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The DSM5, ICD-10-11 and PDM:
Concepts of Personality, Ethics and
Validity
PPA Fall 2012 Ethics Workshop
We have three competing diagnostic systems of personality:
DSM5, ICD10 and PDM. If we are to ethically base our
diagnoses on “information and techniques sufficient to
substantiate their findings,” then which do we use and why?
Robert M. Gordon, Ph.D. ABPP in Clinical Psychology and
Psychoanalysis
Janet Etzi, PsyD, Professor, Immaculata University
Outline
1. What is diagnosis and why diagnose?
2. Case example of a ethical and risk management
issue over Dx.
3. Big changes in DSM 5’s Personality Disorders.
4. The ICD 10-PD and the ICD 11 PD,
5. Participate in an experiment on diagnostic
formulation and learn more about Dx.
6. The PDM- a personality centered approach,
7. Why Mental Functioning is important to Dx,
8. An Integration of the PDM, ICD or DSM.
Start with a good diagnostic formulation
“Once I have a good feel for the person, the
work is going well, I stop thinking
diagnostically and simply immerse myself in
the unique relationship that unfolds between
me and the client…one can throw away the
book and savor individual uniqueness.”
Nancy McWilliams (2011) Psychoanalytic Diagnosis: Understanding
Personality Structure in the Clinical Process, Second Edition.
Main Reasons for Diagnosing
1. Its usefulness for treatment planning.
“Understanding character styles help the therapist
be more careful with boundaries with a histrionic
patient, more pursuant of the flat affect with the
obsessional person, and more tolerant of silence
with a schizoid client.”
2. Its implications for prognosis. “Realistic goals
protect patients from the demoralization and
therapist from burnout.”
Why Diagnose?
3. Its value in enabling the therapist to convey empathy.
Once one knows that a depressed patient also has a
borderline rather neurotic level personality structure, the
therapist will not be surprised if during the second year of
treatment she makes a suicide gesture. Or once a borderline
client starts to have hope of real change, that the borderline
client often panics and flirts with suicide in an effort to protect
himself from traumatic disappointment.
4. Its role in reducing the probability that certain easily frighten people
will flee from treatment. It is helpful for the therapist to communicate to
hypomanic or counter-dependent patients an understanding of how hard
it may be for them to stay in therapy.
Why Diagnose?
5. Its value in risk management. Often therapists
mistakenly use a presenting symptom as the
only diagnosis and missed the borderline level
of personality or psychopathic personality and
got into trouble.
6. It’s value in process and outcome research.
Personality Structure and Treatment
• McWilliams points out that for many neurotic
level people, the best time to make
interpretations is when the patient is a state
of emotional arousal, so that the patient is
less likely to intellectualize the affect.
• With borderline clients, who also require a
supportive approach, the opposite
consideration applies, because when they are
very upset, it is hard for them to take anything
in.
Why have competence in diagnoses?
9.01 Bases for Assessments
“(a) Psychologists base the opinions
contained in their recommendations,
reports, and diagnostic or evaluative
statements, including forensic testimony,
on information and techniques sufficient
to substantiate their findings.”
This includes interview, assessments and
diagnostic taxonomies that pass the Frye
Test, i.e. DSM, ICD and PDM.
9
“I have often served as an expert witness in
malpractice cases where psychologists had missed
the psychopathic or borderline traits in patients.
The DSM classifies antisocial and borderline
personality disorders by precise and narrow
symptoms. This is often misleading. Psychopathy
can be a complex personality pattern that
combines with or is obscured by other personality
patterns, and borderline can be viewed as an
entire level of personality organization that can be
applied to the various personality disorders.”
Gordon, R.M., (2007) PDM Valuable in Identifying High-Risk Patients. The National Psychologist, 16, 6, November/December, page 4.
Risk Factors in Litigious Patients
Borderline Personality Organization
Psychopathic traits
History of acting out
“My Psychologist Abandoned Me!”
Patient claiming millions of dollars in damages
• Middle age woman, with no history of psychological
problems seeks help after her husband commits
suicide.
• Psychologist gives the Beck Depression Inventory, it
shows depression and the psychologist does CBT.
• He is symptom focused in his orientation.
Complaint to Licensing Board and Civil Suit for
Damages
• At first the patient is sweet and appreciative.
• Calls psychologist frequently between sessions.
• Begins to stalk him and insist on an outside relationship with him.
• At his “rejection,” she becomes suicidal and requires hospitalization
• Psychologist refers her to other psychologists for treatment and does
a termination session with her.
• Later she sues for abandonment.
• He did not manage her as someone with a dependent personality
disorder at the borderline level personality organization.
Patient using sessions for sadomasochistic gratification
• Constantly testing the boundaries and insisting on
frequent phone contact between sessions
• Threatening suicide, but refusing to be cooperative with
the treatment plan
• Idealizing the therapist and fearing his abandonment
while devaluing the treatment
• Infuriating the therapist with complaints about his not
helping her, while she was resisting treatment (projective
identification)
Admission notes at first hospital stay soon after start of
treatment
“… She was increasingly depressed and it
seems that despite treatment with
antidepressants from her primary care doctor
and despite psychotherapy which had been
started with Therapist Y in the past three
months, the patient’s overall condition had
continued to decline…”
Mental health outpatient note by subsequent
therapist
“Therapist Y suddenly stopped her treatment
so she started to harass him, follow him,
follow him everywhere, go to his house, hide
in the bushes, in short she was stalking him.
