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Diagnosis in the DSM-5
CHRISTOPHER J. HOPWOOD, PHD
MICHIGAN STATE UNIVERSITY
Disclaimers
 This workshop is not affiliated with or endorsed by
the American Psychiatric Association
 There will be additional editorial and content
changes to the DSM-5 prior to its publication in May,
2013
Outline
 The Past: Competing models of psychopathology
 The Present: Specific changes in the DSM-5
 The Edge: DSM-5 personality disorders
 The Future: DSM-5.1 and beyond
 Note about slides and handouts
Initial Questions
 What do you use the DSM for?
Initial Questions
 What do you use the DSM for?
 How do you conduct clinical assessment?
 Do you use psychometric instruments?
 What instruments?
Initial Questions
 What do you use the DSM for?
 How do you conduct clinical assessment?
 How useful is the DSM for your treatment decisions
and clinical predictions?
Initial Questions
 What do you use the DSM for?
 How do you
conduct
clinical
assessment?
Not very,
but I need
to list
something to get reimbursed
 What instruments?
I would rearrange
things slightly, but it more or less
 What theoretical
perspective?
covers psychopathology, which is one part of
 How useful is the DSM for your treatment decisions
assessment
and clinical predictions?
It covers psychopathology well, and this is the single
most important among domains of assessment
It provides most of what you need to know for
assessment
The Example of Diabetes
 Diagnosis and treatment in ancient civilizations
 The Intersection of medical practice and basic
research in 18th Century France
 Contemporary diagnosis and treatment

Mechanisms, structure, and function
A Clinical Example: MMPI profile
120
110
100
90
80
70
60
50
40
30
L
F
K
HS
D
HY
PD
MF
PA
PT
SC
MA
SI
A Clinical Example: Clinical features
 32 year old Caucasian Male
 Born unwanted to an introverted lab-scientist father
and fragile factory working mother in a midwestern,
predominately Lutheran community
 Mother often unavailable due to depression and
substance use, father often unavailable due to
workaholism
 Had a number of medical complications in early
childhood, one of which involved a threat to remove
his penis; parents reflected how these experiences
drew him “inward”
A Clinical Example: Clinical features
 Developed an interest in anatomy, would frequently kill





and dissect animals
As a teen, began masturbating to fantasies involving
animal parts and male peers
Daydreamed about killing and having sex with a jogger
who past his home
Efforts to be part of social groups routinely failed; began
using substances and developed a reputation as a clown
for approval
Parents relationship deteriorated during his high school,
separated when he was 18; was sent to live with relatives
Mother kidnapped child, left him alone in house, and
instructed him not to report their whereabouts
A Clinical Example: Clinical features
 Went to college briefly but failed and was unable to





develop a social network; described as “awkward loner”
Began using alcohol to fit in and self-medicate
Had difficulties holding a job, fired for absenteeism
Began having sex with men in bathhouses
Convicted of public exposure; then molesting a 13 year
old whom he had given soporiphic before taking nude
pictures
Court was convinced by remorse, he got 5 years
probation
A Clinical Example: Clinical features
(Nichols, 2007)
 Killed 17 people in a typical pattern
 Go to gay bar, invite a man to his




home
Behave oddly and sometimes
have intercourse
Develop fears of abandonment
when the man motioned to leave
Administer soporiphic, play with
anatomy
Murder the man, play more with
anatomy, including canibalism
Jeffrey Dahmer
A Clinical Example: Clinical features
http://www.youtube.com/watch?v=ErB0R4wlB64
A Clinical Example
 Psychiatric Diagnosis?
 Traits?
 Functional Formulation?
 Implicit Dynamics?
Nomothetic
Idiographic
Outline
 The Past: Competing models of psychopathology
 The Present: Specific changes in the DSM-5
 The Edge: DSM-5 personality disorders
 The Future: DSM-5.1 and beyond
Theoretical Models of Psychopathology
 Descriptive Psychiatry
 Quantitative Psychology
The Past: Competing Models of Psychopathology
Medical Model
The Past: Competing Models of Psychopathology
Assumptions of the Medical Model
 Psychiatric disorders are like any other medical




disorder
Abnormal and normal behavior are qualitatively
different
Disorders are qualitatively different from one
another
Biology is a privileged level of analysis
The research goal of taxonomy is to describe
symptoms reliably to work backwards to underlying
biological cause
The Past: Competing Models of Psychopathology
Kraepelin
 1856-1926
 German psychiatrist notable for
developing psychiatric taxonomy
rooted in biological hypotheses
 Trained with Wundt, unlike
contemporaries in psychiatry
advocated detailed behavioral
analysis
 Chapter organization was based
on his textbook approach
The Past: Competing Models of Psychopathology
Adolf Meyer
 1866-1950
 Swiss psychiatrist who emigrated
to US, early APA president
 Introduced Freud and Kraepelin
to US psychiatry
 Emphasized phenomenology and
subjective experience
 Focused on importance of detailed
case history
The Past: Competing Models of Psychopathology
Anti-Classification Movement
 Rosenhan study
 Szasz
 Laing
 Humanism
 Anti-pharmacology
The Past: Competing Models of Psychopathology
Neo-Kraepelinian Propositions (Klerman, 1978)
 Psychiatry is a branch of medicine based on science
 Psychiatry treats people with illness, who are
different than people who are not sick
 There are discrete mental illnesses which are
biological in origin
 Classification should be based on reliable description
and hypotheses about underlying biology
Feigner, Robins, Guze, and neo-Kraepelinianism
 Feigner criteria (1972)
 Clinical description
 Laboratory studies (biological or
psychometric evidence)
 Delimitation from other disorders
 Follow-up research (to rule out other
explanations)
 Family study (i.e., behavior genetic
research)
 The Invisible College and
reactionary psychiatry (Blashfield, 1984)
The Past: Competing Models of Psychopathology
The Invisible College
and DSM-III
(Blashfield, 1984)
The Past: Competing Models of Psychopathology
The Invisible College
and DSM-III
(Blashfield, 1984)
Robins, Guze, and Washington
School
The Past: Competing Models of Psychopathology
The Invisible College
and DSM-III
(Blashfield, 1984)
Spitzer, Endicott, Fleiss, and
NYSPI
The Past: Competing Models of Psychopathology
Feigner, Robins, Guze, and neo-Kraepelinianism
 Feigner criteria (1972)
 Clinical description
 Laboratory studies (biological or
psychometric evidence)
 Delimitation from other disorders
 Follow-up research (to rule out other
explanations)
 Family study (i.e., behavior genetic
research)
 The Invisible College and
reactionary psychiatry (Blashfield, 1984)
 DSM-III
The Past: Competing Models of Psychopathology
Feigner et al. (1972) depression criteria
 Dysphoric mood
 5 of 9 criteria (appetite, sleep, energy, lethargy,
anhedonia, guilt, concentration, suicidality)
 At least one month
 No other psychiatric or medical explanation
The Past: Competing Models of Psychopathology
Limitations of the Medical Model
 Where are the causes and effective treatments?
 How much is diagnosis influenced by pharma and
insurance?
 Is psychopathology fully reducible to signs and
symptoms?


What about those complications that Meyer emphasized and his
notion of a detailed case history?
Did the Washington school ever intend the diagnostic formulation to
be complete? Or did external forces reduce clinical assessment to
DSM checklists?
 Psychiatric exclusivity

The problem of reviewing for psychiatry journals as microcosmic for
the problem of the diagnostic manual being written by a single
profession
The Past: Competing Models of Psychopathology
Limitations of the Medical Model
 Many aspects of the model are demonstrably wrong
 With rare exceptions normal behavior is not qualitatively
different than abnormal behavior
 Current psychiatric phenotypes have predictable patterns of
comorbidity
 A number of factors affect functioning and outcomes for
persons with psychopathology that are not in the manual
The Past: Competing Models of Psychopathology
Question
 Have you ever recorded patient information for
purposes not directly to treatment delivery?
The Past: Competing Models of Psychopathology
What is important about the medical model?
 Clinical experience
 Reliable description
 Biology
 Pragmatic, categorical worldview
 Treatment matching
The Past: Competing Models of Psychopathology
Quantitative Trait Psychology
The Past: Competing Models of Psychopathology
Assumptions of Quantitative Trait Psychology
 The nature of psychopathology is a testable question
 Although multi-method evidence is ideal, people can
generally self-report their difficulties
 Signs reflect real entities plus error (circles and
squares)
 The best way to develop an effective taxonomy and
identify treatments is to carve nature at its joints
The Past: Competing Models of Psychopathology
Two streams
 Structure of traits – implications for psychiatry
 Structure of psychopathology – implications for
integration with personality
The Past: Competing Models of Psychopathology
Two streams
 Structure of traits – implications for psychiatry
 Structure of psychopathology – implications for
integration with personality
The Past: Competing Models of Psychopathology
Allport
 1897-1967
 First Personality textbook
 Trait psychologist who emphasized
how everyone is unique
 Lexical hypothesis
 Allport & Odbert (1936)
The Past: Competing Models of Psychopathology
Cattell
 1905-1998
 Built psychometric models from
agriculture and intellectual
assessment

Spearman, Thurstone, Guilford, Burt
 Developed the notion of using factor
analysis for test development that
currently dominates basic personality
research
 Proposed 16 primary traits
The Past: Competing Models of Psychopathology
The Big Five
 Digman, Goldberg, Costa, McCrae and others
‘settled’ on the Big Five





Neuroticism
Extroversion
Openness to Experience/Intellect
Agreeableness
Conscientiousness
 Wiggins, Widiger, Costa, and many others
demonstrated the importance of big five traits to
clinical psychology
The Past: Competing Models of Psychopathology
Two streams
 Structure of traits – implications for psychiatry
 Structure of psychopathology – implications for
integration with personality
The Past: Competing Models of Psychopathology
Eysenck
 Interested in understanding the
structure of psychopathology
 Used factor analysis and
experimental research with multiple
methods and samples
 Identified similar factors



Neuroticism
Extroversion
Psychoticism
The Past: Competing Models of Psychopathology
Achenbach
 Seminal study in 1966 applying
factor analysis to childhood
psychopathology
 Two broad factors


Internalizing
Externalizing
The Past: Competing Models of Psychopathology
Krueger
 Structure of comorbidity (Krueger, 1999)
The Past: Competing Models of Psychopathology
Trait Hierarchy
The Past: Competing Models of Psychopathology
Evidence for Traits
 Cross-cultural validity (Terraciano et al., 2010)
 Heritability (Hopwood et al., 2011)
 Links to Biological Structure (De Young et al., 2009)
 Course (Roberts et al., 2006)
 Cross-instrument validity (McCrae et al., 2011)
 Prediction of psychopathology (Kotov et al., 2010; Samuel &
Widiger, 2008)
The Past: Competing Models of Psychopathology
How “personality” are PDs?
Samuel & Widiger (2008) Meta-Analysis (16 Independent samples)
N
E
O
A
C
Paranoid
0.40
-0.21
-0.04
-0.34
-0.11
Schizoid
0.22
-0.46
-0.11
-0.16
-0.10
Schizotypal
0.38
-0.28
0.09
-0.17
-0.14
Antisocial
0.18
0.04
0.08
-0.36
-0.33
Borderline
0.54
-0.12
0.10
-0.24
-0.29
Histrionic
0.10
0.33
0.15
-0.11
-0.11
Narcissistic
0.11
0.09
0.07
-0.37
-0.10
Avoidant
0.52
-0.49
-0.08
-0.07
-0.16
Dependent
0.44
-0.15
-0.03
0.08
-0.20
Obsessive
Mean
Median
0.18
0.31
0.30
-0.12
-0.14
-0.14
-0.04
0.02
0.02
-0.05
-0.18
-0.17
0.24
-0.13
-0.13
Kotov et al. (2010) “Axis I” meta-analysis
N
E
O
A
C
PDs
0.31
-0.14
0.02
-0.18
-0.13
Axis I
0.39
-0.24
-0.09
-0.02
-0.30
Advantages of a quantitative perspective
 Provides quantitative model for understanding
individual differences in psychopathology
The Past: Competing Models of Psychopathology
Meehl
 Taxometrics
 Quantitative procedures to tell if a construct
is distributed continuously or not
 Current evidence – discontinuities are rare
(Haslam, 2011)
 Actuarial prediction
 All measures are potentially useful – this is a
falsifiable question
 Clinicians are good at picking variables
 Clinicians are bad at combining variables
The Past: Competing Models of Psychopathology
Advantages of a quantitative perspective
 Provides quantitative model for understanding
individual differences in psychopathology
 Provides a model for developing assessment methods
The Past: Competing Models of Psychopathology
(Cronbach, Meehl and) Loevinger
 Construct Validation
 Theory = Content Validity
 Structure = Structural Validity, Reliability
 Nomological Network

Convergent, Discriminant, Criterion Validity
 Trait realism
 Psychological Disorders as
hypothetical constructs
The Past: Competing Models of Psychopathology
Advantages of a quantitative perspective
 Provides quantitative model for understanding
individual differences in psychopathology
 Provides a model for developing assessment methods
 Provides a coherent framework within which to
understand


