1

New Diagnostic Considerations DSM-5, ICD10-11, PDM Review

J&K Seminars2013

Robert M. Gordon, Ph.D. ABPP

2

Objectives

1. Major new elements of DSM-52. The highlights of ICD-10 and preparing for

October 1, 20143. The ICD-11 research4. The PDM for better understanding of people

and for informing psychological treatment5. PDM Research6. How do these various taxonomies help with

ethical and risk management issues?

3

Exercise in Psychodiagnoses

Learn about:• Personality organization• Personality patterns• Strengths and weaknesses• Emergent symptoms• Cultural and Contexual issues • Issues related to ethical and risk issues• Countertransference and boundary issues• Contribute to the science of psychological

taxonomy. Participation is voluntary.

4

Which Taxonomic Organization for Mental and Behavioral Science?

Like a Biological Organization? Like a Periodic Table?

5

The term “Diagnosis” is derived from Greek - meaning a distinguishing, to perceive, to know thoroughly.

6

What is Missing?

7

In 1854, after a major outbreak of cholera struck London, John Snow, a physician, linked the outbreak to contaminated water from this hand pump

on Broadwick Street. He removed the handle and stopped the epidemic.

8

Reasons for a mental health taxonomy

• Ethical and humanistic dilemmas with diagnosing personality

• Nosologies: Different ways to characterize disease

• Different nosologies for different folks• Risk managements issues• Need for a personality-based taxonomy that

informs psychological treatments

9

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.

10

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 demoralization and therapists from burnout.”

11

Why Diagnose?3. Its value in enabling the therapist to convey empathy. Once one knows that a depressed patient also has aBorderline, rather neurotic level personality structure, thetherapist will not be surprised if during the second year oftreatment she makes a suicide gesture. Or, once a borderline client starts to have hope of real

change, that he often panics and flirts with suicide in an effort to protect himself from traumatic disappointment.

12

Why Diagnose?

4. Its role in reducing the probability that certain easily-frightened 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.

13

Why Diagnose?

5. Its value in risk management: Often therapists mistakenly used a presenting symptom as the only diagnosis and missed the borderline level of personality or psychopathic personality and got into trouble.

6. Its value in process and outcome research.

14

Ethical Standard in rendering diagnostic opinionsBy Dr. Stephen Behnke, APA Ethics Director

• A good starting point is to reflect upon our values as psychologists and to consider the significance of rendering a diagnosis.

• Principle A, Beneficence and Nonmaleficence, exhorts

psychologists "to benefit those with whom they work and take care to do no harm.”

• Promoting welfare and safeguarding from harm are thus values

central to our profession. Rendering a diagnosis has direct relevance to each.

Diagnoses, record reviews and the new Ethics Code, Ethical Standard 9.01 guides psychologists in rendering diagnostic opinions.By Dr. Stephen Behnke, APA Ethics Director January 2005, Vol 36, No.1

15

Rendering Diagnoses

“In few areas of practice does a psychologist exercise greater authority and influence than to render a diagnosis, for in so doing the psychologist comes to know and convey information that may profoundly affect that individual's life.”

16

Implications of a Diagnosis: Clinical, Personal and Social

“In the clinical context, a diagnosis reveals the nature of an illness. A correct diagnosis provides a basis for effective treatment. An incorrect diagnosis may delay or impede effective treatment or

even exacerbate a situation by inviting inappropriate treatment. A diagnosis has personal significance insofar as it can become central

to how a person experiences him- or herself. While a correct diagnosis of a severe disorder can be enormously

difficult to integrate into one's sense of self, an incorrect diagnosis can be crippling.

A diagnosis is also a label to which others respond and thus has profound social implications. Social judgments are made in response to a diagnosis of mental illness, and diagnoses can play an important role in awarding entitlements and determining placement.

17

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.

18

Risk Factors in Litigious Patients

Borderline Personality OrganizationPsychopathic traits

History of acting out

19

“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.

20

Which Diagnostic Taxonomy Should We Use?

• DSM-5?• ICD-10?• PDM?

21

DSM-5

• The DSM-5 May 2013.• Research started in 1999.• The DSM makes the American Psychiatric

Association over $5 million a year, historically adding up to over $100 million.

22

DSM5

23

DSM-5 Moves from Multi-axial system to a similar ICD-10 System

24

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

25

DSM-5 has major reliability problems• Only 5 diagnoses achieved kappa levels of

agreement between 0.60-0.79. • The nine DSM-5 disorders in the kappa range of

0.40-0.59 previously would have been considered just plain poor, but DSM-5 puffs these up as "good.”

• Then DSM-5 calls “acceptable” 6 disorders that achieved unacceptable reliabilities with kappas of 0.20-0.39.

• Major Depressive Disorder and Generalized Anxiety Disorder were among those that achieved the unacceptable kappas in 0.20-0.39 range.

26

Originally proposed only 6 personality disorders and a complex trait system

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

27

DSM5: T 04 Antisocial 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.

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.

28

B. Pathological personality traits in the following domains:1. Antagonism, characterized by:

a. Manipulativeness b. Deceitfulness c. Callousness d. Hostility

2. Disinhibition, characterized by: a. Irresponsibility b. Impulsivity c. Risk taking

29

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.

