Slide 2 Presenters: Robert M. Gordon, Ph.D., & Alan C.
Tjeltveit, Ph.D. 1 Slide 3 Educational Objectives: Learn about the
ethical issues involved with making and using a diagnosis, learn
about the DSM-5, ICD-10 and PDM, and learn how to integrate these
systems. Goals: Understand the ethical and risk issues involved in
not diagnosing accurately, identify the ethical issues associated
with how we (and others) use diagnoses, and learn the difference
between diagnosis as a label of disease as compared to diagnosis as
a means to understand in order to better help. 2 Slide 4 Lecture
you about the gross ethical violations that many of youthrough
ignorance, malice, or bothroutinely commit and should STOP doing
Provide precise, foolproof, 100% certain answers to all ethical
dilemmas What we will NOT do today Slide 5 What We Will Do
Delineate general ethical principles and specific ethical standards
of relevance to any diagnostic approach Contend that the best
ethical clinical practice involves careful thought about diagnosis;
there are many ways to practice well Discuss some ways of thinking
that may help you best practice in accord with professional ethical
principles and standards and your own approaches to your practice
and/or research Slide 6 Diagnostic Systems The DSMit is claimedis
the Bible of diagnosis NIMH Director Thomas Insel declared on April
29, 2013, that While DSM has been described as a Bible for the
field, it is, at best, a dictionary The DSMs weakness is its lack
of validity NIMH will be re-orienting its research away from DSM
categories
http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml
Slide 7 Thomas Insel Director, NIMH Official picture Note what hes
leaning on Source of photo: Herper, 2013 Slide 8 NIMHs alternative
Research Domain Criteria (RDoC)
http://www.nimh.nih.gov/research-funding/rdoc/nimh-
research-domain-criteria-rdoc.shtml Slide 9 Draft Research Domain
Criteria Negative Valence Systems Acute threat (fear) Potential
threat (anxiety) Sustained threat Loss Frustrative nonreward
Positive Valence Systems Approach motivation Initial responsiveness
to reward Sustained responsiveness to reward Reward learning Habit
Cognitive Systems Attention Perception Working memory Cognitive
(effortful) control Systems for Social Processes Affiliation and
attachment Social Communication Perception & Understanding of
Self Agency Self-Knowledge Perception & Understanding of Others
Arousal and Regulatory Systems Arousal Circadian Rhythms Sleep and
wakefulness Slide 10 Research Domain Criteria: Is anything relevant
to diagnosis left out? Agency Persons The Self Personality
Relationships Community Culture Narrative Meaning Spirituality
Ethics ? Slide 11 Research Domain Criteria Some see this as
praiseworthy scientific progress The chair of the Psychiatry
Department at Columbia asserts that psychiatry needs to base its
decisions more on biology, and less on behavior (Herper, 2013) Some
psychologists see RDoC as either biological reductionism or slanted
toward biological causation Given the current state of the
research, the RDoC can be read primarily as a promissory note,
which is backed up by an ideology which holds that: 1.
Psychological problems are medical problems 2. Medical problems
are, at root, biological problems 3. Real cures will only come at
the root level Slide 12 NIMH director & the American
Psychiatric Association president-elect, May 14, 2013 Today, the
DSM [no number], along with the ICD represents the best information
currently available for clinical diagnosis of mental disorders.
Patients, families, and insurers can be confident that effective
treatments are available and that the DSM is the key resource for
delivering the best available care. The National Institute of
Mental Health (NIMH) has not changed its position on DSM-5 [which
was?]. As NIMH's Research Domain Criteria (RDoC) project website
states, "The diagnostic categories represented in the DSM-IV [!]
and the International Classification of Diseases-10 (ICD-10,
containing virtually identical disorder codes) remain the
contemporary consensus standard for how mental disorders are
diagnosed and treated.