Comorbidity
Heterogeneity
The Past: Competing Models of Psychopathology
Applying the hierarchy (Hopwood et al., in press)
 DSM-5 Traits
 Negative Affect, Detachment, Antagonism, Disinhibition,
Psychoticism
 25 facets
 PAI
 Psychopathology
 Suicide, Aggression, Treatment Motivation, Social Support,
Stress
 Exploratory Structural Equation Model with target
rotation
The Past: Competing Models of Psychopathology
Applying the hierarchy: Structure (Hopwood et al., in press)
Negative Affectivity
Submissiveness
Separation Insecurity
Anxiousness
Emotional Lability
Suspiciousness
Detachment
Restricted Affectivity
Depressivity
Withdrawal
Intimacy Avoidance
Anhedonia
Antagonism
Manipulativeness
Deceitfulness
Hostility
Callousness
Attention Seeking
Grandiosity
Disinhibition
Irresponsibility
Impulsivity
Distractability
Perseveration
Rigid Perfectionism
Risk Taking
Psychoticism
Eccentricity
Perceptual Dysregulation
Unusual Beliefs
Negative Affectivity
Detachment
Antagonism
Disinhibition
Psychoticism
.27
.48
.70
.59
.32
.01
.04
.20
.11
.28
-.23
.01
-.07
.12
.26
.03
.21
.15
.25
.20
.11
.18
.13
.16
.29
-.34
.15
-.01
-.21
.06
.38
.40
.71
.27
.62
.15
-.07
.09
.05
-.05
.11
.36
.05
.01
.30
.13
.40
.20
.39
.23
.07
.07
.36
-.12
.23
.05
.01
.17
.39
.31
-.32
.03
.52
.41
.58
.54
.39
.52
.18
.28
.32
.14
.16
-.10
.05
.19
-.10
.30
.13
.20
-.06
-.05
.16
.35
.45
-.31
.16
-.10
.08
.20
.20
-.33
.21
.26
-.10
.09
.28
.30
.30
.56
.44
.17
-.34
.56
.45
.19
.25
.32
.18
-.09
.15
.13
.08
.12
.13
.10
.16
.18
.28
.27
.17
-.06
.31
.58
.61
The Past: Competing Models of Psychopathology
Applying the hierarchy: “Comorbidity“ (Hopwood et al., in press)
Anxiety Disorders
Obsessive Compulsive
Phobias
Traumatic Stress
Borderline Features
Affective Instability
Identity Problems
Negative Relationships
Self Harm
Negative Affectivity
Detachment
Antagonism
Disinhibition
Psychoticism
.44
.17
.34
-.38
.22
.50
.25
-.04
-.04
.42
.44
.09
.07
.23
.44
.43
.35
.32
.39
.20
.48
.13
-.04
.42
.25
.43
.23
.26
.32
.16
.04
-.06
.30
.47
.32
The Past: Competing Models of Psychopathology
Applying the hierarchy: Heterogeneity (Hopwood et al., in press)
Negative Affectivity Detachment Antagonism Disinhibition Psychoticism
Mania
Activity Level
Grandiosity
.25
-.12
.33
.08
.46
.03
-.29
.46
-.22
.20
Irritability
.48
.14
.53
.08
.10
The Past: Competing Models of Psychopathology
Applying the hierarchy: Levels of analysis
(Hopwood et al., in press)
The Past: Competing Models of Psychopathology
Applying the hierarchy:
How much breadth do you need? (Hopwood et al., in press)
Anxiety
Insecurity
Lability
Anger
Perfectionism
Sleep Problems (.19)
.13
.07
.11
Suicidal Ideation (.58)
.35
.09
.32
.29
Interpersonal Problems (.63)
.39
.23
.18
.39
.07
The Past: Competing Models of Psychopathology
Advantages of a quantitative perspective
 Provides quantitative model for understanding
individual differences in psychopathology
 Provides a model for developing assessment methods
 Provides a coherent framework within which to
understand


Comorbidity
Heterogeneity
 Provides a connection between basic science and
clinical application
The Past: Competing Models of Psychopathology
Links to Dynamics
 Wiggins: Structure of interpersonal
behavior commensurate with
Agreeableness (warmth) and
Extraversion (dominance)
 Watson: Structure of affect
commensurate with Neuroticism
(negative affectivity), Extraversion
(positive affectivity)
The Past: Competing Models of Psychopathology
Limitations of a quantitative perspective
 Primarily studied in normal psychological literature with
questionnaires
 Paradox of broad topics and small concerns




Types vs. traits
Number of types or traits
Best way to rotate factors
Best fit indicators
 Limited efforts to connect to clinical practice in a
tangible way
 Mistrust among clinicians who see the quantitative
perspective as “cold” and among psychiatry as “numbery”
The Past: Competing Models of Psychopathology
Summary
 There is a clinical need to describe disorders, ideally
including underlying biology
 However, it is important to recognize that


to the degree that motives, perceptions, and social contexts
affect behavior, psychopathology can not be fully reduced to
biological processes without losing important meaning
Behaviors are structured by hierarchical personality and
cognitive architectures
 In other words, psychiatric taxonomy needs
quantitative clinical psychology
The Past: Competing Models of Psychopathology
Outline
 The Past: Competing models of psychopathology
 The Present: Specific changes in the DSM-5
 The Edge: DSM-5 personality disorders
 The Future: DSM-5.1 and beyond
In the beginning
 Regier et al., 2009:
 Indictment of Feigner Criteria
Comorbidity
 Non-specific treatment response
 “combined influence of syndromes…more significant than any of
their individual effects”
 “unlikely to find single gene underpinnings”

The Present: DSM-5
In the beginning
 Regier et al., 2009:
 Hierarchies
“the presence of any disorder would cause the manifestations of
disorders lower in the hierarchy”
 Implicit in Kraepelin, Explicit in Jaspers
 Lost in DSM-III-R


Dimensions

“We have decided that one, if not the major, difference between
DSM-IV and DSM-V will be the more prominent use of
dimensional measures.”
The Present: DSM-5
Process
 1999 – Goals and White Papers




Basic definition
Dimensional criteria
Development, gender, and culture
Neuroscientific research
 Meetings

APA, WHO, NIMH, NIDA, NIAAA
 Leadership selected by APA: Kupfer, Regier


Study Groups
Diagnostic Cluster Work Groups
Literature Reviews
 Re-analysis
 Initial Proposals
 Comments

The Present: DSM-5
Process
 Field Trials
 Description
 Comorbidity
 Issues with reliability
The Present: DSM-5
Description of DSM-5 Field Trials (Clarke et al., 2013)
 279 clinicians
 2246 patients
 86% seen for 2 interviews
 Diverse in age, ethnicity, geography
 Certain phenotypes oversampled to ensure adequate
base rates
The Present: DSM-5
Comorbidity in Field Trials
Trimorbid MDD, PTSD, AUD?
The Present: DSM-5
DSM-5 Field Trials Reliability
 Spitzer et al., 2013
 Fleiss Standard of kappas in DSM-III, IV


.40 = minimum, .70 = good
Kappas for DSM-5 field trials dip into .30s, which is a cause for
concern
 Kraemer et al., 2013
 “The methodology and understanding of kappa have advanced
over the last 30 years”
The Present: DSM-5
DSM-5 Field Trials Reliability
DSM-III
DSM-5
patients selected by
clinicians
patients referred to clinicians
blinding between clinicians
taken on trust
blinding ensured by design
very small samples for low
adequate (over) sampling
base rate disorders leading to
large confidence intervals
The Present: DSM-5
DSM-5 Field Trials Reliability
 Kraemer et al., 2013
 Inter-clinician kappas for most areas of medicine tend to be
around .40
 “It is important that our expectations of DSM-5 diagnoses be
viewed in the context of what is known about the reliability
and validity of diagnoses throughout medicine and not be
unrealistically high”
The Present: DSM-5
Rolling out the Manual
 Work Groups developed revised proposals
 Comments invited
 Final proposals passed to committees
Scientific Review
 Clinical Public Health

 DSM-5 Task Force led by Kupfer and Regier advises
APA Board of Trustees
 APA Board of Trustees makes final decisions
 Available for purchase currently, available in May
2013
The Present: DSM-5
Changes in the DSM-5
 The Number 5
 Connection to Medicine and Biological Focus
 Connection with ICD
 Chapter reorganization
 Issues of culture, demography
 Dimensional severity assessments
 Criterion Sets
The Present: DSM-5
Changes in the DSM-5
 The Number 5
 Connection to Medicine and Biological Focus
 Connection with ICD
 Chapter reorganization
 Issues of culture, demography
 Dimensional severity assessments
 Criterion Sets
The Present: DSM-5
DSM-5, not DSM-V
 Use of Arabic numerals is meant to reflect a
paradigm shift towards greater responsivity
 Practically: more revisions

5.1, 5.2, 5.3….
 Challenge: how to be responsive to research without
driving clinicians and mental health systems nuts!
 Conflict of interest?


DSM-5: $200
ICD-10: Public Domain
The Present: DSM-5
Changes in the DSM-5
 The Number 5
 Connection to Medicine and Biological Focus
 Connection with ICD
 Chapter reorganization
 Issues of culture, demography
 Dimensional severity assessments
 Criterion Sets
The Present: DSM-5
Medicine
 More dimensional ratings of cross-cutting constructs
 Developmental organization of disorders
 Dropped multi-axial format
The Present: DSM-5
Multi-Axial Diagnosis
 Distinctions between “Axis II” and other disorders
have been falsified
 No other medical profession uses a multi-axial model
 Axis III gets equal status (albeit possibly in a
different manual)
 Cultural/Social issues and Functioning will be
incorporated into symptom descriptions or assessed
as cross-cutting dimensions
The Present: DSM-5
Biology
 Behavior Genetics
 GWAS
 Imaging
 Psychophysiology
The Present: DSM-5
Behavior Genetics
 Everything is ~50% heritable…and the rest is mostly
error
 However

Developmental patterns
Eating Disorders
 Antisocial Behavior: Rule Breaking and Aggression




Epigentics
GxE
GrE
The Present: DSM-5
GWAS (Lancet, 2013)
 Findings from family and twin studies suggest that genetic contributions to
psychiatric disorders do not in all cases map to present diagnostic
categories. We aimed to identify specific variants underlying genetic effects
shared between the five disorders in the Psychiatric Genomics Consortium:
autism spectrum disorder, attention deficit-hyperactivity disorder, bipolar
disorder, major depressive disorder, and schizophrenia.
 33 332 cases and 27 888 controls
 Our findings show that specific SNPs are associated with a range of
psychiatric disorders of childhood onset or adult onset. In particular,
variation in calcium-channel activity genes seems to have pleiotropic
effects on psychopathology.
 Overall




very few findings
highly inconsistent
very small effects
effects that exist are pleiotropic or can be organized around higher order dimensions
The Present: DSM-5
Imaging
(DeYoung et al., 2010)
The Present: DSM-5
Psychophysiology
 P300
 In general, less
deflection is associated
with more impulsive,
poorer decision making
 Traditionally examined
with alcohol disorders
The Present: DSM-5
Psychophysiology (Patrick et al., 2006)
 Evaluated P300 relation to alcohol, drug, nicotine
dependence as well as conduct disorder and
antisocial personality
 Correlation with externalizing pathology = .25
 With this correlation covaried, no correlations with
specific disorders was significant
The Present: DSM-5
Changes in the DSM-5
 The Number 5
 Connection to Medicine and Biological Focus
 Connection with ICD
 Chapter reorganization
 Issues of culture, demography
 Dimensional severity assessments
 Criterion Sets
The Present: DSM-5
ICD
 Current version: ICD-10
 ICD-11 scheduled for 2015
 DSM-5 connection to ICD reviewed for all symptom
criteria
 Chapter organization designed to bring DSM in line
with ICD

Developmental Organization across and within chapters
The Present: DSM-5
Changes in the DSM-5
 The Number 5
 Connection to Medicine and Biological Focus
 Connection with ICD
 Chapter reorganization
 Issues of culture, demography
 Dimensional severity assessments
 Criterion Sets
The Present: DSM-5
Chapter Organization
 Kraepelinian organization was arbitrary
 There are non-arbitary ways to arrange disorders
 Covariance (Krueger, 1999)
 Development
 Brings DSM-5 structure in line with ICD as well as
other areas of medicine
The Present: DSM-5
Chapter Organization: DSM-5 approach
 Include all mental disorders in Section II
 List domains of disorder and disorders within
domains developmentally
 Keep classical distinctions (e.g., mood and anxiety)
 New domains (e.g., obsessive and traumatic)
 Encourage clinical use and research on content of
Section III
The Present: DSM-5
Section II: Essential Elements: Diagnostic
Criteria and Codes
Neurodevelopmental Disorders
Intellectual Disabilities
 Intellectual Disability (Intellectual Developmental Disorder)
 Global Developmental Delay
 Unspecified Intellectual Disability
Communication Disorders
 Language Disorder
 Speech Sound Disorder (previously Phonological Disorder)
 Childhood Onset Fluency Disorder (Stuttering)
 Social (Pragmatic) Communication Disorder
 Unspecified Communication Disorder
Autism Spectrum Disorder
 Autism Spectrum Disorder
The Present: DSM-5
Section II: Essential Elements: Diagnostic
Criteria and Codes
Neurodevelopmental Disorders
Attention-Deficit/Hyperactivity Disorder
 Attention-Deficit/Hyperactivity Disorder
 Other Specified Attention-Deficit/Hyperactivity Disorder
 Unspecified Attention-Deficit/Hyperactivity Disorder
Specific Learning Disorder
 Specific Learning Disorder
Motor Disorders
 Developmental Coordination Disorder
 Stereotypic Movement Disorder
 Tourette’s Disorder
 Persistent (Chronic) Motor or Vocal Tic Disorder
 Provisional Tic Disorder
 Other Specified Tic Disorder
 Unspecified Tic Disorder
Other Neurodevelopmental Disorders
 Other Specified Neurodevelopmental Disorder
 Unspecified Neurodevelopmental Disorder
The Present: DSM-5
Section II: Essential Elements: Diagnostic
Criteria and Codes
Schizophrenia Spectrum and Other Psychotic Disorders













