Presentation on theme: "New Diagnostic Considerations DSM-5, ICD10-11, PDM Review"— Presentation transcript:
1 New Diagnostic Considerations DSM-5, ICD10-11, PDM Review J&K Seminars2013Robert M. Gordon, Ph.D. ABPP
2 Objectives Major new elements of DSM-5 The highlights of ICD-10 and preparing for October 1, 2014The ICD-11 researchThe PDM for better understanding of people and for informing psychological treatmentPDM ResearchHow do these various taxonomies help with ethical and risk management issues?
3 Exercise in Psychodiagnoses Learn about:Personality organizationPersonality patternsStrengths and weaknessesEmergent symptomsCultural and Contexual issuesIssues related to ethical and risk issuesCountertransference and boundary issuesContribute to the science of psychological taxonomy. Participation is voluntary.
4 Which Taxonomic Organization for Mental and Behavioral Science? Like a Biological Organization?Like a Periodic Table?
5 The term “Diagnosis” is derived from Greek - meaning a distinguishing, to perceive, to know thoroughly.
7 In 1854, after a major outbreak of cholera struck London, John Snow, a physician, linked the outbreak to contaminated water from this hand pump on Broadwick Street. He removed the handle and stopped the epidemic.
8 Reasons for a mental health taxonomy Ethical and humanistic dilemmas with diagnosing personalityNosologies: Different ways to characterize diseaseDifferent nosologies for different folksRisk managements issuesNeed for a personality-based taxonomy that informs psychological treatments
9 Start with a good diagnostic formulation “Once I have a good feel for the person, the work is going well, I stop thinking diagnostically and simply immerse myself in the unique relationship that unfolds between me and the client…one can throw away the book and savor individual uniqueness.” Nancy McWilliams (2011) Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process, Second Edition.
10 Main Reasons for Diagnosing 1. Its usefulness for treatment planning. “Understanding character styles help the therapist be more careful with boundaries with a histrionic patient, more pursuant of the flat affect with the obsessional person, and more tolerant of silence with a schizoid client.”2. Its implications for prognosis. “Realistic goals protect patients from demoralization and therapists from burnout.”
11 Why Diagnose? Once one knows that a depressed patient also has a 3. Its value in enabling the therapist to convey empathy.Once one knows that a depressed patient also has aBorderline, rather neurotic level personality structure, thetherapist will not be surprised if during the second year oftreatment she makes a suicide gesture.Or, once a borderline client starts to have hope of real change,that he often panics and flirtswith suicide in an effort to protect himself fromtraumatic disappointment.
12 Why Diagnose?Its role in reducing the probability that certain easily-frightened people will flee from treatment: It is helpful for the therapist to communicate to hypomanic or counter-dependent patients an understanding of how hard it may be for them to stay in therapy.
13 Why Diagnose?5. Its value in risk management: Often therapists mistakenly used a presenting symptom as the only diagnosis and missed the borderline level of personality or psychopathic personality and got into trouble.6. Its value in process and outcome research.
14 Ethical Standard in rendering diagnostic opinions By Dr Ethical Standard in rendering diagnostic opinions By Dr. Stephen Behnke, APA Ethics DirectorA good starting point is to reflect upon our values as psychologists and to consider the significance of rendering a diagnosis.Principle A, Beneficence and Nonmaleficence, exhorts psychologists "to benefit those with whom they work and take care to do no harm.”Promoting welfare and safeguarding from harm are thus values central to our profession. Rendering a diagnosis has direct relevance to each.Diagnoses, record reviews and the new Ethics Code, Ethical Standard 9.01 guides psychologists in rendering diagnostic opinions.By Dr. Stephen Behnke, APA Ethics Director January 2005, Vol 36, No.1
15 Rendering Diagnoses“In few areas of practice does a psychologist exercise greater authority and influence than to render a diagnosis, for in so doing the psychologist comes to know and convey information that may profoundly affect that individual's life.”
