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 presented in chapters 12 and 13 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. 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.

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