Schizotypal Personality Disorder
Delusional Disorder
Brief Psychotic Disorder
Schizophreniform Disorder
Schizophrenia
Schizoaffective Disorder
Substance/Medication-Induced Psychotic Disorder
Psychotic Disorder Due to Another Medical Condition
Catatonia Associated With Another Mental Disorder (Catatonia Specifier)
Catatonic Disorder Due to Another Medical Condition
Unspecified Catatonia
Other Specified Schizophrenia Spectrum and Other Psychotic Disorder
Unspecified Schizophrenia Spectrum and Other Psychotic Disorder
The Present: DSM-5
Section II: Essential Elements: Diagnostic
Criteria and Codes
Bipolar and Related Disorders
 Bipolar I Disorder
 Bipolar II Disorder
 Cyclothymic Disorder
 Substance/Medication-Induced Bipolar and Related Disorder
 Bipolar and Related Disorder Due to Another Medical Condition
 Other Specified Bipolar and Related Disorder
 Unspecified Bipolar and Related Disorder
Depressive Disorders
 Disruptive Mood Dysregulation Disorder
 Major Depressive Disorder, Single and Recurrent Episodes
 Persistent Depressive Disorder (Dysthymia)
 Premenstrual Dysphoric Disorder
 Substance/Medication-Induced Depressive Disorder
 Depressive Disorder Due to Another Medical Condition
 Other Specified Depressive Disorder
 Unspecified Depressive Disorder
The Present: DSM-5
Section II: Essential Elements: Diagnostic
Criteria and Codes
Anxiety Disorders
 Separation Anxiety Disorder
 Selective Mutism
 Specific Phobia
 Social Anxiety Disorder (Social Phobia)
 Panic Disorder
 Panic Attack
 Agoraphobia
 Generalized Anxiety Disorder
 Substance/Medication-Induced Anxiety Disorder
 Anxiety Disorder Due to Another Medical Condition
 Other Specified Anxiety Disorder
 Unspecified Anxiety Disorder
The Present: DSM-5
Section II: Essential Elements: Diagnostic
Criteria and Codes
Obsessive-Compulsive and Related Disorders
 Obsessive-Compulsive Disorder
 Body Dysmorphic Disorder
 Hoarding Disorder
 Trichotillomania (Hair-Pulling Disorder)
 Excoriation (Skin-Picking) Disorder
 Substance/Medication-Induced Obsessive-Compulsive and Related Disorder
 Obsessive-Compulsive and Related Disorder Due to Another Medical Condition
 Other Specified Obsessive-Compulsive and Related Disorder
 Unspecified Obsessive-Compulsive and Related Disorder
Trauma- and Stressor-Related Disorders
 Reactive Attachment Disorder
 Disinhibited Social Engagement Disorder
 Posttraumatic Stress Disorder
 Acute Stress Disorder
 Adjustment Disorders
 Other Specified Trauma- and Stressor-Related Disorder
 Unspecified Trauma- and Stressor-Related Disorder
The Present: DSM-5
Section II: Essential Elements: Diagnostic
Criteria and Codes
Dissociative Disorders
 Dissociative Identity Disorder
 Dissociative Amnesia
 Depersonalization/Derealization Disorder
 Other Specified Dissociative Disorder
 Unspecified Dissociative Disorder
Somatic Symptom and Related Disorders
 Somatic Symptom Disorder
 Illness Anxiety Disorder
 Conversion Disorder (Functional Neurological Symptom Disorder)
 Psychological Factors Affecting Other Medical Conditions
 Factitious Disorder
 Other Specified Somatic Symptom and Related Disorder
 Unspecified Somatic Symptom and Related Disorder
The Present: DSM-5
Section II: Essential Elements: Diagnostic
Criteria and Codes
Feeding and Eating Disorders
 Pica
 Rumination Disorder
 Avoidant/Restrictive Food Intake Disorder
 Anorexia Nervosa
 Bulimia Nervosa
 Binge Eating Disorder
 Other Specified Feeding and Eating Disorder
 Unspecified Feeding and Eating Disorder
Elimination Disorders
 Enuresis
 Encopresis
 Other Specified Elimination Disorder
 Unspecified Elimination Disorder
The Present: DSM-5
Section II: Essential Elements: Diagnostic
Criteria and Codes
Sleep-Wake Disorders

Insomnia Disorder

Hypersomnolence Disorder

Narcolepsy





Breathing-Related Sleep Disorders
Obstructive Sleep Apnea Hypopnea Syndrome
Central Sleep Apnea
Sleep-Related Hypoventilation
Circadian Rhythm Sleep-Wake Disorders














Parasomnias
Non–Rapid Eye Movement Sleep Arousal Disorders
Sleepwalking
Sleep Terrors
Nightmare Disorder
Rapid Eye Movement Sleep Behavior Disorder
Restless Legs Syndrome
Substance/Medication-Induced Sleep Disorder
Other Specified Insomnia Disorder
Unspecified Insomnia Disorder
Other Specified Hypersomnolence Disorder
Unspecified Hypersomnolence Disorder
Other Specified Sleep-Wake Disorder
Unspecified Sleep-Wake Disorder
The Present: DSM-5
Section II: Essential Elements: Diagnostic
Criteria and Codes
Sexual Dysfunctions
 Delayed Ejaculation
 Erectile Disorder
 Female Orgasmic Disorder
 Female Sexual Interest/Arousal Disorder
 Genito-Pelvic Pain/Penetration Disorder
 Male Hypoactive Sexual Desire Disorder
 Premature (Early) Ejaculation
 Substance/Medication-Induced Sexual Dysfunction
 Other Specified Sexual Dysfunction
 Unspecified Sexual Dysfunction
The Present: DSM-5
Section II: Essential Elements: Diagnostic
Criteria and Codes
Gender Dysphoria
 Gender Dysphoria
 Other Specified Gender Dysphoria
 Unspecified Gender Dysphoria
Disruptive, Impulse-Control, and Conduct Disorders
 Oppositional Defiant Disorder
 Intermittent Explosive Disorder
 Conduct Disorder
 Antisocial Personality Disorder
 Pyromania
 Kleptomania
 Other Specified Disruptive, Impulse-Control, and Conduct Disorder
 Unspecified Disruptive, Impulse-Control, and Conduct Disorder
The Present: DSM-5
Section II: Essential Elements: Diagnostic
Criteria and Codes
Substance-Related and Addictive Disorders
 Substance Use Disorders
 Substance-Induced Disorders
 Substance Intoxication
 Substance Withdrawal
 Substance/Medication-Induced Disorders Included
Elsewhere in the Manual
 Same substances as DSM-IV, plus gambling
The Present: DSM-5
Section II: Essential Elements: Diagnostic
Criteria and Codes
Neurocognitive Disorders
 Delirium
 Other Specified Delirium
 Unspecified Delirium
 Major & Mild Neurocognitive Disorders
 Major or Mild Neurocognitive Disorder Due to Alzheimer’s Disease
 Major or Mild Frontotemporal Neurocognitive Disorder
 Major or Mild Neurocognitive Disorder with Lewy Bodies
 Major or Mild Vascular Neurocognitive Disorder
 Major or Mild Neurocognitive Disorder Due to Traumatic Brain Injury
 Substance/Medication-Induced Neurocognitive Disorder
 Major or Mild Neurocognitive Disorder Due to HIV Infection
 Major or Mild Neurocognitive Disorder Due to Prion Disease
 Major or Mild Neurocognitive Disorder Due to Parkinson’s Disease
 Major or Mild Neurocognitive Disorder Due to Huntington’s Disease
 Neurocognitive Disorder Due to Another Medical Condition
 Major or Mild Neurocognitive Disorder Due to Multiple Etiologies
 Unspecified Neurocognitive Disorder
The Present: DSM-5
Section II: Essential Elements: Diagnostic
Criteria and Codes
Personality Disorders
 Paranoid Personality Disorder
 Schizoid Personality Disorder
 Schizotypal Personality Disorder
 Antisocial Personality Disorder
 Borderline Personality Disorder
 Histrionic Personality Disorder
 Narcissistic Personality Disorder
 Avoidant Personality Disorder
 Dependent Personality Disorder
 Obsessive-Compulsive Personality Disorder
 Personality Change Due to Another Medical Condition
 Other Specified Personality Disorder
 Unspecified Personality Disorder
The Present: DSM-5
Section II: Essential Elements: Diagnostic
Criteria and Codes
Paraphilic Disorders
 Voyeuristic Disorder
 Exhibitionistic Disorder
 Frotteuristic Disorder
 Sexual Masochism Disorder
 Sexual Sadism Disorder
 Pedophilic Disorder
 Fetishistic Disorder
 Transvestic Disorder
 Other Specified Paraphilic Disorder
 Unspecified Paraphilic Disorder
The Present: DSM-5
Section II: Essential Elements: Diagnostic
Criteria and Codes
Other Mental Disorders
 Other Specified Mental Disorder Due to Another
Medical Condition
 Unspecified Mental Disorder Due to Another
Medical Condition
 Other Specified Mental Disorder
 Unspecified Mental Disorder
Medication-Induced Movement Disorders and
Other Adverse Effects of Medication
The Present: DSM-5
Section III: Emerging Measures and
Models




Assessment Measures
Cultural Formulation
Alternative DSM-5 Model for Personality Disorders
Conditions for Further Study








Attenuated Psychosis Syndrome
Depressive Episodes With Short-Duration Hypomania
Persistent Complex Bereavement Disorder
Caffeine Use Disorder
Internet Gaming Disorder
Neurobehavioral Disorder Due to Prenatal Alcohol Exposure (NDPAE)
Suicidal Behavior Disorder
Nonsuicidal Self-Injury
The Present: DSM-5
Changes in the DSM-5
 The Number 5
 Connection to Medicine and Biological Focus
 Connection with ICD
 Chapter reorganization
 Issues of culture, demography
 Dimensional severity assessments
 Criterion Sets
The Present: DSM-5
Culture and demography
 Included diverse individuals on study groups and




work groups
Study group dedicated to reviewing all proposals for
cultural issues
Provide assessment tool for clinical formulation
List culture-bound syndromes
Description of cultural expressions of disorders
The Present: DSM-5
Cultural Formulation Interview
 Based on DSM-IV model
 Updated as a specific measure (14 items), subjected to
field trials

Cultural identity of the individual


Including acculturation for immigrants
Cultural explanations of individual’s illness
Idioms of distress
 Meaning of symptoms in cultural context


Other cultural factors related to functioning


Social stressors and supports
Cultural aspects of treatment relationship
Cultural assumptions about mental health care
 Status issues

The Present: DSM-5
Changes in the DSM-5
 The Number 5
 Connection to Medicine and Biological Focus
 Connection with ICD
 Chapter reorganization
 Issues of culture, demography
 Dimensional severity assessments
 Criterion Sets
The Present: DSM-5
Severity assessments
 Cross-cutting dimensions
 Mood
 Anxiety
 Social Dysfunction
 Self-Concept
 Sleep
 Attention
 Cognition
 Certain Disorders
 Autism Spectrum
The Present: DSM-5
Changes in the DSM-5
 The Number 5
 Connection to Medicine and Biological Focus
 Connection with ICD
 Chapter reorganization
 Issues of culture, demography
 Dimensional severity assessments
 Criterion Sets
The Present: DSM-5
Changes to Disorder Criteria
 Autism spectrum
 ADHD
 PTSD
 Depression
 Disruptive Mood Dysregulation Disorder
 Substance Use Disorders
 Psychotic Disorders
 Eating Disorders
The Present: DSM-5
Changes to Disorder Criteria
 Autism spectrum
 ADHD
 PTSD
 Depression
 Disruptive Mood Dysregulation Disorder
 Substance Use Disorders
 Psychotic Disorders
 Eating Disorders
The Present: DSM-5
Autism Spectrum
 DSM-IV
 Autism: profound, early onset difficulties with social behavior,
communication, and atypical behaviors
 Asperger’s: (later age of onset, absence of language delay)
 PDD: sub-threshold autism
 DSM-5 proposal
 Replace these categories with a single diagnosis, ASD
Require all monothetic social communication criteria
 Meet polythetic criteria for restricted, repetitive behaviors