16 Implications of a Diagnosis: Clinical, Personal and Social “In the clinical context, a diagnosis reveals the nature of an illness.A correct diagnosis provides a basis for effective treatment.An incorrect diagnosis may delay or impede effective treatment or even exacerbate a situation by inviting inappropriate treatment.A diagnosis has personal significance insofar as it can become central to how a person experiences him- or herself.While a correct diagnosis of a severe disorder can be enormously difficult to integrate into one's sense of self, an incorrect diagnosis can be crippling.A diagnosis is also a label to which others respond and thus has profound social implications. Social judgments are made in response to a diagnosis of mental illness, and diagnoses can play an important role in awarding entitlements and determining placement.
17 Throw Away Occam’s Razor (law of parsimony) Clinicians should follow the general rule of recording as many diagnoses as are necessary to cover the clinical picture.Hickam's Dictum: "Patients can have as many diseases as they damn well please." John Hickam, MD.When recording more than one diagnosis, it is usually best to give the main diagnosis, and to label any others as subsidiary or additional diagnoses.
18 Risk Factors in Litigious Patients Borderline Personality Organization Psychopathic traits History of acting out
19 “I have often served as an expert witness in malpractice cases where psychologists had missed the psychopathic or borderline traits in patients.The DSM classifies antisocial and borderline personality disorders by precise and narrow symptoms. This is often misleading. Psychopathy can be a complex personality pattern that combines with or is obscured by other personality patterns, and borderline can be viewed as an entire level of personality organization that can be applied to the various personality disorders.”Gordon, R.M., (2007) PDM Valuable in Identifying High-Risk Patients. The National Psychologist, 16, 6, November/December, page 4.
20 Which Diagnostic Taxonomy Should We Use? DSM-5?ICD-10?PDM?
21 DSM-5 The DSM-5 May 2013. Research started in 1999. The DSM makes the American Psychiatric Association over $5 million a year, historically adding up to over $100 million.
22 DSM-5 Moves from Multi-axial system to a similar ICD-10 System
23 Main DSM-5 CategoriesNeurodevelopmental DisordersSchizophrenia Spectrum and Other Psychotic DisordersBipolar and Related DisordersDepressive DisordersAnxiety DisordersObsessive-Compulsive and Related DisordersTrauma and Stressor Related DisordersDissociative DisordersSomatic Symptom DisordersFeeding and Eating DisordersElimination DisordersSleep-Wake DisordersSexual DysfunctionsGender DysphoriaDisruptive, Impulse Control, and Conduct DisordersSubstance Use and Addictive DisordersNeurocognitive DisordersPersonality DisordersParaphilic DisordersOther Disorders
24 DSM-5 has major reliability problems Only 5 diagnoses achieved kappa levels of agreement betweenThe nine DSM-5 disorders in the kappa range of 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 ofMajor Depressive Disorder and Generalized Anxiety Disorder were among those that achieved the unacceptable kappas in range.
25 The six specific types are as follows: Originally proposed only 6 personality disorders and a complex trait systemThe six specific types are as follows:T 00 Borderline Personality DisorderT 01 Obsessive-Compulsive Personality DisorderT 02 Avoidant Personality DisorderT 03 Schizotypal Personality DisorderT 04 Antisocial Personality Disorder (Dyssocial Personality Disorder)T 05 Narcissistic Personality DisorderT 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. Manipulativenessb. Deceitfulnessc. Callousnessd. Hostility2. Disinhibition, characterized by:a. Irresponsibilityb. Impulsivityc. 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. Empathyb. IntimacyB. Pathological personality traits in the following domains:1. Negative Affectivity, characterized by:a. Emotional labilityb. Anxiousnessc. Separation insecurityd. Depressivity2. Disinhibition, characterized by:a. Impulsivityb. Risk taking3. Antagonism, characterized by:a. Hostility
40 Why Will DSM-5 Cost $199 a Copy? By Allen Frances, M.D. 1/24/13 Huffington PostDSM-5 has just announced its price -- an incredible $199First, 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 placeThe codes clinicians need for insurance purposes are available for free on the internetDSM-5 is so clunkily written, no teacher will ever want to assign it to studentsPeople 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 DSM-5 Is Guide Not Bible—Ignore Its Ten Worst Changes By Allen J. Frances, M.D. Psychology Today DecMore 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 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 , 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).
