The Pathological Context and Diagnosis

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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 charac-terology 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.

To consider further the relationship between diagnosis and prognosis, the organization and description of the diagnostic nomenclature is presented in the following chapter, along with a compilation of the diagnostic nosology.

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