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 ID: 777201
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Slide1
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
Slide2Outline
What is diagnosis and why diagnose?
Case example of a ethical and risk management issue over Dx.
Big changes in DSM 5’s Personality Disorders.
The ICD 10-PD and the ICD 11 PD,
Participate in an experiment on diagnostic formulation and learn more about Dx.
The PDM- a personality centered approach,
Why Mental Functioning is important to Dx,
An Integration of the PDM, ICD or DSM.
Slide3The term “Diagnosis” is derived from Greek- meaning a distinguishing, to perceive, to know thoroughly.
Slide4Start 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.
Slide5Main 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.”
Slide6Why 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.
Slide7Why 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.
Slide8Personality 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.
Slide99
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.
Slide10“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.
Slide11Risk Factors in Litigious Patients
Borderline Personality
Organization
Psychopathic traits
History of acting out
Slide12“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.
Slide13Complaint 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.
Slide14Patient 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)
Slide15Admission 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…”
Slide16Mental 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…”
Slide17Mental 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…”
Slide18Whether 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.”
Slide19“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.”
Slide20Slide21Throw 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.
Slide22The 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
Slide23DSM 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.
Slide24DSM 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.
Slide25DSM 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 validity- does it also mean that it has more generalizable validity to complex personality structures?)
Slide26DSM-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)
Slide27Main 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 DisordersSubstance Use and Addictive DisordersNeurocognitive DisordersPersonality DisordersParaphilic DisordersOther Disorders
Slide28DSM 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.
Slide29Five 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
).
Slide30DSM 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
i
nformation 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).
Slide31Guide 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
)
If so, record the type and the severity of impairment.
5. 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.
Slide32Revised 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).
Slide33Slide34First- 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.
F
ive levels of self-interpersonal functioning
impairment, ranging from no impairment, i.e., healthy functioning (Level = 0) to extreme impairment (Level = 4)
Slide35Slide36Slide37Slide38Slide39Slide40Is 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
Slide41DSM5: 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.
AND2. 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.
Slide42B. 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
Slide43DSM 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
Slide44DSM 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. IntimacyB. 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
Slide45DSM 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.
Slide46DSM-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.
Slide47Slide48Rate 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
Slide49Rate the twenty-five specific trait facets comprising the five domains
Negative Affectivity
Emotional
lability
Anxiousness
Separation insecurity
Perseveration
Submissiveness
Hostility
Depressivity
Suspiciousness
Slide50Detachment
Restricted affectivity
Withdrawal
Anhedonia
Intimacy avoidance
Slide51Antagonism
Manipulativeness
Deceitfulness
Grandiosity
Attention seeking
Callousness
Slide52Disinhibition
Irresponsibility
Impulsivity
Distractibility
Risk taking
(lack of) Rigid perfectionism
Slide53Psychoticism
Unusual beliefs and experiences
Eccentricity
Cognitive and Perceptual dysregulation
Slide54The 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.”
Slide55The 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.
Slide56ICD 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.
Slide57ICD 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).
Slide58Neurosis 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.
Slide59ICD-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".
Slide60ICD 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
Slide61F60.2 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.
Slide62ICD 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.”
Slide63F60.3 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)
Slide64ICD-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
R
ecruited through 23
IUPsyS
member national psychological associations in 23 countries
10
low and middle-income countriesAdministered in 5 languages (English, Spanish, French, German, Turkish)
Slide65ICD-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.
Slide66Psychologists
’ Role
in
Making
Diagnoses
% Participants
Slide67Purpose of Classification
% Participants
Slide68Number of
Categories Desired
% Participants
Slide69Strict
Criteria
vs.