46 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.
47 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”
48 Communication Disorders The DSM-5 communication disorders include:language disorderspeech sound disorderchildhood-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.
49 Attention-Deficit/Hyperactivity Disorder The same 18 symptoms are used as in DSM-IVthe 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,
50 Specific Learning Disorder Specific learning disorder combines the DSM-IV diagnoses of reading disorder, mathematics disorder, disorder of written expression, and learning disorder not otherwise specified. Because learning deficits in the areas of reading, written expression, and mathematics commonly occur together, coded specifiers for the deficit types in each area are included.
51 Schizophrenia Spectrum and Other Psychotic Disorders 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
52 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.
53 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.
54 Delusional DisorderCriterion A for delusional disorder no longer has the requirement that the delusions must be nonbizarre. A specifier for bizarre type delusions provides continuity with DSM-IV. The demarcation of delusional disorder from psychotic variants of obsessive-compulsive disorder and body dysmorphic disorder is explicitly noted with a new exclusion criterion, which states that the symptoms must not be better explained by conditions such as obsessive-compulsive or body dysmorphic disorder with absent insight/delusional beliefs.
55 CatatoniaIn DSM-5, catatonia may be diagnosed as a specifier for depressive, bipolar, and psychotic disorders
56 Bipolar and Related Disorders Bipolar DisordersCriterion 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 Disordercategorization 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 SpecifierAdded 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.
57 Depressive DisordersDSM-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.
58 BereavementIn 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
59 Anxiety DisordersThe DSM-5 chapter on anxiety disorder no longer includes obsessive-compulsive disorder (which is included with the obsessive-compulsive and related disorders) or posttraumatic stress disorder and acute stress disorder (which is included with the trauma- and stressor-related disorders). However, the sequential order of these chapters in DSM-5 reflects the close relationships among them.
60 PTSDThe 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.
61 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.
62 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.
63 ICD HistoryThe 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).
64 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, The transition to ICD-10 is required for everyone covered by the Health Insurance Portability Accountability Act (HIPAA), Medicare and Medicaid.
65 ICD-10 mental and behavioural disorders consists of 10 main groups: F0: Due to known physiological conditionsF1: Due to use of psychoactive substancesF2: Schizophrenia, schizotypal and delusional disordersF3: Mood [affective] disordersF4: Anxiety, dissociative, stress-related and somatoform disordersF5: Behavioural syndromes associated with physiological disturbances and physical factorsF6: Disorders of personality and behaviour in adult personsF7: Intellectual disabilitiesF8: Pervasive and specific developmental disordersF9: Behavioural and emotional disorders with onset usually occurring in childhood and adolescenceIn addition, a group of "unspecified mental disorders".
66 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
67 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
68 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)
69 Dr. Geoffrey M. Reed World Health Organization ICD-11 Survey Overview2 September 20102155 global psychologists participated in the WHO and International Union of Psychological Sciences (IUPsyS)Recruited through 23 IUPsyS member national psychological associations in 23 countries10 low and middle-income countriesAdministered in 5 languages (English, Spanish, French, German, Turkish)Parallel to survey conducted by WHO and World Psychiatric Association (WPA) of 4887 psychiatrists in 44 countriesWPA International Congress
70 ICDICD-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).
71 Collaborators Geoffrey M. Reed Spencer C. Evans Ann D. Watts João Mendonça CorreiaPatricia EsparzaMario MajMichael C. RobertsShekhar Saxena
72 2155 Participating Psychologists Dr. Geoffrey M. Reed World Health Organization2155 Participating Psychologists2 September 2010Europen = 1398USAn = 108Asian = 139LatinAmerican = 165Africa n = 121EasternMediterraneann = 224WORLDN = 2155WPA International Congress
81 Reactions to Adverse Life Events Dr. Geoffrey M. Reed World Health Organization2 September 2010Reactions to Adverse Life Events% ParticipantsWPA International Congress
82 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.’