http://www.nimh.nih.gov/news/science-news/2013/dsm-5-and-rdoc-shared-
interests.shtml?utm_source=govdelivery&utm_medium=email&utm_campaign=govdelivery,
emendations by Rick Froman
http://www.nimh.nih.gov/news/science-news/2013/dsm-5-and-rdoc-shared-
interests.shtml?utm_source=govdelivery&utm_medium=email&utm_campaign=govdelivery
Slide 13 Why does this matter? Whatever diagnostic system we use
Behavior analytic ICD: 9, 9-CM, 10, or (beginning in 2015) 11 DSM:
IV-TR or 5 RDoC we face ethical issues regarding diagnosis The
current controversy over the DSM-5 is an opportunity to reflect
deeply on diagnosis in relationship to professional ethics Slide 14
Case: Carlos 18-year-old high school junior (getting Cs) in the
technical track of an underfunded under-performing school district
in which 80% of the students are below the poverty line Came from
the Dominican Republic at 10 & mainstreamed Tested as having an
IQ of 69 at 12 (no IEP; unclear why) Parents are divorced, one
older brother is in prison Has a girl friend (theyre in a band
together) After his best friend was killed in a car accident, he
was deeply depressed for 10 days (full range of symptoms) Had
pre-18 scrapes with the law (weapon & mj possession) Wants to
join the army after high school What are the ethical issues
associated with diagnosing Carlos? Slide 15 Ethical Principles
& Standards Relevant to Diagnosis Their intent is to guide and
inspire psychologists toward the very highest ethical ideals of the
profession Principle A: Beneficence and Nonmaleficence
Psychologists strive to benefit those with whom they work and take
care to do no harm Slide 16 How can optimal diagnosis benefit
Better understanding/ assessment Better treatment: what to do how
to be (e.g., patient) how to relate (relationship style) Better
communication among professionals and with clients Better research
Combats client isolation (Im not the only one) Helps connect
individuals with others having similar problems (those whove been
there) so they can receive social support challenge Slide 17 How
can diagnosis harm? Diagnosis may Harm clients Harm family members
and friends Harm society Harm may be (& probably usually is)
unintentional Harm may stem from a clients interpretation of the dx
Harm may stem from how others use and interpret diagnoses Slide 18
How may diagnosis harm? Leads to less than optimal, ineffective, or
harmful treatment Leads to misunderstanding persons and their
problems Labels may stick Stigma Damage a persons self-
understanding Decrease client responsibility/motivation to change
Create unwarranted guilt or shame Focus attention away from key
dimensions of a persons problems Convince a person to accept as
natural (& hence inevitable) what they can, in fact, change
Make it more difficult or cost more to get health and/or life
insurance Slide 19 How may diagnosis harm? Result in not being
hired Job loss Living down to expectations associated with a
diagnosis Increased health care costs Increase expenses to Clients
Employers Society ? Slide 20 Principle B: Fidelity and
Responsibility Psychologists are aware of their professional and
scientific responsibilities to society and to the specific
communities in which they work Psychologists seek to manage
conflicts of interest that could lead to exploitation or harm Slide
21 Standard 3. Human Relations 3.06 Conflict of Interest
Psychologists refrain from taking on a professional role when
personal, scientific, professional, legal, financial or other
interests or relationships could reasonably be expected to (1)
impair their objectivity, competence or effectiveness in performing
their functions as psychologists American Psychological
Association. (2010). Ethical principles of psychologists and code
of conduct. Retrieved from http://apa.org/ethics/code/index.aspx
Slide 22 Figure 1. Comparison of financial conflicts of interest
among DSM-IV and DSM-5 task force and work group members. Cosgrove
L, Krimsky S (2012) A Comparison of DSM-IV and DSM-5 Panel Members'
Financial Associations with Industry: A Pernicious Problem
Persists. PLoS Med 9(3): e1001190. doi:10.1371/journal.pmed.1001190
http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001190
Slide 23 Principle C: Integrity Psychologists seek to promote
accuracy, honesty, and truthfulness in the science, teaching and
practice of psychology Insurance fraud ? Slide 24 Principle D:
Justice Psychologists recognize that fairness and justice entitle
all persons to access to and benefit from the contributions of
psychology and to equal quality in the processes, procedures and
services being conducted by psychologists. Psychologists exercise
reasonable judgment and take precautions to ensure that their
potential biases do not lead to or condone unjust practices Slide
25 Principle E: Respect for People's Rights and Dignity
Psychologists are aware that special safeguards may be necessary to
protect the rights and welfare of persons or communities whose
vulnerabilities impair autonomous decision making Psychologists are
aware of and respect cultural, individual and role differences,
including those based on age, gender, gender identity, race,
ethnicity, culture, national origin, religion, sexual orientation,
disability, language and socioeconomic status and consider these
factors when working with members of such groups Psychologists try
to eliminate the effect on their work of biases based on those
factors, and they do not knowingly participate in or condone
activities of others based upon such prejudices Slide 26 Standard
9. Assessment 9.01 Bases for Assessments (a) Psychologists base the
opinions contained in their diagnostic statements on information
sufficient to substantiate their findings. (See also Standard 2.04,
Bases for Scientific and Professional Judgments.) Standard 2.
