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New Diagnostic Considerations DSM-5, ICD10-11, PDM Review J&K Seminars 2013 Robert M. Gordon, Ph.D. ABPP 1.

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Presentation on theme: "New Diagnostic Considerations DSM-5, ICD10-11, PDM Review J&K Seminars 2013 Robert M. Gordon, Ph.D. ABPP 1."— Presentation transcript:

1 New Diagnostic Considerations DSM-5, ICD10-11, PDM Review J&K Seminars 2013 Robert M. Gordon, Ph.D. ABPP 1

2 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

3 Exercise in Psychodiagnoses Learn about: Personality organization Personality patterns Strengths and weaknesses Emergent symptoms Cultural and Contexual issues Issues related to ethical and risk issues Countertransference and boundary issues Contribute to the science of psychological taxonomy. Participation is voluntary. 3

4 Which Taxonomic Organization for Mental and Behavioral Science? Like a Biological Organization? Like a Periodic Table? 4

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6 What is Missing? 6

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. 7

8 Reasons for a mental health taxonomy Ethical and humanistic dilemmas with diagnosing personality Nosologies: Different ways to characterize disease Different nosologies for different folks Risk managements issues Need for a personality-based taxonomy that informs psychological treatments 8

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. 9

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.” 10

11 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

12 Why Diagnose? 4.Its role in reducing the probability that certain easily-frightened people will flee from treatment: It is helpful for the therapist to communicate to hypomanic or counter- dependent patients an understanding of how hard it may be for them to stay in therapy. 12

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. 13

14 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

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.” 15

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. 16

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. 17

18 Risk Factors in Litigious Patients Borderline Personality Organization Psychopathic traits History of acting out 18

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. 19

20 Which Diagnostic Taxonomy Should We Use? DSM-5? ICD-10? PDM? 20

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. 21

22 DSM-5 Moves from Multi-axial system to a similar ICD-10 System 22

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 23

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. 24

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 25

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. 26

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 27

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 28

29 The History, Politics and Assumptions of DSM-5 29

30 What Should Have Been 30

31 What Actually Occurred 31

32 How Not to Refine a Diagnostic System Lessons from DSM-5 Work in Isolation Encourage Secrecy Ignore Contradictory Evidence 32

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37 December 1, 2012 The Proposal is Rejected by the American Psychiatric Association 37

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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. 40

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. 41

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). 42

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. 43

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. 44

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 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). 45

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. 46

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” 47

48 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. 48

49 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, 49

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. 50

51 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 51

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. 52

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. 53

54 Delusional Disorder Criterion A for delusional disorder no longer has the requirement that the delusions must be nonbizarre. A specifier for bizarre type delusions provides continuity with DSM-IV. The demarcation of delusional disorder from psychotic variants of obsessive-compulsive disorder and body dysmorphic disorder is explicitly noted with a new exclusion criterion, which states that the symptoms must not be better explained by conditions such as obsessive- compulsive or body dysmorphic disorder with absent insight/delusional beliefs. 54

55 Catatonia In DSM-5, catatonia may be diagnosed as a specifier for depressive, bipolar, and psychotic disorders 55

56 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. 56

57 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. 57

58 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 58

59 Anxiety Disorders The DSM-5 chapter on anxiety disorder no longer includes obsessive-compulsive disorder (which is included with the obsessive- compulsive and related disorders) or posttraumatic stress disorder and acute stress disorder (which is included with the trauma- and stressor-related disorders). However, the sequential order of these chapters in DSM-5 reflects the close relationships among them. 59

60 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. 60

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. 61

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. 62

63 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). 63

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, 2011. The transition to ICD-10 is required for everyone covered by the Health Insurance Portability Accountability Act (HIPAA), Medicare and Medicaid. 64

65 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". 65

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 66

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 67

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) 68

69 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 69

70 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). 70

71 Collaborators Geoffrey M. Reed Spencer C. Evans Ann D. Watts João Mendonça Correia Patricia Esparza Mario Maj Michael C. Roberts Shekhar Saxena 71

72 USA n = 108 Europe n = 1398 Africa Africa n = 121 EasternMediterranean n = 224 Asia n = 139 LatinAmerica n = 165 2155 Participating Psychologists WORLD N = 2155 72

