New Diagnostic Considerations
DSM-5, ICD10-11, PDM Review
J&K Seminars
2013
Robert M. Gordon, Ph.D. ABPP
1
Objectives
1. Major new elements of DSM-5
2. The highlights of ICD-10 and preparing for
October 1, 2014
3. The ICD-11 research
4. The PDM for better understanding of people
and for informing psychological treatment
5. PDM Research
6. How do these various taxonomies help with
ethical and risk management issues?
2
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.
3
Which Taxonomic Organization for
Mental and Behavioral Science?
Like a Biological Organization?
Like a Periodic Table?
4
5
What is Missing?
6
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.
7
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
8
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.
9
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.”
10
Why Diagnose?
3. Its value in enabling the therapist to convey empathy.
Once one knows that a depressed patient also has a
Borderline, rather neurotic level personality structure, the
therapist will not be surprised if during the second year of
treatment she makes a suicide gesture.
Or, once a borderline client starts to have hope of real change,
that he often panics and flirts
with suicide in an effort to protect himself from
traumatic disappointment.
11
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 counterdependent patients an understanding of how
hard it may be for them to stay in therapy.
12
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.
13
Ethical Standard in rendering diagnostic opinions
By 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
14
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.”
15
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.
16
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.
17
Risk Factors in Litigious Patients
Borderline Personality Organization
Psychopathic traits
History of acting out
18
“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.
19
Which Diagnostic Taxonomy Should
We Use?
• DSM-5?
• ICD-10?
• PDM?
20
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.
21
DSM5
22
DSM-5 Moves from Multi-axial system
to a similar ICD-10 System
23
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
24
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.
25
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
26
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.
27
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
28
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 taking
3. Antagonism, characterized by:
a. Hostility
29
The History, Politics and Assumptions
of DSM-5
30
What Should Have Been
31
What Actually Occurred
32
How Not to Refine a Diagnostic
System
Lessons from DSM-5
Work in Isolation
Encourage Secrecy
Ignore Contradictory Evidence
33
34
35
36
37
December 1, 2012
The Proposal is Rejected by
the American Psychiatric
Association
38
39
40
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.
41
DSM-5 Is Guide Not Bible—Ignore Its Ten Worst Changes
By 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.
42
• 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).
43
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.
44
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.
45
Attacks on DSM5
46
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).
47
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.
48
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”
49
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.
50
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,
51
Specific Learning Disorder
• Specific learning disorder combines the DSMIV 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.
52
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
53
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.
54
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.
55
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 obsessivecompulsive or body dysmorphic disorder with
absent insight/delusional beliefs.
56
Catatonia
• In DSM-5, catatonia may be diagnosed as a
specifier for depressive, bipolar, and psychotic
disorders
57
Bipolar and Related Disorders
Bipolar 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.
58
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.
59
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
60
Anxiety Disorders
• The DSM-5 chapter on anxiety disorder no
longer includes obsessive-compulsive disorder
(which is included with the obsessivecompulsive and related disorders) or
posttraumatic stress disorder and acute stress
disorder (which is included with the traumaand stressor-related disorders). However, the
sequential order of these chapters in DSM-5
reflects the close relationships among them.
61
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.
62
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.
63
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.”
64
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.
65
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).
66
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.
67
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".
68
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 disorder
F60.6 Avoidant personality disorder
F60.7 Dependent personality disorder
F60.8 Other specific personality disorders
F60.81 Narcissistic personality disorder
F60.89 Other specific personality disorder
F60.9 Personality disorder, unspecified
69
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
70
• F60.3 Emotionally unstable personality disorder
marked tendency to act impulsively without consideration of the
consequences, together with affective instability. The ability to plan
ahead may be minimal, and outbursts of intense anger may often
lead to violence or "behavioral explosions";
• F60.30 Impulsive type
emotional instability and lack of impulse control, Outbursts of
violence or threatening behavior are common, particularly in
response to criticism by others.
•
Includes: explosive and aggressive personality (disorder) Excludes: dissocial personality disorder (F60.2)
• F60.31 Borderline type
the patient's own self-image, aims, and internal preferences
(including sexual) are often unclear or disturbed. There are usually
chronic feelings of emptiness; intense and unstable relationships may
cause repeated emotional crises and may be associated with
excessive efforts to avoid abandonment and a series of suicidal
threats or acts of self-harm (although these may occur without
obvious precipitants).
•
Includes: borderline personality (disorder)
71
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
72
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).