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 taking3. Antagonism, characterized by: a. Hostility

30

The History, Politics and Assumptions of DSM-5

31

What Should Have Been

32

What Actually Occurred

33

How Not to Refine a Diagnostic System

Lessons from DSM-5Work in Isolation

Encourage SecrecyIgnore Contradictory Evidence

34

35

36

37

38

December 1, 2012The Proposal is Rejected by

the American Psychiatric Association

39

40

41

Why Will DSM-5 Cost $199 a Copy?By Allen Frances, M.D. 1/24/13 Huffington Post

DSM-5 has just announced its price -- an incredible $199 • First, APA has sunk more than $25 million into DSM-5 and wants to

recoup as much of its investment as it can. • DSM-IV cost one fifth as much -- just $5 million -- of which half came

from external grants.• APA is probably counting on having captive buyers who are forced to

pay its price, however exorbitant it may be. • DSM-5 boycotts are sprouting up all over the place• The codes clinicians need for insurance purposes are available for

free on the internet• DSM-5 is so clunkily written, no teacher will ever want to assign it to

students• People are not likely to rush out to buy a ridiculously expensive

DSM-5 that has already been discredited as unsafe and scientifically unsound.

42

DSM-5 Is Guide Not Bible—Ignore Its Ten Worst ChangesBy Allen J. Frances, M.D. Psychology Today Dec 2 2012

• More than fifty mental health professional associations petitioned for an outside review of DSM-5 to provide an independent judgment of its supporting evidence and to evaluate the balance between its risks and benefits. Professional journals, the press, and the public also weighed in - expressing widespread astonishment about decisions that sometimes seemed not only to lack scientific support but also to defy common sense.

43

• Fortunately, some of its most egregiously risky and unsupportable proposals were eventually dropped under great external pressure (most notably 'psychosis risk', mixed anxiety/depression, internet and sex addiction, rape as a mental disorder, 'hebephilia', cumbersome personality ratings, and sharply lowered thresholds for many existing disorders).

44

1) Disruptive Mood Dysregulation Disorder will turn temper tantrums into a mental disorder.

2) Normal grief will become Major Depressive Disorder. 3) The everyday forgetting characteristic of old age will now be misdiagnosed as Minor Neurocognitive Disorder. 4) DSM 5 will likely trigger a fad of Adult Attention Deficit Disorder leading to widespread misuse of stimulant drugs for performance enhancement and recreation and contributing to the already large illegal secondary market in diverted prescription drugs. 5) Excessive eating 12 times in 3 months is no longer just a manifestation of gluttony but it is a psychiatric illness called Binge Eating Disorder.

45

6) The changes in the DSM-5 definition of Autism will result in lowered rates - perhaps by 50% according to outside research groups.

7) First time substance abusers will be lumped in definitionally in with hard core addicts despite their very different treatment needs and prognosis and the stigma this will cause. 8) Behavioral Addictions that eventually can spread to make a mental disorder of everything we like to do a lot. Watch out for careless overdiagnosis of internet and sex addiction and the development of lucrative treatment programs to exploit these new markets. 9) DSM-5 obscures the already fuzzy boundary been Generalized Anxiety Disorder and the worries of everyday life. 10) DSM-5 has opened the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings.

46

Attacks on DSM5

47

Neurodevelopmental Disorders

Intellectual Disability (Intellectual Developmental Disorder)• Diagnostic criteria for intellectual disability (intellectual

developmental disorder) emphasize the need for an assessment of both cognitive capacity (IQ) and adaptive functioning.

• Severity is determined by adaptive functioning rather than IQ score. Moreover, a federal statue in the United States (Public Law 111-256, Rosa’s Law) replaces the term “mental retardation” with intellectual disability.

• The term intellectual developmental disorder was placed in parentheses to reflect the ICD-11 (to be released in 2015).

48

Intellectual Disability (Intellectual Developmental Disorder)

• DSM-IV criteria had required an IQ score of 70 as the cutoff for diagnosis; the new criteria recommend IQ testing and describe “deficits in adaptive functioning that result in failure to meet developmental and sociocultural standards for personal independence and social responsibility.”

• The new criteria also include severity measures for mild, moderate, severe, and profound intellectual disability.

49

Autism Spectrum Disorder (ASD)

• Consolidation of DSM-IV criteria for autism, Asperger’s, childhood disintegrative disorder, and pervasive developmental disorder-not otherwise specific (PDD-NOS)—into one diagnostic category called autism spectrum disorder (ASD).

• The new criteria describe two principal symptoms: “deficits in social communication and social interaction” and “restrictive and repetitive behavior patterns”

50

Communication Disorders

The DSM-5 communication disorders include:• language disorder • speech sound disorder • childhood-onset fluency disorder (a new name

for stuttering)• social (pragmatic) communication disorder, a

new condition for persistent difficulties in the social uses of verbal and nonverbal communication.

51

Attention-Deficit/Hyperactivity Disorder

• The same 18 symptoms are used as in DSM-IV• the onset criterion has been changed from “symptoms

that caused impairment were present before age 7 years” to “several inattentive or hyperactive-impulsive symptoms were present prior to age 12”;

• subtypes have been replaced with presentation specifiers that map directly to the prior subtypes;

• a comorbid diagnosis with autism spectrum disorder is now allowed;

• a symptom threshold change has been made for adults with the cutoff for ADHD of five symptoms, instead of six required for younger persons,

52

Specific Learning Disorder

• Specific learning disorder combines the DSM-IV diagnoses of reading disorder, mathematics disorder, disorder of written expression, and learning disorder not otherwise specified. Because learning deficits in the areas of reading, written expression, and mathematics commonly occur together, coded specifiers for the deficit types in each area are included.

53

Schizophrenia Spectrum and Other Psychotic Disorders

• Schizophrenia• Elimination of the special attribution of bizarre

delusions and Schneiderian first-rank auditory hallucinations (e.g., two or more voices conversing).

