ApsaA 2013 Research Presentation on Personality - Mmpi

Report
Operationalizing the PDM with the
Psychodiagnostic Chart:
A Separate Dimension of Personality
Structure (Organization1) for the
PDM
Healthy-Neurotic, Borderline,
Psychotic Levels of Personality
I use “Personality Structure” and “Personality Organization” interchangeably
PDM’s Current Taxonomy
Personality Patterns and Disorders
Mental Functioning
Manifest Symptoms and Concerns
What Do Psychologists Want From a Taxonomy?
WHO Survey of 2155 Psychologists from 23 Countries
Q9 - 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
Desire for a Parsimonious Taxonomy
% Participants
In clinical settings, how many diagnostic categories
should a classification system contain to be most useful
for mental health professionals?
60%
50%
50%
40%
35%
30%
20%
11%
10%
4%
0%
10 to 30
31 to 100
101 to 200
More than 200
From Earliest Findings: Personality Structure is a
Main Factor in Treatment Choice
1930 Fenichel, 1936 Jones, 1937 Alexander
all reported substantial benefits with
psychoanalysis with the great majority of the
neurotic patients, but found much lower
improvement percentages in those diagnosed
psychotic.
Kernberg (1983) stated that Borderline patients
do best with a special kind of psychoanalytic
psychotherapy.
“The impact of level of
personality organization on treatment
response: a systematic review.” (2012)
To the most recent:
•
“Higher initial levels of PO are moderately to strongly
associated with better treatment outcome.
•
level of PO may interact with the type of intervention
(i.e., interpretive versus supportive) in predicting
treatment outcome...”
Koelen JA, Luyten P, Eurelings-Bontekoe LH, Diguer L, Vermote R, Lowyck B, Bühring ME.
(2012). The impact of level of personality organization on treatment response: a systematic
review. Psychiatry, 75(4), 355-374.
Nancy McWilliams ( 2011) Psychoanalytic Diagnosis: Understanding Personality
Structure in the Clinical Process.
McWilliams’ taxonomy is fundamentally based
on two dimensions:
1. Personality Organization and
2. Character Organization.
An Operationalized Psychodynamic
Diagnostic Manual Guide
Robert M. Gordon and Robert F. Bornstein
PDC Is A User Friendly Guide to the
Adult Section of the PDM
•
•
•
•
•
•
•
Short- 3pages
Easy- all scales are 1-10
Intuitive and Empirical
Categorical and Dimensional
Flexible-can do part or all
Integrates with the DSM and ICD
Good Reliability and Construct Validitypreliminary field evidence
(Gordon and Stoffey 2012 in press)
PDC Adds:
• A Distinct Over Arching Personality Structure
Dimension (Health-Neurotic, Borderline,
Psychotic)
• A Cultural- Contextual Dimension
PDC’s Taxonomy
Personality Structure
Personality Patterns
Mental Functioning
ICD Symptoms
Cultural-Contextual Issues
PDC’s Personality Structure Scale
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
__
Healthy Level- 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
Considering the 7 ratings above, rate the person’s overall personality structure from
1 (Psychotic) to 10 (Healthy)
Psychotic
1
2
Borderline
3
4
5
Neurotic
6
7
8
Healthy
9
10
2. Personality Patterns or Disorders- Scoring
1. Review the P axis in the PDM for the
personality patterns most descriptive of your
client (or use the Psychodynamic Diagnostic
Prototypes-PDP).
2. Begin by checking off as many descriptors
that may apply.
PDM Categories- Check as Many as Describe Your Client:
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
2. Personality Patterns or Disorders- Scoring
Then decide on the most dominant
personality pattern or disorder, and rate the
level of severity (1-10).
3. Mental Functioning- Rate Each 1-10
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 (use a single number not a range)
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. Manifest Symptoms and Concerns
Write in as many as 4 symptoms and rate the
degree of severity (1= severe and 10= mild)
Here you may use the symptoms that may be
the focus of the person’s chief complaint.
Most commonly it will be a mood or anxiety
disorder, substance abuse, adjustment
disorder, or interpersonal crisis. You may use
the DSM or ICD codes.
5. Cultural, Contextual, and Other
Relevant Considerations
This is a qualitative section where the
practitioner may write how cultural or
contextual factors may contribute to the
symptoms, and/or degree of suffering.
Clinical Example Using the PDC
• “Bana” is a 28 year old woman from Syria. Her husband was killed in the
war and she has no children. Her brother was able to get her to the US this
year.