73
Collaborators
•
Geoffrey M. Reed
•
Spencer C. Evans
•
Ann D. Watts
•
João Mendonça Correia
•
Patricia Esparza
•
Mario Maj
•
Michael C. Roberts
•
Shekhar Saxena
74
2155 Participating
Psychologists
Europe
n = 1398
USA
Asia
n = 108
n = 139
Latin
America
Africa
n = 165
n = 121
WORLD
N = 2155
Eastern
Mediterranean
n = 224
75
Who Makes Diagnoses?
Q39 - In the settings where you normally practice,
who is responsible for making individual diagnoses?
% Participants
100%
80%
60%
75%
60%
40%
20%
20%
4%
7%
Nurses
Other
0%
Psychologists Psychiatrists
Other
physicians
76
Psychologists’ Role in
Making Diagnoses
Q40 - In the one setting where you practice most,
what role do you as a psychologist play in making
individual diagnoses?
% Participants
60%
57%
50%
40%
32%
30%
20%
6%
10%
4%
0%
I make diagnoses
independently
I contribute to
I have no active role
diagnostic
in making a diagnosis
formulations made
by other health
professionals
Other
77
Use of Classification
Systems
% Participants
Q7 - As part of your day-to-day clinical work, how often
do you use a formal classification system for mental
disorders, such as the ICD, DSM, or a national
classification?
40%
35%
30%
25%
20%
15%
10%
5%
0%
36%
24%
18%
16%
6%
Always or
almost always
Often
Sometimes
Rarely
Never
78
Classification System
Most Used
Q8 - In your day-to-day clinical work, which
classification system for mental disorders do you
use most?
% Participants
60%
51%
50%
44%
40%
30%
20%
10%
4%
1%
0%
ICD-10
ICD-9
DSM-IV
Other
79
Purpose of Classification
Q9 - From your perspective, which is the single, most
important purpose of a diagnostic classification system?
50%
39%
% Participants
40%
33%
30%
20%
16%
10%
3%
5%
4%
Facilitate
research
Basis for
generating
national health
statistics
Other
0%
Communication Communication
Inform
among
between
treatment and
clinicians
clinicians and management
patients
decisions
80
Number of
Categories Desired
Q10 - In clinical settings, how many diagnostic categories
should a classification system contain to be most useful
for mental health professionals?
% Participants
60%
50%
50%
40%
35%
30%
20%
11%
10%
4%
0%
10 to 30
31 to 100
101 to 200
More than 200
81
Strict Criteria vs.
Flexible Guidance
Q14 - For maximum utility in clinical settings, a
diagnostic manual should contain:
% Participants
100%
78%
80%
78%
60%
ICD-10
Users
40%
22%
22%
20%
DSM-IV
Users
0%
Clear and strict diagnostic criteria Flexible guidance that allows for
cultural variation and clinical
judgment
82
A Dimensional Component
Q17 - Should a diagnostic system incorporate a dimensional
component, where some disorders are rated on a scale rather
than just as present or absent?
60%
50%
% Participants
50%
40%
30%
ICD-10
Users
46%
34%
28%
20%
13% 11%
10%
9%
9%
DSM-IV
Users
0%
Yes, for more
detailed and
personalized
diagnosis
Yes, more accurate
reflection of
psychopathology
No, too
complicated in
clinical settings
No, insufficient
research on
reliability
83
Reactions to Adverse
Life Events
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)?
60%
56%
50%
% Participants
51%
49%
44%
ICD-10
Users
40%
30%
DSM-IV
Users
20%
10%
0%
Yes
No
84
Usability Across Cultures
by 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.’
% Completely or Mostly Agree by Region (Weighted)
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
43%
38%
33%
31%
32%
18%
Africa
Asia
Eastern
Mediterranean
Europe
Latin America
USA
85
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%
86
Categories With the
Lowest 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
87
0.62
Categories With the
Lowest 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
88
0.56
ICD-10 / ICD-11 Schizotypal Disorder
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
89
DSM-IV Schizotypal Personality Disorder
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
90
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 affectivity
b. Withdrawal
3. Negative Affectivity, characterized by:
a. Suspiciousness
91
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.”
92
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
93
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
94
The New York Times Book Review
For 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.
95
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.
96
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.
97
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.
98
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 ThompsonBrenner (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.