So he called 911 and she was in jail last month
for one week. When she got out she is going
to sue Therapist Y for suddenly stopping her
therapy…”
Mental health outpatient note by subsequent therapist con’t:
• “AXIS I: Posttraumatic stress disorder 309.81;
• AXIS II: Mixed personality disorder with borderline
and obsessive-compulsive components…
• AXIS V: Global assessment of functioning 55; highest
in past 65…”
Whether Therapist Y appropriately terminated his treatment of Patient X.
“The APA ethics committee and state licensing board
hearing both rejected Patient X’s complaint. She
was not benefiting from treatment and he was
ethically bound to terminate treatment if the
patient is not benefiting. He gave her the names of
other therapists. He is not responsible if because of
her psychopathology she doesn’t want other
therapists and she doesn’t want to get better.”
“Whether the treatment provided by Therapist Y was
appropriate.”
“Yes it was. He appears to provide primarily cognitive
behavior therapy ... However, the problem was not
that there was inappropriate treatment but Ms. X
was uncooperative and resistant to treatment.”
Throw Away Occam’s Razor (law of parsimony)
•Clinicians should follow the general rule of
recording as many diagnoses as are necessary to
cover the clinical picture.
•Hickam's Dictum: "Patients can have as many
diseases as they damn well please" John Hickam, MD.
•When recording more than one diagnosis, it is
usually best to give the main diagnosis, and to label
any others as subsidiary or additional diagnoses.
The DSM-IV was originally published in 1994 and listed more
than 250 mental disorders.
The DSM-IV is based on five different dimensions.
Axis I: Clinical Syndromes
clinical symptoms that cause significant impairment
Axis II: Personality and Mental Retardation
long-term problems that are overlooked in the presence of Axis I disorders
Axis III: Medical Conditions
physical and medical conditions that may influence or worsen Axis I and
Axis II disorders
Axis IV: Psychosocial and Environmental Problems
Axis V: Global Assessment of Functioning
client's overall level of functioning
DSM 5
• The DSM 5 is due May 2013 and will
supersede the DSM-IV which was last revised
in 2000.
• Research started in 1999.
• The DSM makes the American Psychiatric
Association over $5 million a year, historically
adding up to over $100 million.
DSM IV’s problem of temporal instability
The average short-term test-retest reliabilities of .54 for specific
PDs and .56 for any PD (Zimmerman, 1994) suggest large
transient error of measurement; (Chmielewski & Watson, 2009)
when using structured interviews.
Longer term test-retest reliabilities of .51 for any PD and .34 for
specific PDs, and the finding of significant diagnostic change
over as little as 6 months (Shea et al., 2002), indicate diagnostic
instability that is inconsistent with the relative stability of
personality traits (Roberts & DelVecchio, 2000).
By making PD diagnoses more trait-based and dimensional, the
DSM-5 is expected to reduce temporal instability.
DSM IV Axis II Poor convergent validity
Meta-analytic convergence between structured interviews, and
between structured interviews and personality questionnaires,
respectively, was .27 for specific PDs and .29 for any PD (Clark et al.,
1997).
In contrast, the proposed DSM- 5 personality trait set is based on an
extensive research literature whose origins are more than half a century
old (e.g., Cattell, 1946), culminating in recent years in a consensual,
highly robust personality trait hierarchical structure (Markon et al.,
2005) that has a high degree of convergent and discriminant validity
across a wide range of measures, primarily questionnaires (O’Connor,
2002b), but also encompassing structured interviews (Stepp et al.,
2005).
(But- If a simpler construct has more stability and convergent validitydoes it also mean that it has more generalizable validity to complex
personality structures?)
DSM-5 Moves from Multi-axial system to a
similar ICD 10 System
•DSM-5 changes to the approach used by ICD 10,
with Axes I, II, and III into one axis.
•Axis IV and Axis V may also copy ICD 10 (making
the dimensional ratings specific to the diagnosis)
Main DSM 5 Categories
• Neurodevelopmental Disorders
• Schizophrenia Spectrum and Other Psychotic Disorders
• Bipolar and Related Disorders
• Depressive Disorders
• Anxiety Disorders
• Obsessive-Compulsive and Related Disorders
• Trauma and Stressor Related Disorders
• Dissociative Disorders
• Somatic Symptom Disorders
• Feeding and Eating Disorders
• Elimination Disorders
• Sleep-Wake Disorders
• Sexual Dysfunctions
• Gender Dysphoria
• Disruptive, Impulse Control, and Conduct Disorders
• Substance Use and Addictive Disorders
• Neurocognitive Disorders
• Personality Disorders
• Paraphilic Disorders
• Other Disorders
DSM 5 Changes to Personality Disorder
The personality domain in DSM-5 is intended
to describe the personality characteristics of
all patients, whether they have a personality
disorder or not.
Five Factor Model and the DSM 5 PD
The proposed model represents an extension of the Five
Factor Model (FFM; Costa & Widiger, 2002) of personality that
encompasses the more maladaptive personality variants
necessary to capture features of PDs.
The 5 domain/25 trait model includes 5 broad, higher-order
personality trait domains – negative affectivity, detachment,
antagonism, disinhibition, and psychoticism – each comprised
of from 3 to 9 lower-order, more specific trait facets that help
flesh out the domains (e.g., manipulativeness and callousness
are specific facets in the antagonism domain).
DSM 5 two dimensional assessments
• The proposed DSM-5 model consists of two
dimensional assessments: 1) a personality
pathology severity scale, the Levels of Personality
Functioning, and 2) a 5 domain/25 facet
pathological personality trait assessment.