• The second change is the addition of a requirement in Criterion A that the individual must have at least one of these three symptoms: delusions, hallucinations, and disorganized speech. At least one of these core “positive symptoms” is necessary for a reliable diagnosis of schizophrenia

54

Schizophrenia subtypes

• The DSM-IV subtypes of schizophrenia (i.e., paranoid, disorganized, catatonic, undifferentiated, and residual types) are eliminated due to their limited diagnostic stability, low reliability, and poor validity.

• Instead, a dimensional approach to rating severity for the core symptoms of schizophrenia.

55

Schizoaffective Disorder

• The primary change to schizoaffective disorder is the requirement that a major mood episode be present for a majority of the disorder’s total duration after Criterion A has been met.

• It makes schizoaffective disorder a longitudinal instead of a cross-sectional diagnosis—more comparable to schizophrenia, bipolar disorder, and major depressive disorder, which are bridged by this condition.

56

Delusional Disorder

• Criterion A for delusional disorder no longer has the requirement that the delusions must be nonbizarre. A specifier for bizarre type delusions provides continuity with DSM-IV. The demarcation of delusional disorder from psychotic variants of obsessive-compulsive disorder and body dysmorphic disorder is explicitly noted with a new exclusion criterion, which states that the symptoms must not be better explained by conditions such as obsessive-compulsive or body dysmorphic disorder with absent insight/delusional beliefs.

57

Catatonia

• In DSM-5, catatonia may be diagnosed as a specifier for depressive, bipolar, and psychotic disorders

58

Bipolar and Related DisordersBipolar Disorders• Criterion A for manic and hypomanic episodes now includes an emphasis on changes

in activity and energy as well as mood. The DSM-IV diagnosis of bipolar I disorder, mixed episode, requiring that the individual simultaneously meet full criteria for both mania and major depressive episode, has been removed. Instead, a new specifier, “with mixed features,” has been added that can be applied to episodes of mania or hypomania when depressive features are present, and to episodes of depression in the context of major depressive disorder or bipolar disorder when features of mania/hypomania are present.

Other Specified Bipolar and Related Disorder• categorization for individuals with a past history of a major depressive disorder who

meet all criteria for hypomania except the duration criterion (i.e., at least 4 consecutive days). A second condition constituting an other specified bipolar and related disorder is that too few symptoms of hypomania are present to meet criteria for the full bipolar II syndrome, although the duration is sufficient at 4 or more days.

Anxious Distress Specifier• Added is a specifier for anxious distress. This specifier is intended to identify patients

with anxiety symptoms that are not part of the bipolar diagnostic criteria.

59

Depressive Disorders

• DSM-5 contains several new depressive disorders, including disruptive mood dysregulation disorder and premenstrual dysphoric disorder.

• To address concerns about potential overdiagnosis and overtreatment of bipolar disorder in children, a new diagnosis, disruptive mood dysregulation disorder, is included for children up to age 18 years who exhibit persistent irritability and frequent episodes of extreme behavioral dyscontrol.

• Finally, DSM-5 conceptualizes chronic forms of depression in a somewhat modified way. What was referred to as dysthymia in DSM-IV now falls under the category of persistent depressive disorder, which includes both chronic major depressive disorder and the previous dysthymic disorder.

60

Bereavement

• In DSM-IV, there was an exclusion criterion for a major depressive episode that was applied to depressive symptoms lasting less than 2 months following the death of a loved one (i.e., the bereavement exclusion). This exclusion is omitted in DSM-5. 1, to remove the implication that bereavement typically lasts only 2 months when both physicians and grief counselors recognize that the duration is more commonly 1–2 years. 2, bereavement is recognized as a severe psychosocial stressor that can precipitate a major depressive episode in a vulnerable individual, and an increased risk for persistent complex bereavement disorder, which is now in Conditions for Further Study in DSM-5 Section III. 3, bereavement-related major depression is most likely to occur in individuals with past personal and family histories of major depressive episodes. It is genetically influenced and is associated with similar personality characteristics, patterns of comorbidity, and risks of chronicity and/or recurrence as non–bereavement-related major depressive episodes

61

Anxiety Disorders

• The DSM-5 chapter on anxiety disorder no longer includes obsessive-compulsive disorder (which is included with the obsessive-compulsive and related disorders) or posttraumatic stress disorder and acute stress disorder (which is included with the trauma- and stressor-related disorders). However, the sequential order of these chapters in DSM-5 reflects the close relationships among them.

62

PTSD• The 3 clusters of DSM-IV symptoms will be divided into

4 clusters in DSM-5: intrusion symptoms, avoidance symptoms, arousal/reactivity symptoms and negative mood and cognitions.

• Criterion A2 (requiring fear, helplessness or horror happen right after the trauma) will be removed.

• The diagnosis is proposed to move from the class of anxiety disorders into a new class of "trauma and stressor-related disorders."

• PTSD assessment measures, such as the CAPS and the PCL, are being revised by the National Center for PTSD to be made available upon the release of DSM-5.

63

Somatic Symptom and Related Disorders

The DSM-5 classification reduces the number of these disorders and subcategories. Diagnoses of somatization disorder, hypochondriasis, pain disorder, and undifferentiated somatoform disorder have been removed.

64

Parental Alienation Syndrome

• Parent-child relational problem "may include negative attributions of the other's intentions, hostility toward or scapegoating of the other, and unwarranted feelings of estrangement."

• Child psychological abuse "non-accidental verbal or symbolic acts by a child's parent or caregiver that result, or have reasonable potential to result, in significant psychological harm to the child.”