99
Psychodynamic Theory as a Complex Adaptive Systeminteraction, 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
PDM’s Current Taxonomy
Personality Patterns and Disorders
Mental Functioning
Manifest Symptoms and Concerns
101
Types of Personality Disorders or Patterns
• P101. Schizoid Personality Disorders
P102. Paranoid Personality Disorders
• P103. Psychopathic (Antisocial) Personality Disorders
P103.1 Passive/Parasitic
P103.2 Aggressive
• P104. Narcissistic Personality Disorders
P104.1 Arrogant/Entitled
P104.2 Depressed/Depleted
• P105. Sadistic and Sadomasochistic Personality Disorders
P105.1 Intermediate Manifestation: Sadomasochistic Personality
Disorders
• P106. Masochistic (Self-Defeating) Personality Disorders
P106.1 Moral Masochistic
P106.2 Relational Masochistic
102
• 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
103
• 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
104
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 SelfRegard)
• 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
105
Symptom Patterns: The Subjective Experience - S Axis
• S301. Adjustment Disorders
S302. Anxiety Disorders
S302.1 Psychic Trauma and Posttraumatic Stress Disorder
S302.2 Phobias
S302.3 Obsessive-Compulsive Disorders
S303. Dissociative Disorders
S304. Mood Disorders
S304.1 Depressive Disorders
S304.2 Bipolar Disorders
S305. Somatoform (Somatization) Disorders
S306. Eating Disorders
S307. Psychogenic Sleep Disorders
S308. Sexual and Gender Identity Disorders
S308.1 Sexual Disorders
S308.2 Paraphilias
S308.3 Gender Identity Disorders
S309. Factitious Disorders
S310. Impulse Control Disorders
S311. Addictive/Substance Abuse Disorders
S312. Psychotic Disorders
S313. Mental Disorders Based on a General Medical Condition
106
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 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: Sense of
Morality
Summary of Child and Adolescent Mental Functioning
107
Child and Adolescent Personality Patterns and Disorders - PCA Axis
Developmental Aspects of Emerging Personality Patterns
PCA101. Fearful of Closeness/Intimacy (Schizoid) Personality
Disorders
PCA102. Suspicious/Distrustful Personality Disorders
PCA103. Sociopathic (Antisocial) Personality Disorders
PCA104. Narcissistic Personality Disorders
PCA105. Impulsive/Explosive Personality Disorders
PCA106. Self-Defeating Personality Disorders
PCA107. Depressive Personality Disorders
PCA108. Somatizing Personality Disorders
PCA109. Dependent Personality Disorders
PCA110. Avoidant/Constricted Personality Disorders
PCA110.1 Counterphobic Personality Disorders
PCA111. Anxious Personality Disorders
PCA112. Obsessive-Compulsive Personality Disorders
PCA113. Histrionic Personality Disorders
PCA114. Dysregulated Personality Disorders
PCA115. Mixed/Other
108
Child and Adolescent Symptom Patterns: The Subjective Experience
•
Anxiety Disorders
SCA301. Anxiety Disorders
SCA302. Phobias
SCA303. Obsessive-Compulsive Disorders
SCA304. Somatization (Somatoform) Disorders
Affect/Mood Disorders
SCA305. Prolonged Mourning/Grief Reaction
SCA306. Depressive Disorders
SCA307. Bipolar Disorders
SCA308. Suicidality
Disruptive Behavior Disorders
SCA309. Conduct Disorders
SCA310. Oppositional-Defiant Disorders
SCA311. Substance Abuse Related Disorders
Reactive Disorders
SCA312. Psychic Trauma and Posttraumatic Stress Disorder
SCA313. Adjustment Disorders (other than developmental)
Disorders of Mental Functioning
SCA314. Motor Skills Disorders
SCA315. Tic Disorders
SCA316. Psychotic Disorders
SCA317. 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
109
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 Disabilities
Psychophysiologic Disorders
SCA319. Bulimia
SCA320. Anorexia
Developmental Disorders
SCA321. Regulatory Disorders
SCA322. Feeding Problems of Childhood
SCA323. Elimination Disorders
SCA323.1 Encopresis
SCA323.2 Enuresis
SCA324. Sleep Disorders
SCA325. Attachment Disorders
SCA326. Pervasive Developmental Disorders
SCA326.1 Autism
SCA326.2 Asperger’s Syndrome
SCA326.3 Pervasive Developmental Disorder (PDD) Not Otherwise Specified
Other Disorders
SCA327. Gender Identity Disorders
110
Disorders of Infancy and Early Childhood – Axis I - Primary Axis