Competence 2.04 Bases for Scientific and Professional Judgments
Psychologists' work is based upon established scientific and
professional knowledge of the discipline Slide 27 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. 26 Slide 28
What Taxonomic Organization for Mental and Behavioral Science? Like
a Biological Organization? Like a Periodic Table? 27 Slide 29 28
Slide 30 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 clientone can throw away the book
and savor individual uniqueness. Nancy McWilliams (2011)
Psychoanalytic Diagnosis: Understanding Personality Structure in
the Clinical Process, Second Edition. 29 Slide 31 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 the demoralization and therapist from
burnout. 30 Slide 32 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 the borderline
client often panics and flirts with suicide in an effort to protect
himself from traumatic disappointment. 31 Slide 33 Why Diagnose? 4.
Its role in reducing the probability that certain easily frighten
people will flee from treatment. It is helpful for the therapist to
communicate to hypomanic or counter-dependent patients an
understanding of how hard it may be for them to stay in therapy. 32
Slide 34 Why Diagnose? 5. Its value in risk management. Often
therapists mistakenly use a presenting symptom as the only
diagnosis and missed the borderline level of personality or
psychopathic personality and got into trouble. 6. Its value in
process and outcome research. 33 Slide 35 Risk Factors in Litigious
Patients Borderline Personality Organization Psychopathic traits
History of acting out 34 Slide 36 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. 35 Slide 37 Which Diagnostic Taxonomy
Should We Use? DSM5? ICD-10? PDM? 36 Slide 38 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. 37 Slide 39 DSM-5 Moves from Multi-axial
system to a similar ICD 10 System 38 Slide 40 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 39 Slide
41 40 Slide 42 Why Will DSM-5 Cost $199 a Copy? By Allen Frances,
M.D. 1/24/13 Huffington Post DSM-5 has just announced its price --
an incredible $199 First, APA has sunk more than $25 million into
DSM-5 and wants to recoup as much of its investment as it can.
DSM-IV cost one fifth as much -- just $5 million -- of which half
came from external grants. APA is probably counting on having
captive buyers who are forced to pay its price, however exorbitant
it may be. DSM-5 boycotts are sprouting up all over the place The
codes clinicians need for insurance purposes are available for free
on the internet DSM-5 is so clunkily written, no teacher will ever
want to assign it to students People are not likely to rush out to
buy a ridiculously expensive DSM-5 that has already been
discredited as unsafe and scientifically unsound. 41 Slide 43 DSM 5
Is Guide Not BibleIgnore Its Ten Worst Changes By Allen J. Frances,
M.D. Psychology Today Dec 2 2012 More than fifty mental health
professional associations petitioned for an outside review of DSM 5
to provide an independent judgment of its supporting evidence and
to evaluate the balance between its risks and benefits.
Professional journals, the press, and the public also weighed in-
expressing widespread astonishment about decisions that sometimes
seemed not only to lack scientific support but also to defy common
sense. 42 Slide 44 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 Slide 45 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 Slide 46 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 Slide 47 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, Rosas 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 Slide
48 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 Slide 49 Autism Spectrum Disorder (ASD)
Consolidation of DSM-IV criteria for autism, Aspergers, 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
Slide 50 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. 49 Slide
51 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, 50
Slide 52 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 Slide 53 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 52 Slide 54 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 Slide 55 Schizoaffective Disorder The
primary change to schizoaffective disorder is the requirement that
a major mood episode be present for a majority of the disorders
total duration after Criterion A has been met. It makes
schizoaffective disorder a longitudinal instead of a
cross-sectional diagnosismore comparable to schizophrenia, bipolar
disorder, and major depressive disorder, which are bridged by this
condition. 54 Slide 56 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. 55
Slide 57 Catatonia In DSM-5, catatonia may be diagnosed as a
specifier for depressive, bipolar, and psychotic disorders 56 Slide
58 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 57 Slide 59
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. 58 Slide 60
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 12 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 nonbereavement-related
major depressive episodes 59 Slide 61 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. 60
Slide 62 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. 61
Slide 63 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 Slide 64 The International Classification of Diseases
ICD The ICD is currently the most widely used statistical
classification system for diseases in the world. This is in fact
the official diagnostic system for mental disorders in the US. The
ICD-10, was developed in 1992. ICD-11 is currently being researched
and should be ready in 2015. 63 Slide 65 ICD History The first
international conference to revise the International Classification
of Causes of Death convened in 1900; with revisions occurring every
ten-years thereafter. In 1948, the World Health Organization (WHO)
