The DSM5, ICD-10 and PDM: Concepts of Personality, Ethics and Validity

The DSM5, ICD-10-11 and PDM: Concepts of Personality, Ethics and ValidityPPA Fall 2012 Ethics WorkshopWe have three competing diagnostic systems of personality: DSM5, ICD10 and PDM. If we are to ethically base our diagnoses on information and techniques sufficient to substantiate their findings, then which do we use and why?

Robert M. Gordon, Ph.D. ABPP in Clinical Psychology and Psychoanalysis Janet Etzi, PsyD, Professor, Immaculata University OutlineWhat is diagnosis and why diagnose?Case example of a ethical and risk management issue over Dx.Big changes in DSM 5s Personality Disorders.The ICD 10-PD and the ICD 11 PD,Participate in an experiment on diagnostic formulation and learn more about Dx. The PDM- a personality centered approach,Why Mental Functioning is important to Dx,An Integration of the PDM, ICD or DSM.

The term Diagnosis is derived from Greek- meaning a distinguishing, to perceive, to know thoroughly. 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.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.

Why Diagnose?3. Its value in enabling the therapist to convey empathy. Once one knows that a depressed patient also has aborderline rather neurotic level personality structure, thetherapist will not be surprised if during the second year oftreatment she makes a suicide gesture. Or once a borderlineclient starts to have hope of real change, that the borderlineclient often panics and flirts with suicide in an effort to protecthimself from traumatic disappointment.

4. Its role in reducing the probability that certain easily frighten peoplewill flee from treatment. It is helpful for the therapist to communicate tohypomanic or counter-dependent patients an understanding of how hardit may be for them to stay in therapy.

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.

Personality Structure and TreatmentMcWilliams points out that for many neurotic level people, the best time to make interpretations is when the patient is a state of emotional arousal, so that the patient is less likely to intellectualize the affect. With borderline clients, who also require a supportive approach, the opposite consideration applies, because when they are very upset, it is hard for them to take anything in.

9Why have competence in diagnoses?9.01 Bases for Assessments

(a) Psychologists base the opinions contained in their recommendations, reports, and diagnostic or evaluative statements, including forensic testimony, on information and techniques sufficient to substantiate their findings. This includes interview, assessments and diagnostic taxonomies that pass the Frye Test, i.e. DSM, ICD and PDM.

9 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 4.10Risk Factors in Litigious PatientsBorderline Personality OrganizationPsychopathic traitsHistory of acting out

11My Psychologist Abandoned Me! Patient claiming millions of dollars in damagesMiddle age woman, with no history of psychological problems seeks help after her husband commits suicide.

Psychologist gives the Beck Depression Inventory, it shows depression and the psychologist does CBT.

He is symptom focused in his orientation.

12Complaint to Licensing Board and Civil Suit for DamagesAt first the patient is sweet and appreciative. Calls psychologist frequently between sessions. Begins to stalk him and insist on an outside relationship with him. At his rejection, she becomes suicidal and requires hospitalizationPsychologist refers her to other psychologists for treatment and does a termination session with her.Later she sues for abandonment.He did not manage her as someone with a dependent personality disorder at the borderline level personality organization.

13Patient using sessions for sadomasochistic gratificationConstantly testing the boundaries and insisting on frequent phone contact between sessionsThreatening suicide, but refusing to be cooperative with the treatment planIdealizing the therapist and fearing his abandonment while devaluing the treatmentInfuriating the therapist with complaints about his not helping her, while she was resisting treatment (projective identification)14Admission notes at first hospital stay soon after start of treatment She was increasingly depressed and it seems that despite treatment with antidepressants from her primary care doctor and despite psychotherapy which had been started with Therapist Y in the past three months, the patients overall condition had continued to decline15Mental health outpatient note by subsequent therapist Therapist Y suddenly stopped her treatment so she started to harass him, follow him, follow him everywhere, go to his house, hide in the bushes, in short she was stalking him. So he called 911 and she was in jail last month for one week. When she got out she is going to sue Therapist Y for suddenly stopping her therapy 16Mental health outpatient note by subsequent therapist cont:AXIS I: Posttraumatic stress disorder 309.81; AXIS II: Mixed personality disorder with borderline and obsessive-compulsive components AXIS V: Global assessment of functioning 55; highest in past 6517Whether Therapist Y appropriately terminated his treatment of Patient X.

The APA ethics committee and state licensing board hearing both rejected Patient Xs complaint. She was not benefiting from treatment and he was ethically bound to terminate treatment if the patient is not benefiting. He gave her the names of other therapists. He is not responsible if because of her psychopathology she doesnt want other therapists and she doesnt want to get better.

18Whether the treatment provided by Therapist Y was appropriate.Yes it was. He appears to provide primarily cognitive behavior therapy ... However, the problem was not that there was inappropriate treatment but Ms. X was uncooperative and resistant to treatment.

19

20Throw Away Occams 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. The DSM-IV was originally published in 1994 and listed more than 250 mental disorders.