• IEC100 Series- Interactive Disorders
IEC101. Anxiety Disorders
IEC102. Developmental Anxiety Disorders
IEC103. Disorders of Emotional Range and Stability
IEC104. Disruptive Behavior and Oppositional Disorders
IEC105. Depressive Disorders
IEC106. Mood Dysregulation: A Unique Type of Interactive and Mixed
Regulatory-Sensory Processing Disorder Characterized by Bipolar Patterns
IEC107. Attentional Disorders
IEC108. Prolonged Grief Reaction
IEC109. Reactive Attachment Disorders
IEC110. Traumatic Stress Disorders
IEC111. Adjustment Disorders
IEC112. Gender Identity Disorders
IEC113. Selective Mutism
IEC114. Sleep Disorders
IEC115. Eating Disorders
IEC116. Elimination Disorders
111
• IEC200 Series - Regulatory-Sensory Processing Disorders (RSPD)
Clinical Evidence and Prevalence of Regulatory-Sensory Processing Differences
Sensory Modulation Difficulties (Type I)
IEC201. Overresponsive, Fearful, Anxious Pattern
IEC202. Overresponsive, Negative, Stubborn Pattern
IEC203. Underresponsive, Self-Absorbed Pattern
IEC203.1 Self-Absorbed and Difficult-to-Engage Type
IEC203.2 Self-Absorbed and Creative Type
IEC204. Active, Sensory Seeking Pattern
Sensory 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 Three
IEC206. 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 Three
Contributing Sensory Discrimination and Sensory-Based Motor Difficulties
112
• 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 Communicating
IEC301. Type I: Early Symbolic, with Constrictions
IEC302. Type II: Purposeful Problem-Solving, with Constrictions
IEC303. Type III: Intermittently Engaged and Purposeful
IEC304. Type IV: Aimless and Unpurposeful
Other Neurodevelopmental Disorders (Including Genetic and Metabolic
Syndromes)
113
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.
114
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.
115
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.
116
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
117
An Operationalized Psychodynamic
Diagnostic Manual Guide
Robert M. Gordon and Robert F. Bornstein (2012)
118
PDC Is A User Friendly Guide to the
Adult Section of the PDM
•
•
•
•
•
•
•
Short- 3pages
Easy - all scales are 1-10
Intuitive and Empirical
Categorical and Dimensional
Flexible - can do part or all
Integrates with the DSM and ICD
Good Reliability and Construct Validitypreliminary field evidence
(Gordon and Stoffey 2013 in press)
119
PDC’s Taxonomy: From Larger to
Smaller Units
Personality Organization
Personality Patterns
Mental Functioning
ICD Symptoms
Cultural-Contextual Issues
120
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 disorder
5. Cultural, Contextual Issues- recent death of husband, war trauma, loss of
father, leaving much of her family and friends behind, immigration fears and
guilt.
121
Testing Dimensional and Categorical
Qualities 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).
122
Testing Dimensional and Categorical
Qualities of Personality Organization with 3 Scales
(L+Pa+Sc)-(Hy+Pt)
Es
Sc, Hy and Es
123
MMPI-2 Hysteria-Hy, Schizophrenia-Sc, and Ego Strength-Es Scales
within the Psychotic, Borderline, and Neurotic Categories of the
Personality Organization Scale
Psychotic (ratings 1-3, n = 13), Borderline (4-6, n = 52), and Neurotic (7-10, n = 33).
Psychotic: Sc >> Hy>> Es; Borderline: (Sc ~ Hy) >> Es; Neurotic: (Sc ~ Hy) > Es all in the average to moderate range.
90
85
80
75
Hy
70
65
60
Sc
55
50
Es
45
40
35
30
Psychotic
Borderline
Neurotic
124
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.
125
Percent of Practitioners Rating the PDC Dimensions as “Helpful—Very
Helpful” in Understanding Their Patient
90
84
79
80
72
70
60
50
50
40
31
30
20
10
0
Levels of Personality
Structure
Dominant Personality
Patterns
Mental Functioning
ICD or DSM Symptoms
Cultural/Contextual
126
Dimensions
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.
127
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
128
Psychodynamic Diagnostic Prototypes
(PDP)
Francesco Gazzillo, PhD
Department of Dynamic and Clinical Psychology
«Sapienza» University of Rome
129
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 “helprejecting 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.