65

The International Classification of Diseases (ICD)

• 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 currently being researched and

should be ready in 2015.

66

ICD History• The first international conference to revise the International

Classification of Causes of Death convened in 1900; with revisions occurring every ten-years thereafter.

• In 1948, the World Health Organization (WHO) assumed responsibility for preparing and publishing the revisions to the ICD every ten-years. WHO sponsored the seventh and eighth revisions in 1957 and 1968, respectively. It later become clear that the established ten-year interval between revisions was too short.

• The America Psychiatric Association has long lobbied against the use of the ICD (but due to federal law is forced to work with the ICD).

67

ICD is Required by HIPAA

• 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. The transition to ICD-10 is required for everyone covered by the Health Insurance Portability Accountability Act (HIPAA), Medicare and Medicaid.

68

ICD-10 MENTAL AND BEHAVIOURAL DISORDERS consists of 10 main groups:

F0: Due to known physiological conditions F1: Due to use of psychoactive substances F2: Schizophrenia, schizotypal and delusional disorders F3: Mood [affective] disorders F4: Anxiety, dissociative, 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: Intellectual disabilities F8: Pervasive and specific developmental disorders F9: Behavioural and emotional disorders with onset usually occurring

in childhood and adolescence In addition, a group of "unspecified mental disorders".

69

ICD-10 Disorders of adult personality and behavior

F60 Specific personality disorders F60.0 Paranoid personality disorder F60.1 Schizoid personality disorder F60.2 Antisocial personality disorder F60.3 Borderline personality disorder F60.4 Histrionic personality disorder F60.5 Obsessive-Compulsive personality disorderF60.6 Avoidant personality disorder F60.7 Dependent personality disorder F60.8 Other specific personality disordersF60.81 Narcissistic personality disorderF60.89 Other specific personality disorderF60.9 Personality disorder, unspecified

70

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.”

• The Borderline was added back into ICD-10

71

• 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 typeemotional 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 typethe 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)

72

ICD-11 Survey Overview

• 2155 global psychologists participated in the WHO and International Union of Psychological Sciences (IUPsyS)

• 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)

• Parallel to survey conducted by WHO and World Psychiatric Association (WPA) of 4887 psychiatrists in 44 countries

73

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 (ICD-9 and 10 apps are free).

74

Collaborators• Geoffrey M. Reed• Spencer C. Evans• Ann D. Watts• João Mendonça Correia• Patricia Esparza• Mario Maj• Michael C. Roberts• Shekhar Saxena

75

USAn = 108

Europen = 1398

Africa n = 121

EasternMediterraneann = 224

Asian = 139

Latin America n = 165

2155 Participating Psychologists

WORLDN = 2155

76

Psychol-ogists

Psychiatrists Other physicians

Nurses Other 0%

20%

40%

60%

80%

100%

75%

60%

20%

4% 7%

Q39 - In the settings where you normally practice, who is responsible for making individual diagnoses?

Who Makes Diagnoses?%

Par

ticip

ants

77

Psychologists’ Role in Making Diagnoses

0%

20%

40%

60% 57%

32%

6% 4%

Q40 - In the one setting where you practice most, what role do you as a psychologist play in making

individual diagnoses?

% P

artic

ipan

ts

78

Use of Classification Systems

% P

artic

ipan

ts

Always or almost always

Often Sometimes Rarely Never0%5%

10%15%20%25%30%35%40% 36%

24%18% 16%

6%

Q7 - As part of your day-to-day clinical work, how often do you use a formal classification system for mental dis-orders, such as the ICD, DSM, or a national classification?

79

Classification System Most Used

% P

artic

ipan

ts

ICD-10 ICD-9 DSM-IV Other 0%

10%

20%

30%

40%

50%

60%51%

1%

44%

4%

Q8 - In your day-to-day clinical work, which classi-fication system for mental disorders do you use

most?

80

Purpose of Classification%

Par

ticip

ants

0%10%20%30%40%50%

33%

16%

39%

3% 5% 4%

Q9 - From your perspective, which is the single, most important purpose of a diagnostic classification system?

81

Number ofCategories Desired

% P

artic

ipan

ts

10 to 30 31 to 100 101 to 200 More than 200 0%

10%

20%

30%

40%

50%

60%

35%

50%

11%4%

Q10 - In clinical settings, how many diagnostic categories should a classification system contain to be most useful

for mental health professionals?

82

Strict Criteria vs.Flexible Guidance

% P

artic

ipan

ts

0%

20%

40%

60%

80%

100%

22%

78%

22%

78%

Q14 - For maximum utility in clinical settings, a diagnostic manual should contain:

ICD-10 Users

DSM-IV Users

83

A Dimensional Component%

Par

ticip

ants

0%

10%

20%

30%

40%

50%

60%

28%

50%

13%9%

34%

46%

11% 9%

Q17 - Should a diagnostic system incorporate a dimensional component, where some disorders are rated on a scale rather

than just as present or absent?

ICD-10 Users

DSM-IV Users

84

Reactions to Adverse Life Events

% P

artic

ipan

ts

Yes No0%

10%

20%

30%

40%

50%

60%56%

44%

49% 51%

Q18 - Should the diagnosis of depression be assigned when the depressive symptoms are a proportionate response to an

adverse life event (e.g., loss of job or home, divorce)?

ICD-10 Users

DSM-IV Users

85

Usability Across Culturesby Region

Q19 – ‘The diagnostic system I use is difficult to apply across cultures, or when the patient/service user is of a different cultural or ethnic background from my own.’