The DSM-IV is based on five different dimensions. Axis I: Clinical Syndromes clinical symptoms that cause significant impairment Axis II: Personality and Mental Retardation long-term problems that are overlooked in the presence of Axis I disorders Axis III: Medical Conditions physical and medical conditions that may influence or worsen Axis I and Axis II disorders Axis IV: Psychosocial and Environmental ProblemsAxis V: Global Assessment of Functioningclient's overall level of functioning DSM 5The DSM 5 is due May 2013 and will supersede the DSM-IV which was last revised in 2000.Research started in 1999.The DSM makes the American Psychiatric Association over $5 million a year, historically adding up to over $100 million.DSM IVs problem of temporal instability

The average short-term test-retest reliabilities of .54 for specific PDs and .56 for any PD (Zimmerman, 1994) suggest large transient error of measurement; (Chmielewski & Watson, 2009) when using structured interviews.

Longer term test-retest reliabilities of .51 for any PD and .34 for specific PDs, and the finding of significant diagnostic change over as little as 6 months (Shea et al., 2002), indicate diagnostic instability that is inconsistent with the relative stability of personality traits (Roberts & DelVecchio, 2000). By making PD diagnoses more trait-based and dimensional, the DSM-5 is expected to reduce temporal instability.DSM IV Axis II Poor convergent validity Meta-analytic convergence between structured interviews, and between structured interviews and personality questionnaires, respectively, was .27 for specific PDs and .29 for any PD (Clark et al., 1997).In contrast, the proposed DSM- 5 personality trait set is based on an extensive research literature whose origins are more than half a century old (e.g., Cattell, 1946), culminating in recent years in a consensual, highly robust personality trait hierarchical structure (Markon et al., 2005) that has a high degree of convergent and discriminant validity across a wide range of measures, primarily questionnaires (OConnor, 2002b), but also encompassing structured interviews (Stepp et al., 2005).

(But- If a simpler construct has more stability and convergent validity- does it also mean that it has more generalizable validity to complex personality structures?)

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

DSM-5 changes to the approach used by ICD 10, with Axes I, II, and III into one axis.

Axis IV and Axis V may also copy ICD 10 (making the dimensional ratings specific to the diagnosis)

Main DSM 5 Categories Neurodevelopmental DisordersSchizophrenia Spectrum and Other Psychotic DisordersBipolar and Related DisordersDepressive DisordersAnxiety DisordersObsessive-Compulsive and Related DisordersTrauma and Stressor Related DisordersDissociative DisordersSomatic Symptom DisordersFeeding and Eating DisordersElimination DisordersSleep-Wake DisordersSexual DysfunctionsGender DysphoriaDisruptive, Impulse Control, and Conduct DisordersSubstance Use and Addictive DisordersNeurocognitive DisordersPersonality DisordersParaphilic DisordersOther DisordersDSM 5 Changes to Personality Disorder

The personality domain in DSM-5 is intended to describe the personality characteristics of all patients, whether they have a personality disorder or not.

Five Factor Model and the DSM 5 PD The proposed model represents an extension of the Five Factor Model (FFM; Costa & Widiger, 2002) of personality that encompasses the more maladaptive personality variants necessary to capture features of PDs. The 5 domain/25 trait model includes 5 broad, higher-order personality trait domains negative affectivity, detachment, antagonism, disinhibition, and psychoticism each comprised of from 3 to 9 lower-order, more specific trait facets that help flesh out the domains (e.g., manipulativeness and callousness are specific facets in the antagonism domain).

DSM 5 two dimensional assessments The proposed DSM-5 model consists of two dimensional assessments: 1) a personality pathology severity scale, the Levels of Personality Functioning, and 2) a 5 domain/25 facet pathological personality trait assessment. Combined, these assessments redefine the core features of a PD and provide the information needed to rate the major diagnostic inclusion criteria for six specific PD categories and for a diagnosis of personality disorder-trait specified (PD-TS) to replace PD not otherwise specified (PDNOS). Guide to Implementation of Assessment of Personality Pathology

1. Is impairment in personality functioning (self and interpersonal) present or not? 2. If so, rate the level of impairment in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning on the Levels of Personality Functioning Scale (0-4). 3. Is one of the 6 defined types present? (antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal) If so, record the type and the severity of impairment.

5. If not, is PD-Trait Specified present? (negative affectivity, detachment, antagonism, disinhibition vs. compulsivity, and psychoticism) If so, record PDTS, identify and list the trait domain(s) that are applicable, and record the severity of impairment on Clinicians Trait Rating Form (0-3).

7. If a PD is present and a detailed personality profile is desired and would be helpful in the case conceptualization, evaluate the trait facets. 8. If neither a specific PD type nor PDTS is present, evaluate the trait domains and/or the trait facets, if these are relevant and helpful in the case conceptualization.Revised General Criteria for Personality Disorder

The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose a personality disorder, the following criteria must be met:

A. Significant impairments in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning.

B. One or more pathological personality trait domains or trait facets.

C. The impairments in personality functioning and the individuals personality trait expression are relatively stable across time and consistent across situations.

D. The impairments in personality functioning and the individuals personality trait expression are not better understood as normative for the individuals developmental stage or socio-cultural environment.

E. The impairments in personality functioning and the individuals personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).