• 1. Level of Personality Structure- is 7 (Neurotic Level). Her capacity scores
are mainly in the 6-9 range. Her lowest rating is in Affect Tolerance (5)
which may be due to her PTSD. She is a good candidate for PDT.
• 2. Personality Patterns or Disorders- mainly Hysterical/Inhibited type at the
Moderate level of severity (6) with some obsessional and dependent
features.
• 3. Mental Functioning- most of the 9 capacities are in the high range. She
has a masters in education, her marriage was good, she has average self
esteem, she can go from inhibited to overly excited expression of affect, her
favored defenses are repression and intellectualization, she has a warm
relationship with her mother and both sets of grandparents, her father was
killed when she was a child, good level of differentiation and integration,
very insightful and excellent moral reasoning.
• 4. Manifest Symptoms- ICD-10: (F43.1) Post-traumatic stress disorder
• 5. Cultural, Contextual Issues- recent death of husband, war trauma, loss of
father, leaving much of her family and friends behind, immigration fears and
guilt.
Construct Validity of the PDC
15 MMPI-2 experts (few were psychodynamic) were asked to use the PDC to
rate about 10 of their last cases of psychotherapy patients, disability or
forensic clients within the last 12 months.
I received 98 cases of PDCs and MMPI-2s.
There was very good construct validity for:
1.
The 7 capacities used for determining the Personality Structure
2.
The Over-All Personality Structure
3.
The Severity of the Personality Patterns
4.
The 9 Mental Functioning Components
5.
Manifest Symptoms and Concerns
Testing the Construct Validity of the Personality
Structure Scale with the MMPI-2
Goldberg Index
Psychotic
vs
Neurotic
(Lie + Paranoia + Schizophrenia) - (Hysteria + Psychasthenia)
T65+ = psychotic
Testing Dimensional and Categorical
Qualities of Personality Structure
• Hysteria scale and Schizophrenia scale correlate
.01 with male sample and .15 with female
sample. They are independent representations of
very different character structures.
• The Ego Strength scale measures responsiveness
to psychotherapy. I found that the Es scale
significantly increased (p<.001, Cohen’s d = .80)
after an average of 3 years of PDT for 55
borderline patients (Gordon, 2001).
Testing Dimensional and Categorical
Qualities of Personality Structure with 3 Scales
(L+Pa+Sc)-(Hy+Pt)
Es
Sc, Hy and Es
A priori hypotheses
• a priori hypotheses using Hy, Sc and Es in testing the
construct validity of the PDC Personality Structure
scale:
• For the psychotic level, we predicted that the Sc scale
mean should be significantly larger than both the Hy
and Es scale means.
• For the borderline level, we predicted that the Sc scale
mean and the Hy scale mean should not be significantly
different (a mix of Schizoid and Hysterical features), but
they both should be significantly larger than the Es
scale mean.
• Finally, for the neurotic level, we predicted that the Es
scale mean Hy and Sc scale means should all be in the
moderate to normal range.
MMPI-2 Hysteria-Hy, Schizophrenia-Sc, and Ego Strength-Es Scales
within the Psychotic, Borderline, and Neurotic Categories of the
Personality Structure Scale
Psychotic (ratings 1-3, n = 13), Borderline (4-6, n = 52), and Neurotic (7-10, n = 33).
Psychotic: Sc >> Hy>> Es; Borderline: (Sc ~ Hy) >> Es; Neurotic: (Sc ~ Hy) > Es all in the average to moderate range.
90
85
80
75
H
y
70
65
Sc
60
55
50
Es
45
40
35
30
Psychotic
Borderline
Neurotic
Percent of Practitioners Rating the PDC Dimensions as “Helpful—Very Helpful”
in Understanding Their Patient
90
80
70
60
50
40
30
20
10
0
Levels of Personality
Structure
Dominant Personality
Patterns
Mental Functioning
ICD or DSM Symptoms
Cultural/Contextual
Dimensions
Personality Structure Dimension: Summary
1. Practitioners want a parsimonious taxonomy that
informs psychotherapy and management issues.
2. Practitioners consider personality structure a
very important dimension in understanding their
patients.
3. Research supports that personality structure
predicts response to treatment and is sensitive
to type of treatment (supportive vs.
interpretive).
4. Research supports the dimensional and
categorical aspects of personality structure
For Copies of the PDC and PDP:
• Email:
rmgordonphd@rcn.com
• Online search for:
“Psychodiagnostic Chart”

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