The Present: DSM-5
Autism Spectrum: The case for change
 Evidentiary Argument
 Quantitative evidence suggests a spectrum rather than
categorical distinctions, that social and communication
symptoms cohere
 Age of onset and language delay relate quantitatively, not
qualitatively, to this spectrum
 Clinical Argument
 Monothetic criteria will result in more qualitative homogeneity
while also permitting more quantitative heterogeneity
 Moral Argument
 Collapsing categories will permit greater access to services for
people who do not have DSM-IV Autism
The Present: DSM-5
Autism Spectrum: Prevalence hysteria in DSM-IV
 Prevalence and access to services
 “59 percent of those who were ‘diagnosed not autistic’ in the
1980s would qualify as having autism today” (Miller et al.,
2013)
1 out of 88 people have autism
 1 in 34 South Korean people have autism

The Present: DSM-5
Autism Spectrum: DSM-5 Prevalence
 McPartland et al., 2012 (also Mattila et al., 2011 from
Finnish epidemiological sample)


Of people with DSM-IV ASD (any of the three) from DSM-IV
field trial, 61% meet for DSM-5 ASD
Of people without DSM-IV Autistic Disorder, 95% also do not
have DSM-5 ASD
 Social Communication Disorder as a solution?
The Present: DSM-5
Autism Spectrum: Prevalence hysteria
 “The American Psychiatric Association voted this
weekend to remove the diagnosis of Asperger’s syndrome
from the so-called bible of psychiatry, the Diagnostic and
Statistical Manual of Psychiatric Disorders. People with
Asperger’s will now more likely be diagnosed as having
autism spectrum disorder. The APA says the change will
lead to more accurate diagnoses for people with autism
— but critics say removing the diagnosis may result in
fewer people getting the services and care they need.”
Excerpt from NPR discussion, 2011
 “DSM-5 under-identifies PDDNOS” (Mayes et al., 2013)
The Present: DSM-5
Autism Spectrum: Prevalence hysteria
 “One child doesn't talk, rocks rhythmically back and
forth and stares at clothes spinning in the dryer. Another
has no trouble talking but is obsessed with trains,
methodically naming every station in his state. Autistic
kids like these hate change, but a big one is looming.”
USA Today, 2012
 “Proposed changes in the definition of autism would
sharply reduce the skyrocketing rate at which the
disorder is diagnosed and might make it harder for many
people who would no longer meet the criteria to get
health, educational and social services” NY Times, 2012
The Present: DSM-5
Autism Spectrum: Prevalence hysteria
http://usatoday30.usatoday.com/news/health/story/
2012-04-05/doctors-change-autismdefinition/54047994/1
1:08
1:35
The Present: DSM-5
Larger Point: Prevalence is important and arbitrary
 The problem of getting appropriate services is a real one, and it is
reasonable to be concerned, even if the hyperbole isn’t necessary.
But…
 How many tall people are there? How many short people are there?
 All the short people get $50 – are you short?
The Present: DSM-5
Deeper issue
Dimensions and Categories
The Present: DSM-5
Validity of Dimensional Models (Markon, 2011)
In 2 meta-analyses involving 58 studies and 59,575 participants, we quantitatively
summarized the relative reliability and validity of continuous (i.e., dimensional)
and discrete (i.e., categorical) measures of psychopathology. Overall, results
suggest an expected 15% increase in reliability and 37% increase in
validity through adoption of a continuous over discrete measure of
psychopathology alone. This increase occurs across all types of samples and forms
of psychopathology, with little evidence for exceptions. For typical observed effect
sizes, the increase in validity is sufficient to almost halve sample sizes necessary
to achieve standard power levels. With important caveats, the current results,
considered with previous research, provide sufficient empirical and theoretical
basis to assume a priori that continuous measurement of psychopathology is
more reliable and valid. Use of continuous measures in psychopathology
assessment has widespread theoretical and practical benefits in
research and clinical settings.
The Future: DSM-5.1 and beyond
Clinical Utility of Dimensional Models (First, 2005)
A potential obstacle to implementing dimensional representations in the
Diagnostic and Statistical Manual of Mental Disorders (DSM) is lack of data
about clinical utility and user acceptability. Adopting a dimensional approach
would likely complicate medical record keeping, create administrative and
clinical barriers between mental disorders and medical conditions, require a
massive retreating effort, disrupt research efforts (e.g., meta-analyses), and
complicate clinicians’ efforts to integrate prior clinical research using DSM
categories into clinical practice. Efforts to empirically demonstrate the clinical
utility of dimensional alternatives should be a prerequisite for their future
implementation in order to establish that their advantages outweigh the
disadvantages. Approaches to promote user acceptability and the
development of an empirical database include dimensionalizing existing DSM
categories and including research dimensions in the DSM appendix.
The Future: DSM-5.1 and beyond
How do you think about patients?
The Future: DSM-5.1 and beyond
Challenge
 Clinical decisions are usually categorical
 It is possible that it is more natural to think about
types of people rather than patterns of variables
 Nature seems to be dimensional
 Do we learn to think differently and tolerate
arbitrary cuts, or do we force nature to accommodate
our cognitive style and clinical needs?
The Future: DSM-5.1 and beyond
Changes to Disorder Criteria
 Autism spectrum
 ADHD
 PTSD
 Depression
 Disruptive Mood Dysregulation Disorder
 Substance Use Disorders
 Psychotic Disorders
 Eating Disorders
The Present: DSM-5
ADHD
 Now a ‘Neurodevelopmental Disorder’
 Oppositional and Conduct disorders now in “Disruptive,
Impulse Control, and Conduct Disorders”
 Relax age-of-onset criterion
 Replace subtypes with specifiers
 Adults
 Age-appropriate criteria
 Expanded impulsivity criteria
 Lowered diagnostic thresholds for adults
 Permit dual diagnosis with autism
The Present: DSM-5
ADHD: Age of onset
 For
 It can be difficult to recall age of onset – only 50% of adults
with ADHD symptoms above diagnostic cut recalled onset
prior to 7, whereas 95% recalled symptoms prior to age 16
 This criterion was based on clinical lore in the first place
 One study suggested that using a cutoff of age 12 would not
affect prevalence (Kessler et al., 2005)
 Against
 Relaxing any criterion will inevitably increase prevalence
 Questions about motives given the most common treatment
for ADHD is pharmaceutical
 Does not fit with commonly accepted theoretical models of
ADHD
The Present: DSM-5
ADHD: Specifiers
 For
 Several studies have shown that inattentive and
hyperactive/impulsive dimensions are correlated, and can
be represented as a bifactor model

ADHD severity
 Hyperactive/impulsive style
 Inattentive style
 Against
 Clinicians are more accustomed to typological approach
 Specifiers are, in essence, still a typological approach
The Present: DSM-5
ADHD: Age-appropriate criteria
 For
 Provides for a more accurate diagnosis for adults (which
would include increasing sensitivity and thus prevalence)
 Has been hard to know if decline in rates is due to actual
declines (as is clinical lore) or insensitivity of childhood
symptoms to portray adult problems (e.g., examples of
things that might be lost include toys, school assignments,
pencils, and books)
 Against
 Giving more behavioral examples and lowering diagnostic
thresholds likely to increase prevalence
 Increasing impulsivity content may worsen diagnostic
overlap
The Present: DSM-5
ADHD: Autism
 For
 No reason a person could not have both autism and ADHD
 Against
 Increase in prevalence in ADHD
The Present: DSM-5
Larger Point: Diagnostic breadth
 Diagnostic Dilemma
 Include everyone with similar features
 Distinguish everyone with different features
 Lumping – Diagnostic heterogeneity
 Splitting – Comorbidity
 Is the hierarchical approach a solution?
The Present: DSM-5
Changes to Disorder Criteria
 Autism spectrum
 ADHD
 PTSD
 Depression
 Disruptive Mood Dysregulation Disorder
 Substance Use Disorders
 Psychotic Disorders
 Eating Disorders
The Present: DSM-5
PTSD
 Listed in "trauma and stressor-related disorders"
 DSM-IV: 3 clusters



re-experiencing
avoidance
arousal
 DSM-5: 4 clusters




intrusion symptoms
avoidance symptoms
arousal/reactivity symptoms
negative mood and cognitions
 Criterion A2 (requiring fear, helplessness or horror
immediately after the trauma) will be removed
The Present: DSM-5
PTSD: the case for change
 PTSD is unique etiologically and splits off from
anxiety disorders in structural research
 More consistent with empirical research on the
structure of symptoms (Anthony et al., 1999)
 Evidence not consistent with the importance of
immediate stress upon exposure to traumatic event
(Karam et al., WHO study, 2010)
 Prevalence is not affected (Nat Center for PTSD, 2012)
The Present: DSM-5
PTSD: the case against change
 To the extent that the disorder is not about the
effects of trauma (i.e., acute stress reaction), the
basis of the disorder is lost (McNally, 2011)
 Adding mood symptoms will increase overlap with
other mood, anxiety, and personality disorders,
despite moving the disorder to its own chapter
The Present: DSM-5
Larger Point: Change is difficult
 Is change worth it?
 Patients are re-classified
 Will affect access to services, forensic issues, billing
procedures, organization of interventions
 National Center for PTSD is re-norming CAPS, PCL
 Will services really improve?
 Another perspective: the manual constrains clinical
care


Do we need the manual to provide effective services once
‘caseness’ is determined? What if there were another way to
determine ‘caseness’ (clinician judgment of dysfunction)?
Need to maintain consistent prevalence
The Present: DSM-5
Changes to Disorder Criteria
 Autism spectrum
 ADHD
 PTSD
 Depression
 Disruptive Mood Dysregulation Disorder
 Substance Use Disorders
 Psychotic Disorders
 Eating Disorders
The Present: DSM-5
Depression and Grief
 DSM-IV grief criterion
 “The
symptoms are not better accounted for by
Bereavement, i.e., after the loss of a loved one,
the symptoms persist for longer than 2 months
or are characterized by marked functional
impairment, morbid preoccupation with
worthlessness, suicidal ideation, psychotic
symptoms, or psychomotor retardation.” (p. 356)
The Present: DSM-5
Depression and Grief: The case for change
 Research support for dropping exclusion
 Only 20% of bereaving people meet criteria for depression
(Brent et al., 1994; 2009)

Depression in the context of loss has a course (Kendler et al., 2008) ,
correlates (Zisook & Kendler, 2007), and treatment response (Zisook et al.,
2001) similar to depression without loss
 Moral argument for dropping exclusion
 Leaving depression untreated because a person is grieving is
unethical (Shear et al., 2011)
 Bereavement increases suicide risk (Ajdacic-Gross et al., 2008)
The Present: DSM-5
Depression and Grief: The case against change
 Research support against dropping exclusion

Research review was based on genuine MDD cases with and without
bereavement
no cases with bereavement without MDD, or in mixed cases, these
were not distinguished
 “The challenge is to distinguish those bereavement-related
depressions that are likely intense normal grief from those that have
turned into pathological depressions” (Wakefield & First, 2011)


Bereavement-excluded depression does not increase risk for future
depressive episodes, whereas DSM-IV depression (with or without
bereavement) does (Mojtabai, 2011)
 Moral argument for dropping exclusion


Cases excluded in DSM-IV by definition lack suicidal ideation
Pathologizing normal reactions
The Present: DSM-5
Larger Point: Harmful Dysfunction (Wakefield, 1992)
 Harm
 Some kind of problem in living
 e.g., Difficulty getting out of bed, difficulty concentrating
 Dysfunction
 Some kind of systemic failure
 e.g., Hypothyroidism
The Present: DSM-5
Changes to Disorder Criteria
 Autism spectrum
 ADHD
 PTSD
 Depression
 Disruptive Mood Dysregulation Disorder
 Substance Use Disorders
 Psychotic Disorders
 Eating Disorders
The Present: DSM-5
Disruptive Mood Dysregulation Disorder
 Severe nonepisodic emotional and behavioral
problems involving irritability
 New diagnostic category for children and
adolescents:





Severe temper outbursts
Negative mood between outbursts
Present for 12 months or more in multiple settings
Onset before age 10
Child must be at least 6 for the diagnosis
The Present: DSM-5
Disruptive Mood Dysregulation Disorder
 Copeland et al (2013)
 Prevalence: .8% to 3.3%, declines with age
 Co-occurrence: “62-92% of the time across ages DMDD is
given with another diagnosis”
Depression
 Oppositional Defiant Disorder


Significant predictor of dysfunction
The Present: DSM-5
Controversies
 Diagnostic splitting
 Role of drug companies (viz., grief criterion for
depression)
 Lack of consensual definition and validity data
The Present: DSM-5
Larger Point: The role of development
 Precursor to unipolar depression to a greater degree than
bipolar depression (Stingaris et al., 2009)
 Is this an early manifestation of depression?