First- If there is impairment in personality functioning (self and interpersonal) then- rate the level of impairment in self and interpersonal functioning on the Levels of Personality Functioning Scale. Five levels of self-interpersonal functioning impairment, ranging from no impairment, i.e., healthy functioning (Level = 0) to extreme impairment (Level = 4)

Is one of the 6 defined types present?If so, record the type and the severity of impairment.

The six specific types are as follows:T 00 Borderline Personality DisorderT 01 Obsessive-Compulsive Personality DisorderT 02 Avoidant Personality DisorderT 03 Schizotypal Personality DisorderT 04 Antisocial Personality Disorder (Dyssocial Personality Disorder)T 05 Narcissistic Personality DisorderT 06 Personality Disorder Trait SpecifiedDSM5: T 04 Antisocial Personality Disorder (Dyssocial 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.AND2. 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.

B. Pathological personality traits in the following domains:1. Antagonism, characterized by: a. Manipulativeness b. Deceitfulness c. Callousness d. Hostility2. Disinhibition, characterized by: a. Irresponsibility b. Impulsivity c. Risk takingDSM IV- BPD Criteria-no more needing at least 5 BPD as indicated by at least 5 of the following: Frantic efforts to avoid real or imagined abandonmentA pattern of unstable and intense interpersonal relationships-"splitting" Identity disturbance: unstable self-image Impulsivity in at least two areas that are potentially self-damagingRecurrent suicidal behavior or self-mutilating behavior Affective instability Chronic feelings of emptiness Inappropriate, intense anger or difficulty controlling anger Paranoid ideation or dissociative symptomsDSM 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.AND2. Impairments in interpersonal functioning (a or b): a. Empathy b. IntimacyB. 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 taking3. Antagonism, characterized by: a. Hostility

DSM 5 PERSONALITY TRAIT RATING FORM If not one of 6 types, then is PD-Trait Specified present? If so, record PDTS, identify and list the trait domain(s) that are applicable, and record the severity of impairment.

If a PD is present and a detailed personality profile is desired and would be helpful in the case conceptualization, evaluate the trait facets.

DSM-5 CLINICIANS PERSONALITY TRAIT RATING FORM Depending on the role of personality in patients clinical pictures, you may rate their traits in one of three ways: (1) just the five broad trait domains for a personality overview, (2) all trait facets for a comprehensive personality profile, or (3) the five trait domains, followed by the component trait facets comprising each of those domains for which the characteristics describe the patient with degree of fit:0=Very little, 1= Mildly, 2= Moderately, 3= Extremely

Please rate patients usual personality, what they are like most of the time.

Rate the five trait domains and the specific trait facets comprising the domains 0=Very little, 1= Mildly, 2= Moderately, 3= ExtremelyNegative Affectivity Detachment Antagonism Disinhibition Psychoticism

Rate the twenty-five specific trait facets comprising the five domains Negative AffectivityEmotional lability Anxiousness Separation insecurity Perseveration Submissiveness Hostility Depressivity Suspiciousness

Detachment Restricted affectivityWithdrawal Anhedonia Intimacy avoidance

Antagonism Manipulativeness Deceitfulness Grandiosity Attention seeking Callousness

Disinhibition Irresponsibility Impulsivity Distractibility Risk taking (lack of) Rigid perfectionism

Psychoticism Unusual beliefs and experiences Eccentricity Cognitive and Perceptual dysregulation

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.

54The International Classification of DiseasesThe 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 planned for 2015.

ICD is Required by HIPPAThe 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, then October 1, 2013.ICD vs DSM-IV A survey of 205 psychiatrists, from 66 different countries across all continents, found that ICD-10 was more frequently used and more valued in clinical practice and training. The DSM-IV was more valued for research, but less clear to mental health professionals, policy makers, patients and families. (Mezzich JE., 2002). Neurosis and Psychosis in ICD 10

The traditional division between neurosis and psychosis has not been used in ICD-10. However, the term "neurotic" is still used for instance, in "Neurotic, stress-related and somatoform disorders". "Psychotic" has been retained as a convenient descriptive term, as in Acute and transient psychotic disorders. The use of neurotic or psychotic does not involve assumptions about psychodynamic mechanisms.

ICD-10 mental and behavioural disorders and consists of 10 main groups:

F0: Organic, including symptomatic, mental disorders F1: Mental and behavioural disorders due to use of psychoactive substances F2: Schizophrenia, schizotypal and delusional disorders F3: Mood [affective] disorders F4: Neurotic, 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: Mental retardation F8: Disorders of psychological development F9: Behavioural and emotional disorders with onset usually occurring in childhood and adolescence In addition, a group of "unspecified mental disorders".