83 Categories Used Most Often ICD-10 and DSM-IVCategories Used Most OftenICD-10%DSM-IVDepressive Episode71%Major Depressive Disorder60%Generalized Anxiety Disorder48%59%Social Phobia46%Post-Traumatic Stress Disorder42%Mixed Anxiety and Depressive Disorder44%Adjustment Disorders41%Recurrent Depressive DisorderAttention-Deficit/Hyperactivity Disorder38%Obsessive-Compulsive Disorder37%Borderline Personality DisorderAdjustment Disorder34%Specific (Isolated) PhobiasSingle Major Depressive EpisodeHyperkinetic (Attention Deficit) DisorderPanic Disorder without Agoraphobia32%Bipolar I Disorder27%Bipolar Affective Disorder28%Alcohol-Related Disorders26%
84 Categories With the Lowest Ease of Use ICD-10EOUDSM-IVAsperger's Syndrome0.50Dissociative Disorders0.48Dissociative [Conversion] DisordersImpulse Control DisordersSchizoaffective Disorder0.51Schizotypal Personality Disorder0.54Schizotypal DisorderSomatoform Disorders0.52Asperger's Disorder0.56Borderline Personality DisorderHyperkinetic (Attention Deficit) DisorderPrimary Sleep Disorders0.58DeliriumBipolar II DisorderMBDs due to Use of Volatile SolventsTic disorders0.59Habit and Impulse DisordersBrief Psychotic Disorder0.60MBDs due to Use of HallucinogensVascular DementiaBipolar Affective DisorderSexual DysfunctionsMixed Anxiety and Depressive DisorderAutistic Disorder0.61Adjustment DisorderDelusional Disorder0.62
85 Categories With the Lowest Goodness of Fit ICD-10GOFDSM-IVDissociative [Conversion] Disorders0.45Schizotypal Personality Disorder0.44Asperger's SyndromeDissociative DisordersHyperkinetic (Attention Deficit) Disorder0.50Somatoform Disorders0.47Schizoaffective Disorder0.51Asperger's Disorder0.48Impulse Control DisordersBorderline Personality Disorder0.49MBDs Due to Use of Hallucinogens0.52Primary Sleep DisordersSchizotypal Disorder0.53Tic disordersVascular DementiaBipolar II DisorderDissocial (Antisocial) Personality Disorder0.550.54Adjustment DisorderAutistic DisorderHabit and Impulse DisordersBrief Psychotic DisorderMixed Anxiety and Depressive Disorder0.56Sexual Dysfunctions
86 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 ideationUnusual perceptual distortionsSuspiciousness or paranoid ideasOccasional transient psychotic episodesVague, circumstantial, stereotyped thinkingObsessive ruminationsNot met diagnostic criteria for schizophrenia
87 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
88 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;AND2. 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. Eccentricityb. Cognitive and perceptual dysregulation:c. Unusual beliefs and experiences2. Detachment, characterized by:a. Restricted affectivityb. Withdrawal3. Negative Affectivity, characterized by:a. Suspiciousness
89 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.”
90 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
91 Developed by A collaborative effort of the: American Psychoanalytic AssociationInternational Psychoanalytical AssociationDivision of Psychoanalysis (39) of the American Psychological AssociationAmerican Academy of Psychoanalysis and Dynamic PsychiatryNational Membership Committee on Psychoanalysis in Clinical Social Work
92 The New York Times Book Review For Therapy, a New Guide With a Touch of Personality January 24, 2006 By BENEDICT CAREYThe 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.