73 Who Makes Diagnoses? % Participants 73

74 Psychologists’ Role in Making Diagnoses % Participants 74

75 Use of Classification Systems % Participants 75

76 Classification System Most Used % Participants 76

77 Purpose of Classification % Participants 77

78 Number of Categories Desired % Participants 78

79 Strict Criteria vs. Flexible Guidance % Participants 79

80 A Dimensional Component % Participants 80

81 Reactions to Adverse Life Events % Participants 81

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.’ 82

83 ICD-10 and DSM-IV Categories Used Most Often ICD-10 and DSM-IV Categories Used Most Often ICD-10%DSM-IV% Depressive Episode 71% Major Depressive Disorder60% Generalized Anxiety Disorder 48% Generalized Anxiety Disorder59% Social Phobia 46% Post-Traumatic Stress Disorder42% Mixed Anxiety and Depressive Disorder 44% Adjustment Disorders41% Recurrent Depressive Disorder 44% Attention-Deficit/Hyperactivity Disorder38% Post-Traumatic Stress Disorder 42% Obsessive-Compulsive Disorder37% Borderline Personality Disorder 42% Social Phobia37% Adjustment Disorder 42% Borderline Personality Disorder34% Specific (Isolated) Phobias 41% Single Major Depressive Episode34% Hyperkinetic (Attention Deficit) Disorder 34% Panic Disorder without Agoraphobia32% Obsessive-Compulsive Disorder 34% Bipolar I Disorder27% Bipolar Affective Disorder 28% Alcohol-Related Disorders26% 83

84 Categories With the Lowest Ease of Use ICD-10EOUDSM-IVEOU Asperger's Syndrome 0.50 Dissociative Disorders0.48 Dissociative [Conversion] Disorders 0.50 Impulse Control Disorders0.50 Schizoaffective Disorder 0.51 Schizotypal Personality Disorder0.54 Schizotypal Disorder 0.51 Schizoaffective Disorder0.54 Somatoform Disorders 0.52 Asperger's Disorder0.56 Borderline Personality Disorder 0.56 Somatoform Disorders0.56 Hyperkinetic (Attention Deficit) Disorder 0.56 Primary Sleep Disorders0.58 Delirium 0.58 Bipolar II Disorder0.58 MBDs due to Use of Volatile Solvents 0.58 Tic disorders0.59 Habit and Impulse Disorders 0.59 Brief Psychotic Disorder0.60 MBDs due to Use of Hallucinogens 0.60 Vascular Dementia0.60 Bipolar Affective Disorder 0.60 Sexual Dysfunctions0.60 Mixed Anxiety and Depressive Disorder 0.60 Autistic Disorder0.61 Adjustment Disorder 0.60 Delusional Disorder0.62 84

85 Categories With the Lowest Goodness of Fit ICD-10GOFDSM-IVGOF Dissociative [Conversion] Disorders 0.45 Schizotypal Personality Disorder0.44 Asperger's Syndrome 0.45 Dissociative Disorders0.45 Hyperkinetic (Attention Deficit) Disorder 0.50 Somatoform Disorders0.47 Schizoaffective Disorder 0.51 Asperger's Disorder0.48 Somatoform Disorders 0.51 Impulse Control Disorders0.48 Borderline Personality Disorder 0.51 Schizoaffective Disorder0.49 MBDs Due to Use of Hallucinogens 0.52 Primary Sleep Disorders0.51 Schizotypal Disorder 0.53 Tic disorders0.53 Vascular Dementia 0.53 Bipolar II Disorder0.53 Dissocial (Antisocial) Personality Disorder 0.55 Borderline Personality Disorder0.54 Adjustment Disorder 0.55 Autistic Disorder0.54 Habit and Impulse Disorders 0.55 Brief Psychotic Disorder0.55 Mixed Anxiety and Depressive Disorder 0.56 Sexual Dysfunctions0.56 85

86 An enduring pattern of unusual speech, perceptions, beliefs and behaviors that are not of sufficient intensity to meet the requirements of schizophrenia. 3 or 4 of the following:  Constricted affect, the individual appearing cold and aloof.  Behaviour or appearance which is odd, eccentric, or peculiar.  Poor rapport with others, tendency towards social withdrawal.  Unusual beliefs, magical thinking or paranoid ideation  Unusual perceptual distortions  Suspiciousness or paranoid ideas  Occasional transient psychotic episodes  Vague, circumstantial, stereotyped thinking  Obsessive ruminations  Not met diagnostic criteria for schizophrenia ICD-10 / ICD-11 Schizotypal Disorder 86

87 A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior… 5 or more of the following: (1) ideas of reference (2) odd beliefs or magical thinking (3) unusual perceptual experiences (4) odd thinking and speech (e.g., vague, circumstantial) (5) suspiciousness or paranoid ideation (6) inappropriate or constricted affect (7) behavior or appearance that is odd, eccentric, or peculiar (8) lack of close friends or confidants other than first-degree relatives (9) excessive social anxiety DSM-IV Schizotypal Personality Disorder 87

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; 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 88

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.” 89

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 90

91 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 91

92 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. 92

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. 93

94 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. 94

95 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. 95

96 Research Support Blatt, (this volume), Norcross (2002), Wampold (2001) have concluded that the nature of the psychotherapeutic relationship, reflecting interconnected aspects of mind and brain operating together in an interpersonal context, predicts outcome more robustly than any specific treatment approach per se. Westen, Novotny, and Thompson- Brenner (2004 and this volume) have presented evidence that treatments that focus on isolated symptoms or behaviors (rather than personality, emotional, and interpersonal patterns ) are not effective in sustaining even narrowly defined changes. 96