ICD 10 Disorders of adult personality and behavior

F60 Specific personality disorders F60.0 Paranoid personality disorder F60.1 Schizoid personality disorder F60.2 Dissocial personality disorder F60.3 Emotionally unstable personality disorder .30 Impulsive type .31 Borderline type F60.4 Histrionic personality disorder F60.5 Anankastic personality disorder (i.e. OCPD)F60.6 Anxious [avoidant] personality disorder F60.7 Dependent personality disorder F60.8 Other specific personality disorders F60.9 Personality disorder, unspecified

F61 Mixed and other personality disorders F61.0 Mixed personality disorders F61.1 Troublesome personality changes F60.2 Dissocial personality disorder

(a) callous unconcern for the feelings of others;(b) gross and persistent attitude of irresponsibility and disregard for social norms, rules and obligations;(c) incapacity to maintain enduring relationships, though having no difficulty in establishing them;(d) very low tolerance to frustration and a low threshold for discharge of aggression, including violence;(e) incapacity to experience guilt or to profit from experience, particularly punishment;(f) marked proneness to blame others, or to offer plausible rationalizations, for the behavior that has brought the patient into conflict with society. There may also be persistent irritability as an associated feature. Conduct disorder during childhood and adolescence, may support the diagnosis. Includes: amoral, antisocial, asocial, psychopathic, and sociopathic personality (disorder) Excludes: conduct disorders, emotionally unstable personality disorder.

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.

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 typeemotional 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 typethe 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) ICD-11 Survey OverviewDeveloped for psychologists by WHO and International Union of Psychological Sciences (IUPsyS)Parallel to survey conducted by WHO and World Psychiatric Association (WPA) of 4887 psychiatrists in 44 countries2155 global psychologists participatedRecruited through 23 IUPsyS member national psychological associations in 23 countries 10 low and middle-income countriesAdministered in 5 languages (English, Spanish, French, German, Turkish)Dr. Geoffrey M. Reed World Health Organization2 September 2010WPA International Congress64ICD-11 2015ICD-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.A study of nearly 5,000 psychiatrists in 44 countries sponsored by WHO, more than 70 percent of the world's psychiatrists use ICD while just 23 percent turn to the DSM. The same pattern is found among psychologists globally.

Psychologists Role in Making Diagnoses% ParticipantsPurpose of Classification% Participants2 September 2010WPA International CongressDr. Geoffrey M. Reed World Health Organization67Number ofCategories Desired% Participants2 September 2010WPA International CongressDr. Geoffrey M. Reed World Health Organization68Strict Criteria vs.Flexible Guidance% Participants2 September 2010WPA International CongressDr. Geoffrey M. Reed World Health Organization69A Dimensional Component% ParticipantsICD-10 and DSM-IV Categories Used Most Often (Why they couldnt get rid of Borderline)ICD-10%DSM-IV% Depressive Episode71% Major Depressive Disorder60% Generalized Anxiety Disorder48% Generalized Anxiety Disorder59% Social Phobia46% Post-Traumatic Stress Disorder42% Mixed Anxiety and Depressive Disorder44% Adjustment Disorders41% Recurrent Depressive Disorder44% Attention-Deficit/Hyperactivity Disorder38% Post-Traumatic Stress Disorder42% Obsessive-Compulsive Disorder37% Borderline Personality Disorder 42% Social Phobia37% Adjustment Disorder42% Borderline Personality Disorder34% Specific (Isolated) Phobias41% Single Major Depressive Episode34% Hyperkinetic (Attention Deficit) Disorder34% Panic Disorder without Agoraphobia32% Obsessive-Compulsive Disorder34% Bipolar I Disorder27% Bipolar Affective Disorder28% Alcohol-Related Disorders26%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

Psychodynamic Theory as a Complex Adaptive System-temperament, affects, cognitions, development, traumas, defenses, fantasies, attachments all interacting at various levels of consciousness.

73Kernbergs (1976, 1984) Differentiation of Personality Organization Neurotic Borderline PsychoticIdentity + - -Integration

Defensive + - -Operations

Reality + +/- -TestingGordon and Stoffey recent research supports that these factors contribute most to personality organization.

74How can we conceptualize borderline more accurately? Kernbergs Levels of Personality Organization1- Normal flexibility and adaptation2- Neurotic level of personality organization3- Borderline level of personality organization: High level borderline Low level borderline4- Psychotic level of personality

7575Borderline Personality OrganizationBasic Characteristics- KernbergIdentity Diffusion No integrated concept of selfNo integrated concept of significant others

Primitive Defenses Splitting Idealization/devaluation Projective identification Omnipotent control Denial Variable Reality Testing

7676PDM System The PDM uses a multi dimensional approach to describe the intricacies of the patient's overall functioning and ways of engaging in the therapeutic process. It begins with a classification of the spectrum of personality patterns and disorders, then offers a "profile of mental functioning" covering in more detail the patient's capacities, and finally considers symptom patterns, with emphasis on the patient's subjective experience.The Psychodynamic Diagnostic ManualOver-all level of personality organization (Healthy, Neurotic or Borderline)Personality patterns and disorders (Temperament, conflicts, affects, cognitions and defensives)Specific capacities of mental functioning (learning, relationships, self regard, affective experience, internal representations, differentiation and integration, psychological mindedness, a sense of morality)The subjective experience of symptoms78Dimension I: Personality Patterns and Disorders The PDM classification of personality patterns has been placed first in the PDM system because of the accumulating evidence that symptoms or problems cannot be understood, assessed, or treated in the absence of an understanding of the mental life of the person who has the symptoms. Dimension II: Mental Functioning The second PDM dimension offers a more detailed description of emotional functioning-the capacities that contribute to an individual's personality and overall level of psychological health or pathology. Dimension III: Manifest Symptoms and Concerns Dimension III presents symptom patterns in terms of the patient's personal experience of his or her prevailing difficulties. The patient may evidence a few or many patterns, which may or may not be related, and which should be seen in the context of the person's personality and mental functioning. Types of Personality DisordersP101. Schizoid Personality DisordersP102. Paranoid Personality Disorders

