Developing Clinical Acumen What Happens When Traits from Different Diagnoses Commingle

Jenna felt overwhelmed by all the information she had gathered during the assessment of her first client. Although her client met the DSM-IV diagnostic criteria for compulsive personality disorder, he also seemed to possess additional traits not easily captured by this diagnosis. When Jenna met with her supervisor, a review of her clinical interview and test results suggested pervasive dependent tendencies, though these fell short of the threshold for dependent personality disorder. Jenna felt relieved when her supervisor suggested that clinical work was both an art and a science. Rather than limit herself to the findings of her instruments, Jenna was free to draw on her total knowledge of the subject, including her own experience of the subject gained in the assessment session, when composing her first clinical report.

to additional questions. The first subject might identify strongly with his father or might regard stubbornness as a negative trait that should be eliminated from his personality, just as his father's should be eliminated. The second subject might feel neglected or might be proud that she was able to come through a difficult childhood with a capacity to stand on her own.

The developmental antecedents of personality are not always available for conscious report, however. Subjects differ in their level of insight as well as their ability to provide biographical details. Some are simply poor historians; others may have repressed large portions of their childhood. The cognitive style of certain personalities, notably the histrionic personality, permits the recall of broad impressions but few specific details. Not everything can be found out in advance; not everything can be found out during the assessment. Profound connections and insights are often made months later as therapist and subject have a chance to reflect on the origin of maladaptive patterns repeated again and again across the years. Once this additional biographical element is added, diagnostic labels begin to look very impoverished indeed.

Because different patterns of developmental pathways lead to different personality disorders, the search for developmental antecedents is often assisted by the person's personality disorder diagnosis. For example, clinical lore suggests that the narcissistic personality is often associated with being the first male or only child. Even if a narcissistic subject has many siblings, it is highly probable that he or she occupied a position of special status in the family. Future narcissists experience noncontingent love so indulging and intense that they fail to learn that others have an independent existence outside their own glow. As a result, they develop egocentricity, arrogance, insensitivity, and a sense of entitlement; they expect others to anticipate their needs and may become rageful when they feel ignored. Each personality disorder has its own characteristic early experiences. In-depth knowledge of these developmental pathways can be used to further focus the clinical interview, thereby validating the clinical diagnosis or suggesting alternatives.

The Nature of Measurement

In the hard sciences, the nomothetic and idiographic approaches often refine each other as science progresses. For example, although astronomers are interested in the properties of particular classes of stars, they are also interested in understanding the behavior of one single, very important star, our own sun. By analyzing its composition and applying complex models of fluid dynamics, many characteristics of solar behavior can be predicted with surprising precision, including the intensity of the next sunspot cycle. Here, one particular entity is understood through the application of universal laws. On the other hand, a peculiar anomaly may also drive science forward. If a new particle is found following the collision of superaccelerated antiprotons, for example, the fundamental theories of nature must be revised so that its existence is an expected result of the experiment. Once the theory has been generalized, the anomaly is an anomaly no more.

Two characteristics of the physical sciences combine to make the constructive interplay between the particular and the general possible. First, instrumentation in the physical sciences is highly developed, allowing extremely precise observations. The nature of the measurement instrument does not contaminate the measurement itself. Temperature provides an example. Everyone understands what it means when the temperature is 32 degrees; whether a mercury or an alcohol thermometer was used is not important. Furthermore, two different instruments in the physical sciences can often be substituted

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