130
The validation of Psychodynamic Diagnostic Prototypes
(PDP; Gazzillo, Lingiardi, Del Corno, 2010)
The Prototypic Assessment
of the Psychodynamic Diagnostic Prototype
5
4
3
2
1
Very good match (patient exemplifies this disorder; prototypical case)
Good match (patient has this disorder; diagnosis applies)
Moderate match (patient has significant features of this disorder)
Slight match (patient has minor features of this disorder)
No match (description does not apply)
The evaluation of all 21 disorders takes about 10-30 minutes
131
The validation of Psychodynamic Diagnostic Prototypes
(PDP; Gazzillo, Lingiardi, Del Corno, 2010)
PDP DISORDERS
Kappa values
Rho values
Schizoid
.64**
.71**
Paranoid
Psychopatic
.51**
.61**
.75**
.77**
Narcissistic
Sadistic
.65**
No categorical diagnosis
.68**
.57**
Sado-masochistic
.59**
.62**
Masochistic
Depressive
Hypomaniac
Somatizing
Dependent
Passive-aggressive
.57**
.56**
.44**
.53**
.55**
.47**
.65**
.81**
.68**
.79**
.69**
.57**
Counter-dependent
.75**
.56**
Phobic
Counter-phobic
.55**
.58**
.71**
.41**
Anxious
Obsessive-compulsive
.61**
.46**
.79**
.60**
Histrionic
Dissociative
.72**
.60**
.84** 132
.57**
Hypotheses
1. Norms for PDP and PDC
2. Concurrent validity between PDP and PDC
3. How PDM Dx inform about boundaries and
countertransference issues
4. How theoretical orientation affects value of
various taxa (PO, PD, MF, Symptoms, Context)
5. Which PD are commonly found at which level
of PO.
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1. Level of Personality Structure
Please rate each capacity from 1 to 10; ratings range from Most
Disturbed (1) to Most Healthy (10).
1. Identity: ability to view self in complex, stable, and accurate ways
2. Object Relations: ability to maintain intimate, stable, and satisfying
relationships
3. Affect Tolerance: ability to experience the full range of age-expected
affects
4. Affect Regulation: ability to regulate impulses and affects with flexibility in
using defenses or coping strategies
5. Superego Integration: ability to use a consistent and mature moral
sensibility
6. Reality Testing: ability to appreciate conventional notions of what is
realistic
7. Ego Resilience: ability to respond to stress resourcefully and to recover
from painful events without undue difficulty
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1. Level of Personality Structure- Rating
Healthy Personality- characterized by 9-10 scores, life problems never get out of
hand and enough flexibility to accommodate to challenging realities.
Neurotic Level- characterized by mainly 6-8 scores, rigidity and limited range of
defenses and coping mechanisms, basically a good sense of identity, healthy
intimacies, good reality testing, fair resiliency, fair affect tolerance and regulation,
favors repression.
Borderline Level- characterized by mainly 3-5 scores, recurrent relational problems,
difficulty with affect tolerance and regulation, poor impulse control, poor sense of
identity, poor resiliency, favors primitive defenses such as denial, splitting and
projective identification.
Psychotic Level- characterized by mainly 1-2 scores, delusional thinking, sometimes
hallucinations, poor reality testing and mood regulation, extreme difficulty
functioning in work and relationships.
Overall Personality Structure
Based on the 7 ratings above, rate person’s overall personality structure from 1
(Psychotic) to 10 (Healthy)
135
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).
136
PDM Categories:
Schizoid
Paranoid
Psychopathic (antisocial); Subtypes - passive/parasitic or aggressive
Narcissistic; Subtypes - arrogant/entitled or depressed/depleted;
Sadistic (and intermediate manifestation, sadomasochistic)
Masochistic (self-defeating); Subtypes - moral masochistic or relational masochistic
Depressive; Subtypes - introjective or anaclitic; Converse manifestation - hypomanic
Somatizing
Dependent (and passive-aggressive versions of dependent); Converse manifestation
- counterdependent
Phobic (avoidant); Converse manifestation - counterphobic
Anxious
Obsessive-compulsive; Subtypes - obsessive or compulsive
Hysterical (histrionic); Subtypes - inhibited or demonstrative/ flamboyant
Dissociative
Mixed/other
Rate: Dominate Personality Disorder or Maladaptive Traits & Overall Severity of Impairment
137
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
138
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.
139
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.
140
For Free Copies:
• For copies of the PDP and PDC, search for:
“Psychodiagnostic Chart”
141
Forensic Issues
• Diagnoses are a guides if useful to the
question
• Diagnoses in Custody Cases
• Diagnoses in Criminal Cases
• Diagnoses in Personal Injury Cases
142
Gordon, R.M., Stoffey, R., & Bottinelli, J. (2008) MMPI-2 Findings of Primitive
Defenses in Alienating Parents
120
110
T-Scores
100
90
80
70
60
50
40
Mother
Alienators
Father
Alienators
Mother
Targets
Father
Targets
Mother
Control
Father
Control
Parents in Child Custody Evaluation
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.
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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
144