P103. Psychopathic (Antisocial) Personality DisordersP103.1 Passive/Parasitic P103.2 Aggressive

P104. Narcissistic Personality DisordersP104.1 Arrogant/EntitledP104.2 Depressed/Depleted

P105. Sadistic and Sadomasochistic Personality DisordersP105.1 Intermediate Manifestation: Sadomasochistic Personality Disorders

P106. Masochistic (Self-Defeating) Personality DisordersP106.1 Moral MasochisticP106.2 Relational Masochistic

P107. Depressive Personality DisordersP107.1 IntrojectiveP107.2 Anaclitic P107.3 Converse Manifestation: Hypomanic Personality Disorder

P108. Somatizing Personality Disorders

P109. Dependent Personality DisordersP109.1 Passive-Aggressive Versions of Dependent Personality DisordersP109.2 Converse Manifestation: Counterdependent Personality Disorders

P110. Phobic (Avoidant) Personality DisordersP110.1 Converse Manifestation: Counterphobic Personality Disorders

P111. Anxious Personality Disorders P112. Obsessive-Compulsive Personality DisordersP112.1 ObsessiveP112.2 Compulsive

P113. Hysterical (Histrionic) Personality DisordersP113.1 InhibitedP113.2 Demonstrative or Flamboyant

P114. Dissociative Personality Disorders (Dissociative Identity Disorder/Multiple Personality Disorder)

P115. Mixed/Other P Axis

85The P Axis- Personality Disorders Considers the Following Factors:

Temperamental, Thematic, Affective, Cognitive, and Defense patterns 86Psychopathic, Sociopathic, Antisocial or Dissocial?The DSM-IV-TR states that psychopathy and sociopathy are obsolete synonyms for Antisocial Personality Disorder.

The World Health Organization stance in its ICD-10 refers to psychopathy, sociopathy, antisocial personality, asocial personality, and amoral personality as synonyms for Dissocial Personality Disorder.

The PDM uses Psychopathic to relate to the personality not just symptoms, and considers all the terms as basically interchangeable.

8787Psychopathy and Narcissism Otto Kernberg (2004) believed psychopathy should fall under a spectrum of pathological narcissism, that ranged from narcissistic personality on the low end, malignant narcissism in the middle, and psychopathy at the high end.

8888P103. Psychopathic (Antisocial) Personality Disorder P103.1 Passive/Parasitic P103.2 AggressiveContributing constitutional-maturational patterns: aggressiveness, high threshold for emotional stimulation

Central tension/preoccupation: Manipulating/being manipulated

Central affects: Rage, envy

Characteristic pathogenic belief about self: I can make anything happen

Characteristic pathogenic belief about others: Everyone is selfish, manipulative, dishonest

Central ways of defending: Reaching for omnipotent control

8989Aggressive SubtypeExplosiveActively predatoryOften violent

9090Passive/Parasitic SubtypeMore dependentLess aggressive, usually non-violentManipulatorCon artist

9191Psychopathic P.D. (PDM)Not all psychopaths are antisocial. Many are successful and social in certain roles (intelligence, law enforcement, attorney, clergy, etc.)Want power for its own sakePleasure in exploiting and duping othersGood at reading the emotions of others, but not their ownLacking a moral center of gravityLose interest in people once no longer useful to themLack of remorseNeed high external stimulationOrganized mainly at the borderline level, and often combines with other personality disorders or patterns (Paranoid, Sadistic, Narcissistic, etc.)

92Robert Hare, Ph.D. author of Snakes in Suits: When Psychopaths Go to Work found that psychopathic traits are common to many CEOs.

He describes psychopaths as Intraspecies predators

93Why the Psychopath is a risk in treatmentThey are very hard to detect.They are con artists. They are experts at sizing you up and exploiting your issues.They can be charming one moment, and dangerous the next.They can seduce you and then destroy your career.They will make false claims against you for the money.

94What to do?Be aware of the diagnosis- Learn the PDM!Keep strict boundaries and ground rules,Use frequent clarifications of roles and rules of therapy, Use confrontations to help with impulse containment, Take protective notes,Get a consult,If you are frightened or uncomfortable, you do not have to treat the patient. Refer to a more appropriate facility.

