Diagnosis of personality disorders: a case study

In this article, I report a case highlighting diagnostic uncertainty about psychopathology on both Axes I and II. It concerns in part the problem of comorbidity in relation to diagnostic classification of Axis II personality disorders. After commenting on these uncertainties in relation to categorical and dimensional models, I also consider a psychoanalytic explanation to illustrate an example in which a theoretical model informs diagnostic interviewing. I emphasize how the clinical information that unfolds from an interview based on this theoretical model generates inferences about psychopathology that extend clinical understanding beyond the formal diagnostic assessment of Axes I and II disorders and assessment by self-report.     

Diagnosis of Personality Disorders: A Case Study

In this article, I report a case highlighting diagnostic uncertainty about psychopathology on both Axes I and II. It concerns in part the problem of comorbidity in relation to diagnostic classification of Axis II personality disorders. After commenting on these uncertainties in relation to categorical and dimensional models, I also consider a psychoanalytic explanation to illustrate an example in which a theoretical model informs diagnostic interviewing. I emphasize how the clinical information that unfolds from an interview based on this theoretical model generates inferences about psychopathology that extend clinical understanding beyond the formal diagnostic assessment of Axes I and II disorders and assessment by self-report.     

A diagnostic tree model for polytomous responses with multiple strategies

Constructed-response items have been shown to be appropriate for cognitively diagnostic assessments because students’ problem-solving procedures can be observed, providing direct evidence for making inferences about their proficiency. However, multiple strategies used by students make item scoring and psychometric analyses challenging. This study introduces the so-called two-digit scoring scheme into diagnostic assessments to record both students’ partial credits and their strategies. This study also proposes a diagnostic tree model (DTM) by integrating the cognitive diagnosis models with the tree model to analyse the items scored using the two-digit rubrics. Both convergent and divergent tree structures are considered to accommodate various scoring rules. The MMLE/EM algorithm is used for item parameter estimation of the DTM, and has been shown to provide good parameter recovery under varied conditions in a simulation study. A set of data from TIMSS 2007 mathematics assessment is analysed to illustrate the use of the two-digit scoring scheme and the DTM.     

Discussion of Difficult Assessment Cases: Psychodynamic Perspectives

I discuss the papers of Kleiger (this issue), Husain (this issue), and Bram (this issue), each of whom described their personality assessment of a very challenging case. Each case illustrates the way in which experienced personality assessors integrate psychoanalytic theory with clinical reasoning, multi-method assessment, and an understanding of the patient–examiner relationship when evaluating patients with serious psychiatric needs. The discussion elaborates particular aspects of each case and integrates the different estuaries through which personality assessors use psychoanalytic theory to develop diagnostic and treatment inferences.     

A Mixed Bag: The Realities of Psychoanalytic Practice

For a variety of reasons, psychoanalytic training is done in somewhat of a vacuum. It teaches a theory and a way of practicing that does not always translate well to day-to-day private practice work. The clinical realities of psychoanalytic practice prove the psychoanalytic method to be one that provides help to a wider audience than classical psychoanalytic training programs might suggest. The psychoanalytic approach offers the analyst many special opportunities to work with and help a wide variety of patients. Analysts who accept both the limitations as well as the wide application and broad benefits of the psychoanalytic approach may have a more fulfilling experience than their training experiences might foster. At the same time, the analyst's level of therapeutic skill, the patient's diagnosis, and many multiple external factors create different limitations in the practice and outcome of psychoanalytic work. Extensive case material is used to show the broad range of patients who are helped by the psychoanalytic method. The clinical material also shows the less than perfect, but often good enough outcomes of these difficult cases with often severely disturbed patients.     

The clinical utility of behavior rating scales: Comments on the diagnostic assessment of ADHD

Responding to Reid and Maag's critique of behavior rating scales in assessing ADHD, published in a previous issue of the Journal of School Psychology, we provided specific recommendations for improving the accuracy of diagnostic decisions using rating scales and affirmed the importance of these procedures in the assessment of ADHD. Strategies for managing the error intrinsic to the use of diagnostic measures, specifically behavior rating scales, were outlined. A multiple stage procedure, involving one or more levels of screening prior to conducting a diagnostic assessment, was recommended as a strategy to increase diagnostic accuracy in a time- and cost-efficient manner.     

Countertransference, supervised analysis, and psychoanalytic training requirements.