93 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.
94 GoalsImprovements 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.
95 BasisThe 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.
96 Research SupportBlatt, (this volume), Norcross (2002), Wampold (2001) have concluded that the nature of the psychotherapeutic relationship, reflecting interconnected aspects of mind and brain operating together in an interpersonal context, predicts outcome more robustly than any specific treatment approach per se. Westen, Novotny, and Thompson-Brenner (2004 and this volume) have presented evidence that treatments that focus on isolated symptoms or behaviors (rather than personality, emotional, and interpersonal patterns ) are not effective in sustaining even narrowly defined changes.
97 Psychodynamic Theory as a Complex Adaptive System- interaction, interdependence and diversity of constructs (temperament, affects, cognitions, development, traumas, defenses, fantasies, attachments), emergences (symptoms), tails (one event can move the entire central tendency) and tipping points (break downs).
98 PDM’s Current Taxonomy Manifest Symptoms and ConcernsMental FunctioningPersonality Patterns and Disorders
102 Profile of Mental Functioning - M Axis Capacity for Regulation, Attention, and LearningCapacity for Relationships (Including Depth, Range, and Consistency)Quality of Internal Experience (Level of Confidence and Self-Regard)Affective Experience, Expression, and CommunicationDefensive Patterns and CapacitiesCapacity to Form Internal RepresentationsCapacity for Differentiation and IntegrationSelf-Observing Capacities (Psychological-Mindedness)Capacity for Internal Standards and Ideals: A Sense of Morality
103 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
104 Classification of Child and Adolescent Mental Health Disorders Profile of Mental Functioning for Children and Adolescents - MCA AxisCapacity 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
108 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
109 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
110 IEC207. Mixed Regulatory-Sensory Processing Patterns IEC207 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 toMixed Regulatory-Sensory Processing Difficulties IEC207.9 Mixed Regulatory-Sensory Processing Patterns where Behavioral or Emotional Problems Are Not Yet In EvidenceIEC300 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)
111 Reactions to the PDMThe 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,
112 From Earliest Findings: Personality Organization is a Main Factor in Treatment Choice 1930 Fenichel, Jones, 1937 Alexanderall 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.
113 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),
114 McWilliams’ taxonomy is fundamentally based on two dimensions: Nancy McWilliams ( 2011) Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process.McWilliams’ taxonomy is fundamentally based on two dimensions:Personality Organization andCharacter Organization.Gordon, R.M. (2013) book review in Division/Review and at Amazon books
115 Robert M. Gordon and Robert F. Bornstein (2012) Psychodiagnostic Chart (PDC) An Operationalized Psychodynamic Diagnostic Manual GuideRobert M. Gordon and Robert F. Bornstein (2012)
116 PDC Is A User Friendly Guide to the Adult Section of the PDM Short- 3pagesEasy - all scales are 1-10Intuitive and EmpiricalCategorical and DimensionalFlexible - can do part or allIntegrates with the DSM and ICDGood Reliability and Construct Validity-preliminary field evidence (Gordon and Stoffey 2013 in press)
117 PDC’s Taxonomy: From Larger to Smaller Units Cultural-Contextual IssuesICD SymptomsMental FunctioningPersonality PatternsPersonality Organization
118 Clinical Example Using the PDC “Bana” is a 28 year old woman from Syria. Her husband was killed in the war and she has no children. Her brother was able to get her to the US this year.1. Level of Personality Organization- is 7 (Neurotic Level). Her capacity scores are mainly in the 6-9 range. Her lowest rating is in Affect Tolerance (5) which may be due to her PTSD. She is a good candidate for PDT.2. Personality Patterns or Disorders- mainly Hysterical/Inhibited type at the Moderate level of severity (6) with some obsessional and dependent features.3. Mental Functioning- most of the 9 capacities are in the high range. She has a masters in education, her marriage was good, she has average self esteem, she can go from inhibited to overly excited expression of affect, her favored defenses are repression and intellectualization, she has a warm relationship with her mother and both sets of grandparents, her father was killed when she was a child, good level of differentiation and integration, very insightful and excellent moral reasoning.4. Manifest Symptoms- ICD-10: (F43.1) Post-traumatic stress disorder5. Cultural, Contextual Issues- recent death of husband, war trauma, loss of father, leaving much of her family and friends behind, immigration fears and guilt.