• Combined, these assessments redefine the core
features of a PD and provide the information
needed to rate the major diagnostic inclusion
criteria for six specific PD categories and for a
diagnosis of personality disorder-trait specified
(PD-TS) to replace PD not otherwise specified
(PDNOS).
Guide to Implementation of Assessment of Personality Pathology
1.
Is impairment in personality functioning (self and interpersonal) present or not?
2.
If so, rate the level of impairment in self (identity or self-direction) and
interpersonal (empathy or intimacy) functioning on the Levels of Personality
Functioning Scale (0-4).
3.
Is one of the 6 defined types present? (antisocial, avoidant, borderline,
narcissistic, obsessive-compulsive, and schizotypal)
4.
5.
6.
If so, record the type and the severity of impairment.
If not, is PD-Trait Specified present? (negative affectivity, detachment,
antagonism, disinhibition vs. compulsivity, and psychoticism)
If so, record PDTS, identify and list the trait domain(s) that are applicable, and
record the severity of impairment on Clinicians’ Trait Rating Form (0-3).
7.
If a PD is present and a detailed personality profile is desired and would be
helpful in the case conceptualization, evaluate the trait facets.
8.
If neither a specific PD type nor PDTS is present, evaluate the trait domains and/or
the trait facets, if these are relevant and helpful in the case conceptualization.
Revised General Criteria for Personality Disorder
The essential features of a personality disorder are impairments in personality (self
and interpersonal) functioning and the presence of pathological personality
traits. To diagnose a personality disorder, the following criteria must be met:
A. Significant impairments in self (identity or self-direction) and interpersonal
(empathy or intimacy) functioning.
B. One or more pathological personality trait domains or trait facets.
C. The impairments in personality functioning and the individual’s personality trait
expression are relatively stable across time and consistent across situations.
D. The impairments in personality functioning and the individual’s personality trait
expression are not better understood as normative for the individual’s
developmental stage or socio-cultural environment.
E. The impairments in personality functioning and the individual’s personality trait
expression are not solely due to the direct physiological effects of a substance
(e.g., a drug of abuse, medication) or a general medical condition (e.g., severe
head trauma).
First- If there is impairment in personality
functioning (self and interpersonal)
then- rate the level of impairment in self and
interpersonal functioning on the Levels of
Personality Functioning Scale.
Five levels of self-interpersonal functioning
impairment, ranging from no impairment, i.e.,
healthy functioning (Level = 0) to extreme
impairment (Level = 4)
Is one of the 6 defined types present?
If so, record the type and the severity of impairment.
•
•
•
•
•
•
•
The six specific types are as follows:
T 00 Borderline Personality Disorder
T 01 Obsessive-Compulsive Personality Disorder
T 02 Avoidant Personality Disorder
T 03 Schizotypal Personality Disorder
T 04 Antisocial Personality Disorder (Dyssocial
Personality Disorder)
T 05 Narcissistic Personality Disorder
T 06 Personality Disorder Trait Specified
DSM5: T 04 Antisocial Personality Disorder (Dyssocial Personality Disorder)
A. Significant impairments in personality functioning manifest by:
1. Impairments in self functioning (a or b):
a. Identity: Ego-centrism; self-esteem derived from personal gain,
power, or pleasure.
b. Self-direction: Goal-setting based on personal gratification;
absence of prosocial internal standards associated with failure to
conform to lawful or culturally normative ethical behavior.
AND
2. Impairments in interpersonal functioning (a or b):
a. Empathy: Lack of concern for feelings, needs, or suffering of
others; lack of remorse after hurting or mistreating another.
b. Intimacy: Incapacity for mutually intimate relationships, as
exploitation is a primary means of relating to others, including by
deceit and coercion; use of dominance or intimidation to control
others.
B.
1.
a.
b.
c.
d.
2.
a.
b.
c.
Pathological personality traits in the following domains:
Antagonism, characterized by:
Manipulativeness
Deceitfulness
Callousness
Hostility
Disinhibition, characterized by:
Irresponsibility
Impulsivity
Risk taking
DSM IV- BPD Criteria-no more needing at least 5
• BPD as indicated by at least 5 of the following:
• Frantic efforts to avoid real or imagined abandonment
• A pattern of unstable and intense interpersonal
relationships-"splitting"
• Identity disturbance: unstable self-image
• Impulsivity in at least two areas that are potentially
self-damaging
• Recurrent suicidal behavior or self-mutilating behavior
• Affective instability
• Chronic feelings of emptiness
• Inappropriate, intense anger or difficulty controlling
anger
• Paranoid ideation or dissociative symptoms
DSM 5: T 00 Borderline Personality Disorder- now Degree
A. Significant impairments in personality functioning manifest by:
1. Impairments in self functioning (a or b):
a. Identity: Markedly impoverished, poorly developed, or unstable self-image, often associated
with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress.
b. Self-direction: Instability in goals, aspirations, values, or career plans.
AND
2. Impairments in interpersonal functioning (a or b):
a. Empathy
b. Intimacy
B. Pathological personality traits in the following domains:
1. Negative Affectivity, characterized by:
a. Emotional lability
b. Anxiousness
c. Separation insecurity
d. Depressivity
2. Disinhibition, characterized by:
a. Impulsivity
b. Risk taking
3. Antagonism, characterized by:
a. Hostility
DSM 5 PERSONALITY TRAIT RATING FORM
If not one of 6 types, then is PD-Trait Specified
present?
If so, record PDTS, identify and list the trait
domain(s) that are applicable, and record the
severity of impairment.