Assess the current presentation
Assess the underlying syndrome
 Is the focus on current presentation consistent with the
medical model?
The Present: DSM-5
Changes to Disorder Criteria
 Autism spectrum
 ADHD
 PTSD
 Depression
 Disruptive Mood Dysregulation Disorder
 Substance Use Disorders
 Psychotic Disorders
 Eating Disorders
The Present: DSM-5
Substance Dependence and Abuse
 Drop distinction between Dependence and Abuse, to
have one single Substance Use Disorder category
The Present: DSM-5
Dependence and Addiction
 “The term dependence is misleading, because people
confuse it with addiction, when in fact the tolerance
and withdrawal patients experience are very normal
responses to prescribed medications that affect the
central nervous system,” said Charles O’Brien, M.D.,
Ph.D., chair of the APA’s DSM Substance-Related
Disorders Work Group. “On the other hand,
addiction is compulsive drug- seeking behavior
which is quite different. We hope that this new
classification will help end this wide-spread
misunderstanding.”
-Recovery Today, 2010
The Present: DSM-5
Substance Dependence and Abuse (The Scientist, 2012)
 Allen Frances, chair of the DSM-IV Task Force
(blog):

“The further watering down of definitional standards will make
psychiatric diagnosis so ubiquitous as to be almost
meaningless—and divert scarce resources away from those
who do need them.”
 Marc Schuckit, member of the Substance Use
Disorder Work Group for the DSM-5 :

"Our goal was to try to make the criteria easier for the usual
clinician to use, and so we're no longer asking them to
remember one criteria set for abuse and a separate set for
dependence.”
The Present: DSM-5
Larger Point: Whose Clinical Utility?
 Schuckit: easier for clinicians
 Frances: focus clinician attention on most severe
These are not evidentiary issues with respect to the nature
of pathology, they are evidentiary issues with respect to
the nature of practice…so what is the point of the
manual, exactly?



Carve nature at its joints
Provide a vehicle for efficient classification
Triage people to appropriate services
 Box (1987): “all models are wrong, but some are useful”
The Present: DSM-5
Changes to Disorder Criteria
 Autism spectrum
 ADHD
 PTSD
 Depression
 Disruptive Mood Dysregulation Disorder
 Substance Use Disorders
 Psychotic Disorders
 Eating Disorders
The Present: DSM-5
Other changes
 Psychotic Disorders
 Add schizotypal personality disorder
 Drop schizophrenia subtypes in favor of dimensional ratings of
positive and negative symptoms
 Eating disorders
 Drop amenorrhea requirement for Anorexia
 Lower frequency of bingeing
 Add Binge Eating Disorder
The Present: DSM-5
DSM-5 Committee Exercise
 Pick leaders with expertise for each topic
 Dropping multi-axial format
 Addressing issues of culture
 Autism spectrum
 ADHD
 PTSD
 Depression grief criterion
 Disruptive Mood Dysregulation Disorder
 Substance abuse/dependence
 Dimensionalizing schizophrenia spectra
 Adding Binge Eating Disorder
 Assemble groups
 Discuss advantages and disadvantages of changing the diagnosis
 Come to a final decision to present to the group
The Present: DSM-5
DSM-5 Committee Exercise
 How much did the proposals change the DSM-IV?
 Dropping multi-axial format
 Addressing issues of culture
 Autism spectrum
 ADHD
 PTSD
 Depression grief criterion
 Disruptive Mood Dysregulation Disorder
 Substance abuse/dependence
 Dimensionalizing schizophrenia spectra
 Adding Binge Eating Disorder
 How much variability of opinion was there within groups?
 How were differences resolved?
 Is this the right way to develop a manual?
The Present: DSM-5
Outline
 The Past: Competing models of psychopathology
 The Present: Specific changes in the DSM-5
 The Edge: DSM-5 personality disorders
 The Future: DSM-5.1 and beyond
The Edge: DSM-5 Personality Disorders
What are Personality Disorders?
 Patients and Families: Chronic and severe
 Insurance Companies: Untreatable
 NIMH: Insufficiently biological
 Clinicians: Annoyance
 Psychoanalysts: Fundamental context
 Descriptive Psychiatrists: Questionable categories
 Quantitative Psychologists: The vanguard of
psychopathology (Krueger, in press)
The Edge: DSM-5 Personality Disorders
DSM-IV (and DSM-5…)
Cluster A
Cluster B
Cluster C
Appendix
Paranoid
Borderline
Avoidant
PassiveAggressive
Dependent
Sadistic
ObsessiveCompulsive
Depressive
Antisocial
Schizoid
Histrionic
Schizotypal
Narcissistic
The Edge: DSM-5 Personality Disorders
Problems with DSM-IV
 Structure (Fossati et al., 2000)
 Dimensionality (Widiger & Clark, 2000)
 Diagnostic overlap (Lenzenweger et al., 2007)
 Link to normal personality (Widiger & Trull, 2009)
 Diagnostic Heterogeneity (Widiger & Trull, 2009)
 Problems with particular diagnoses
 Antisocial PD vs. Psychopathy (Hare, 1991)
 Grandiose and Vulnerable Narcissism (Pincus et al., 2009)
 Many PDs understudied (Widiger & Trull, 2009)
 No specific treatments (Widiger & Trull, 2009)
The Edge: DSM-5 Personality Disorders
Proposed Solutions
 Dimensionalize
 Link to established basic models of personality
 Distinguish symptoms from traits
 Trim list of disorders
 Distinguish general from PD-specific symptoms
 Determine optimal way of characterizing PD
symptoms
The Edge: DSM-5 Personality Disorders
Proposed Solutions
 Dimensionalize
 Link to established basic models of personality
 Distinguish symptoms from traits
 Trim list of disorders
 Distinguish general from PD-specific symptoms
 Determine optimal way of characterizing PD
symptoms
The Edge: DSM-5 Personality Disorders
What does “Dimensional” mean?
 No qualitative distinction between normal and
abnormal

How do you determine caseness?
 Using severity ratings within diagnostic categories?
 Doesn’t solve the co-occurrence problem, but provides more
valid data
 Variable centered constructs
 Hybrid system in which categories are constellations of
dimensions
The Edge: DSM-5 Personality Disorders
Proposed Solutions
 Dimensionalize
 Link to established basic models of personality
 Distinguish symptoms from traits
 Trim list of disorders
 Distinguish general from PD-specific symptoms
 Determine optimal way of characterizing PD
symptoms
The Edge: DSM-5 Personality Disorders
Trait Models
Markon, K.E., Krueger, R.F., & Watson, D. (2005). Delineating the structure of normal and abnormal personality: An
integrative hierarchical approach. Journal of Personality and Social Psychology, 88, 139-157.
The Edge: DSM-5 Personality Disorders
Trait Models
 Integrate competing theories of normative
personality (Widiger & Simonsen, 2005; Wright et al., in review)
 Link to biological structures and processes (DeYoung et al., 2010)
 Integrate normal personality, abnormal personality,
and psychopathology (Markon et al., 2005)
 Well-defined heritability profile and course (Hopwood et al., 2010)
The Edge: DSM-5 Personality Disorders
Proposed Solutions
 Dimensionalize
 Link to established basic models of personality
 Distinguish symptoms from traits
 Trim list of disorders
 Distinguish general from PD-specific symptoms
 Determine optimal way of characterizing PD
symptoms
The Edge: DSM-5 Personality Disorders
Personality and Psychopathology
There is nothing special about the relationship
between personality traits and personality disorders
The Edge: DSM-5 Personality Disorders
Normative vs. Pathological Personality: Trait
Specificity
N
E
O
A
C
PDs
0.31
-0.14
0.02
-0.18
-0.13
Axis I
0.39
-0.24
-0.09
-0.02
-0.30
The Edge: DSM-5 Personality Disorders
Normative vs. Pathological Personality:
Specificity (Ruiz et al., 2008)
The Edge: DSM-5 Personality Disorders
Personality and Psychopathology
So how are personality traits and personality disorders
different?
The Edge: DSM-5 Personality Disorders
Normative vs. Pathological Personality:
Distributions (CLPS)
The Edge: DSM-5 Personality Disorders
Normative vs. Pathological Personality: Stability
(Hopwood et al., in press) (Morey et al., 2007)
Figure 1. Mean 10-year rank-order stability values for personality traits and disorders.
The Edge: DSM-5 Personality Disorders
Normative vs. Pathological Personality:
Incremental Validity (Morey et al., 2007)
Disorders
increment normal
traits
Hybrid model
performs best
Normal traits
increment
disorders
The Edge: DSM-5 Personality Disorders
Normative vs. Pathological Personality: Trait
Predictions
(Hopwood et al., 2007)
The Edge: DSM-5 Personality Disorders
Normative vs. Pathological Personality:
Clinical Utility
Personality Trait
Personality Problem
Valueless
Problematic
Stable
Malleable
Decontextualized
Occur in Social Contexts
No Treatments
Treatments
The Edge: DSM-5 Personality Disorders
Proposed Solutions
 Dimensionalize
 Link to established basic models of personality
 Distinguish symptoms from traits
 Trim list of disorders
 Distinguish general from PD-specific symptoms
 Determine optimal way of characterizing PD
symptoms
The Edge: DSM-5 Personality Disorders
Exercise
 You are on the DSM-5 committee and have been
mandated to trim the number of PDs down to 6 or less.
What do you cut?










Schizotypal
Schizoid
Paranoid
Antisocial
Borderline
Narcissistic
Histrionic
Dependent
Avoidant
Obsessive-Compulsive
The Edge: DSM-5 Personality Disorders
Exercise
 How similar is your list to the DSM-5 proposal?
 Antisocial
 Avoidant
 Borderline
 Narcissistic
 Obsessive-Compulsive
 Schizotypal
 On the strategy of trimming disorders…
The Edge: DSM-5 Personality Disorders
Proposed Solutions
 Dimensionalize
 Link to established basic models of personality
 Distinguish symptoms from traits
 Trim list of disorders
 Distinguish general from PD-specific symptoms
 Determine optimal way of characterizing PD
symptoms
The Edge: DSM-5 Personality Disorders
Severity and Style (Hopwood et al., 2011)
GAF
Social Dysfunction
Work Dysfunction
Leisure Dysfunction
C
P
C
P
C
P
C
P
-.56*
-.44*
.52*
.50*
.33*
.38*
.49*
.41*
Peculiarity
-.14*
-.23*
.25*
.20*
.03
.14
.13*
.21*
Withdrawal
-.09
-.05
.12*
.08
.02
.07
.13*
.14*
Fearfulness
-.01
.02
.06
-.04
.10
-.10
.16*
.03
Instability
-.17*
-.05
.04
.01
.09
.05
.01
-.01
Deliberateness
.12*
.09
-.10
-.07
-.07
-.11
-.07
-.06
ΔR2
.07*
.07*
.09*
.05*
.02
.05
.07*
.07*
Overall R2
.38*
.26*
.35*
.30*
.14*
.17*
.30*
.24*
Step 1
Severity
Step 2
C = concurrent, P = 3-year prospective
The Edge: DSM-5 Personality Disorders
Proposed Solutions
 Dimensionalize
 Link to established basic models of personality
 Distinguish symptoms from traits
 Trim list of disorders
 Distinguish general from PD-specific symptoms
 Determine optimal way of characterizing PD
symptoms
The Edge: DSM-5 Personality Disorders
Continuous or Prototype Diagnoses
 Symptom counts
 More reliable than categories (Heumann & Morey, 1990)
 More valid than categories (Morey et al., 2007)
 Prototypes
 DSM-I and II
 SWAP (Westen & Shedler, 2000)
The Edge: DSM-5 Personality Disorders
Continuous or Prototype Diagnoses
Samuel et al. in press
 320 patients rated by treating clinicians using a
prototype form and structured diagnostic interview
by research interviewers for

AVPD, BPD, OCPD, STPD
 Diagnostic interview incremented prototype for
indicating patient functioning in every case
 Prototype rating never incremented interview
 Results replicated for self-report of PD vs. prototype
 On the strategy of proposing prototypes…
The Edge: DSM-5 Personality Disorders
DSM-5 Work Group Proposal
 Level: Self and Interpersonal dysfunction
 Types: 6 PD types defined by trait constellations
 Traits: 5 higher order and 25 lower order traits
The Edge: DSM-5 Personality Disorders
Level
Self:
Identity: Experience of oneself as unique, with clear boundaries between self
and others; stability of self-esteem and accuracy of self-appraisal; capacity for,
and ability to regulate, a range of emotional experience
Self-direction: Pursuit of coherent and meaningful short-term and life goals;
utilization of constructive and prosocial internal standards of behavior; ability to
self-reflect productively
Interpersonal:
Empathy: Comprehension and appreciation of others’ experiences and
motivations; tolerance of differing perspectives; understanding of the effects of
own behavior on others
Intimacy: Depth and duration of positive connections with others; desire and
capacity for closeness; mutuality of regard reflected in interpersonal behavior
The Edge: DSM-5 Personality Disorders
Level Ratings
 0-4 (4 is worst), field studies to determine cutoff
 Empathy = 0



Capable of accurately understanding others’ experiences and
motivations in most situations.
Comprehends and appreciates others’ perspectives, even if
disagreeing.
Is aware of the effect of own actions on others.
 Empathy = 4



