Davies DSM Rasch(3)

8/9/2019 Davies DSM Rasch(3)

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Story of Personality in the DSM

Story of one of themost profound

measurement

debacles of modernhistory.

The DSM-IV Manual


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What is the DSM-IV?

The Diagnostic andStatistical Manual of Mental

disorders.American Psychiatric

Association.Considered a world standard.

Describes all officially

recognized mental

disorders.

The DSM-IV Manual


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Achieved Modern Form in 1980

In 1970s, professional status of psychiatrywas in trouble.

Mission of DSM-III: Reliability.

Adopted prototypal model.Adopted multiaxial model.


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The Structure of the DSM:

Multiaxial Model: Lines of Causality in Psychopathology

Axis I:

Clinical

Syndromes

Anxiety, Depression =

Fever, Cough

Axis II: Personality

Disorders

Histrionic, Sadistic =

Immune System

Axis IV: Psychosocial

Environment

Marriage, Money =

Infectious Agents

Multiaxial model is anintrinsically integrative

conception.

Provides a model of how

psychopathology emerges

and is perpetuated.

Specifically requires us to

develop an integrative

conception of the patient

that transcends a list of

diagnoses.

Interactionof Axis IV

and Axis II

produces

Axis I


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The Personality Disorders

Schizoid Avoidant Dependent

Histrionic Narcissistic Antisocial

Compulsive

Schizotypal Borderline

Paranoid


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Arbitrary Diagnostic Boundaries

DSM-III (1980) adopted behaviorally specificcriteria sets in order to increase diagnostic

reliability.

No justifications for any diagnostic thresholds.Dramatic changes in prevalence rates across DSMs

Schizotypal prevalence dropped from 11% to 1%

from DSM-III to III-R

This is like publishing a test with no external validitystudies.


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Massive Comorbidity of PDs

PD constructs are useless when patientsreceive four or five diagnoses.

Structured interviews consistently find extensive

co-morbidity of PDs.This situation has existed in DSM-III, published

in 1980 (nearly 30 years)

Examples of co-morbidities

Narcissistic and Antisocial

Borderline, Histrionic, and Dependent


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PDNOS is most used Diagnosis

In other words, existing PD categories dont

provide adequate coverage.

The majority of patients with personality

pathologyare currently undiagnosable onAxis II. Westen & Arkowitz-Weston (1998)

Can a taxonomy endure when its constructs

fail to diagnose over half the patients?


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DSM-IV PDs Represented as Diseases

May fall on separate Axis, but still

diagnosed as diseases.

Disease assumes a focal point or single

cause from which the disorder emanates.

Personality disorders are disorders of the

entire matrix of the person.


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Borderline PD, Criteria 1 to 4

No standardization of diagnostic criteria.Different types, and different levels of inference.

As diseases, diagnostic criteria are simply markers of

disease.

DSM Diagnostic Criterion

Behavioral 1. frantic efforts to avoid real or imagined abandonment

Psychodynamic 2. a pattern of unstable and intense interpersonalrelationships characterized by alternating between extremesof idealization and devaluation

Psychodynamic 3. identity disturbance: markedly and persistently unstableself image or sense of self

Trait 4. impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, recklessdriving, binge eating)


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Borderline PD, Criteria 5 to 9DSM Diagnostic Criterion

Behavioral 5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

Emotional 6. affective instability due to a marked reactivity of mood(e.g., intense episodic dysphoria, irritability, or anxiety usuallylasting a few hours and only rarely more than a few days)

Psychodynamic 7. chronic feelings of emptiness

Emotional 8. inappropriate, intense anger or difficulty controlling anger(e.g., frequent displays of temper, constant anger, recurrentphysical fights)

9. transient, stress-related paranoid ideation or severedissociative symptoms


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The Essential Insight

Personalitydisorders consist of

personality traits.


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Six Trait Domains

Negative Emotionality: Experiences a wide range of negative emotions(e.g., anxiety, depression, guilt-shame, worry, etc.), and the behavioral andinterpersonal manifestations of those experiences.

Introversion: Withdrawal from other people, ranging from intimate

relationships to the world at large; restricted affective experience and

expression; limited hedonic capacity.

Antagonism: Exhibits diverse manifestations of antipathy toward others,and a correspondingly exaggerated sense of self-importance.

Disinhibition: Diverse manifestations of being present- (vs. future- or past-)

oriented, so that behavior is driven by current internal and external stimuli,

rather than by past learning and consideration of future consequences.

Compulsivity: The tendency to think and act according to a narrowly

defined and unchanging ideal, and the expectation that this ideal should

be adhered to by everyone.

Schizotypy: Exhibits a range of odd or unusual behaviors and cognitions,

including both process (e.g., perception) and content (e.g., beliefs).


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The Structure of PP in DSM-V

A set of typesoperationalizedin terms of astandard set of

traits. Prototypes

operationalizedas traits.

Trait 1

Trait 2

And so on

Trait 1

Trait 2

And so on

Trait 1

Trait 2

And so on

PD

PD

PD

PD

PD

Narrower Tendency

Typical Behavior

Typical Feeling

Tier 1 Tier 2 Tier 3

PD

PD


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Tier 2: Six Broad TraitTier 2: Six Broad Trait

Dimensions, with FacetsDimensions, with Facets


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Negative Emotionality

Negative Emotionality

Emotional Lability

Anxiousness

Submissiveness

Separation Insecurity

DSM-V

Pessimism

Low Self-Esteem

Guilt-Shame

Self-Harm

Depressivity

Suspiciousness

Negative Emotionality:

Experiences a wide range of

negative emotions, and the

behavioral and interpersonalmanifestations of those

experiences.