Africa Asia Eastern Mediterranean Europe Latin America USA0%5%

10%15%20%25%30%35%40%45%50%

43%

33%38%

31% 32%

18%

% Completely or Mostly Agree by Region (Weighted)

86

ICD-10 and DSM-IV Categories Used Most Often

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%

87

Categories With theLowest Ease of Use

ICD-10 EOU DSM-IV EOU

Asperger's Syndrome 0.50 Dissociative Disorders 0.48

Dissociative [Conversion] Disorders 0.50 Impulse Control Disorders 0.50

Schizoaffective Disorder 0.51 Schizotypal Personality Disorder 0.54

Schizotypal Disorder 0.51 Schizoaffective Disorder 0.54

Somatoform Disorders 0.52 Asperger's Disorder 0.56

Borderline Personality Disorder 0.56 Somatoform Disorders 0.56

Hyperkinetic (Attention Deficit) Disorder 0.56 Primary Sleep Disorders 0.58

Delirium 0.58 Bipolar II Disorder 0.58

MBDs due to Use of Volatile Solvents 0.58 Tic disorders 0.59

Habit and Impulse Disorders 0.59 Brief Psychotic Disorder 0.60

MBDs due to Use of Hallucinogens 0.60 Vascular Dementia 0.60

Bipolar Affective Disorder 0.60 Sexual Dysfunctions 0.60

Mixed Anxiety and Depressive Disorder 0.60 Autistic Disorder 0.61

Adjustment Disorder 0.60 Delusional Disorder 0.62

88

Categories With theLowest Goodness of Fit

ICD-10 GOF DSM-IV GOF

Dissociative [Conversion] Disorders 0.45 Schizotypal Personality Disorder 0.44

Asperger's Syndrome 0.45 Dissociative Disorders 0.45

Hyperkinetic (Attention Deficit) Disorder 0.50 Somatoform Disorders 0.47

Schizoaffective Disorder 0.51 Asperger's Disorder 0.48

Somatoform Disorders 0.51 Impulse Control Disorders 0.48

Borderline Personality Disorder 0.51 Schizoaffective Disorder 0.49

MBDs Due to Use of Hallucinogens 0.52 Primary Sleep Disorders 0.51

Schizotypal Disorder 0.53 Tic disorders 0.53

Vascular Dementia 0.53 Bipolar II Disorder 0.53

Dissocial (Antisocial) Personality Disorder 0.55 Borderline Personality Disorder 0.54

Adjustment Disorder 0.55 Autistic Disorder 0.54

Habit and Impulse Disorders 0.55 Brief Psychotic Disorder 0.55

Mixed Anxiety and Depressive Disorder 0.56 Sexual Dysfunctions 0.56

89

An enduring pattern of unusual speech, perceptions, beliefs and behaviors that are not of sufficient intensity to meet the requirements of schizophrenia. 3 or 4 of the following: Constricted affect, the individual appearing cold and aloof. Behaviour or appearance which is odd, eccentric, or peculiar. Poor rapport with others, tendency towards social withdrawal. Unusual beliefs, magical thinking or paranoid ideation Unusual perceptual distortions Suspiciousness or paranoid ideas Occasional transient psychotic episodes Vague, circumstantial, stereotyped thinking Obsessive ruminations Not met diagnostic criteria for schizophrenia

ICD-10 / ICD-11 Schizotypal Disorder

90

A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior…5 or more of the following:

(1) ideas of reference(2) odd beliefs or magical thinking (3) unusual perceptual experiences(4) odd thinking and speech (e.g., vague, circumstantial)(5) suspiciousness or paranoid ideation(6) inappropriate or constricted affect(7) behavior or appearance that is odd, eccentric, or peculiar(8) lack of close friends or confidants other than first-degree relatives(9) excessive social anxiety

DSM-IV Schizotypal Personality Disorder

91

DSM-5 Schizotypal Personality Disorder

A. Significant impairments in personality functioning:1. Impairments in self functioning (a or b):

a. Identity: Confused boundaries between self and others; b. Self-direction: Unrealistic or incoherent goals; AND

2. Impairments in interpersonal functioning (a or b):a. Empathy: Difficulty understanding impact of behaviors on others;b. Intimacy: Marked impairments in developing close relationships.

B. Pathological personality traits in the following domains:1. Psychoticism, characterized by:

a. Eccentricity b. Cognitive and perceptual dysregulation:c. Unusual beliefs and experiences

2. Detachment, characterized by:a. Restricted affectivityb. Withdrawal

3. Negative Affectivity, characterized by:a. Suspiciousness

92

DSM-5 Schizotypal Personality Disorder

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.”

93

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

94

Developed by

• A collaborative effort of the: • American Psychoanalytic Association • International Psychoanalytical Association • Division of Psychoanalysis (39) of the American

Psychological Association • American Academy of Psychoanalysis and Dynamic

Psychiatry • National Membership Committee on Psychoanalysis

in Clinical Social Work

95

The New York Times Book ReviewFor Therapy, a New Guide With a Touch of

Personality January 24, 2006 By BENEDICT CAREY

• The encyclopedia of mental disorders known as the Diagnostic and Statistical Manual is built on a principle that many therapists find simplistic: that people's symptoms are the most reliable way to classify their mental troubles.

96

The New York Times Book Review• The most striking proposal in the new manual

is its insistence that personality be evaluated first, and symptoms considered secondary.

• The first section of the book describes 14 different personality patterns. It also restores others that were dropped from recent editions of the DSM, like sadistic, masochistic and passive-aggressive personality patterns.