Pronounced inability to consider and understand others’ experience
and motivation.
Attention to others' perspectives virtually absent (attention is
hypervigilant, focused on need-fulfillment and harm avoidance).
Social interactions can be confusing and disorienting.
The Edge: DSM-5 Personality Disorders
Types
 6 types
 Based on trait criteria (all traits must be met)
 Antisocial
 Avoidant
 Borderline
 Narcissistic
 Obsessive-Compulsive
 Schizotypal
The Edge: DSM-5 Personality Disorders
Traits
 5 domains based on PSY-5, Big 5 models
 25 lower order traits linked to specific PDs
 0-3 scale (3 is worst)
 Can be used to assess individuals
 without PD
 with PD who don’t fit into type (PDTS)
 in addition to type
The Edge: DSM-5 Personality Disorders
Traits-Disorder Crosswalk
 Schizotypal
 All three psychoticism traits
 Suspisciousness, Withdrawal, Restricted Affectivity
 Antisocial
 Hostility, Manipulativeness, Deceitfulness, Callousness,
Irresponsibility, Impulsivity, Risk Taking
 Borderline
 Separation Insecurity, Anxiousness, Emotional Lability,
Depressivity, Impulsivity, Risk Taking
The Edge: DSM-5 Personality Disorders
Traits-Disorder Crosswalk
 Narcissistic
 Attention Seeking, Grandiosity
 Avoidant
 Anxiousness, Withdrawal, Intimacy Avoidance, Anhedonia
 Obsessive Compulsive
 Perseveration, Rigid Perfectionism
The Edge: DSM-5 Personality Disorders
NA
DET
ANT
DIS
PSY
Submissiveness
Restricted Affectivity
Separation Insecurity
Anxiousness
Emotional Lability
Hostility
Perseveration
Suspiciousness
Depressivity
Withdrawal
Intimacy Avoidance
Anhedonia
Manipulativeness
Deceitfulness
Callousness
Attention Seeking
Grandiosity
Irresponsibility
Impulsivity
Distractibility
Rigid Perfectionism
Risk Taking
Eccentricity
Perceptual Dysregulation
Unusual Beliefs and Experiences
Hopwood et al., 2012
STPD
.15
.31
.28
.39
.42
.38
.51
.51
.51
.51
.31
.46
.29
.39
.39
.18
.31
.41
.26
.39
.37
.10
.61
.61
.64
ASPD
.04
.26
.18
.17
.22
.40
.35
.37
.38
.23
.29
.28
.43
.55
.54
.30
.28
.49
.56
.40
.11
.53
.38
.44
.37
BPD
.20
.17
.45
.53
.56
.53
.54
.46
.61
.35
.26
.49
.29
.40
.37
.24
.20
.44
.39
.47
.32
.18
.46
.55
.41
NPD
.11
.25
.31
.31
.32
.48
.41
.44
.31
.28
.24
.25
.49
.51
.47
.51
.54
.36
.30
.32
.36
.16
.39
.43
.38
AVPD
.38
.24
.40
.51
.41
.38
.48
.38
.51
.48
.24
.50
.12
.28
.20
.10
.12
.27
.10
.39
.28
-.16
.36
.36
.21
OCPD
.26
.23
.28
.42
.35
.32
.46
.27
.27
.28
.18
.22
.23
.19
.15
.18
.25
.15
.11
.30
.54
-.07
.34
.35
.31
The Edge: DSM-5 Personality Disorders
The challenge
Coverage, construct consistency  more overlap,
diagnostic heterogeneity
Discriminant validity  limited coverage,
consistency with past definitions
Solution: Divorce PD symptoms and traits
The Edge: DSM-5 Personality Disorders
DSM-5 Proposal
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.
3. Is one of the 6 defined types present?
4. If so, record the type and the severity of impairment.
5. If not, is PD-Trait Specified present?
6. If so, record PDTS, identify and list the trait domain(s) that are
applicable, and record the severity of impairment.
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.
The Edge: DSM-5 Personality Disorders
Jennifer
Case
Example
 28 year old woman
 History of abuse by father and romantic partners
 Close to mother and several women but chronic
difficulties in romantic relationships with men
 PTSD from witnessing death of child 3 years prior
 Long history of self-harming behavior including
promiscuous sex, alcohol and drug abuse increased with
trauma
 Recently sought treatment after being fired for missing
work (6 months), moving to shelter (2 weeks), shoplifting
for food and alcohol (2 weeks), cutting (2x in 1 week)
The Edge: DSM-5 Personality Disorders
Jennifer’s DSM-IV diagnosis
 Borderline PD (7)
 + unstable relationships, identity disturbance, impulsivity, suicidal
behavior, affective instability, emptiness, inappropriate anger
 - efforts to avoid abandonment, stress related paranoia
 Histrionic PD (5)
 + inappropriate sexual behavior, rapidly shifting and shallow emotions,
use of physical appearance for attention, theatricality, suggestibility
 - uncomfortable unless center of attention, impressionistic speech,
considers relationships to be closer than they are
 Antisocial PD (3 + Conduct Disorder)
 + childhood conduct disorder, failure to conform, deceitfulness,
impulsivity, recklessness, irresponsibility
 - lack of remorse and aggressiveness
The Edge: DSM-5 Personality Disorders
Jennifer’s Level of Functioning
Self
 Identity = 4
 Self-direction = 3
Interpersonal
 Empathy = 2
 Intimacy = 4
The Edge: DSM-5 Personality Disorders
Jennifer’s
Diagnosis
(PDTS)
Jennifer’s
Traits
Negative Emotionality
Submissiveness
Restricted Affectivity
Separation Insecurity
Anxiousness
Emotional Lability
Hostility
Perseveration
Detachment
Suspiciousness
Depressivity
Withdrawal
Intimacy Avoidance
Anhedonia
1
0
2
3
3
1
0
2
2
1
1
1
Antagonism
Manipulativeness
Deceitfulness
Callousness
Attention-Seeking
Grandiosity
Disinhibition
Irresponsibility
Impulsivity
Distractibility
Rigid Perfectionism
Risk Taking
Psychoticism
Eccentricity
Cognitive
Dysregulation
Unusual
Beliefs/Experiences
1
1
0
2
0
3
3
2
0
3
0
2
0
Borderline Traits in Red
The Edge: DSM-5 Personality Disorders
Jennifer’s DSM-5 Summary Diagnosis
 PD Trait Specified with Deficits in Identity and
Intimacy and the following significant traits:





Anxiousness
Emotional Lability
Irresponsibility
Impulsivity
Risk Taking
The Edge: DSM-5 Personality Disorders
Exercise
 Which diagnosis
 describes the patient more accurately?
 best suggests treatment strategies?
 is most efficient?
 do you prefer overall?
The Edge: DSM-5 Personality Disorders
DSM-5.0
 Task Force recommended Work Group proposal
 Board of Trustees voted to retain DSM-IV model
 The Work Group proposal will be printed verbatim
in Section III
The Edge: DSM-5 Personality Disorders
The traits are in
 What does this decision mean for the short-term?
 Alternative PD diagnoses?
 Clinical use of trait model
 What does this decision mean for the long-term?
 The first step towards a reconceptualization?
The Edge: DSM-5 Personality Disorders
Momentum
 RDoC
 Unified Treatments
 Comorbidity problems and the increasing acceptance
of dimensionality has positioned quantitative
psychology as a guidepost
The Edge: DSM-5 Personality Disorders
Outline
 The Past: Competing models of psychopathology
 The Present: Specific changes in the DSM-5
 The Edge: DSM-5 personality disorders
 The Future: DSM-5.1 and beyond
The Future: DSM-5.1 and beyond
What is the point?
 Patient welfare (Box’s models)
 Diagnostic validity
 Diagnostic and treatment efficiency
 Trainability
 Parsimony
 Link between assessment and treatment
 How do we get there?
 Modesty and openness
 Maturity
Integration of competing models
 Integration of science and practice

The Future: DSM-5.1 and beyond
Two Goals
 Validity
 Clinical Utility
 Is there a tension between these goals?
 Validity is a prerequisite for clinical utility, and dimensional
models are more valid than categorical ones (Krueger & Markon, 2010)
 Clinical utility is the first priority, and the issues with
dimensional models are too great to adopt them at this time
(First, 2005)
The Future: DSM-5.1 and beyond
Theoretical Models of Psychopathology
 Descriptive Psychiatry
 Quantitative Psychology
 Psychoanalysis
 Learning Theory
The Past: Competing Models of Psychopathology
Psychoanalysis
The Past: Competing Models of Psychopathology
Assumptions of Psychoanalysis
 Psychopathology reflects compromise formations
between desires and social acceptability
 Disorders blend together dynamically, with a basic
distinction between between neurotic, character, and
psychotic illness based on psychosocial maturation
 Effective taxonomy needs to take the complexity of
patient presentation across levels of analysis into
account
The Past: Competing Models of Psychopathology
Freud
 Research in neurology,
neuropathology, anesthesia
The Past: Competing Models of Psychopathology
Freud’s research accomplishments prior to
psychoanalysis (Galbis-Reig, 2004)
 Freud first studied the phylogenetic association between the central





nervous system of lower vertebrates and humans.
Using Crayfish, Freud demonstrated that nerve fibers emerge from a
web-like substance in the neurons and that the structure is always
fibrillary.
Freud introduced the use of gold chloride to stain nerve tissues.
Freud studied the structure and function of the medulla oblongata
and the connection between the posterior columns of the spinal cord,
the acoustic nerve, and the cerebellum.
Freud wrote the first analytical and scientific summary of
research on cocaine and was the first investigator to predict its
potential use as a local anesthetic.
Freud wrote four major texts on neurological disorders from
1891-1893 and was an international expert in aphasia and paralysis.
The Past: Competing Models of Psychopathology
Freud
 Research in neurology,




neuropathology, anesthesia
Applied Neurology
Hypnosis, catharsis: Unconscious
Fundamental tension between
drives and socialization plays out in
relation to society, and takes
different forms over time
Psychoanalysis:


Personality theory
Clinical Technique
The Past: Competing Models of Psychopathology
Diaspora
 Complexity and freshness of the topic
 Historical forces such as anti-semitism and
feminism
 Core values (and the need to make bets)
Diaspora
 Complexity and freshness of the topic
Model
Value
 Historical
forces such as anti-semitism
and
feminism
Id: Freud
Neurology
Ego: values
A. Freud,(and
Rappaport,
Adaptation
 Core
the
need
to make bets)
Reich, Shapiro
Interpersonal: Horney,
Fromm, Sullivan, Blatt
Justice and empiricism
Object Relations: Klein,
Mahler, Winnicot, Bion
Mother-infant relationship
Self: Kohut
Experience
Contributions of psychoanalysis
 Major principles have evidentiary merit (Westen, 1998)
 Unconscious (Underwood, 1996)
 Developmental factors (Sroufe, 2005)
 Social behavior regulates affect (Sadikaj et al., 2010)
 Importance of motives (Karoly, 1999)
 Psychotherapy is effective (Shedler, 1010)
 Focus on dynamics
 Influences across different spans of times
 Non-linear associations
 Conflicts between systems
The Past: Competing Models of Psychopathology
Limitations of psychoanalysis
 Metapsychology

With respect to window-makers, to look at a window as if it is the
point is to misunderstand the purpose of a window
 Insularity


Dissemination
Antagonism towards contemporary research methods
 “Failure to lead”


Disinterest in integration is ironic given that it is the most
comprehensive model
When opportunities arose the analytic community bristled
 Politically unpopular, out of fashion

However, some exciting stuff is happening in psychology (e.g.,
process dissociation, TMT)
The Past: Competing Models of Psychopathology
What might psychoanalysis contribute to nosology?
 Structure



Self-Other-Affect
Implicit-Explicit
Autonomy-Sociotropy
 Dynamics



Impulse-Defense
Thematic recurrence
Plasticity of drives
 Treatment



Rich clinical description of phenotypes
Use of relationship
Focus on affect and thematic connections
Theoretical Models of Psychopathology
 Descriptive Psychiatry
 Quantitative Psychology
 Psychoanalysis
 Learning Theory
The Past: Competing Models of Psychopathology
Learning Theory
The Past: Competing Models of Psychopathology
Assumptions of Learning Theory
 Observable behavior is the most trustworthy and
therefore most important behavior
 Psychopathology requires inference and should be
approached skeptically
 Most dysfunctional behavior is a function of learning
history and triggering contextual factors
 Assessment requires understanding the function of
behaviors, which vary from case to case
The Past: Competing Models of Psychopathology
Watson
 1879-1958
 The “behaviorist manifesto”
 Offered an inductive, basic science
alternative to understanding
behavior rooted in British
Associationism
The Past: Competing Models of Psychopathology
Skinner
 1904-1990
 Focused on instrumental learning
and contingent factors in behavior
 Together with classical
conditioning, provided a coherent
model for understanding the
influence of proximal context
The Past: Competing Models of Psychopathology
Social and Cognitive Models
 Spence and others: fleshed out schedules of
reinforcment, discrimination learning, etc.
 Bandura and others: added notion of social learning
and modeling
 Tolman and others: added notion of cognition, which
paved the way for cognitive revolution
The Past: Competing Models of Psychopathology
“CBT”
 Effort to be more practical and better
connected to contemporary science
 Notion of using thoughts to affect
change in emotions and behavior
 Teach a scientific mode of
information processing
 Use what works
The Past: Competing Models of Psychopathology
Where did “CBT” come from?
 Learning
 Logical extension of Watson’s efforts to understand behavior
using basic science
 Contemporary with cognitive revolution
 Ego Psychology
 Logical Extension of Freudian emphasis on drives and drive
reduction
 Emphasis on cognition and notion of cooling down affect
toward insight (making unconscious conscious)
The Past: Competing Models of Psychopathology
The Faustian bargain between
CBT and the Medical Model
 Did you ever wonder why CBT cornered the market
on manuals and RCTs?



