Verified by 
Key points
- Personality assessments are labor intensive.
- A diagnosis made too quickly can be costly, to both the individual and their larger community.
- One diagnosis may give way to an entirely different diagnosis during a careful evaluation.
- Interviewing collateral sources often is of critical importance.
It is difficult to know another person well. It is especially challenging when that individual is aware that his future may depend on an assessment by a stranger.
In my writings and in court testimony, I have emphasized that psychological evaluations impacting important decisions about a person require in-depth assessment. This usually entails spending hours interviewing him and others who know him well, reviewing documents, and, in some instances, administering psychological tests.
Forty-three-year-old Van* came to my office after he had been arrested for two offenses. As I evaluated him, one clinical picture emerged only to be replaced by a very different one. Characteristics of what turned out to be an autism spectrum disorder initially resembled those of a personality disorder.
Van described approaching women to engage them in “a slapping game” which he found arousing. While at a bar one evening, he invited a young woman to play, then grabbed her arm “to show her how.” Van recalled, “She didn’t seem to want to play. So I left.” The next day, he was arrested and charged with assaulting a minor. (The female was younger than he thought.)
On another occasion, after downing several drinks at a bar, Van walked to a bus stop. He recalled that his urge to urinate was so intense that he was “about to burst.” Wanting to avoid waiting in line to use a bathroom and fearing he might lose control of his bladder on the long ride home, he urinated behind a bush. A policeman observed him and charged Van with indecent exposure.
Van acknowledged that neither the assault nor the indecent exposure constituted first offenses. “I like women to slap me,” he admitted and confessed that he had approached many, some of whom were willing to engage with him. With regard to the indecent exposure, many times Van had urinated outdoors.
As a child and an adult, Van was a loner. His mother told me, “He doesn’t know how to be a friend. He never did.” Van had no lasting relationships other than with his parents and had never dated. He functioned well enough to earn a bachelor’s degree, then to hold a job as a telemarketer.
Van tired of fundraising and considered it beneath him. He bitterly resented Frank, his supervisor, for underestimating his potential and refusing to promote him. Van ruminated over how to “humiliate and bring Frank down, then “make him eat dirt.” Van insisted that he had a “right” to be promoted to a position of greater responsibility. “I’m not one to forgive,” he declared to me.
Because he did not receive the promotion to which he claimed he was “entitled,” Van sought revenge. He indicated that he would derive tremendous satisfaction from getting Frank terminated. He imagined composing formal grievances and embroiling others at work to execute his vendetta. He did not succeed and resigned.
Subsequently, he left other jobs because they did not provide the conditions or opportunities that he thought he deserved. Van expected employers to suit his requirements rather than vice versa. He fantasized about “bringing down” not only other work supervisors but also political and sports celebrities toward whom he had an intense dislike for reasons that were unclear.
Van rejected his parents’ offer to pay for him to return to school and acquire marketable skills. No job appealed to him. Van told me, “I want to get a job with someone important who has clout.” Fascinated by well-known public figures, he stated, “I want to be a political commentator.”
Van complained, “My whole life has been peaks and valleys.” His life remained in turmoil. The only people he relied upon were his parents whom he constantly argued with and lied to. His mother and father despaired over how untruthful their son was, especially with respect to his alcohol consumption. Any suggestion they offered about jobs, he rejected.
Van was evidencing features of a personality disorder, possibly of a narcissistic type. The fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) listed the following criteria for that disorder:
- "Has a sense of entitlement"
- “Lacks empathy; is unwilling to recognize or identify with the feelings and needs of others”
- “Is often envious of others or believes that others are envious of him”
- “Shows arrogant, haughty behaviors or attitudes”
The DSM-5 noted that when such people experience shame or humiliation, they may become “socially withdrawn and depressed,” a description that seemed to apply to Van.
As I spent more time with Van, however, a different picture emerged. I found that he was paralyzed by fear of being humiliated and rejected. He was completely inept at reading people and lacked the capacity to form interdependent relationships.
Van never experienced sexual arousal by urinating outdoors. He commented, “To forget to zip up your fly is disgusting.” He dreaded even the possibility of wetting himself after he consumed alcohol and had to take a bus home. (He refused to apply for a driver’s license out of fear he would hurt someone in an accident.)
Although Van seemed obsessed with “humiliating enemies,” he did not act on such thoughts. He was far more preoccupied with fears of being humiliated by someone else. He commented, “I have a lot of self-loathing. That’s why I want women to punish me.”
Having held his telemarketing position for years, he desired to move on to a job with more responsibility than sitting in a tiny room phoning strangers to raise funds. Although he believed that he was capable of more, he always had reasons for not applying for a different position. His parents suggested he work as a store’s cashier and try to advance from there. Van was paralyzed by fears that he would make a mistake, get accused of theft, or be criticized for working too slowly. While telling me, “I have to get a life,” Van was so terrified of rejection that he would not join a group or even attend a function with people who shared common interests.
Van became fixated on politicians and celebrity sports figures whom he either venerated from afar or despised to a point that he focused on any setback or embarrassment that these public figures experienced. Van perseverated in thinking about these people and spoke about them with me at every meeting. He savored thoughts about how their careers could end prematurely.
Learning how Van functioned from day to day and having opportunities (with his permission) to speak with his parents, I concluded that he satisfied the criteria to be diagnosed with an autism spectrum disorder, far different from my initial impression that he had a personality disorder. The DSM-5 lists the following characteristics of autism spectrum disorder:
- “Deficits in social-emotional capacity… and failure to initiate or respond to social interactions”
- “Difficulty making friends”
- “Highly restricted, fixated interests that are abnormal in intensity”
- “Insistence on sameness, inflexible adherence to routines”
To others, Van might appear aloof, mean-spirited, unapproachable, and self-consumed. The reality was that he was meek, fearful of people, distrustful of others’ motives, and immobilized by a certainty that his shortcomings would be exposed.
I concluded in my report to his attorney, “[Van] is a person with psychological problems. He is not a criminal.” A cursory evaluation of this man could have resulted in enormous injustice and incalculable damage to him.
*Names have been changed to protect confidentiality