95Profile 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 Summary of Basic Mental Functioning Scale M201. Optimal Age- and Phase-Appropriate Mental CapacitiesM202. Reasonable Age- and Phase-Appropriate Mental CapacitiesM203. Age- and Phase-Appropriate Capacities M204. Mild Constrictions and InflexibilityM204.1 Encapsulated character formationsM204.2 Encapsulated symptom formationsM205. Moderate Constrictions and Alterations in Mental FunctioningM206. Major Constrictions and Alterations in Mental FunctioningM207. Defects in Integration and Organization and/or Differentiation of Self- and Object RepresentationsM208. Major Defects in Basic Mental Functions Psychodiagnostic Chart (PDC)An Integration of the Psychodynamic Diagnostic Manual (PDM), ICD and DSM

Robert M. Gordon and Robert F. BornsteinGoal of the PDC To offer a person-based nosology by integrating the PDM, ICD and DSM; this integrated nosology may be used for: better diagnoses, treatment formulations, progress reports, outcome assessment, research on personality and psychopathology. USE Our overarching aim is to make psychodiagnoses more useful to the practitioner by combining the symptom-focused ICD or DSM with the full range and depth of human mental functioning addressed by the PDM.

How to Use The clinician must perform (or have access to) diagnostic interview data and psychological assessment data to derive optimal ratings. We recognize that this is not always feasible, and in many instances the clinician will code an initial impression, then re-assess as additional information accrues. If this is used for progress notes, there will be opportunities to re-assess and revise the persons diagnosis as well. The validity of this chart can be enhanced with the integration of relevant psychological tests.

Scoring For consistency and ease of scoring, all dimensional ratings go from most disturbed (1) to healthy (10). We advise against using ratings of 10 except in unusual circumstances.

Psychodiagnostic Chart1. PERSONALITY STRUCTURELEVEL OF PERSONALITY STRUCTUREWe start with the overall personality structure or severity, ranging from psychotic to healthy. The PDM uses seven mental capacities to assess level of severity. Three steps are involved:Rate each capacity using the 1-10 scale. Review the definitions of personality structure (healthy, neurotic, borderline and psychotic)Indicate the overall level of personality structure. For example, a 3 would be a low functioning borderline structure; an 8 would be a high functioning neurotic structure.

1. Level of Personality Structure

Please rate each capacity from 1 to 10; ratings range from Most Disturbed (1) to Most Healthy (10).1. Identity: ability to view self in complex, stable, and accurate ways 2. Object Relations: ability to maintain intimate, stable, and satisfying relationships 3. Affect Tolerance: ability to experience the full range of age-expected affects

4. Affect Regulation: ability to regulate impulses and affects with flexibility in using defenses or coping strategies

5. Superego Integration: ability to use a consistent and mature moral sensibility 6. Reality Testing: ability to appreciate conventional notions of what is realistic 7. Ego Resilience: ability to respond to stress resourcefully and to recover from painful events without undue difficulty

1. Level of Personality Structure- RatingHealthy 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 StructureBased on the 7 ratings above, rate persons overall personality structure from 1 (Psychotic) to 10 (Healthy)

2. Dominant Personality Patterns or Disorders

These are relatively stable ways of thinking, feeling, behaving and relating to others. Normal level temperaments and traits (e.g., extroversion) do not involve impairment, while personality disorders involve impairment at the neurotic, borderline, or severe (psychotic) level. You may substitute ICD or DSM personality disorders for those of the PDM. If the person does not have a personality disorder, but a maladaptive trait or personality style, then rate the trait or style as mild (e.g., obsessional traits-8). Check off as many as apply.

2. Personality Patterns or Disorders- Scoring Review the P axis in the PDM for the personality patterns most descriptive of your client (or use the PDP, SWAP, OPD, etc.). 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).

PDM Categories:SchizoidParanoidPsychopathic (antisocial); Subtypes - passive/parasitic or aggressiveNarcissistic; Subtypes - arrogant/entitled or depressed/depleted;Sadistic (and intermediate manifestation, sadomasochistic)Masochistic (self-defeating); Subtypes - moral masochistic or relational masochisticDepressive; Subtypes - introjective or anaclitic; Converse manifestation - hypomanicSomatizingDependent (and passive-aggressive versions of dependent); Converse manifestation - counterdependentPhobic (avoidant); Converse manifestation - counterphobicAnxiousObsessive-compulsive; Subtypes - obsessive or compulsiveHysterical (histrionic); Subtypes - inhibited or demonstrative/ flamboyantDissociativeMixed/other Rate: Dominate Personality Disorder or Maladaptive Traits & Overall Severity of Impairment

3. MENTAL FUNCTIONING

Rate (1-10) the 9 different mental capacities according to the level of maturation or functioning.

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

4. ICD, DSM or PDM 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. However, you treat the person, not just the symptoms. 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, better explain symptoms and/or degree of suffering. Importance of a Psychodynamic Understanding of PersonalityThe 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.

114What Do Practitioners Want in a Diagnostic Taxonomy? Comparing the PDM with DSM and ICDFifty practitioners have taken the survey to date, with 80% of respondents having doctorates and 20% masters degrees; 54% were women. Half of the respondents identified themselves as Psychodynamic (50%); the rest were Eclectic (22%), Cognitive-Behavioral (12%), Humanistic/Existential (10%), Systems (4%), and Other (2%).