• "The DSM is a taxonomy of diseases or disorders of function. Ours is a taxonomy of people,“ the new manual declares.

97

Goals

• Improvements in the diagnosis and treatment of mental disorders that will permit a fuller understanding of the functioning of the mind and brain and their development.

98

Basis

• The PDM is based on current neuroscience, treatment outcome research, and other empirical investigations. Research on brain development and the maturation of mental processes suggests that patterns of emotional, social, and behavioral functioning involve many areas working together rather than in isolation.

99

Research Support

• Blatt, (this volume), Norcross (2002), Wampold (2001) have concluded that the nature of the psychotherapeutic relationship, reflecting interconnected aspects of mind and brain operating together in an interpersonal context, predicts outcome more robustly than any specific treatment approach per se. Westen, Novotny, and Thompson-Brenner (2004 and this volume) have presented evidence that treatments that focus on isolated symptoms or behaviors (rather than personality, emotional, and interpersonal patterns ) are not effective in sustaining even narrowly defined changes.

Psychodynamic Theory as a Complex Adaptive System- interaction, interdependence and diversity of constructs (temperament, affects, cognitions, development, traumas, defenses, fantasies, attachments), emergences (symptoms), tails (one event can move the entire central tendency) and tipping points (break downs).

100

101

PDM’s Current Taxonomy

102

Types of Personality Disorders or Patterns

• P101. Schizoid Personality DisordersP102. 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

103

• 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

104

• 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

105

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

106

Symptom Patterns: The Subjective Experience - S Axis

• S301. Adjustment DisordersS302. Anxiety Disorders S302.1 Psychic Trauma and Posttraumatic Stress Disorder S302.2 Phobias S302.3 Obsessive-Compulsive DisordersS303. Dissociative DisordersS304. Mood Disorders S304.1 Depressive Disorders S304.2 Bipolar DisordersS305. Somatoform (Somatization) DisordersS306. Eating DisordersS307. Psychogenic Sleep DisordersS308. Sexual and Gender Identity Disorders S308.1 Sexual Disorders S308.2 Paraphilias S308.3 Gender Identity DisordersS309. Factitious DisordersS310. Impulse Control DisordersS311. Addictive/Substance Abuse DisordersS312. Psychotic DisordersS313. Mental Disorders Based on a General Medical Condition

107

Classification of Child and Adolescent Mental Health Disorders

Profile of Mental Functioning for Children and Adolescents - MCA 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 CommunicationDefensive Patterns and CapacitiesCapacity to Form Internal RepresentationsCapacity for Differentiation and IntegrationSelf-Observing Capacities (Psychological-Mindedness)Capacity for Internal Standards and Ideals: Sense of MoralitySummary of Child and Adolescent Mental Functioning

108

Child and Adolescent Personality Patterns and Disorders - PCA Axis

Developmental Aspects of Emerging Personality Patterns PCA101. Fearful of Closeness/Intimacy (Schizoid) Personality DisordersPCA102. Suspicious/Distrustful Personality DisordersPCA103. Sociopathic (Antisocial) Personality DisordersPCA104. Narcissistic Personality DisordersPCA105. Impulsive/Explosive Personality DisordersPCA106. Self-Defeating Personality DisordersPCA107. Depressive Personality DisordersPCA108. Somatizing Personality DisordersPCA109. Dependent Personality DisordersPCA110. Avoidant/Constricted Personality Disorders PCA110.1 Counterphobic Personality Disorders PCA111. Anxious Personality DisordersPCA112. Obsessive-Compulsive Personality DisordersPCA113. Histrionic Personality DisordersPCA114. Dysregulated Personality DisordersPCA115. Mixed/Other

109

Child and Adolescent Symptom Patterns: The Subjective Experience

• Anxiety DisordersSCA301. Anxiety DisordersSCA302. PhobiasSCA303. Obsessive-Compulsive DisordersSCA304. Somatization (Somatoform) DisordersAffect/Mood DisordersSCA305. Prolonged Mourning/Grief ReactionSCA306. Depressive DisordersSCA307. Bipolar DisordersSCA308. SuicidalityDisruptive Behavior DisordersSCA309. Conduct DisordersSCA310. Oppositional-Defiant DisordersSCA311. Substance Abuse Related DisordersReactive DisordersSCA312. Psychic Trauma and Posttraumatic Stress DisorderSCA313. Adjustment Disorders (other than developmental)Disorders of Mental FunctioningSCA314. Motor Skills DisordersSCA315. Tic DisordersSCA316. Psychotic DisordersSCA317. Neuropsychological Disorders SCA317.1 Visual-Spatial Processing Disorders SCA317.2 Language and Auditory Processing Disorders SCA317.3 Memory Impairments SCA317.4 Attention Deficit/Hyperactivity Disorder (AD/HD) SCA317.5 Executive Function Disorders SCA317.6 Severe Cognitive Deficits

110

Child and Adolescent Symptom Patterns: The Subjective Experience

• SCA318. Learning Disorders SCA318.1 Reading Disorders SCA318.2 Mathematics Disorders SCA318.3 Disorders of Written Expression SCA318.4 Nonverbal Learning Disabilities SCA318.5 Social-Emotional Learning DisabilitiesPsychophysiologic DisordersSCA319. BulimiaSCA320. AnorexiaDevelopmental DisordersSCA321. Regulatory DisordersSCA322. Feeding Problems of ChildhoodSCA323. Elimination Disorders SCA323.1 Encopresis SCA323.2 EnuresisSCA324. Sleep DisordersSCA325. Attachment DisordersSCA326. Pervasive Developmental Disorders SCA326.1 Autism SCA326.2 Asperger’s Syndrome SCA326.3 Pervasive Developmental Disorder (PDD) Not Otherwise SpecifiedOther DisordersSCA327. Gender Identity Disorders