119 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).
120 (L+Pa+Sc)-(Hy+Pt) Es Sc, Hy and Es Testing Dimensional and Categorical Qualities of Personality Organization with 3 Scales(L+Pa+Sc)-(Hy+Pt)EsSc, Hy and EsHy and Sc have very low corrections , Es and Sc moderate correlations, Es and Hy low to moderate correlations.
121 MMPI-2 Hysteria-Hy, Schizophrenia-Sc, and Ego Strength-Es Scales within the Psychotic, Borderline, and Neurotic Categories of the Personality Organization ScalePsychotic (ratings 1-3, n = 13), Borderline (4-6, n = 52), and Neurotic (7-10, n = 33).Psychotic: Sc >> Hy>> Es; Borderline: (Sc ~ Hy) >> Es; Neurotic: (Sc ~ Hy) > Es all in the average to moderate range.N=98 In hypothesis B.1., we predicted the Sc scale mean should be significantly larger than both the Hy and Es scale means for the psychotic level. Pairwise comparisons supported that prediction: Sc was significantly larger than Es (M = 85.77, SD = vs , SD = 6.78, p = .001) and significantly larger than Hy (M = 85.77, SD = vs , SD = 18.46, p = .017).In hypothesis B.2.for the borderline level, we predict that both the Sc scale mean and the Hy scale mean should not be significantly different (borderline as a mix of psychotic and neurotic features), but they both should be significantly larger than the Es scale mean. That prediction was supported: Sc and Hy were not significantly different, but Sc was significantly larger than Es (M = 62.21, SD = 12.31, vs , SD = 10.25, p = .001) and Hy was also significantly larger than Es (64.21, SD = vs , SD = 10.25, p = .001).Finally, for the neurotic level, we predicted in hypothesis B.3. that the Es, Sc and Hy scales should all be in the normal-moderate range. There were significant mean differences between Es (M = 49.55, SD = 10.16) in comparison to both Hy (M = 59.85, SD = 12.15) and Sc,(M = 56.18, SD = 9.28). Hy and Sc were in the moderate range, and Ego strength moved up to the average range showing support for the prediction (see Figure 1 for the MMPI-2 scale means within each level).We next examined the pattern of means for each of the Hy, Sc, and Es scales separately across each of the three scale categories. A series of One-Way ANOVAs was used to test the hypothesized outcomes. For hypothesis C.1., we predicted significant mean differences for Hy across the psychotic, borderline, and neurotic scale categories, with the largest scale mean for psychotic followed by borderline and lastly the neurotic category (See Table 4 for the means and standard deviations). The ANOVA indicated that there were significant differences among the three scale categories on the Hy scale, F (2, 95) = 3.96, p < = .022, 2= .08. Scheffe post hoc tests indicated that patients rated as psychotic scored significantly higher on the Hy scales in comparison to patients rated as neurotic (M = vs. M = 59.85, p = .023). Although in the predicted direction, there was no significance mean difference between patients rated as psychotic and those rated as borderline (M = vs , p = .154) nor was there significant mean differences between patients rated as borderline and those rated as neurotic (M = vs , p = .379).For hypothesis C.2., we predicted significant mean differences for Sc across the psychotic, borderline, and neurotic scale categories, with the largest scale mean for psychotic followed by borderline and lastly the neurotic category (see Table 4 for the means and standard deviations). The ANOVA indicated that there were significant differences among the three scale categories on the Sc scale, F (2, 95) = 26.15, p <.001, 2= .36. Scheffe post hoc tests indicated that patients rated as psychotic scored significantly higher on the Sc scale in comparison to those rated as borderline (M = vs , p = .001) and neurotic (M = vs , p = .001). There was no significant mean difference between patients rated as borderline versus neurotic (M = vs , p = .104).We predicted for hypothesis C.3., significant mean differences for Es across the psychotic, borderline, and neurotic scale categories, with the largest scale mean for neurotic, followed by borderline and lastly the psychotic category (see Table 4 for the means and standard deviations). This final ANOVA also found significant mean differences among the three scale categories on the Es scale, F (2, 95) = , p. = 001,2= .20. Scheffe post hoc tests indicated that patients rated as neurotic scored significantly higher on the Es scale in comparison to those rated as borderline (M = vs , p = .028), and psychotic (M = vs. M = 34.31, p = .001). There was also a significance mean difference between patients rated as borderline and those rated as psychotic (M = vs , p = .012).