(Bornstein, R.F. and Gordon, R.M. 2012, in press, What Do Practitioners Want in a Diagnostic Taxonomy? Comparing the PDM with DSM and ICD. Division Review: A Quarterly Psychoanalytic Forum)

68% rated PDM Personality Structure as helpful-very helpful.58% rated PDM Mental Functioning as helpful-very helpful.44% rated PDM Dominant Personality Patterns or Disorders as helpful-very helpful.18% rated DSM GAF scores as helpful-very helpful.14% rated ICD or DSM symptoms as helpful-very helpful.Finally, Use the ICD and integrate it with the PDMFor better risk managementFor more empathy and better treatment formulationFor insurance requirements

Thank you. GAF From 11/27/00 to 3/28/05

WhenDateGAF (current)WhenDateGAF (current)

Before11/27/0050After3/18/0355

Before4/3/0140After4/17/0365

Before4/23/0150After5/5/0360

Before5/23/0160After6/5/0360

Before8/22/0160After7/8/0365

Before10/17/0160After8/5/0362.5

Before11/27/0160After8/10/0365

Before1/23/0265After8/21/0360

Before4/30/0250After10/2/0360

Before6/4/0235After10/8/0365

Before6/10/0260After10/30/0360

Before7/5/0260After11/25/0360

Before9/5/0260After12/24/0360

Before12/16/0265After1/20/0460

Before2/24/0330After2/18/0455

BeforeAverage:53.67After3/31/0457.5

St. dev.:10.93After4/28/0455

After6/30/0455

After3/28/0555

Average:59.74

St. dev.:3.62

When looking at patients DSM Axis V GAF scores over a period of about 4.5 years, while seeing Dr. Y (before termination) and after, we see no injury. In fact, she becomes more stable and improved over time. PAGE 3

General Criteria for a Personality Disorder General Criteria for a Personality Disorder

DSM-IV DSM-5 Criteria - Revised June 2011

1. An enduring pattern of inner experience and behavior the deviates markedly from the expectations of the individual's culture. This pattern is manifested in two (or more) of the following areas: 1. Cognition (i.e., ways of perceiving and interpreting self, other people and events) 2. Affectivity (i.e., the range, intensity, liability, and appropriateness of emotional response) 3. Interpersonal functioning 4. Impulse control 2. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. 3. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning. 4. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood. 5. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder. 6. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug abuse, a medication) or a general medical condition (e.g., head trauma). The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose a personality disorder, the following criteria must be met: 1. Significant impairments in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning. 2. One or more pathological personality trait domains or trait facets. 3. The impairments in personality functioning and the individuals personality trait expression are relatively stable across time and consistent across situations. 4. The impairments in personality functioning and the individuals personality trait expression are not better understood as normative for the individuals developmental stage or socio- cultural environment. 5. The impairments in personality functioning and the individuals personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).

SELF INTERPERSONAL

LevelIdentitySelf-DirectionEmpathyIntimacy

0-Ongoing awareness of a unique self; maintains role-appropriate boundaries. -Consistent and self-regulated positive self-esteem, with accurate self-appraisal. -Capable of experiencing, tolerating and regulating a full range of emotions.-Sets and aspires to reasonable goals based on a realistic assessment of personal capacities.-Utilizes appropriate standards of behavior, attaining fulfillment in multiple realms. -Can reflect on, and make constructive meaning of, internal experience.-Capable of accurately understanding others experiences and motivations in most situations. -Comprehends and appreciates others perspectives, even if disagreeing. -Is aware of the effect of own actions on others.-Maintains multiple satisfying and enduring relationships in personal and community life. -Desires and engages in a number of caring, close and reciprocal relationships.-Strives for cooperation and mutual benefit and flexibly responds to a range of others ideas, emotions and behaviors.

SELF INTERPERSONAL

LevelIdentitySelf-DirectionEmpathyIntimacy

1-Relatively intact sense of self, with some decrease in clarity of boundaries when strong emotions and mental distress are experienced.-Self-esteem diminished at times, with overly critical or somewhat distorted self-appraisal.-Strong emotions may be distressing, associated with a restriction in range of emotional experience.-Excessively goal-directed, somewhat goal-inhibited, or conflicted about goals. -May have an unrealistic or socially inappropriate set of personal standards, limiting some aspects of fulfillment. -Able to reflect upon internal experiences, but may overemphasize a single (e.g., intellectual, emotional) type of self-knowledge.-Somewhat compromised in ability to appreciate and understand others experiences; may tend to see others as having unreasonable expectations or a wish for control.-Although capable of considering and understanding different perspectives, resists doing so.-Inconsistent is awareness of effect of own behavior on others.-Able to establish enduring relationships in personal and community life, with some limitations on degree of depth and satisfaction.-Capacity and desire to form intimate and reciprocal relationships, but may be inhibited in meaningful expression and sometimes constrained if intense emotions or conflicts arise. -Cooperation may be inhibited by unrealistic standards; somewhat limited in ability to respect or respond to others ideas, emotions and behaviors.