Flexible Guidance
% Participants
Slide70A Dimensional Component
% Participants
Slide71ICD-10 and DSM-IV
Categories Used Most Often (Why they couldn’t get rid of Borderline)
ICD-10
%
DSM-IV
%
Depressive
E
pisode
71%
Major
Depressive Disorder
60%
Generalized
A
nxiety
D
isorder
48%
Generalized
Anxiety Disorder
59%
Social
P
hobia
46%
Post
-Traumatic Stress Disorder
42%
Mixed
A
nxiety
and
Depressive
D
isorder
44%
Adjustment
Disorders
41%
Recurrent
D
epressive
D
isorder
44%
Attention
-Deficit/Hyperactivity Disorder
38%
Post-Traumatic
S
tress
D
isorder
42%
Obsessive
-Compulsive Disorder
37%
Borderline
P
ersonality
D
isorder
42%
Social
Phobia
37%
Adjustment
D
isorder
42%
Borderline
Personality Disorder
34%
Specific (Isolated) Phobias
41%
Single
Major Depressive Episode
34%
Hyperkinetic (Attention
D
eficit
)
Disorder
34%
Panic
Disorder
without
Agoraphobia
32%
Obsessive-Compulsive
D
isorder
34%
Bipolar
I Disorder
27%
Bipolar
A
ffective
D
isorder
28%
Alcohol
-Related Disorders
26%
Slide72A 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
Slide73Psychodynamic Theory as a Complex Adaptive System-temperament, affects, cognitions, development, traumas, defenses, fantasies, attachments all interacting at various levels of consciousness.
73
Slide74Kernberg’s (1976, 1984) Differentiation
of Personality
Organization
Neurotic
Borderline
Psychotic
Identity + - -
Integration
Defensive + - -
OperationsReality + +/- -
TestingGordon and Stoffey recent research supports that these factors contribute most to personality organization.
Slide75How 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
Slide76Borderline 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
Slide77PDM 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.
Slide78The 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
Slide79Dimension 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.
Slide80Dimension II: Mental Functioning
The
second PDM dimension offers a more detailed description of emotional functioning-the capacities that contribute to an individual's personality and overall level of psychological health or pathology.
Slide81Dimension 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.
Slide82Types 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/DepletedP105. Sadistic and Sadomasochistic Personality Disorders
P105.1 Intermediate Manifestation: Sadomasochistic Personality DisordersP106. Masochistic (Self-Defeating) Personality Disorders P106.1 Moral Masochistic P106.2 Relational Masochistic
Slide83P107.
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 DisordersP110. Phobic (Avoidant) Personality Disorders P110.1 Converse Manifestation: Counterphobic Personality DisordersP111. Anxious Personality Disorders
Slide84P112. 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
Slide85P Axis
Slide86The P Axis- Personality Disorders Considers the Following Factors:
Temperamental,
Thematic,
Affective,
Cognitive, and
Defense patterns
Slide87Psychopathic, 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
.
Slide88Psychopathy 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.
Slide89P103. 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
Slide90Aggressive Subtype
Explosive
Actively predatory
Often violent
Slide91Passive/Parasitic Subtype
More dependent
Less aggressive, usually non-violent
Manipulator
Con artist
Slide92Psychopathic 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.)
Slide93Robert 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”
Slide94Why 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.
Slide95What 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.
Slide96Profile 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
Slide97Summary 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 FunctioningM207. Defects in Integration and Organization and/or Differentiation of Self- and Object RepresentationsM208. Major Defects in Basic Mental Functions
Slide98Psychodiagnostic Chart (PDC)
An Integration of the Psychodynamic Diagnostic Manual (PDM), ICD and DSM
Robert M. Gordon and Robert F. Bornstein
Slide99Goal of the PDC
To offer a person-based nosology by integrating the PDM, ICD and DSM; this integrated nosology may be used for:
better diagnoses,
treatment formulations,
progress reports,
outcome assessment,
research on personality and psychopathology.
Slide100USE
Our overarching aim is to make psychodiagnoses more useful to the practitioner by combining the symptom-focused ICD or DSM with the full range and depth of human mental functioning addressed by the PDM.
Slide101How 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.
Slide102Scoring
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.
Slide103Psychodiagnostic Chart
Slide1041. 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.
Slide1051. 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
Slide1061. 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)
Slide1072. 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.
Slide1082. 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).
Slide109PDM 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
DissociativeMixed/other Rate: Dominate Personality Disorder or Maladaptive Traits & Overall Severity of Impairment
Slide1103. MENTAL FUNCTIONING
Rate (1-10) the 9 different mental capacities according to the level of maturation or functioning.
Slide1113. 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
Slide1124. 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.
Slide1135. 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.
Slide114Importance 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.
Slide115What Do Practitioners Want in a Diagnostic Taxonomy? Comparing the PDM with DSM and ICD
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)
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.”
Slide116Finally, 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.