111

Disorders of Infancy and Early Childhood – Axis I - Primary Axis

• IEC100 Series- Interactive DisordersIEC101. Anxiety DisordersIEC102. Developmental Anxiety DisordersIEC103. Disorders of Emotional Range and StabilityIEC104. Disruptive Behavior and Oppositional DisordersIEC105. Depressive Disorders IEC106. Mood Dysregulation: A Unique Type of Interactive and Mixed Regulatory-Sensory Processing Disorder Characterized by Bipolar PatternsIEC107. Attentional DisordersIEC108. Prolonged Grief ReactionIEC109. Reactive Attachment DisordersIEC110. Traumatic Stress DisordersIEC111. Adjustment DisordersIEC112. Gender Identity DisordersIEC113. Selective MutismIEC114. Sleep DisordersIEC115. Eating DisordersIEC116. Elimination Disorders

112

• IEC200 Series - Regulatory-Sensory Processing Disorders (RSPD)Clinical Evidence and Prevalence of Regulatory-Sensory Processing DifferencesSensory Modulation Difficulties (Type I)IEC201. Overresponsive, Fearful, Anxious PatternIEC202. Overresponsive, Negative, Stubborn PatternIEC203. Underresponsive, Self-Absorbed Pattern IEC203.1 Self-Absorbed and Difficult-to-Engage Type IEC203.2 Self-Absorbed and Creative TypeIEC204. Active, Sensory Seeking PatternSensory Discrimination Difficulties (Type II) and Sensory-Based Motor Difficulties (Type III)IEC205. Inattentive, Disorganized Pattern IEC205.1 With Sensory Discrimination Difficulties IEC205.2 With Postural Control Difficulties IEC205.3 With Dyspraxia IEC205.4 With Combinations of All ThreeIEC206. Compromised School and/or Academic Performance Pattern IEC206.1 With Sensory Discrimination Difficulties IEC206.2 With Postural Control Difficulties IEC206.3 With Dyspraxia IEC206.4 With Combinations of All ThreeContributing Sensory Discrimination and Sensory-Based Motor Difficulties

113

• IEC207. Mixed Regulatory-Sensory Processing Patterns IEC207.1 Attentional Problems IEC207.2 Disruptive Behavioral Problems IEC207.3 Sleep Problems IEC207.4 Eating Problems IEC207.5 Elimination Problems IEC207.6 Selective Mutism IEC207.7 Mood Dysregulation, including Bipolar Patterns IEC207.8 Other Emotional and Behavioral Problems Related to

• Mixed Regulatory-Sensory Processing Difficulties IEC207.9 Mixed Regulatory-Sensory Processing Patterns where Behavioral or Emotional Problems Are Not Yet In Evidence

• IEC300 Series - Neurodevelopmental Disorders of Relating and CommunicatingIEC301. Type I: Early Symbolic, with ConstrictionsIEC302. Type II: Purposeful Problem-Solving, with ConstrictionsIEC303. Type III: Intermittently Engaged and PurposefulIEC304. Type IV: Aimless and UnpurposefulOther Neurodevelopmental Disorders (Including Genetic and Metabolic Syndromes)

114

Reactions to the PDM

• 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.

115

From Earliest Findings: Personality Organization 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.

116

To the most recent: “The impact of level of personality organization on treatment response: a

systematic review.” (2012) • “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.

117

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. • Gordon, R.M. (2013) book review in Division/Review and at Amazon books

118

Psychodiagnostic Chart (PDC)An Operationalized Psychodynamic Diagnostic

Manual Guide

Robert M. Gordon and Robert F. Bornstein (2012)

119

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 Validity-

preliminary field evidence (Gordon and Stoffey 2013 in press)

120

PDC’s Taxonomy: From Larger to Smaller Units

121

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 Organization- 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 disorder5. Cultural, Contextual Issues- recent death of husband, war trauma, loss of father, leaving much of her family and friends behind, immigration fears and guilt.

122

Testing Dimensional and CategoricalQualities of Personality Organization

• 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).

123

Testing Dimensional and CategoricalQualities of Personality Organization with 3 Scales

124

Psychotic Borderline Neurotic30

35

40

45

50

55

60

65

70

75

80

85

90

Hy

Sc

Es

MMPI-2 Hysteria-Hy, Schizophrenia-Sc, and Ego Strength-Es Scales within the Psychotic, Borderline, and Neurotic Categories of the

Personality Organization ScalePsychotic (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.

125

Example of a Psychotic Level Personality: Schizotypal

• In ICD-10, Schizotypal disorder is classified as a clinical disorder associated with schizophrenia rather than a personality disorder as with DSM-IV and 5.

• It is not in the PDM.

126

Percent of Practitioners Rating the PDC Dimensions as “Helpful—Very Helpful” in

Understanding Their Patient

Levels of Personality Structure

Dominant Personality Patterns

Mental Functioning ICD or DSM Symptoms Cultural/Contextual Dimensions

0

10

20

30

40

50

60

70

80

9084

72

79

31

50

127

Personality Organization Dimension: Summary

1. Practitioners want a parsimonious taxonomy that informs psychotherapy and management issues.

2. Practitioners consider personality organization a very important dimension in understanding their patients.

3. Research supports that personality organization predicts response to treatment and is sensitive to type of treatment (supportive vs. interpretive).

