Diagnosis and The Nth Dimension



Let's take an excursion and relate an aspect of a television screen to some deep issues in psychology and mental health.


A TV screen consists of no more than tiny dots of red, green, and blue. These pixels are so tiny that you don't see them as such, what you see is a picture with a broad spectrum of colors and hues.


The three pixel colors: red, green, blue are dimensions of the TV's image, yet combined, you are treated to a wonderful breath of experience. Contributing to the subtlety of a TV image is the 'weight' of each dimension. RGB, where each pixel is bold is going to provide a different hue in the spectrum than RgB, where the 'g' is a less intense pixel.


If a dimension such as RGG is going to be useful as a concept, it should be pure and essential. In other words, each color, like a prime number, should be difficult, and ideally impossible to break down into simpler components. Every school child knows that when yellow and blue are combined, one gets green, so yellow is more essential than green.


I began to think of these things and relate them to psychology and personality years ago. Raised as a psychiatrist, I was used to 'categorical' rather than dimensional ways of thinking about diagnosis: does my patient have schizophrenia, is he depressed, is he manic, or is he a borderline personality? It was all like distinguishing a chickadee from a cardinal. I was hardly aware of dimensional perspectives until a psychologist friend of mine offered to teach me about psychological testing. I went from learning about the Rorschach, to exploring the MMPI, to eventually landing on an enjoyment of the Myers Briggs Personality Inventory. The latter is a popular instrument that classifies normal people's personality style. The test is a classic illustration of a dimensional system.


There are four dimensions to the Myers: Extroversion - Introversion (I -E) is the most well known and intuitive to understand. The three other dimensions, N-S, T-F, J-P have somewhat confusing names, but are relatively intuitive when explained properly. N people have slippery minds so can enjoy and understand the amusing leaps of logic, of comics like Robin Williams. S individuals are more literal and will have more difficulty following the comic's train of thought.


T people tend to calculate the resolution to a problem based on logic, think Mr. Spock. F people allow sympathy and context to weigh into their decisions more than Ts.


J individuals are rule bound. I like to say that a J will assume a rule was created by Moses until proven otherwise. Ps will assume it was created by a fool.


All told, the four binary dimensions of the Myers-Briggs categorize 16 personality types;


In the 50s the psychologist, David Keirsey, used the Myers as a basis to attach descriptive labels onto the 16 possible outcomes of the Myers-Briggs. The labels were designed to help people correlate the Myers personality test with observable behavior.


I am, for example an INTP. My type is labelled, 'The Thinker,' per Keirsey. An ENTP, differing from me only in the introversion extroversion dimension is describes as, 'The Debater.' Other types are: 'The Protector,' 'The Advocate,' and so on. Fans of the TV series 'Blacklist,' will no doubt enjoy these labels. These descriptors allow one to predict the behavior of a person whose personality is described by the somewhat abstract output of the standard Myers-Briggs test.


So what does all of this have to do with clinical practice? Consider that our patients are concerned, as we should be too, about their functioning more than their diagnoses. We clinicians use diagnosis as a way of designing treatment options and interventions. Patients simply want to get better. The problem with categorical systems such as the DSM and ICD is that they are conceptually somewhat shallow, they allow is to label things, sometimes in the absence of deep understanding.. The beauty of dimensional systems is that they are inherently more conceptual because they invite us to think about the essential elements behind a patient's behavior or diagnosis. The deeper our conceptual understanding of our patients, the more nuanced will be our interventions to help them.


Additionally, dimensional ways of thinking are economical. Think of it, 4 dimensions in the Myers Briggs allow us to develop a perspective on 16 personality types.


Admittedly, the science of psychology has not fully developed a dimensional perspective on diagnosis and personality. There have been problems with the accuracy of various test instruments currently in use, and there is debate as to whether the various dimensions that psychologists promote are really fundamental components of personality and diagnosis as is our RGB on the TV screen. Nevertheless, dimensional systems offer a pathway with great promise for future research.


And just as we may be searching for a reliable dimensional system to describe our patients, it is interesting to contemplate what might be the relatively few dimensions that constitute what we would consider a highly skilled therapist.


How about curiosity, intelligence, restraint, good social skills, and disciplined training for starters?












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