagnosis involves internal phenomena such as deficits,
anxiety, and idiosyncratic ideation or mood.
A
third diagnostic level includes character structure, which is intermediate
between the internal and external dimensions.
Integrating Diagnostic Levels
One constant in the personality and in the corresponding diagnostic component linked to it is the character structure. This is the relatively stable, enduring network of traits and dispositions that expresses the typical personality style or approach of any particular individual.
Because
the presence of characterology is universal, it is appropriate to present,
whenever possible, a diagnostic assessment that includes this level. If the
psychologist consolidates the overall test results and summarizes the analyses
throughout all the preceding sections of the report, the patient’s character
formation can usually be specified.
The
patient’s typical character formation exists regardless of the superficiality or
depth of pathology. Consequently, an individual functioning at a neurotic or symptom
level; a patient in a psychotic state; or an organically impaired person all
possess, at a basic level of their personality, the quality of character or
personality structure.
The
importance of the characterological aspect of functioning makes it essential to
specify its nature even if it is damaged or fragmented. On the basis of the
analysis of character functioning throughout the report, and in connection with
material relevant to character traits, on interpersonal behavior, the
diagnostic impression most consistent with test results regarding the patient’s
character style should be specified.
For
example, a diagnosis of obsessive-compulsive personality disorder would reflect
this level. If the findings additionally indicate the presence of neurotic or
symptom phenomena, these can be considered to be components of the diagnostic
formulation at a separate level. Such neurotic or symptom features can be
specified in the diagnostic assessment that summarizes the totality of the
patient’s pathological functioning.
In
keeping with the previous illustration of the obsessive-compulsive personality disorder,
if phobic disturbances also are reflected in test results, this anxiety-related
level of diagnosis can become a diagnostic qualifier: the diagnosis becomes obsessive-compulsive
personality disorder with phobic features. If, in addition, the test findings
reported indicate the presence of a psychotic process or organic impairment,
these levels of personality disturbance would also be encapsulated in the diagnostic assessment to elaborate further the summary of pathological
functioning.
An integrative diagnostic formulation will also indicate qualitative features that add clarity and refinement to the summary description of the patient. In this way, the relative contribution made by each level toward personality functioning can be delineated.
An integrative diagnostic formulation will also indicate qualitative features that add clarity and refinement to the summary description of the patient. In this way, the relative contribution made by each level toward personality functioning can be delineated.
The
reader of the report can be informed in the diagnostic formulation if, for
example, a psychotic process is chronic or acute, incipient and emerging, or
progressing toward remission or residual status. The psychosis may be an
underlying process in relation to the patient’s character structure, or it may be
overt.
In
addition, even if the character or personality structure is not fully intact,
the specific nature of the characterological context that is impaired by a
psychotic or organic process can be specified. If an organic impairment is
found, it is useful to clarify whether it is mild or profound, acute or chronic.
The characterological context in which the organic impairment occurs is
essential to report, as is the presence of any neurotic symptoms that have appeared. This kind of specificity can
have a significant bearing on prognosis and intervention.
For
example, if a phobia or sexual impotence is linked to a symptom level of
functioning in an organically impaired patient, quite different implications
would be drawn than if these phenomena appeared to derive from the organicity
itself. Any
outstanding features that distinguish the diagnostic status of the patient can
be added to the diagnostic statement.
This addition enables the diagnostic summary
to reflect more accurately the major factors of personality functioning; for
example, the addition of an indication of depressive features to any diagnostic
formulation where this is appropriate.
Information
concerning a subject’s alcohol abuse or drug addiction might also be appended
in cases in which these involvements are known and have influenced the test
results sufficiently to warrant reporting of associated findings.
The
various kinds of added features that are linked to the diagnostic formulation
may or may not be related to the original presenting complaint or symptom. Nevertheless,
the summary of diagnostic levels and their integration affords a context in
which the presenting problem that brought the patient into the referral sequence
can be considered in depth.
The Pathological Context and Diagnosis
Because the patient was referred for testing and evaluation as a result of presenting complaints and the confusion surrounding them, it is logical to address the context of the presenting complaint when developing and formalizing the diagnostic summary. Simply restating the problem in diagnostic terms is not sufficient because it fails to enhance the explanatory power of the assessment and does not summarize the test findings.
For
example, simply reporting alcohol abuse does not clarify any processes involved.
Consequently, a diagnosis of the pathological context in which the presenting
problem is embedded is a crucial part of the diagnostic effort. Thus, relating the
presenting complaint to its pathological context is the logical conclusion to the
entire report. This means that the essential diagnostic effort and conclusion
by the psychologist will involve detailing the aspects of personality
disturbance that relate to and clarify the presenting problem.
Alcoholism
can serve as an example to indicate that a presenting problem needs to be
embedded in a careful diagnostic formulation because it illustrates the way in
which a symptom gains meaning through more careful assessment of the
accompanying personality problems. The patient’s presenting complaint, drinking
too much, may relate to underlying psychotic vulnerabilities, together with a
pathological character structure. For instance, a characterological disturbance
involving phenomena of dependency and passivity may lead to excessive reliance
on drinking to reduce anxiety and attempt to retain integrity in personality
functioning.