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). 97

98 PDM’s Current Taxonomy Manifest Symptoms and Concerns Mental Functioning Personality Patterns and Disorders 98

99 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 99

100 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 100

101 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 101

102 Profile of Mental Functioning - M Axis Capacity for Regulation, Attention, and Learning Capacity for Relationships (Including Depth, Range, and Consistency) Quality of Internal Experience (Level of Confidence and Self- Regard) Affective Experience, Expression, and Communication Defensive Patterns and Capacities Capacity to Form Internal Representations Capacity for Differentiation and Integration Self-Observing Capacities (Psychological-Mindedness) Capacity for Internal Standards and Ideals: A Sense of Morality 102

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 103

104 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 104

105 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 105

106 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 106

107 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 107

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 108

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 109

110 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) 110

111 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. 111

112 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. 112

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), 355-374. 113

114 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 114

115 Robert M. Gordon and Robert F. Bornstein (2012) 115

116 PDC Is A User Friendly Guide to the Adult Section of the PDM Short- 3pages Easy - all scales are 1-10 Intuitive and Empirical Categorical and Dimensional Flexible - can do part or all Integrates with the DSM and ICD Good Reliability and Construct Validity- preliminary field evidence (Gordon and Stoffey 2013 in press) 116

117 PDC’s Taxonomy: From Larger to Smaller Units Cultural-Contextual Issues ICD Symptoms Mental Functioning Personality Patterns Personality Organization 117

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 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. 118

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). 119

120 Testing Dimensional and Categorical Qualities of Personality Organization with 3 Scales (L+Pa+Sc)-(Hy+Pt)Es Sc, Hy and Es 120

121 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. 121

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. 122

123 Percent of Practitioners Rating the PDC Dimensions as “Helpful—Very Helpful” in Understanding Their Patient 123

124 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. 124

125 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 125

126 Psychodynamic Diagnostic Prototypes (PDP) Francesco Gazzillo, PhD Department of Dynamic and Clinical Psychology «Sapienza» University of Rome 126

127 PDP narrative description P105.1 Intermediate Manifestation: Sadomasochistic Personality Disorders Some individuals alternate between sadistic and sadomasochistic attitudes and behaviors (Kernberg, 1988). Patients with this psychology are much more emotionally alive and capable of attachment than those with primary psychopathic, narcissistic, or sadistic personality structures. Their relationships, however, are intense and explosive. Sometimes they let themselves be dominated to an extreme extent, and sometimes they viciously attack the person to whom they previously capitulated. They tend to see themselves as victims of others’ aggression whose only choices are to surrender their will entirely or to fight back belligerently. The “help- rejecting complainer” described by Frank and his colleagues (Frank, Margolin, Nash, Stone, Varon & Ascher, 1952) is one version of this psychology. In psychotherapy, such patients tend to alternate between attacking the therapist and feeling insulted and demeaned by him or her. Because sadomasochistic personality disorder is found at the borderline level of severity, treatment considerations include those for borderline patients generally. 127

128 The validation of Psychodynamic Diagnostic Prototypes (PDP; Gazzillo, Lingiardi, Del Corno, 2010) The Prototypic Assessment of the Psychodynamic Diagnostic Prototype 5 Very good match (patient exemplifies this disorder; prototypical case) 4 Good match (patient has this disorder; diagnosis applies) 3 Moderate match (patient has significant features of this disorder) 2 Slight match (patient has minor features of this disorder) 1 No match (description does not apply) The evaluation of all 21 disorders takes about 10-30 minutes 128

129 The validation of Psychodynamic Diagnostic Prototypes (PDP; Gazzillo, Lingiardi, Del Corno, 2010) PDP DISORDERS Kappa valuesRho values Schizoid.64**.71** Paranoid.51**.75** Psychopatic.61**.77** Narcissistic.65**.68** SadisticNo categorical diagnosis.57** Sado-masochistic.59**.62** Masochistic.57**.65** Depressive.56**.81** Hypomaniac.44**.68** Somatizing.53**.79** Dependent.55**.69** Passive-aggressive.47**.57** Counter-dependent.75**.56** Phobic.55**.71** Counter-phobic.58**.41** Anxious.61**.79** Obsessive-compulsive.46**.60** Histrionic.72**.84** Dissociative.60**.57** 129

130 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. 130

131 131

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) 132

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). 133

134 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 134

135 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 135

136 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. 136

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. 137

138 For Free Copies: For copies of the PDP and PDC, search for: “Psychodiagnostic Chart” 138

139 Forensic Issues Diagnoses are a guides if useful to the question Diagnoses in Custody Cases Diagnoses in Criminal Cases Diagnoses in Personal Injury Cases 139

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. 140

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 141

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