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NEO Agreeableness versus DSM-V Antagonism

Agreeableness

Trust

Straightforwardness

Altruism

Compliance

Modesty

Tender-Mindedness

Five Factor Model DSM-V

Antagonism

Callousness

Manipulativeness

Narcissism

Histrionism

Hostility

Aggression

Oppositionality

Deceitfulness

Antagonism:

Exhibits diversemanifestations of

antipathy toward

others, and a

correspondingly

exaggerated sense

of self-importance.


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Good Construct Definitions

SubmissivenessSubservience and unassertiveness

Advice and reassurance seeking

Lack of confidence in decision-making;subordination of ones needs to those of

others

Adaptation of ones behavior to the interests

and desires of others


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Personality Types in DSM-VPersonality Types in DSM-V


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The PDs Reconceptualized

DSM-IV PDs now re-conceptualized as acollection of personality traits.The PDs can only be operationalized in terms of

the 37 traits.

Each PD is some subset of the 37.

If you want the PDs to include more content,

then you have to argue for numbers 38, 39, 40

and so on.


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First Important Consequence

The PDs can be compared and contrastedin terms of the 37.In DSM-IV, you might have ideas about the

relationships between the PDs, but these were

literary inferences not officially recognized.


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Antisocial and Narcissistic in DSM-V

Callousness

Aggression

Antagonism

Manipulativeness

Hostility

Deceitfulness

Narcissism

Irresponsibility

Recklessness

Impulsivity

Antisocial

Histrionism

Narcissism

Disinhibition DSM-V Narcissistnot necessarilydisinhibited.


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Antagonism

Negative

Emotionality

Borderline, Dependent, and Histrionic in DSM-V

Emotional Lability

Self-Harm

Separation Insecurity

Anxiousness

Low Self-Esteem

Depressivity

Hostility

Aggression

Impulsivity

Histrionism

Dependent

Dissociation PronenessSchizotypy

Submissiveness

BorderlineHistrionic


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Psychology Moves to Forefront

Psychiatrists diagnose.

Psychologists measure.Psychologists know what to do with traits.

Continuity between normality and pathology.

This is the moment in history where

measurement enters the DSM.

Possible to measure personality pathology for

first time.


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New Inventories

Older instruments just dont allow assessment ofthe 37 pathological traits.MMPI-2 and MMPI-2-RF better suited for Axis I.

MCMI-III at least has the PDs

But the MCMI-III is too short to assess 37 traits. With the Grossman Facet scales, Millon is following his

own system of traits.

The FFM is geared toward normal personality.

Some FFM facet parallel DSM-V, others are unique.Does not include Schizotypy at all.


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Measurement versus Authority

Changes the way the personality pathology willbe revised in future DSMs.

Past DSMsRevised based on expert consensus.

Measurement came later.

Future DSMsMuch more empirically driven.

The committees will be hungry for data.Any researcher could influence the DSM.


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Current Scales are Classical Test Theory

DAPP-BQ Submissiveness 1. If I am pressured, I will usually give in. 16. I usually go along with other people's suggestions.

48. I go along with what other people want even when its not what I want.

50. In a discussion, I usually end up agreeing with the other persons point of view.

53. I hesitate to express opinions that I think others will disagree with.

77. I try to get other people to make my decisions for me.

124. I need people to tell me what to do. 133. I doubt my own ability to do the right thing without advice from other people.

152. I tend to follow other people's wishes.

155. I tend to believe what people say without question.

177. I find it hard to resist persuasive people.

205. People often take advantage of me.

213. I am easily fooled by others. 220. I am not very good at being assertive with others.

224. I let people walk all over me.

256. I feel unsure about my decisions until I check them out with others.


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0 1 2-1-2-3 3

Eventually,

Logits will

replace

diagnosticthresholds


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The Logistic Curve and Therapy

Rasch model isa probabilisticGuttman model

The Logisticcurve gives usappropriatetargets for

therapy. 205. Peopleoften takeadvantage of

me.

77. I try to get otherpeople to make my

decisions for me.

Hierarchy of items = Hierarchy of


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Hierarchy of items = Hierarchy of

Therapeutic Goals

1. If I am pressured, I will usually give in.

16. I usually go along with other people's suggestions.

48. I go along with what other people want even when its

not what I want.

50. In a discussion, I usually end up agreeing with the other

persons point of view.

53. I hesitate to express opinions that I think others willdisagree with.

77. I try to get other people to make my decisions for me.

124. I need people to tell me what to do.

133. I doubt my own ability to do the right thing without

advice from other people.

152. I tend to follow other people's wishes. 155. I tend to believe what people say without question.

177. I find it hard to resist persuasive people.

Item

Difficu

lties

Potential formost

improvement

in

functioning.


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Conclusion

DSM-V marks the moment thatmeasurement enters psychiatry.

This promises a vigorous future role for

psychologists.

And finally links measurement to

psychotherapy.Cant do this in classical test theory.

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Davies DSM Rasch(3)