122 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.
123 Percent of Practitioners Rating the PDC Dimensions as “Helpful—Very Helpful” in Understanding Their PatientOf the 61 practitioners surveyed, 80% held doctorates and 20% held masters degrees. Fifty-two percent of the respondents were women. Most of the participating practitioners’ primary theoretical orientations were other than psychodynamic: Psychodynamic (44%), Eclectic (21%), Cognitive-Behavioral (15%), Humanistic/existential (13%), and Systems (3%).Practitioners rated on 7-point scales (1 = Not at all helpful; 7 = Very helpful) how helpful the PDC was in improving both their understanding of their patients and in treatment planning beyond their ICD and DSM diagnosis. Practitioners were also asked to rate how helpful specific scales of the PDC were in understanding their patients. Seventy-nine percent of the practitioners rated the PDC as “helpful-very helpful” in improving their understanding of their patient beyond their ICD or DSM diagnosis, 67% rated the PDC as “helpful-very helpful” in the treatment planning of their patient beyond their ICD or DSM diagnosis, 84% rated the PDC’s level of Personality Structure Scale as “helpful-very helpful” in understanding their patient, 72% rated Dominate Personality Patterns and Disorders Scale as “helpful-very helpful” in understanding their patient, 79% rated the Mental Functioning Scale as “helpful-very helpful” in understanding their patient, and 50% rated the Cultural/Contextual Dimension as “helpful-very helpful” in understanding their patient. In comparison to the above PDC scales, only 31% rated the ICD or DSM symptoms as “helpful-very helpful” in understanding their patient
124 Personality Organization Dimension: Summary Practitioners want a parsimonious taxonomy that informs psychotherapy and management issues.Practitioners consider personality organization a very important dimension in understanding their patients.Research supports that personality organization predicts response to treatment and is sensitive to type of treatment (supportive vs. interpretive).Research supports a psychotic level personality organization.