If a PD is present and a detailed personality profile is
desired and would be helpful in the case
conceptualization, evaluate the trait facets.
DSM-5 CLINICIANS’ PERSONALITY
TRAIT RATING FORM
Depending on the role of personality in patients’ clinical
pictures, you may rate their traits in one of three ways:
(1) just the five broad trait domains for a personality
overview,
(2) all trait facets for a comprehensive personality profile, or
(3) the five trait domains, followed by the component trait
facets comprising each of those domains for which the
characteristics describe the patient with degree of fit:
0=Very little, 1= Mildly, 2= Moderately, 3= Extremely
Please rate patients’ usual personality, what they are like
most of the time.
Rate the five trait domains and the specific trait facets comprising the
domains
0=Very little, 1= Mildly, 2= Moderately, 3= Extremely
•
•
•
•
•
Negative Affectivity
Detachment
Antagonism
Disinhibition
Psychoticism
Rate the twenty-five specific trait facets
comprising the five domains
Negative Affectivity
•
•
•
•
•
•
•
•
Emotional lability
Anxiousness
Separation insecurity
Perseveration
Submissiveness
Hostility
Depressivity
Suspiciousness
Detachment
•
•
•
•
Restricted affectivity
Withdrawal
Anhedonia
Intimacy avoidance
Antagonism
•
•
•
•
•
Manipulativeness
Deceitfulness
Grandiosity
Attention seeking
Callousness
Disinhibition
•
•
•
•
•
Irresponsibility
Impulsivity
Distractibility
Risk taking
(lack of) Rigid perfectionism
Psychoticism
• Unusual beliefs and experiences
• Eccentricity
• Cognitive and Perceptual dysregulation
The only two non-US members of the DSM-5 Personality
Disorders Work group (Roel Verheul and John Livesley)
resigned in April 2012:
“First, the proposed classification is unnecessarily complex,
incoherent, and inconsistent. … Second, the proposal displays
a truly stunning disregard for evidence.
The current proposal represents the worst possible outcome: it
displays almost total discontinuity with DSM-IV while failing to
improve validity and clinical utility of the classification.”
The International Classification of
Diseases
• The ICD is currently the most widely used
statistical classification system for diseases in
the world.
• This is in fact the official diagnostic system for
mental disorders in the US.
• The ICD-10, was developed in 1992.
• ICD-11 is planned for 2015.
ICD is Required by HIPPA
• The deadline for the United States to begin
using Clinical Modification ICD-10-Clinical
Modification (CM) is currently October 1,
2014.
• The deadline was previously October 1, 2011,
then October 1, 2013.
ICD vs DSM-IV
•
A survey of 205 psychiatrists, from 66
different countries across all continents,
found that ICD-10 was more frequently
used and more valued in clinical practice
and training.
• The DSM-IV was more valued for
research, but less clear to mental health
professionals, policy makers, patients
and families. (Mezzich JE., 2002).
Neurosis and Psychosis in ICD 10
• The traditional division between neurosis and
psychosis has not been used in ICD-10. However,
the term "neurotic" is still used for instance, in
"Neurotic, stress-related and somatoform
disorders".
• "Psychotic" has been retained as a convenient
descriptive term, as in “Acute and transient
psychotic disorders.”
• The use of “neurotic or psychotic” does not
involve assumptions about psychodynamic
mechanisms.
ICD-10 MENTAL AND BEHAVIOURAL DISORDERS and consists of 10 main
groups:
F0: Organic, including symptomatic, mental disorders
F1: Mental and behavioural disorders due to use of
psychoactive substances
F2: Schizophrenia, schizotypal and delusional disorders
F3: Mood [affective] disorders
F4: Neurotic, stress-related and somatoform disorders
F5: Behavioural syndromes associated with physiological
disturbances and physical factors
F6: Disorders of personality and behaviour in adult persons
F7: Mental retardation
F8: Disorders of psychological development
F9: Behavioural and emotional disorders with onset usually
occurring in childhood and adolescence
In addition, a group of "unspecified mental disorders".
ICD 10 Disorders of adult personality and behavior
F60 Specific personality disorders
F60.0 Paranoid personality disorder
F60.1 Schizoid personality disorder
F60.2 Dissocial personality disorder
F60.3 Emotionally unstable personality disorder
.30 Impulsive type
.31 Borderline type
F60.4 Histrionic personality disorder
F60.5 Anankastic personality disorder (i.e. OCPD)
F60.6 Anxious [avoidant] personality disorder
F60.7 Dependent personality disorder
F60.8 Other specific personality disorders
F60.9 Personality disorder, unspecified
F61 Mixed and other personality disorders
F61.0 Mixed personality disorders
F61.1 Troublesome personality changes
F60.2 Dissocial personality disorder
(a) callous unconcern for the feelings of others;
(b) gross and persistent attitude of irresponsibility and disregard for social
norms, rules and obligations;
(c) incapacity to maintain enduring relationships, though having no
difficulty in establishing them;
(d) very low tolerance to frustration and a low threshold for discharge of
aggression, including violence;
(e) incapacity to experience guilt or to profit from experience, particularly
punishment;
(f) marked proneness to blame others, or to offer plausible rationalizations,
for the behavior that has brought the patient into conflict with society.
There may also be persistent irritability as an associated feature.
Conduct disorder during childhood and adolescence, may support the diagnosis.
Includes: amoral, antisocial, asocial, psychopathic, and sociopathic personality (disorder)
Excludes: conduct disorders, emotionally unstable personality disorder.
