Hannah initially presented, in early middle age, with a history of severe social problems. She was always in conflict with someone at work about something, and she was quite depressed. Clearly, Hannah had some sort of nonverbal learning disability impairing her social perception. Although psychological testing done several years before had been interpreted as within normal limits, I thought that this was a mistaken diagnostic impression and that there was evidence of a nonverbal learning disability. Week after week, Hannah described new situations in which her conduct had provoked reproach or scorn at work because she either hadn't noticed or had completely misinterpreted what was going on between people. Fortunately, her supervisor seemed to understand that her difficulties in social perception were unintentional. She was willing to take time with Hannah to explain some of her mistakes. This supervisor was usually a supportive coach, but she got angry at Hannah when her gaffes involved people outside of her department, potentially making the supervisor look bad. As a result of Hannah's intense dedication to her job and her supervisor's coaching, she has consistently achieved perfect attendance records at work--for ten years at the time of writing. I believe that it is a record unmatched within her midsized company.
It would have been easy to misdiagnose Hannah as suffering from some sort
of displaced aggression, to see her as directing her anger away from her
parents, where it might presumably have formed in her early development,
and targeting it at her peers and herself instead. But she was not expressing
displaced aggression or defensiveness through her social behavior, not alienating
people through deliberate or even unconsciously intended self-defeating
choices. Indeed, to do so would have required the ability to accurately
perceive how others were feeling and what they were doing in social interactions,
which is precisely what Hannah could not do. The diagnosis of a social perception
deficit based on a nonverbal learning disability put the focus where it
belonged, on Hannah's problems understanding interpersonal interactions.
However, the diagnosis of a social perception disorder didn't explain why the disorder was so severe, as severe as I had ever seen, even though her test scores indicated only a mild nonverbal deficit. The most useful diagnosis is the one that explains a patient's symptoms both specifically and comprehensively, and I hadn't gotten there yet with Hannah.