4. Research supports a psychotic level personality organization.

128

Current PDM Study

• Data collected from 13 workshops from Nov. 2012- July 2013.

• Estimated N= 500+ practitioners and doctoral students

Lead researcher Robert M. Gordon

129

Psychodynamic Diagnostic Prototypes (PDP)

Francesco Gazzillo, PhDDepartment of Dynamic and Clinical Psychology

«Sapienza» University of Rome

130

PDP narrative description

P105.1 Intermediate Manifestation: Sadomasochistic Personality Disorders

Some individuals alternate between sadistic and sadomasochistic attitudes and behaviors (Kernberg, 1988). Patients with this psychology are much more emotionally alive and capable of attachment than those with primary psychopathic, narcissistic, or sadistic personality structures. Their relationships, however, are intense and explosive. Sometimes they let themselves be dominated to an extreme extent, and sometimes they viciously attack the person to whom they previously capitulated. They tend to see themselves as victims of others’ aggression whose only choices are to surrender their will entirely or to fight back belligerently. The “help-rejecting complainer” described by Frank and his colleagues (Frank, Margolin, Nash, Stone, Varon & Ascher, 1952) is one version of this psychology. In psychotherapy, such patients tend to alternate between attacking the therapist and feeling insulted and demeaned by him or her. Because sadomasochistic personality disorder is found at the borderline level of severity, treatment considerations include those for borderline patients generally.

131

The validation of Psychodynamic Diagnostic Prototypes (PDP; Gazzillo, Lingiardi, Del Corno, 2010)

The Prototypic Assessment of the Psychodynamic Diagnostic Prototype

5 Very good match (patient exemplifies this disorder; prototypical case)

4 Good match (patient has this disorder; diagnosis applies)3 Moderate match (patient has significant features of this disorder) 2 Slight match (patient has minor features of this disorder)1 No match (description does not apply) 

The evaluation of all 21 disorders takes about 10-30 minutes 

132

The validation of Psychodynamic Diagnostic Prototypes (PDP; Gazzillo, Lingiardi, Del Corno, 2010)

PDP DISORDERS Kappa values Rho valuesSchizoid .64** .71**

Paranoid .51** .75**Psychopatic .61** .77**

Narcissistic .65** .68**Sadistic No categorical diagnosis .57**

Sado-masochistic .59** .62**

Masochistic .57** .65**Depressive .56** .81**

Hypomaniac .44** .68**Somatizing .53** .79**Dependent .55** .69**

Passive-aggressive .47** .57**

Counter-dependent .75** .56**

Phobic .55** .71**Counter-phobic .58** .41**

Anxious .61** .79**Obsessive-compulsive .46** .60**

Histrionic .72** .84**Dissociative .60** .57**

133

Hypotheses1. Norms for PDP and PDC2. Concurrent validity between PDP and PDC3. How PDM Dx inform about boundaries and

countertransference issues4. How theoretical orientation affects value of

various taxa (PO, PD, MF, Symptoms, Context) 5. Which PD are commonly found at which level

of PO.

134

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 affects4. 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

135

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 StructureBased on the 7 ratings above, rate person’s overall personality structure from 1 (Psychotic) to 10 (Healthy)

136

2. Personality Patterns or Disorders- Scoring

Review the P axis in the PDM for the

personality patterns most descriptive of your client (use the PDP).

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).

137

PDM Categories: SchizoidParanoidPsychopathic (antisocial); Subtypes - passive/parasitic or aggressiveNarcissistic; Subtypes - arrogant/entitled or depressed/depleted;Sadistic (and intermediate manifestation, sadomasochistic)Masochistic (self-defeating); Subtypes - moral masochistic or relational masochisticDepressive; Subtypes - introjective or anaclitic; Converse manifestation - hypomanicSomatizingDependent (and passive-aggressive versions of dependent); Converse manifestation -

counterdependentPhobic (avoidant); Converse manifestation - counterphobicAnxiousObsessive-compulsive; Subtypes - obsessive or compulsiveHysterical (histrionic); Subtypes - inhibited or demonstrative/ flamboyantDissociativeMixed/other Rate: Dominate Personality Disorder or Maladaptive Traits & Overall Severity of Impairment

138

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

139

4. ICD or DSM 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.

140

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.

141

For Free Copies:

• For copies of the PDP and PDC, search for:

“Psychodiagnostic Chart”

142

Forensic Issues

• Diagnoses are a guides if useful to the question

• Diagnoses in Custody Cases• Diagnoses in Criminal Cases• Diagnoses in Personal Injury Cases

143

40

50

60

70

80

90

100

110

120

MotherAlienators

FatherAlienators

MotherTargets

Father Targets

MotherControl

FatherControl

Parents in Child Custody Evaluation

T-S

core

s

L+K-F GI

Figure 1: Mean T scores and standard deviations of parents' MMPI-2s from 158 court ordered child custody evaluations. T50 is an average score and T65 is high and clinically significant. L+K-F indicates splitting defenses and the Goldberg Index (L+Pa+Sc)-(Hy+Pt) indicates a borderline level of functioning and the favoring of primitive defenses such a projective identification. Parents who alienate their children from the other parent project their bad self onto the other parent and then treat that parent accordingly.

Gordon, R.M., Stoffey, R., & Bottinelli, J. (2008) MMPI-2 Findings of Primitive Defenses in Alienating Parents

144

Take Home Message:Diagnoses are to help you

understand a person’s problems. The law requires an ICD code.

In addition use whatever system is most helpful to you in understanding

and helping the client/patient