ICD 10 and Borderline
• “After initial hesitation, a brief description of
borderline personality disorder (F60.31) was
finally included as a subcategory of
emotionally unstable personality disorder
(F60.3), again in the hope of stimulating
investigations.”
• F60.3 Emotionally unstable personality disorder
marked tendency to act impulsively without consideration of the
consequences, together with affective instability. The ability to plan
ahead may be minimal, and outbursts of intense anger may often
lead to violence or "behavioral explosions";
• F60.30 Impulsive type
emotional instability and lack of impulse control, Outbursts of
violence or threatening behavior are common, particularly in
response to criticism by others.
•
Includes: explosive and aggressive personality (disorder) Excludes: dissocial personality disorder (F60.2)
•
F60.31 Borderline type
the patient's own self-image, aims, and internal preferences
(including sexual) are often unclear or disturbed. There are usually
chronic feelings of emptiness; intense and unstable relationships may
cause repeated emotional crises and may be associated with
excessive efforts to avoid abandonment and a series of suicidal
threats or acts of self-harm (although these may occur without
obvious precipitants).
•
Includes: borderline personality (disorder)
ICD-11 Survey Overview
• Developed for psychologists by WHO and International
Union of Psychological Sciences (IUPsyS)
• Parallel to survey conducted by WHO and World
Psychiatric Association (WPA) of 4887 psychiatrists in 44
countries
• 2155 global psychologists participated
• Recruited through 23 IUPsyS member national
psychological associations in 23 countries
• 10 low and middle-income countries
• Administered in 5 languages (English, Spanish, French,
German, Turkish)
ICD-11 2015
• ICD-11 will draw on research about how clinicians
conceptualize mental disorders in hopes of
creating a more intuitive and psychological
classification system.
• ICD-11 will be available for free on the Internet.
• A study of nearly 5,000 psychiatrists in 44
countries sponsored by WHO, more than 70
percent of the world's psychiatrists use ICD while
just 23 percent turn to the DSM. The same
pattern is found among psychologists globally.
Psychologists’ Role in
Making Diagnoses
% Participants
In the one setting where you practice most, what role
do you as a psychologist play in making individual
diagnoses?
60%
57%
50%
40%
32%
30%
20%
10%
6%
4%
I have no active
role in making a
diagnosis
Other
0%
I make diagnoses
independently
I contribute to
diagnostic
formulations made
by other health
professionals
Purpose of Classification
From your perspective, which is the single, most
important purpose of a diagnostic classification system?
50%
39%
% Participants
40%
33%
30%
20%
16%
10%
3%
5%
4%
Facilitate
research
Basis for
generating
national health
statistics
Other
0%
Communication Communication
Inform
among
between
treatment and
clinicians
clinicians and management
patients
decisions
Number of
Categories Desired
In clinical settings, how many diagnostic categories
should a classification system contain to be most useful
for mental health professionals?
% Participants
60%
50%
50%
40%
35%
30%
20%
11%
10%
4%
0%
10 to 30
31 to 100
101 to 200
More than 200
Strict Criteria vs.
Flexible Guidance
For maximum utility in clinical settings, a diagnostic
manual should contain:
% Participants
100%
78%
80%
78%
60%
ICD-10
Users
40%
22%
22%
DSM-IV
Users
20%
0%
Clear and strict diagnostic
criteria
Flexible guidance that allows
for cultural variation and clinical
judgment
A Dimensional Component
Should a diagnostic system incorporate a dimensional component, where some
disorders are rated on a scale rather than just as present or absent?
60%
50%
50%
% Participants
40%
30%
ICD-10 Users
46%
34%
28%
DSM-IV
Users
20%
13%
11%
10%
9%
9%
0%
No, insufficient
research on
reliability
No, too
complicated in
clinical settings
Yes, more accurate
reflection of
psychopathology
Yes, for more
detailed and
personalized
diagnosis
ICD-10 and DSM-IV
Categories Used Most Often (Why they couldn’t get rid of
Borderline)
ICD-10
%
DSM-IV
%
Depressive Episode
71%
Major Depressive Disorder
60%
Generalized Anxiety Disorder
48%
Generalized Anxiety Disorder
59%
Social Phobia
46%
Post-Traumatic Stress Disorder
42%
Mixed Anxiety and Depressive Disorder
44%
Adjustment Disorders
41%
Recurrent Depressive Disorder
44%
Attention-Deficit/Hyperactivity Disorder
38%
Post-Traumatic Stress Disorder
42%
Obsessive-Compulsive Disorder
37%
Borderline Personality Disorder
42%
Social Phobia
37%
Adjustment Disorder
42%
Borderline Personality Disorder
34%
Specific (Isolated) Phobias
41%
Single Major Depressive Episode
34%
Hyperkinetic (Attention Deficit) Disorder
34%
Panic Disorder without Agoraphobia
32%
Obsessive-Compulsive Disorder
34%
Bipolar I Disorder
27%
Bipolar Affective Disorder
28%
Alcohol-Related Disorders
26%
A diagnostic framework that attempts to
characterize the whole person--the depth as
well as the surface of emotional, cognitive, and
social functioning; from healthy to disturbed in
a mixed categorical -dimensional system
Psychodynamic Theory as a Complex Adaptive Systemtemperament, affects, cognitions, development, traumas, defenses, fantasies,
attachments all interacting at various levels of consciousness.