125 Current PDM StudyData collected from 13 workshops from Nov July 2013.Estimated N= 500+ practitioners and doctoral studentsLead researcher Robert M. Gordon
126 Psychodynamic Diagnostic Prototypes (PDP) Francesco Gazzillo, PhDDepartment of Dynamic and Clinical Psychology«Sapienza» University of Rome126
127 PDP narrative description P105.1 Intermediate Manifestation:Sadomasochistic Personality DisordersSome individuals alternate between sadistic and sadomasochistic attitudes and behaviors (Kernberg, 1988). Patients with this psychology are much more emotionally alive and capable of attachment than those with primary psychopathic, narcissistic, or sadistic personality structures. Their relationships, however, are intense and explosive. Sometimes they let themselves be dominated to an extreme extent, and sometimes they viciously attack the person to whom they previously capitulated. They tend to see themselves as victims of others’ aggression whose only choices are to surrender their will entirely or to fight back belligerently. The “help-rejecting complainer” described by Frank and his colleagues (Frank, Margolin, Nash, Stone, Varon & Ascher, 1952) is one version of this psychology. In psychotherapy, such patients tend to alternate between attacking the therapist and feeling insulted and demeaned by him or her. Because sadomasochistic personality disorder is found at the borderline level of severity, treatment considerations include those for borderline patients generally.127
128 The Prototypic Assessment The validation of Psychodynamic Diagnostic Prototypes (PDP; Gazzillo, Lingiardi, Del Corno, 2010)The Prototypic Assessmentof the Psychodynamic Diagnostic Prototype5 Very good match (patient exemplifies this disorder; prototypical case)4 Good match (patient has this disorder; diagnosis applies)3 Moderate match (patient has significant features of this disorder)2 Slight match (patient has minor features of this disorder)1 No match (description does not apply)The evaluation of all 21 disorders takes about minutes128
129 Obsessive-compulsive The validation of Psychodynamic Diagnostic Prototypes (PDP; Gazzillo, Lingiardi, Del Corno, 2010)PDP DISORDERSKappa valuesRho valuesSchizoid.64**.71**Paranoid.51**.75**Psychopatic.61**.77**Narcissistic.65**.68**SadisticNo categorical diagnosis.57**Sado-masochistic.59**.62**MasochisticDepressive.56**.81**Hypomaniac.44**Somatizing.53**.79**Dependent.55**.69**Passive-aggressive.47**Counter-dependentPhobicCounter-phobic.58**.41**AnxiousObsessive-compulsive.46**.60**Histrionic.72**.84**Dissociative129
130 Hypotheses Norms for PDP and PDC Concurrent validity between PDP and PDCHow PDM Dx inform about boundaries and countertransference issuesHow theoretical orientation affects value of various taxa (PO, PD, MF, Symptoms, Context)Which PD are commonly found at which level of PO.
131 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 Object Relations: ability to maintain intimate, stable, and satisfying relationships 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 Superego Integration: ability to use a consistent and mature moral sensibility Reality Testing: ability to appreciate conventional notions of what is realistic Ego Resilience: ability to respond to stress resourcefully and to recover from painful events without undue difficulty
132 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)
133 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).
134 Psychopathic (antisocial); Subtypes - passive/parasitic or aggressive PDM Categories:SchizoidParanoidPsychopathic (antisocial); Subtypes - passive/parasitic or aggressiveNarcissistic; Subtypes - arrogant/entitled or depressed/depleted;Sadistic (and intermediate manifestation, sadomasochistic)Masochistic (self-defeating); Subtypes - moral masochistic or relational masochisticDepressive; Subtypes - introjective or anaclitic; Converse manifestation - hypomanicSomatizingDependent (and passive-aggressive versions of dependent); Converse manifestation - counterdependentPhobic (avoidant); Converse manifestation - counterphobicAnxiousObsessive-compulsive; Subtypes - obsessive or compulsiveHysterical (histrionic); Subtypes - inhibited or demonstrative/ flamboyantDissociativeMixed/otherRate: Dominate Personality Disorder or Maladaptive Traits & Overall Severity of Impairment
135 3. Mental Functioning1. Capacity for Attention, Memory, Learning, and Intelligence2. 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 Communication5. Level of Defensive or Coping Patterns1-2: 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 andexternal reality are all well distinguished)8. Self-Observing Capacity (psychological mindedness)9. Realistic sense of Morality
136 4. ICD or DSM SYMPTOMSSymptoms 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.
137 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.
138 “Psychodiagnostic Chart” For Free Copies:For copies of the PDP and PDC, search for:“Psychodiagnostic Chart”
139 Forensic Issues Diagnoses are a guides if useful to the question Diagnoses in Custody CasesDiagnoses in Criminal CasesDiagnoses in Personal Injury Cases
140 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.
141 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