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