73
Kernberg’s (1976, 1984) Differentiation of Personality
Organization
Neurotic
Borderline
Psychotic
Identity
+
Integration
-
-
Defensive +
Operations
-
-
Reality
Testing
+/-
-
+
Gordon and Stoffey recent research supports that these factors contribute most to personality organization.
How can we conceptualize “borderline” more accurately?
Kernberg’s Levels of Personality Organization
1- Normal flexibility and adaptation
2- Neurotic level of personality organization
3- Borderline level of personality organization:
– High level borderline
– Low level borderline
4- Psychotic level of personality
Borderline Personality Organization
Basic Characteristics- Kernberg
Identity Diffusion
No integrated concept of self
No integrated concept of significant others
Primitive Defenses
– Splitting
– Idealization/devaluation
– Projective identification
– Omnipotent control
– Denial
Variable Reality Testing
PDM System
The PDM uses a multi dimensional approach to
describe the intricacies of the patient's overall
functioning and ways of engaging in the therapeutic
process. It begins with a classification of the
spectrum of personality patterns and disorders, then
offers a "profile of mental functioning" covering in
more detail the patient's capacities, and finally
considers symptom patterns, with emphasis on the
patient's subjective experience.
The Psychodynamic Diagnostic Manual
• Over-all level of personality organization
(Healthy, Neurotic or Borderline)
• Personality patterns and disorders
(Temperament, conflicts, affects, cognitions and
defensives)
• Specific capacities of mental functioning
(learning, relationships, self regard, affective
experience, internal representations, differentiation
and integration, psychological mindedness, a sense of
morality)
• The subjective experience of symptoms
Dimension I: Personality Patterns and
Disorders
The PDM classification of personality patterns
has been placed first in the PDM system
because of the accumulating evidence that
symptoms or problems cannot be understood,
assessed, or treated in the absence of an
understanding of the mental life of the person
who has the symptoms.
Dimension II: Mental Functioning
The second PDM dimension offers a more
detailed description of emotional functioningthe capacities that contribute to an
individual's personality and overall level of
psychological health or pathology.
Dimension III: Manifest Symptoms and
Concerns
Dimension III presents symptom patterns in
terms of the patient's personal experience of
his or her prevailing difficulties. The patient
may evidence a few or many patterns, which
may or may not be related, and which should
be seen in the context of the person's
personality and mental functioning.
Types of Personality Disorders
P101. Schizoid Personality Disorders
P102. Paranoid Personality Disorders
P103. Psychopathic (Antisocial) Personality Disorders
P103.1 Passive/Parasitic
P103.2 Aggressive
P104. Narcissistic Personality Disorders
P104.1 Arrogant/Entitled
P104.2 Depressed/Depleted
P105. Sadistic and Sadomasochistic Personality Disorders
P105.1 Intermediate Manifestation: Sadomasochistic Personality
Disorders
P106. Masochistic (Self-Defeating) Personality Disorders
P106.1 Moral Masochistic
P106.2 Relational Masochistic
P107. Depressive Personality Disorders
P107.1 Introjective
P107.2 Anaclitic
P107.3 Converse Manifestation: Hypomanic Personality
Disorder
P108. Somatizing Personality Disorders
P109. Dependent Personality Disorders
P109.1 Passive-Aggressive Versions of Dependent
Personality Disorders
P109.2 Converse Manifestation: Counterdependent
Personality Disorders
P110. Phobic (Avoidant) Personality Disorders
P110.1 Converse Manifestation: Counterphobic Personality
Disorders
P111. Anxious Personality Disorders
P112. Obsessive-Compulsive Personality Disorders
P112.1 Obsessive
P112.2 Compulsive
P113. Hysterical (Histrionic) Personality Disorders
P113.1 Inhibited
P113.2 Demonstrative or Flamboyant
P114. Dissociative Personality Disorders (Dissociative Identity
Disorder/Multiple Personality Disorder)
P115. Mixed/Other
P Axis
The P Axis- Personality Disorders Considers the Following
Factors:
Temperamental,
Thematic,
Affective,
Cognitive, and
Defense patterns
Psychopathic, Sociopathic, Antisocial or Dissocial?
• The DSM-IV-TR states that psychopathy and sociopathy
are obsolete synonyms for “Antisocial Personality
Disorder.”
• The World Health Organization stance in its ICD-10 refers
to psychopathy, sociopathy, antisocial personality, asocial
personality, and amoral personality as synonyms for
“Dissocial Personality Disorder.”
• The PDM uses “Psychopathic” to relate to the personality
not just symptoms, and considers all the terms as
basically interchangeable.
Psychopathy and Narcissism
Otto Kernberg (2004) believed psychopathy
should fall under a spectrum of pathological
narcissism, that ranged from narcissistic
personality on the low end, malignant
narcissism in the middle, and psychopathy at
the high end.
P103. Psychopathic (Antisocial) Personality Disorder
P103.1 Passive/Parasitic
P103.2 Aggressive
• Contributing constitutional-maturational patterns: aggressiveness,
high threshold for emotional stimulation
• Central tension/preoccupation: Manipulating/being manipulated
• Central affects: Rage, envy
• Characteristic pathogenic belief about self: I can make anything
happen
• Characteristic pathogenic belief about others: Everyone is selfish,
manipulative, dishonest
• Central ways of defending: Reaching for omnipotent control
Aggressive Subtype
• Explosive
• Actively predatory
• Often violent
Passive/Parasitic Subtype
•
•
•
•
More dependent
Less aggressive, usually non-violent
Manipulator
Con artist
Psychopathic P.D. (PDM)
• Not all psychopaths are antisocial. Many are successful and
social in certain roles (intelligence, law enforcement, attorney,
clergy, etc.)