Because psychoanalysts have an ever expanding appreciation for the many factors that contribute to the psychoanalytic treatment process, they no longer view themselves simply as the receiver of the patient's transferences. When patient and analyst meet in the consulting room, they bring along with them a blend of intrapsychic and external ingredients--including countertransference--that make up the analytic soup. Candidates in psychoanalytic training must contend with even more sources of indirect countertransference reactions (Racker 1968) than experienced graduate analysts, due to aspects of the training experience itself. The author contends that minimum graduation requirements for supervised analyses are one such source of indirect countertransference. Four clinical examples of control analyses demonstrate this form of indirect countertransference during the assessment, opening, middle, and termination phases. These examples are followed by implications and recommendations for didactic psychoanalytic training curricula, countertransference awareness, supervision of control cases, institute governance policies and procedures, publication of clinical material, and future research.     

Clinical diagnostic and sociocultural dimensions of deliberate self-harm in Mumbai, India

Patients' accounts complement psychiatric assessment of deliberate self-harm (DSH). In this study we examined psychiatric disorders, and sociocultural and cross-cultural features of DSH. SCID diagnostic interviews and a locally adapted EMIC interview were used to study 196 patients after DSH at a general hospital in Mumbai, India. Major depression was the most common diagnosis (38.8%), followed by substance use disorders (16.8%), but 44.4% of patients did not meet criteria for an enduring Axis-I disorder (no diagnosis, V-code, or adjustment disorder). Psychache arising from patient-identified sociocultural contexts and stressors complements, but does not necessarily fulfill, criteria for explanatory psychiatric disorders.     

Teaching posttraining: influencing diagnostic strategy with instructions at test

It is believed that medical diagnosis involves two complementary processes, analytic and similarity-based. There is considerable debate as to which of these processes defines diagnostic expertise and how best to teach clinical diagnosis and reduce diagnostic errors. The purpose of these studies is to document the use of these strategies in medical students. We shifted the balance in use of these processes and improved diagnostic accuracy with instructions given posttraining at the moment of diagnosis. Analytic processing reflecting the degree to which cases contain the diagnostic rules was indexed by the rate of accuracy on typical versus atypical cases (typicality effect). Similarity-based processing reflecting the degree to which cases resemble previously encountered cases was indexed by the rate of accuracy on similar versus dissimilar cases (similarity effect). Two studies are presented illustrating that diagnosis involves the coordination of analytic and similarity-based processes and that differential instruction given at test shifts the balance in the use of these processes. Study 1 illustrated that participants adopting an analytic strategy exhibit a larger effect of typicality. Participants adopting a similarity-based strategy exhibit a larger effect of similarity. The diagnostic approach of students given no instructions was predominantly analytic. Dual instructions in which participants first employed similarity-based processing followed by the application of rules improved overall accuracy. Study 2 investigated two versions of dual instructions and illustrated that assessing a case with the rules of diagnosis first may inhibit the subsequent use of similarity-based reasoning. The implications for diagnostic expertise and pedagogy are discussed.     

Effects of experience and training on diagnostic accuracy

In this reexamination of a previously published report (R. Brammer, 1997), psychologists and psychology students (N = 138) were provided an artificial intelligence program that simulated a clinical interview, The "client" provided paragraph-length answers to the questions participants chose to ask. At the end of their interview, the participants provided a brief diagnosis for the client. A path analysis revealed that clinical experience is a strong predictor of the ability of form an accurate diagnosis and that an individual's level of training, mediated by the number of diagnostic questions asked, also helps to derive accurate diagnoses.     

Role of specific similarity in a medical diagnostic task.

Three experiments are reported showing that diagnosis of skin disorders by medical residents and general practitioners was facilitated by similar cases previously seen in the same context. Diagnosis of similar cases was facilitated more than that of dissimilar cases in the same diagnostic category, demonstrating that facilitation was not solely due to activation of the diagnostic category as a whole. Because diagnosis was posed in a multiple-choice format that always included the correct diagnosis, the relative disadvantage of dissimilar items was not due to the unavailability of the category name. The similarity effect also occurred with 2-week delay between the initial case and the test cases. Variations in diagnostic procedure, ranging from giving a quick first impression to arguing for given alternative diagnoses before selection, did not interact with the effect of similarity. This result suggests that the similarity effect is not strongly dependent on a particular diagnostic strategy.     