Alcohol
intake may also be used by the patient as an anesthesia to mask an ongoing
chronic experience of rage—by drinking, the patient is self-medicating the
rage. Diagnosing the pathological character structure of the patient clarifies
the role of the presenting complaint as a reflection of a specific personality
conflict. Similarly, if there is an underlying psychotic process to which the
dependent and passive characterology is affixed, this can also be useful in
understanding the phenomenon of the presenting drinking problem. Thus, the personality context in which the
presenting problem occurs is an important focus of diagnostic effort.
In
relation to this example of a drinking problem as a presenting symptom, additional
diagnostic factors may need to be considered. If the drinking continues for a
period of years, an organic brain syndrome may result. The diagnosis of this syndrome,
and its effects on the patient’s current functioning and prognosis, would be
crucial in the diagnostic assessment that summarizes the findings of the psychological testing. This example illustrates the complexity of the context
of disturbance that needs to be diagnosed in order to assess the patient’s
pathology meaningfully and in such a way as to clarify the prognostic
considerations.
Another
example of a presenting problem that illuminates the complex relationships
among levels of pathology that need to be diagnostically clarified is sexual impotence.
As a conversion or somatized symptom, the problem of impotence in the male may
simply be associated with the diagnosis of a conversion type of histrionic
state. Or, impotence can be a derivative symptom of depression. Thus, the
context of character formation that exists in the individual is also important
in understanding the nature and role of this symptom.
Therefore,
an assessment of the character structure would be essential to include in the
diagnostic summary. For instance, this characterology may reveal the
individual’s readiness to rely on withholding, passive-aggressive interpersonal
traits, which is not only a compatible context for the conversion symptom of
impotence, but also is helpful in revealing additional problems derived from
character structure. In turn, these problems may reflect a more general kind of
impotence such as an inability to complete projects, develop or advance a
career, or achieve fulfillment in a wide range of endeavors.
Further,
the passive-aggressive characterological context may reveal the motive to frustrate
and assert individuality in a passive, covert way that provides additional meaning
to the presenting impotence system. A phenomenon of depression may be either a
consequence or contributing factor that is appropriate to diagnose as well.
Summary
The subtle interplay between symptoms and the various levels of personality disturbance were discussed here.
Whenever
the interaction of these diagnostic dimensions becomes apparent from the
results of testing, it is valuable for the psychologist to integrate them into
the diagnostic formulation. Thus, it is frequently useful to detail the context
of character in which symptoms occur, even clearly neurotic or anxiety level
ones, as well as any underlying psychotic or organic phenomena.
It
is beneficial to describe the interplay and joint occurrence of any or all of
these diagnostic levels as they contribute to personality functioning. Such a formulation
enables a clear appreciation of the complex connections that influence the
appearance of symptomatology. The interplay between the various levels of personality,
and the extent of the relative impact of each, contribute to the prognostic
formulation as well as to a choice of intervention strategy.
Diagnostic principles.
The
elements of diagnosis include the following:
• Diagnosis can shift: Character change can occur as a result of therapy intervention; symptoms can be alleviated; states of remission can be achieved; or pathology can intensify.
• A relationship obtains between the presenting problem and the diagnosis: The presenting disturbance is usually an example in microcosm of the underlying personality problem.
• Pathology may be acute or chronic: The duration of the symptom complaint is the key question. Generally, an acute diagnosis suggests a better prognosis.
• There are levels of diagnosis: Diagnosis can refer to characterology, anxiety or neurotic symptoms, psychotic, and organic phenomena, as well as to any incipient pathological process. The prominence of any of these four levels also corresponds to the principle of the diagnostic shift. The levels of diagnosis should be integrated. This integration is made with reference to character
structure, anxiety disorders, or even underlying incipient psychotic states. The diagnosis can refer to:
• Behavioral manifestations;
• Internal phenomena involving deficits, anxiety, idiosyncratic ideation, and mood;
• Character structure—the enduring network of traits and dispositions of the personality;
• Psychotic or organic features.
The pathological context is related to diagnosis. The pathological process in which the presenting problem is embedded should constitute a major part of the diagnostic picture.
• Diagnosis can shift: Character change can occur as a result of therapy intervention; symptoms can be alleviated; states of remission can be achieved; or pathology can intensify.
• A relationship obtains between the presenting problem and the diagnosis: The presenting disturbance is usually an example in microcosm of the underlying personality problem.
• Pathology may be acute or chronic: The duration of the symptom complaint is the key question. Generally, an acute diagnosis suggests a better prognosis.
• There are levels of diagnosis: Diagnosis can refer to characterology, anxiety or neurotic symptoms, psychotic, and organic phenomena, as well as to any incipient pathological process. The prominence of any of these four levels also corresponds to the principle of the diagnostic shift. The levels of diagnosis should be integrated. This integration is made with reference to character
structure, anxiety disorders, or even underlying incipient psychotic states. The diagnosis can refer to:
• Behavioral manifestations;
• Internal phenomena involving deficits, anxiety, idiosyncratic ideation, and mood;
• Character structure—the enduring network of traits and dispositions of the personality;
• Psychotic or organic features.
The pathological context is related to diagnosis. The pathological process in which the presenting problem is embedded should constitute a major part of the diagnostic picture.
References
Henry
Kellerman and Anthony Burry, Handbook of Psychodiagnostic Testing, Fourth
Edition, 2007, Springer ScienceBusiness Media, LLC.
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