Organizing treatment around latent disorder constructs?
Packaged treatments rather than functional interventions?
“Evidence-based” as a reason not to need evidence?
 Was this strategic?
 Treatment-Patient matching research has mostly failed
The Past: Competing Models of Psychopathology
Matching Alcoholism Treatments to Client Heterogeneity:
Project MATCH posttreatment drinking outcomes
Two parallel but independent randomized clinical trials were conducted, one with alcohol dependent
clients receiving outpatient therapy (N = 952; 72% male) and one with clients receiving aftercare therapy
following inpatient or day hospital treatment (N = 774; 80% male). Clients were randomly assigned to one
of three 12-week, manual-guided, individually delivered treatments: Cognitive Behavioral Coping Skills
Therapy, Motivational Enhancement Therapy or Twelve-Step Facilitation Therapy. Clients were then
monitored over a 1-year posttreatment period.
Clients attended on average two-thirds of treatment sessions offered, indicating that substantial amounts of
treatment were delivered, and research follow-up rates exceeded 90% of living subjects interviewed at the
1-year posttreatment assessment. Significant and sustained improvements in drinking outcomes were
achieved from baseline to 1-year posttreatment by the clients assigned to each of these well-defined and
individually delivered psychosocial treatments. There was little difference in outcomes by type of
treatment. Only one attribute, psychiatric severity, demonstrated a significant attribute by treatment
interaction: In the outpatient study, clients low in psychiatric severity had more abstinent days after 12-step
facilitation treatment than after cognitive behavioral therapy. Neither treatment was clearly superior for
clients with higher levels of psychiatric severity.
The findings suggest that psychiatric severity should be considered when assigning clients to outpatient
therapies. The lack of other robust matching effects suggests that, aside from psychiatric severity, providers
need not take these client characteristics into account when triaging clients to one or the other of these
three individually delivered treatment approaches, despite their different treatment philosophies.
(Journal of Studies on Alcohol, 1997 Jan;58(1):7-29.)
The Past: Competing Models of Psychopathology
The Faustian bargain between
CBT and the Medical Model
 Did you ever wonder why CBT cornered
the market on manuals and RCTs?



Organizing treatment around latent disorder
constructs?
Packaged treatments rather than functional
interventions?
“Evidence-based” as a reason not to need
evidence?
 Was this strategic?


Treatment-Patient matching research has
mostly failed
CBT and other treatments tend to tie metaanalytically
The Past: Competing Models of Psychopathology
Psychotherapy for Depression in Adults
Although the subject has been debated and examined for more than 3 decades, it is
still not clear whether all psychotherapies are equally efficacious. The authors
conducted 7 meta-analyses (with a total of 53 studies) in which 7 major
types of psychological treatment for mild to moderate adult depression (cognitive–
behavior therapy, nondirective supportive treatment, behavioral activation
treatment, psychodynamic treatment, problem-solving therapy, interpersonal
psychotherapy, and social skills training) were directly compared with other
psychological treatments. Each major type of treatment had been examined in at
least 5 randomized comparative trials. There was no indication that 1 of the
treatments was more or less efficacious, with the exception of interpersonal
psychotherapy (which was somewhat more efficacious; d = 0.20) and nondirective
supportive treatment (which was somewhat less efficacious than the other
treatments; d = 0.13). The drop-out rate was significantly higher in cognitive–
behavior therapy than in the other therapies, whereas it was significantly lower in
problem-solving therapy. This study suggests that there are no large differences in
efficacy between the major psychotherapies for mild to moderate depression.
(Cuipers et al., Journal of Consulting and Clinical Psychology 2008; 76:909 –922)
The Past: Competing Models of Psychopathology
The Faustian bargain between
CBT and the Medical Model
 Did you ever wonder why CBT cornered the market
on manuals and RCTs?



Organizing treatment around latent disorder constructs?
Packaged treatments rather than functional interventions?
“Evidence-based” as a reason not to need evidence?
 Was this strategic?
 Treatment-Patient matching research has mostly failed
 CBT and other treatments tend to tie meta-analytically
 Contemporary “CBT” is becoming unified
The Past: Competing Models of Psychopathology
Strengths of Learning and CBT perspectives
 Values straightforward, parsimonious explanations
 Intended to be efficient
 Notion of stepped care built in to treatment
 Flexible and responsive to evidence
 Focuses on functions
 Why did this person become depressed here and not there?
 What interventions seem to be helping, and to what degree?
The Past: Competing Models of Psychopathology
Limitations of “CBT”
 Focus on diagnosis and symptoms
 Essential functionalism was lost (temporarily?)
The virtue of behaviorism is its focus on why a person is doing
what they are doing
 This is lost when the explanation becomes a latent disorder
construct


Assessment is over-simplified as checklists

Who is carrying the flag for functional assessment?
 ABA
 Haynes’ Clinical Case Modeling
The Past: Competing Models of Psychopathology
Clinical Case Modeling (Haynes et al., 1997)
Back to the Future: A Different Strategy?
The Future: DSM-5.1 and beyond
A Different Strategy
 Respect all of the major nosological traditions
toward a transtheoretical model that maximizes
the clinical utility and evidentiary links of clinical
formulation
 Next: A thought experiment/demonstration of how
this could happen
The Future: DSM-5.1 and beyond
Step 1: Structure
 Trait models provide the broad architecture for individual
differences in personality and psychopathology
 Five-factor level of traits provides a parsimonious entry
point for classification
N
E
A
O (P)
C
The Future: DSM-5.1 and beyond
Traits as Psychological Systems:
A medical model analogy
The Future: DSM-5.1 and beyond
Step 2: Clinical Focus
 Psychoanalysis, with its focus on the mapping of problems
in living to clinical encounter, provides experience-near
clinical focus
 At the broadest level, various schools agree (Kernberg, 1984)
Patient’s Mind
Self
Other
Affect
The Future: DSM-5.1 and beyond
Step 3: Integration via Systems
N
Affect
E
A
O
C
Self
Other
The Future: DSM-5.1 and beyond
Step 3: Systems as the bridge
N
Affect
E
A
O
Self
C
Other
The Future: DSM-5.1 and beyond
How did Extraversion get split?
 E facets on NEO-PI-R (Costa & McCrae, 1992)
 Interpersonal
Gregariousness
 Warmth
 Assertiveness


Affective
Activity
 Excitement-Seeking
 Positive Affectivity

The Future: DSM-5.1 and beyond
Experimental Evidence (Morrone-Stupinsky & Lane, 2007)
 Extraversion is comprised of agentic and affiliative components, which are
characterized by distinct positive emotional states of positive activation and
warmth-affection, respectively. This study examined these positive
emotions using the International Affective Picture System, a standardized
set of pictures used to induce emotion.
 Compared to response to neutral pictures, the following target emotions
were induced: (1) affiliative pictures induced warmth-affection and
pleasantness, (2) agentic pictures induced positive activation, pleasantness,
and arousal, (3) high arousal nonagentic pictures induced pleasantness and
arousal, and (4) low arousal nonaffiliative pictures induced pleasantness.
 Agentic picture-induced positive affective ratings were significantly related
to a trait measure of social potency, but not to other extraversion scales.
 The results support a multicomponent conceptualization of the
extraversion trait, where agentic and affiliative components are associated
with distinctive positive emotional experience.
The Future: DSM-5.1 and beyond
What about O and C? (Saucier, 1992)
The Future: DSM-5.1 and beyond
What about O and C?
 Issues like impulse control and thought disorder are
important
 Interstitiality
 Some aspects are wrapped into Agency and Communion
(depends on where you cut the hierarchy)




Achievement
Sensation-seeking
Openness to new relationships
Concern for others
 It would be practically useful to assess cognitive features
in addition to the integrative model
The Future: DSM-5.1 and beyond
Systems as the bridge
N
Affect
E
Self
A
Other
The Future: DSM-5.1 and beyond
The interpersonal system
The Future: DSM-5.1 and beyond
The Interpersonal System: Agency and Communion
Agency
Communion
Interpersonal Behavior Interpersonal
Dominance
Interpersonal Warmth
Trait
Achievementorientation (C),
Gregariousness (E),
Stimulus-Seeking (O)
Sociability (E),
Agreeableness (A),
Fitting in (C),
Socialization (N),
Tolerance (O)
Regulation
Esteem
Anxiety
Functioning
Work
Love
Gender
Masculine
Feminine
Pronouns
I
We
The Future: DSM-5.1 and beyond
Theorist
Agency
Communion
Freud
Ability to work
Ability to love
Adler (1912)
Striving for superiority
Social interest
Horney (1937)
Moving against others
Moving towards others
Fromm (1941)
Separate entity
Oneness with the world
Erikson (1950)
Autonomy; Generativity
Basic trust; Intimacy
Sullivan (1953)
Need for power
Security
Leary (1957)
Control
Affiliation
Foa (1974)
Status
Love
Hogan (1983)
Achieving status
Achieving popularity
Beck (1983)
Autonomy
Sociotropy
McAdams (1985)
Power motivation
Intimacy motivation
Buss (1991)
Negotiating status
Forming alliances
Depue (1995)
Dopamine
Oxytocin
Digman (1997)
Beta (E, O)
Alpha (N, A, C)
The Future: DSM-5.1 and beyond
The Interpersonal Circumplex
The Future: DSM-5.1 and beyond
Interpersonal Taxonomy: Personality Disorders
The Future: DSM-5.1 and beyond
Interpersonal Taxonomy: Severity and Style
The Future: DSM-5.1 and beyond
Interpersonal Taxonomy: Severity and Style
Profile 1: High Severity, Cold
Style
Profile 2: High Severity, Warm
Style
Dominant
Cold
Dominant
Warm Cold
Submissive
Profile 3: Low Severity,
Warm Style
Dominant
Warm
Submissive
Cold
Submissive
The Future: DSM-5.1 and beyond
Interpersonal Taxonomy: Heterogeneity in GAD
Dominant
Antagonistic
Extraverted
Cold
Warm
Introverted
Agreeable
Submissive
The Future: DSM-5.1 and beyond
Interpersonal Taxonomy: Heterogeneity
 GAD (Salzer et al., 2008)
 Bulimia Nervosa (Hopwood et al., 2007)
 Depression (Cain et al., 2011)
 PTSD (Thomas et al., 2012)
 Social Phobia (Kachin et al., 2001)
 Fear of Failure (Wright et al., 2009)
The Future: DSM-5.1 and beyond
Interpersonal Taxonomy: Levels within Systems
 The inter-individual structure of the IPC allows for a
comparison of functioning interpersonal several domains
 Leary’s (1957) levels and process dissociation
 Self/other report IPC assessment batteries