The “Rituals” of the Relational Perspective: Theoretical Shifts and Clinical Implications

This paper attempts a closer look at the theoretical foundations for some of the clinical shifts that underlie a relational psychoanalytic approach. It also posits that what unites relational writers who come from different psychoanalytic traditions—that is, Freudian, Kleinian, Object Relations, Self Psychology—has more to do with the kinds of questions asked than with the particular answers that are offered. Specifically these questions have to do with the epistemological basis for how we know what we know as analysts, the model of mind we employ to understand our patients, and the mode of therapeutic action that evolves from these two earlier shifts. Several clinical examples are offered.     

A psychoanalytic perspective on attention-deficit/hyperactivity disorder

Psychoanalysts have tended to view the diagnosis of AD/HD either with skepticism or as a contraindication to analytic treatment. The author reviews the history of this puzzling diagnostic entity, which is estimated to account for up to fifty percent of child referrals, and suggests that a psychoanalytic perspective on the underlying disturbance in ego functioning helps to clarify the nature of the symptom picture. Whatever the etiology, which may be compound, she suggests that psychoanalytic treatment, most often in conjunction with psychopharmacological therapy, can address the core disturbance in ego integration that creates the familiar triad of inattention, impulsivity, and hyperactivity.     

Specific Cognitive Deficits in ADHD: A Diagnostic Concern in Differential Diagnosis

We present a critical account of existing tools used to diagnose children with Attention Deficit Hyperactivity Disorder and to make a case for the assessment of cognitive impairments as a part of diagnostic system. Surveys have shown that clinicians rely almost entirely upon subjective reports or their own clinical judgment when arriving at diagnostic decisions relating to this prevalent disorder. While information from parents and teachers should always be carefully considered, they are often influenced by a host of emotional and perceptual factors. It increases the possibility for misdiagnosis of a condition like ADHD. Recent experimental literature on ADHD has identified unique underlying cognitive dysfunction, specific to ADHD. Therefore, we propose that there is a need to incorporate information on cognitive mechanisms underlying ADHD and inculcate such information in the diagnostic system, which will provide a more sensitive as well as specific tool in differential diagnosis of ADHD.     

The impact of theory on psychological testing: how psychoanalytic theory makes diagnostic testing more enjoyable and rewarding.

Systematically applying psychoanalytic theory to psychological testing cultivates a practical, useful, and enjoyable experience of test administration, test scoring, and test interpretation. Furthermore, by grounding psychological testing in psychoanalytic theory, testing becomes rewarding because there is a lively clinical interplay between testing and psychotherapy. These potential sources of enjoyment and skill for the psychological examiner are explored, and several clinical examples are given for illustrative purposes. The need to appreciate the impact of a given theoretical frame of reference is highlighted.     

The competent psychoanalytic supervisor: Some thoughts about supervision competences for accountable practice and training

What are the competences required to satisfactorily practice effective or “good enough” psychoanalytic supervision? In this paper, I would like to consider that question. Over the past approximate 15-year period, increasing attention has been directed toward more specifically identifying and defining the components of competent psychoanalytic practice. But any parallel attention toward identifying and defining the components of competent psychoanalytic supervision practice has, in comparison, been sorely limited if not virtually absent. If we are to best practice competent psychoanalytic supervision and best train future psychoanalytic supervisors for competent practice, effort needs to be made to concretely delineate the competences that are requisite for such practice. In what follows, I present and adapt six broad-based families of internationally relevant supervision competence areas for use in psychoanalytic supervision: (1) knowledge about/understanding of psychoanalytic supervision models, methods, and intervention; (2) knowledge about/skill in attending to matters of ethical, legal, and professional concern; (3) knowledge about/skill in managing psychoanalytic supervision relationship processes; (4) knowledge about/skill in conducting psychoanalytic supervisory assessment and evaluation; (5) knowledge about/skill in fostering attention to difference and diversity; and (6) openness to/utilization of a self-reflective, self-assessment stance in psychoanalytic supervision. Although by no means an exhaustive list, 30 supervision competences (five per family) are proposed as significant for guiding competent psychoanalytic supervision practice and supervisor training, and a brief explanatory comment is offered in support of each broad-based family of competences.     

Ego function assessment of the psychoanalytic process

Pressing needs for objective and rapid clinical assessment of the psychoanalytic process are emerging in the current climate of social and medical change. The Ego Function assessment (EFA) method is presented as an available, valid, and reliable quantitative technique which can be used by clinicians for such objective evaluations. EFA formulations are dynamically highly relevant. They are directly derived from psychoanalytic theory and practice.