SELF INTERPERSONAL

LevelIdentitySelf-DirectionEmpathyIntimacy

2-Excessive dependence on others for identity definition, with compromised boundary delineation. -Vulnerable self-esteem controlled by exaggerated concern about external evaluation, with a wish for approval. Sense of incompleteness or inferiority, with compensatory inflated, or deflated, self-appraisal. -Emotional regulation depends on positive external appraisal. Threats to self-esteem may engender strong emotions such as rage or shame.-Goals are more often a means of gaining external approval than self-generated, and thus may lack coherence and/or stability. -Personal standards may be unreasonably high (e.g., a need to be special or please others) or low (e.g., not consonant with prevailing social values). Fulfillment is compromised by a sense of lack of authenticity. -Impaired capacity to reflect upon internal experience. -Hyper-attuned to the experience of others, but only with respect to perceived relevance to self. -Excessively self-referential; significantly compromised ability to appreciate and understand others experiences and to consider alternative perspectives.-Generally unaware of or unconcerned about effect of own behavior on others, or unrealistic appraisal of own effect.-Capacity and desire to form relationships in personal and community life, but connections may be largely superficial. -Intimate relationships are largely based on meeting self-regulatory and self-esteem needs, with an unrealistic expectation of being perfectly understood by others. -Tends not to view relationships in reciprocal terms, and cooperates predominantly for personal gain.

SELF INTERPERSONAL

LevelIdentitySelf-DirectionEmpathyIntimacy

3-A weak sense of autonomy/agency; experience of a lack of identity, or emptiness. Boundary definition is poor or rigid: may be over identification with others, overemphasis on independence from others, or vacillation between these. -Fragile self-esteem is easily influenced by events, and self-image lacks coherence. Self-appraisal is un-nuanced: self-loathing, self-aggrandizing, or an illogical, unrealistic combination. -Emotions may be rapidly shifting or a chronic, unwavering feeling of despair.-Difficulty establishing and/or achieving personal goals. -Internal standards for behavior are unclear or contradictory. Life is experienced as meaningless or dangerous. -Significantly compromised ability to reflect upon and understand own mental processes. -Ability to consider and understand the thoughts, feelings and behavior of other people is significantly limited; may discern very specific aspects of others experience, particularly vulnerabilities and suffering. -Generally unable to consider alternative perspectives; highly threatened by differences of opinion or alternative viewpoints. -Confusion or unawareness of impact of own actions on others; often bewildered about peoples thoughts and actions, with destructive motivations frequently misattributed to others.-Some desire to form relationships in community and personal life is present, but capacity for positive and enduring connection is significantly impaired.-Relationships are based on a strong belief in the absolute need for the intimate other(s), and/or expectations of abandonment or abuse. Feelings about intimate involvement with others alternate between fear/rejection and desperate desire for connection. -Little mutuality: others are conceptualized primarily in terms of how they affect the self (negatively or positively); cooperative efforts are often disrupted due to the perception of slights from others.

SELF INTERPERSONAL

LevelIdentitySelf-DirectionEmpathyIntimacy

4-Experience of a unique self and sense of agency/autonomy are virtually absent, or are organized around perceived external persecution. Boundaries with others are confused or lacking. -Weak or distorted self-image easily threatened by interactions with others; significant distortions and confusion around self-appraisal. -Emotions not congruent with context or internal experience. Hatred and aggression may be dominant affects, although they may be disavowed and attributed to others. -Poor differentiation of thoughts from actions, so goal-setting ability is severely compromised, with unrealistic or incoherent goals. -Internal standards for behavior are virtually lacking. Genuine fulfillment is virtually inconceivable. -Profound inability to constructively reflect upon own experience. Personal motivations may be unrecognized and/or experienced as external to self.-Pronounced inability to consider and understand others experience and motivation. -Attention to others' perspectives virtually absent (attention is hypervigilant, focused on need-fulfillment and harm avoidance). -Social interactions can be confusing and disorienting.-Desire for affiliation is limited because of profound disinterest or expectation of harm. Engagement with others is detached, disorganized or consistently negative. -Relationships are conceptualized almost exclusively in terms of their ability to provide comfort or inflict pain and suffering. -Social/interpersonal behavior is not reciprocal; rather, it seeks fulfillment of basic needs or escape from pain.

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Provisional map of specific core criteria (facet traits) into personality trait domains Personality Domains

I. Negative Affectivity II. Detachment III. Antagonism IV. Disinhibition V. Psychoticism

Core criteria (facet traits) 1. Emotional Lability X 2. Anxiousness X 3. Separation Insecurity X 4. Perseveration X 5. Submissiveness X 6. Hostility X X 7. Restricted Affectivity (- X) X 8. Depressivity X X 9. Suspiciousness X X 10. Withdrawal X 11. Anhedonia X 12. Intimacy Avoidance X 13. Manipulativeness X 14. Deceitfulness X 15. Grandiosity X 16. Attention Seeking X 17. Callousness X 18. Irresponsibility X 19. Impulsivity X 20. Rigid Perfectionism (- X) 21. Distractibility X 22. Risk Taking X 23. Unusual Beliefs & Experiences X 24. Eccentricity X 25. Cognitive and Perceptual Dysregulation X Note. X means that this core criterion is one way in which a broad personality domain is manifested in specific persons, and provisional data suggest the specific connections seen above. Sometimes, core criteria are connected with more than one domain, and this is indicated when more than one X appears in a given row. (-X) means that the absence of the core criterion is indicative of a specific personality domain.