Traits (Markey & Markey, 2009; Wiggins, 1995)
Behaviors (Moskowitz, 1994)
Problems (Alden, Wiggins, & Pincus, 1990; Soldz, Budman, Demby, & Merry, 1995)
Efficacies (Locke & Sadler, 2007)
Strengths (Hatcher & Rogers, 2009)
Values (Locke, 2000)
Sensitivities (Hopwood et al., 2009).
The Future: DSM-5.1 and beyond
(BC); 135°
Competitive
Vindictive
Sensitive to Antagonism
(DE); 180°
Indifferent
Cold-hearted
Sensitive to Remoteness
(FG); 225°
Aloof
Socially Avoidant
Sensitive to Timidity
(PA); 90°
Assertive
Domineering
Sensitive to Control
A
g
e
n
c
y
(NO); 45°
Gregarious
Intrusive
Sensitive to
Attention Seeking
Communion
(LM); 0°
Warm
Overly Nurturing
Sensitive to Affection
(JK); 315°
Trusting
Exploitable
Sensitive to Dependency
(HI); 270°
Submissive
Nonassertive
The Future: DSM-5.1 and beyond
Sensitive to Passivity
Case Example
The Future: DSM-5.1 and beyond
Interpersonal Taxonomy: Variability Across Situations
Lewin (1936): B = f (P, E)
Leary (1957, p. 121) proposed two variance parameters
related to problematic functioning
“rigidity, which brings a narrow adjustment to one aspect of the
environment, and unstable oscillation, which is an intense attempt to adjust
to all aspects of the presented environment.”
The Future: DSM-5.1 and beyond
Variability in Intra-individual Structure
r=0
r=–
r=+
The Future: DSM-5.1 and beyond
Intra-individual Variability: Pulse
Dominant
Antagonistic
Extraverted
Warm
Cold
Introverted
Agreeable
Submissive
(Moskowitz & Zuroff, 2004)
Intra-individual Variability: Spin
Dominant
Antagonistic
Extraverted
Warm
Cold
Introverted
Agreeable
Submissive
(Cote, Moskowitz & Zuroff, 2011; Erikson, Newman, & Pincus, 2009; Moskowitz & Zuroff, 2004; Russel
et al., 2007)
Interpersonal Taxonomy of Dynamics:
Complementarity (Carson, 1969; Sadler et al., 2009)
Dominant
Antagonistic
Extraverted
Cold
Warm
Introverted
Agreeable
Submissive
The Future: DSM-5.1 and beyond
Interpersonal Taxonomy of Dynamics:
Copy Processes (e.g., Critchfield, 2009)
 Identification
 Recapitulation
Dominant
Antagonistic
Extraverted
 Introjection
Cold
Warm
Introverted
Agreeable
Submissive
The Future: DSM-5.1 and beyond
Interpersonal Assessment of Dynamics
 Across Situations
 Different relationships
 Same relationship, different context
 Within Situations
 Course of a difficult interaction
 Psychotherapy session
The Future: DSM-5.1 and beyond
Interpersonal
Variability Across
Situations (Roche et al., 2013)
The Future: DSM-5.1 and beyond
Interpersonal Variability Across Situations (Roche et al., 2013)
The Future: DSM-5.1 and beyond
Procedure for Assessment of Interpersonal
Variability within Situations
The Future: DSM-5.1 and beyond
Complementarity Coefficient
Warmth
Control
r = -1
1
Time
The Future: DSM-5.1 and beyond
Intra-individual Structure in Psychotherapy
Gloria with Ellis
Gloria with Rogers
r = .19
r = .12
Gloria with Perls
r = –.56
The Future: DSM-5.1 and beyond
Assessment of Interpersonal Dynamics in
Psychopathology
Control
Experimental
BPD
The Future: DSM-5.1 and beyond
Cross-correlation: Affiliation
r = .86
The Future: DSM-5.1 and beyond
Assessment of Interpersonal Dynamics
 Generally strong complementarity effects on both
dimensions overall
 Both participants were warmer in the control
condition (d = .65 for women, 1.30 for men)
 Greater complementarity on warmth for the
experimental group (d = 1.07)
 Greater complementarity on dominance for the
control group (d = .65)
The Future: DSM-5.1 and beyond
Interpersonal Taxonomy: Clinical Styles (Andrews, 1989)
Dominant
Ellis
Antagonistic
Perls
Extraverted
Beck
Cold
Davanloo
Warm
Rogers
Introverted
Kernberg
Agreeable
Kohut
Submissive
The Future: DSM-5.1 and beyond
Interpersonal Taxonomy: Interventions
 Two implications
 Selection into best-fitting school
 Therapeutic flexibility
 “Evidence-Based Practice”
 Using certain techniques
 Using techniques certain ways
The Future: DSM-5.1 and beyond
Interpersonal Taxonomy: Therapeutic Tasks (Tracey, 1999)
The Future: DSM-5.1 and beyond
Interpersonal Taxonomy: Supervision (Tracey et al., 2012)
Parallel processes in supervision occur when (1) the therapist brings the
interaction pattern that occurs between the therapist and client into
supervision and enacts the same pattern but with the therapist trainee
in the client's role, or (2) the trainee takes the interaction pattern in
supervision back into the therapy session as the therapist, now enacting
the supervisor's role. We examined these processes in the interactions
of 17 therapy/supervision triads (i.e., supervisor, therapist/trainee, and
client). Each session was rated for dominance and affiliation, and the
similarity of these dimensions across equal status pairs (supervisortherapist and trainee-client) was examined. It was hypothesized that if
parallel process existed, there would be more similarity in dominance
and affiliation between equal status pairs in contiguous sessions than
would be true relative to general responses; the dominance and
affiliation would be more closely matched than would be expected given
general response tendencies. This was examined separately for each
supervision triad using single-case randomization tests.
The Future: DSM-5.1 and beyond
Interpersonal Taxonomy: Supervision (Tracey et al., 2012)
Significant results were obtained for each dyad
indicating the presence of parallel processes in each
supervision triad. Additionally, the relation between
parallel processes over the course of treatment and
client outcome was examined using hierarchical
Bayesian modeling. Results indicate that a positive
client outcome was associated with increasing
similarity of therapist behavior to the supervisor over
time on both affiliation and dominance (increasing
parallel process) and an inverted U pattern of highlow-high similarity of client behavior to trainee
behavior over time. This study provides support for the
existence of bidirectional parallel processes at the level
of interpersonal interaction.
The Future: DSM-5.1 and beyond
Affective Taxonomy: Trait and State
 Temperament dimensions (Rothbart & Ahadi, 1994; Watson et al., 2009)
 Positive Emotionality/Surgency
 Negative Emotionality
 (Constraint/Effortful Control)
 Adult personality dimensions
 Neuroticism
 Extraversion
 (Conscientiousness)
 State affects (Watson et al., 2009; Russell, 1980, Carver et al., 1994)
 Positive Affect/Arousal/Activation
 Negative Affect/Valence/Inhibition
The Future: DSM-5.1 and beyond
Affective Categories and Dimensions
The Future: DSM-5.1 and beyond
Step 4: Functions
The Future: DSM-5.1 and beyond
Step 4: Functions (CAPS)
The Future: DSM-5.1 and beyond
Step 4:
Functions
The Future: DSM-5.1 and beyond
Functional Affective Dynamics: Case example
r = .42
Step 5: Psychiatric Taxonomy
 Categories are still arbitrary, but now there is a
clinically useful and evidence-based system
underneath it
Nomothetic
Idiographic
The Future: DSM-5.1 and beyond
Psychiatric Taxonomy: Step A
 Review Systems
 Interpersonal




Affect




Agency
Communion
Organization
Arousal
Valence
Constraint
Intellect






Intelligence
Achievement
Attention
Memory
Executive Functioning
Schizotypy
The Future: DSM-5.1 and beyond
Psychiatric Taxonomy: Step B
 Discern Patterns
 Interpersonal




Affect




Agency +
Communion
Organization
Arousal +
Valence
Constraint
Intellect






Intelligence
Achievement
Attention
Memory
Executive Functioning Schizotypy
The Future: DSM-5.1 and beyond
Psychiatric Taxonomy: Step C
 Get specific durations, frequencies, and contexts
 Interpersonal




Affect




Agency + elevated in last 2 months
Communion
Organization
Arousal + elevated in last 2 months
Valence
Constraint
Intellect






Intelligence
Achievement
Attention
Memory
Executive Functioning – functionally related to affective arousal
Schizotypy
The Future: DSM-5.1 and beyond
Psychiatric Taxonomy: Step D
 Establish Dysfunction
 Interpersonal




Affect




Agency + lost friendships and job
Communion
Organization
Arousal + poor sleep and eating habits
Valence
Constraint
Intellect






Intelligence
Achievement
Attention
Memory
Executive Functioning – disorganization and poor planning
Schizotypy
The Future: DSM-5.1 and beyond
Psychiatric Taxonomy: Step E
 Apply diagnostic match
Agency + lost friendships and job
 Arousal + poor sleep and eating habits
 Executive Functioning – disorganization and poor
planning

 How to do this is an interesting question
 The main difference in this approach is that the
symptom domains are all cross-cutting
 There would still be a need for specific indicators
(e.g., trauma, eating, objects of obsessions)
The Future: DSM-5.1 and beyond
Another Example
Presenting concerns: Suicide risk, loneliness, lack of support, impulsive aggression
Affect
 Impulse control: low
 NA: high, vacillates from anger to sadness to emptiness rapidly; moderated by attachment loss
 PA: low
Interpersonal
 Organization: low
 D: low, moderated by anger
 W: low, but with underlying desire/wish for closeness
Cognitive
 PSY: low
 IQ: high
Most likely diagnosis?
The Future: DSM-5.1 and beyond
A Third Example
 Suppose I refer a patient with Bulimia Nervosa.
 How many questions does that answer? What else
would you want to know?
The Future: DSM-5.1 and beyond
Another Example
Presenting concerns: Eating in binges, marital conflict
Affect
 Impulse control: low
 NA: high but often suppressed, moderated by sense of control
 PA: low, moderated by loss of control
Interpersonal
 Organization: somewhat low
 D: low, but with underlying wish for control
 W: high, but with underlying desire/wish for separation
Cognitive
 PSY: low
 IQ: average
The Future: DSM-5.1 and beyond
Implications
 Integration of brain and behavior
 Currently exists an antagonism between basic research and practice
 Systems thinking is an integrative path forward with momentum in basic and applied clinical
psychology and medicine
 Integration of dimensional and categorical thinking
 Categories are arbitrary constellations of dimension scores
 Broad and hierarchical: beyond lumping and splitting
 Trans-theoretical
 Dominant viewpoints are political
 Beyond extra-scientific influences and treatment packaging
 Focused on the lived life and clinical setting
 Box’s models…
 Beyond the DSM as serving all purposes
 Practical utility
 Existing assessment tools
 Dynamic assessment tools
 Existing treatment models
 Integrative treatment models
 Revisiting the notion of treatment matching
The Future: DSM-5.1 and beyond
Pushing it even further: Including dynamics
 Presenting problem
 Themes on 2 circles plus PSY, C, and cognition
 Can vary in hierarchical specificity depending on initial findings
 Can vary across levels within systems
 Could use multi-method assessment
 Patterning in problem situations
 Influence of exogenous variables
 Treatment of “personality” with relationship or treatment of
“symptoms” with technique: Involvement of interpersonal issues
 Dynamic assessments of functions with joystick, EMA
 Developmental dynamics
 Implicit wishes and Fears
 Optional
 Match to diagnostic concept
The Future: DSM-5.1 and beyond
Pushing it even further: A Clinical Example
Presenting concerns: Suicide risk, loneliness, lack of support, impulsive aggression
Affect
 Impulse control: low
 NA: high, vacillates from anger to sadness to emptiness rapidly; moderated by attachment loss
 PA: low
Interpersonal
 Organization: low
 D: low, moderated by anger
 W: low, but with underlying desire/wish for closeness
Cognitive
 PSY: low
 IQ: high
Diagnosis: Borderline Personality Disorder
The Future: DSM-5.1 and beyond
Lower in the Hierarchy
 NA



PAI Suicidal Ideation, Affective Depression, Affective Instability, Self-harm,
Traumatic Stress
Informant DSM-5 Separation Insecurity, Depressivity, Anhedonia
Rorschach D, Afr, SumV, S-CON+
 Impulse Control



PAI Self Harm, Sensation Seeking, Aggression
Informant DSM-5 Risk Taking, Hostility
Rorschach EB+ (extratensive), S-%
 Detachment



PAI Nonsupport, Resentment
Informant DSM-5 Submissiveness, Suspiciousness
Rorschach AG, GHR:PHR
The Future: DSM-5.1 and beyond
Levels of interpersonal functioning
The Future: DSM-5.1 and beyond
Daily Diary:
Functional precursors to suicidal ideation
r = .42
Pushing it even further: A Clinical Example
 Joystick Findings
 Therapist submissiveness leads to patient coldness
 Initially

Discussed this with patient
 Patient

submissive, eventually dominant
interpreted therapist submissiveness as disinterest
Pattern remitted, leading to more efficient and productive
sessions
The Future: DSM-5.1 and beyond
Pushing it even further: A Clinical Example
 Formulation: desires warmth but expects coldness so
acts aloof, gets coldness back. Attachment anxiety +
temperamentally limited impulse control lead to
maladaptive behaviors including aggression and selfharm.
 Treatment Hypotheses:


Short term: Warmth on the part of the therapist will provide
comfort and will reinforce the patient’s warmth. Discussing and
planning more adaptive ways to cope with negative feelings will
reduce risk for self-harm and relationship problems.
Long-term: Focusing on painful affects associated with significant
developmental experiences will improve mentalization,
perceptual accuracy, affect regulation, maturity of defenses, and
functioning.
The Future: DSM-5.1 and beyond
Two Concluding Points
 Diagnosis is essentially the closest match of idiographic style with a
nomothetic concept or category.




But level of severity is still an essentially arbitrary clinical decision, which basically
amounts to ‘I think this person needs help’.
The DSM is a cover for the anxiety created by this responsibility.
In order to see the world more as it is, we are going to need to face the fact that this is
a value judgment more squarely.
The goal of taxonomy is to bridge the gap between researchers and
clinicians.



Diabetes Example
Currently clinicians go from idiographics to diagnosis but there is a lot in
between
There are advantages of filling this in:


Clinicians use more evidence-based models, can do more to tailor treatments to existing
research evidence, have an evidence based structure with which to select and organize
assessments
Researchers not constrained by categories that are not that useful, oriented towards clinically
important question
The Future: DSM-5.1 and beyond
Applying this to your own case
 Presenting Problems:
 Diagnosis:
 Interpersonal System



Organization:
Agency:
Communion:
 Affect System



Constraint:
Positive Affect/Arousal:
Negative Affect:
 Cognition


Psychoticism:
Intellect:
Applying this to your own case
 Environmental Factors:
 Functional Dynamics:
 Wishes and Fears:
 Issues of Culture and Demography: