Looking beyond the Obvious Presuming Diagnosis Undermines the Clinical Process

An intelligent-looking undergraduate senior majoring in mathematical physics presented at the university counseling center complaining that his grades were slipping and that he felt "incredibly anxious." During the clinical interview, he announced that he was much more intelligent than the other students and always received the highest grades in his mathematics and physics classes, at least until recently. Further exploration revealed that his father was a mathematical physicist at the same university, but had recently accepted the position of department chair at another institution on the opposite coast. Although intellectual testing in fact showed superior intellectual ability, it was also true that the son identified strongly with his father and greatly enjoyed the time he spent with his father, who tutored him through the most difficult problems. Several weeks into counseling, he was able to admit that he feared that without his father, he would no longer receive such high marks and others would revise their opinion of his intelligence accordingly. He received a presumptive diagnosis of narcissistic-dependent personality disorder, later changed to narcissistic-dependent style. Although his self-image was somewhat inflated, he could not be called grandiose, he did not dominate and exploit others shamelessly, and he was not void of empathy (features typical of a pure narcissistic personality disorder). Cognitive techniques focused on identifying and refuting catastrophic cognitions associated with the possibility of receiving a low grade ("My father won't love me anymore"). Simultaneously, his narcissistic needs, along with his dependency on his father for esteem, were addressed by suggesting that he tutor other students in mathematics or physics, all of whom praised his command of the material.

with the various perspectives on personality. Unfortunately, this is not the case. Often, the diagnostic criteria are redundant, weighting the diagnosis heavily toward one perspective while omitting another perspective completely. Personality criteria should do more than classify persons into categories, a rather minimalistic function. Instead, diagnostic criteria should encourage a substantive and integrative understanding of the patient across all domains in which personality is expressed. Future DSMs will probably gravitate toward this position, but the DSM-IVjust isn't there yet. As a result, a therapist relying exclusively on the DSM-IV may remain unaware of important aspects of functioning that work to reinforce and perpetuate a patient's difficulties, thus sabotaging the outcome of therapy. If the constraints on therapeutic change lie elsewhere in the personality, the therapist may be left treating abnormalities peripheral to the real problem.

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