• Want power for its own sake
• Pleasure in exploiting and duping others
• Good at reading the emotions of others, but not their own
• Lacking a moral center of gravity
• Lose interest in people once no longer useful to them
• Lack of remorse
• Need high external stimulation
• Organized mainly at the borderline level, and often combines
with other personality disorders or patterns (Paranoid,
Sadistic, Narcissistic, etc.)
Robert Hare, Ph.D. author of Snakes
in Suits: When Psychopaths Go to
Work found that psychopathic traits
are common to many CEOs.
He describes psychopaths as
”Intraspecies predators”
Why the Psychopath is a risk in treatment
• They are very hard to detect.
• They are con artists. They are experts at sizing you
up and exploiting your issues.
• They can be charming one moment, and
dangerous the next.
• They can seduce you and then destroy your
career.
• They will make false claims against you for the
money.
What to do?
• Be aware of the diagnosis- Learn the PDM!
• Keep strict boundaries and ground rules,
• Use frequent clarifications of roles and rules of
therapy,
• Use confrontations to help with impulse
containment,
• Take ‘protective’ notes,
• Get a consult,
• If you are frightened or uncomfortable, you do
not have to treat the patient. Refer to a more
appropriate facility.
Profile of Mental Functioning - M Axis
• Capacity for Regulation, Attention, and Learning
• Capacity for Relationships (Including Depth, Range, and Consistency)
• Quality of Internal Experience (Level of Confidence and Self-Regard)
• Affective Experience, Expression, and Communication
• Defensive Patterns and Capacities
• Capacity to Form Internal Representations
• Capacity for Differentiation and Integration
• Self-Observing Capacities (Psychological-Mindedness)
• Capacity for Internal Standards and Ideals: A Sense of Morality
Summary of Basic Mental Functioning Scale
M201. Optimal Age- and Phase-Appropriate Mental
Capacities
M202. Reasonable Age- and Phase-Appropriate
Mental Capacities
M203. Age- and Phase-Appropriate Capacities
M204. Mild Constrictions and Inflexibility
M204.1 Encapsulated character formations
M204.2 Encapsulated symptom formations
M205. Moderate Constrictions and Alterations in
Mental Functioning
M206. Major Constrictions and Alterations in Mental
Functioning
M207. Defects in Integration and Organization
and/or Differentiation of Self- and Object
Representations
M208. Major Defects in Basic Mental Functions
An Integration of the Psychodynamic
Diagnostic Manual (PDM), ICD and DSM
Robert M. Gordon and Robert F. Bornstein
Goal of the PDC
To offer a person-based nosology by
integrating the PDM, ICD and DSM; this
integrated nosology may be used for:
1. better diagnoses,
2. treatment formulations,
3. progress reports,
4. outcome assessment,
5. research on personality and
psychopathology.
USE
Our overarching aim is to make
psychodiagnoses more useful to the
practitioner by combining the symptomfocused ICD or DSM with the full range
and depth of human mental functioning
addressed by the PDM.
How to Use
The clinician must perform (or have access to)
diagnostic interview data and psychological
assessment data to derive optimal ratings. We
recognize that this is not always feasible, and in
many instances the clinician will code an initial
impression, then re-assess as additional
information accrues. If this is used for progress
notes, there will be opportunities to re-assess
and revise the person’s diagnosis as well. The
validity of this chart can be enhanced with the
integration of relevant psychological tests.
Scoring
For consistency and ease of scoring, all
dimensional ratings go from most disturbed
(1) to healthy (10). We advise against using
ratings of “10” except in unusual
circumstances.
Psychodiagnostic Chart
Personality Structure
Personality Patterns
Mental Functioning
Symptoms
Cultural-Contextual Issues
1. PERSONALITY STRUCTURE
LEVEL OF PERSONALITY STRUCTURE
We start with the overall personality structure or severity, ranging
from psychotic to healthy. The PDM uses seven mental capacities to
assess level of severity. Three steps are involved:
Rate each capacity using the 1-10 scale.
Review the definitions of personality structure (healthy, neurotic,
borderline and psychotic)
Indicate the overall level of personality structure. For example, a “3”
would be a low functioning borderline structure; an “8” would be a
high functioning neurotic structure.
1. Level of Personality Structure
Please rate each capacity from 1 to 10; ratings range from Most Disturbed (1) to Most Healthy (10).
1. Identity: ability to view self in complex, stable, and accurate ways
2. Object Relations: ability to maintain intimate, stable, and satisfying relationships
3. Affect Tolerance: ability to experience the full range of age-expected affects
4. Affect Regulation: ability to regulate impulses and affects with flexibility in using
defenses or coping strategies
5. Superego Integration: ability to use a consistent and mature moral sensibility
6. Reality Testing: ability to appreciate conventional notions of what is realistic
7. Ego Resilience: ability to respond to stress resourcefully and to recover from
painful events without undue difficulty
1. Level of Personality Structure- Rating
Healthy Personality- characterized by 9-10 scores, life problems never get out of
hand and enough flexibility to accommodate to challenging realities.
Neurotic Level- characterized by mainly 6-8 scores, rigidity and limited range of
defenses and coping mechanisms, basically a good sense of identity, healthy
intimacies, good reality testing, fair resiliency, fair affect tolerance and regulation,
favors repression.
Borderline Level- characterized by mainly 3-5 scores, recurrent relational problems,
difficulty with affect tolerance and regulation, poor impulse control, poor sense of
identity, poor resiliency, favors primitive defenses such as denial, splitting and
projective identification.
Psychotic Level- characterized by mainly 1-2 scores, delusional thinking, sometimes
hallucinations, poor reality testing and mood regulation, extreme difficulty
functioning in work and relationships.
Overall Personality Structure
Based on the 7 ratings above, rate person’s overall personality structure from 1
(Psychotic) to 10 (Healthy)
2. Dominant Personality Patterns or Disorders
These are relatively stable ways of thinking,
feeling, behaving and relating to others. Normal
level temperaments and traits (e.g.,
extroversion) do not involve impairment, while
personality disorders involve impairment at the
neurotic, borderline, or severe (psychotic) level.
You may substitute ICD or DSM personality
disorders for those of the PDM. If the person
does not have a personality disorder, but a
maladaptive trait or personality style, then rate
the trait or style as “mild” (e.g., obsessional
traits-8). Check off as many as apply.
2. Personality Patterns or Disorders- Scoring
Review the P axis in the PDM for the
personality patterns most descriptive of your
client (or use the PDP, SWAP, OPD, etc.).
Begin by checking off as many descriptors that
apply. Then decide on the most dominant
personality patterns or disorders, and the
level of severity (1-10).
PDM Categories:
Schizoid
Paranoid
Psychopathic (antisocial); Subtypes - passive/parasitic or aggressive
Narcissistic; Subtypes - arrogant/entitled or depressed/depleted;
Sadistic (and intermediate manifestation, sadomasochistic)
Masochistic (self-defeating); Subtypes - moral masochistic or relational masochistic
Depressive; Subtypes - introjective or anaclitic; Converse manifestation - hypomanic
Somatizing
Dependent (and passive-aggressive versions of dependent); Converse manifestation
- counterdependent
Phobic (avoidant); Converse manifestation - counterphobic
Anxious
Obsessive-compulsive; Subtypes - obsessive or compulsive
Hysterical (histrionic); Subtypes - inhibited or demonstrative/ flamboyant
Dissociative
Mixed/other
Rate: Dominate Personality Disorder or Maladaptive Traits & Overall Severity of Impairment
3. MENTAL FUNCTIONING
Rate (1-10) the 9 different mental
capacities according to the level of
maturation or functioning.
3. Mental Functioning
1. Capacity for Attention, Memory, Learning, and Intelligence
2. Capacity for Relationships and Intimacy (including depth, range, and consistency)
3. Quality of Internal Experience (level of confidence and self-regard)
4. Affective Comprehension, Expression, and Communication
5. Level of Defensive or Coping Patterns
1-2: Psychotic level (e.g., delusional projection, psychotic denial, psychotic distortion)
3-5: Borderline level (e.g., splitting, projective identification, idealization/devaluation,
denial, acting out)
6-8: Neurotic level (e.g., repression, reaction formation, rationalization,
displacement, undoing)
9-10: Healthy level (e.g., anticipation, sublimation, altruism, and humor)
6. Capacity to Form Internal Representations (sense of self and others are realistic and
guiding)
7. Capacity for Differentiation and Integration (self, others, time, internal experiences
and
external reality are all well distinguished)
8. Self-Observing Capacity (psychological mindedness)
9. Realistic sense of Morality
4. ICD, DSM or PDM SYMPTOMS
Symptoms are considered in the context of:
1. level of personality structure,
2. personality pattern or disorder
3. mental functioning.
Here you may use the symptoms that may be
the focus of the chief complaint and necessary
for third party reimbursement. However, you
treat the person, not just the symptoms.
5. Cultural, Contextual, and Other
Relevant Considerations
This is a qualitative section where the
practitioner may write how cultural or
contextual factors contribute to symptoms,
better explain symptoms and/or degree of
suffering.
Importance of a Psychodynamic Understanding of Personality
• The PDM was introduced to 192 psychologists in a
several ethics and MMPI-2 workshops
• (65 Psychodynamic, 76 CBT and 51 Other)
• Over all the psychologists gave the PDM a 90%
favorable rating.
•
Gordon, R.M. (2009). Reactions to the Psychodynamic Diagnostic Manual (PDM) by Psychodynamic,
CBT and Other Non- Psychodynamic Psychologists. Issues in Psychoanalytic Psychology, 31,1, 55-62.
What Do Practitioners Want in a Diagnostic
Taxonomy? Comparing the PDM with DSM and ICD
•68% rated PDM Personality Structure as “helpful-very
helpful.”
•58% rated PDM Mental Functioning as “helpful-very
helpful.”
•44% rated PDM Dominant Personality Patterns or
Disorders as “helpful-very helpful.”
•18% rated DSM GAF scores as “helpful-very helpful.”
•14% rated ICD or DSM symptoms as “helpful-very helpful.”
•
Fifty practitioners have taken the survey to date, with 80% of respondents having doctorates and 20% masters degrees; 54% were women.
Half of the respondents identified themselves as Psychodynamic (50%); the rest were Eclectic (22%), Cognitive-Behavioral (12%),
Humanistic/Existential (10%), Systems (4%), and Other (2%).
•
(Bornstein, R.F. and Gordon, R.M. 2012, in press, What Do Practitioners Want in a Diagnostic Taxonomy? Comparing the PDM with DSM
and ICD. Division Review: A Quarterly Psychoanalytic Forum)
Finally, Use the ICD and integrate it
with the PDM
• For better risk management
• For more empathy and better treatment
formulation
• For insurance requirements
Thank you.