assumed responsibility for preparing and publishing the revisions
to the ICD every ten-years. WHO sponsored the seventh and eighth
revisions in 1957 and 1968, respectively. It later become clear
that the established ten-year interval between revisions was too
short. The America Psychiatric Association has long lobbied against
the use of the ICD (but due to federal law is forced to work with
the ICD). 64 Slide 66 ICD is Required by HIPPA The deadline for the
United States to begin using Clinical Modification ICD-10-Clinical
Modification (CM) is currently October 1, 2014. The deadline was
previously October 1, 2011. The transition to ICD-10 is required
for everyone covered by the Health Insurance Portability
Accountability Act (HIPAA), Medicare and Medicaid. 65 Slide 67
ICD-10 MENTAL AND BEHAVIOURAL DISORDERS consists of 10 main groups:
F0: Due to known physiological conditions F1: Due to use of
psychoactive substances F2: Schizophrenia, schizotypal and
delusional disorders F3: Mood [affective] disorders F4: Anxiety,
dissociative, stress-related and somatoform disorders F5:
Behavioural syndromes associated with physiological disturbances
and physical factors F6: Disorders of personality and behaviour in
adult persons F7: Intellectual disabilities F8: Pervasive and
specific developmental disorders F9: Behavioural and emotional
disorders with onset usually occurring in childhood and adolescence
In addition, a group of "unspecified mental disorders". 66 Slide 68
ICD 10 Disorders of adult personality and behavior F60 Specific
personality disorders F60.0 Paranoid personality disorder F60.1
Schizoid personality disorder F60.2 Antisocial personality disorder
F60.3 Borderline personality disorder F60.4 Histrionic personality
disorder F60.5 Obsessive-Compulsive personality disorder F60.6
Avoidant personality disorder F60.7 Dependent personality disorder
F60.8 Other specific personality disorders F60.81 Narcissistic
personality disorder F60.89 Other specific personality disorder
F60.9 Personality disorder, unspecified 67 Slide 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 68 Slide 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). 69 Slide 71 Purpose of
Classification % Participants 70 Slide 72 Number of Categories
Desired % Participants 71 Slide 73 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% 72 Slide 74 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 73 Slide 75 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 74 Slide 76 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 75
Slide 77 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 76 Slide 78 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 77 Slide
79 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. 78 Slide 80 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 79
Slide 81 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). 80 Slide 82 PDMs Current Taxonomy Manifest Symptoms and
Concerns Mental Functioning Personality Patterns and Disorders 81
Slide 83 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 82 Slide 84 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 83 Slide
85 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
84 Slide 86 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 85 Slide 87 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 86 Slide 88
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 87 Slide 89 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 88
Slide 90 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 89 Slide 91
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 Aspergers Syndrome
SCA326.3 Pervasive Developmental Disorder (PDD) Not Otherwise
Specified Other Disorders SCA327. Gender Identity Disorders 90
Slide 92 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 91 Slide 93
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 92 Slide 94 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) 93 Slide 95 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) Overall 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. 94 Slide 96 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 95 Slide 97
Robert M. Gordon and Robert F. Bornstein (2012) 96 Slide 98 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) 97 Slide 99 PDCs
Taxonomy: From Larger to Smaller Units Cultural-Contextual Issues
ICD Symptoms Mental Functioning Personality Patterns Personality
Organization 98 Slide 100 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. 99 Slide 101 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 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. 102 Slide 104 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. 103 Slide 105 Percent of Practitioners Rating the PDC
Dimensions as HelpfulVery Helpful in Understanding Their Patient
104 Slide 106 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 105 Slide 107
Psychodynamic Diagnostic Prototypes (PDP) Francesco Gazzillo, PhD
Department of Dynamic and Clinical Psychology Sapienza University
of Rome 106 Slide 108 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. 107 Slide 109 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 108 Slide 110 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. 109 Slide 111 110 Slide 112 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 persons overall personality structure from 1
(Psychotic) to 10 (Healthy) 111 Slide 113 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). 112 Slide 114 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 113 Slide
115 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 114 Slide 116 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.
115 Slide 117 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. 116 Slide 118 For Free Copies: For copies of the PDP and
PDC, search for: Psychodiagnostic Chart 117 Slide 119 In addition,
use whatever system is most helpful to you in understanding and
helping the client/patient 118
