Diagnosing personality disorders.
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Ambulatory Care↗
Biomedical subjects
D Westen
Publications and source records attributed to D Westen.
Personality profiles in eating disorders: rethinking the distinction between axis I and axis II.
OBJECTIVE: Like other DSM-IV axis I syndromes, eating disorders are diagnosed without respect to personality, which is coded on axis II. The authors assessed the utility of segregating eating disorders and personality pathology and examined the extent to which personality patterns account for meaningful variation within axis I eating disorder diagnoses. METHOD: One hundred three experienced psychiatrists and psychologists used a Q-sort procedure (the Shedler-Westen Assessment Procedure-200) that assesses personality and personality pathology to describe a patient they were currently treating for bulimia or anorexia. Data were subjected to a cluster-analytic procedure (Q-analysis) to determine whether patients clustered into coherent groupings on the basis of their personality profiles. Categorical and dimensional personality diagnoses were then used to predict measures relevant to adaptation and etiology, controlling for axis I diagnosis. RESULTS: Three categories of patients emerged: a high-functioning/perfectionistic group, a constricted/overcontrolled group, and an emotionally dysregulated/undercontrolled group. This categorization demonstrated substantial incremental validity beyond axis I diagnosis in predicting eating disorder symptoms, adaptive functioning (Global Assessment of Functioning scores and history of psychiatric hospitalization), and etiological variables (sexual abuse history). CONCLUSIONS: Axis I symptoms are a useful component, but only one component, in the accurate diagnosis of eating disorders. Classifying patients with eating disorders by eating symptoms alone groups together patients with anorexic symptoms who are high functioning and self-critical with those who are highly disturbed, constricted, and avoidant, and groups together patients with bulimic symptoms who are high functioning and self-critical with those who are highly disturbed, impulsive, and emotionally dysregulated. These distinctions may be relevant to etiology, prognosis, and treatment.
Adult↗
A multidimensional meta-analysis of treatments for depression, panic, and generalized anxiety disorder: an empirical examination of the status of empirically supported therapies.
The authors report a meta-analysis of high-quality studies published from 1990-1998 on the efficacy of manualized psychotherapies for depression, panic disorder, and generalized anxiety disorder (GAD) that bear on the clinical utility and external validity of empirically supported therapies. The results suggest that a substantial proportion of patients with panic improve and remain improved; that treatments for depression and GAD produce impressive short-term effects: that most patients in treatment for depression and GAD do not improve and remain improved at clinically meaningful follow-up intervals: and that screening procedures used in many studies raise questions about generalizability, particularly in light of a systematic relation across studies between exclusion rates and outcome. The data suggest the importance of reporting, in both clinical trials and meta-analyses, a range of outcome indices that provide a more comprehensive, multidimensional portrait of treatment effects and their generalizability. These include exclusion rates, percent improved, percent recovered, percent who remained improved or recovered at follow-up, percent seeking additional treatment at follow-up, and data on both completer and intent-to-treat samples.
Anxiety Disorders↗
Identity disturbance in borderline personality disorder: an empirical investigation.
OBJECTIVE: Identity disturbance is one of the nine criteria for borderline personality disorder in DSM-IV, yet the precise nature of this disturbance has received little empirical attention. This study examines 1) the extent to which identity disturbance is a single construct, 2) the extent to which it distinguishes patients with borderline personality disorder, and 3) the role of sexual abuse in identity disturbance in patients with borderline personality disorder. METHOD: The authors constructed an instrument that consisted of 35 indicators of identity disturbance culled from relevant clinical and theoretical literature and asked clinicians to rate a patient on each of the items. The patient group consisted of 95 subjects diagnosed with borderline personality disorder (N=34), another personality disorder (N=20), or no personality disorder (N=41). Relevant diagnostic, demographic, and developmental history data were also collected. The authors used factor analysis to ascertain whether identity disturbance is a unitary construct and then examined the relation between dimensions of identity disturbance and borderline diagnosis after controlling for sexual abuse history. RESULTS: Four identity disturbance factors were identified: role absorption (in which patients tend to define themselves in terms of a single role or cause), painful incoherence (a subjective sense of lack of coherence), inconsistency (an objective incoherence in thought, feeling, and behavior), and lack of commitment (e.g., to jobs or values). All four factors, but particularly painful incoherence, distinguished patients with borderline personality disorder. Although sexual abuse was associated with some of the identity factors, particularly painful incoherence, borderline pathology contributed unique variance beyond abuse history to all four identity disturbance factors. The data also provided further evidence for an emerging empirical distinction between two borderline personality disorder types: one defined by emotional dysregulation and dysphoria, the other by histrionic characteristics. CONCLUSIONS: Identity disturbance is a multifaceted construct that distinguishes patients with borderline personality disorder from other patients. Some of its components are related to a history of sexual abuse, whereas others are not. Identity disturbance appears to be characteristic of borderline patients whether or not they have an abuse history.
Borderline Personality Disorder↗
A prototype matching approach to diagnosing personality disorders: toward DSM-V.
The current diagnostic system for personality disorders (PD) has a number of problems that may require a thorough revision for DSM-V. This article (a) outlines problems with the current taxonomy that suggest the need for a different approach to PD diagnosis that preserves the strengths of the current system while addressing some inherent weaknesses; (b) discusses key issues that must be addressed in moving toward DSM-V, such as revising the distinction between Axis I and Axis II and combining categorical and dimensional diagnosis; and (c) describes a prototype matching approach to diagnosis, which we believe has the potential to be both psychometrically sound and faithful to the clinical data.
Humans↗
Revising and assessing axis II, Part I: developing a clinically and empirically valid assessment method.
OBJECTIVE: Personality pathology is difficult to measure. Current instruments have problems with validity and rely on a direct-question format that may be inappropriate for the assessment of personality. In addition, they are designed specifically to address current DSM-IV categories and criteria, which limits their utility in making meaningful revisions of those criteria. These problems suggest the need for consideration of alternative approaches to assessing and revising axis II. METHOD: This article describes the development and validation of an assessment tool designed to allow clinicians to provide detailed, clinically rich personality descriptions in a systematic and quantifiable form (the Shedler-Westen Assessment Procedure, or SWAP-200). A total of 797 randomly selected psychiatrists and psychologists used the SWAP-200 to describe either an actual patient or a hypothetical, prototypical patient with one of 14 personality disorders (one of the 10 DSM-IV axis II disorders or one of four disorders included in the appendix or in DSM-III-R) or a healthy, high-functioning patient. RESULTS: The data yielded aggregated descriptions of actual patients in each diagnostic category (N = 530) as well as aggregated descriptions of hypothetical, prototypical patients (N = 267). SWAP-200 descriptions of patients with personality disorders showed high convergent and discriminant validity on a variety of criteria. The diagnostic procedure lends itself to both categorical and dimensional personality disorder diagnoses. Descriptions of individual patients resemble MMPI profiles, based on the degree of match between the patient's profile and a criterion group, except that they are based on clinician observation rather than self-report. CONCLUSIONS: The SWAP-200 represents an approach to the measurement and classification of personality disorders that has potential for refining axis II categories and criteria empirically in ways that are both psychometrically and clinically sound.
Adult↗
Revising and assessing axis II, Part II: toward an empirically based and clinically useful classification of personality disorders.
OBJECTIVE: The DSM-IV classification of personality disorders has not proven satisfying to either researchers or clinicians. Incremental changes to categories and criteria using structured interviews may no longer be useful in attempting to refine axis II. An alternative approach that quantifies clinical observation may prove useful in developing a clinically rich, useful, empirically grounded classification of personality pathology. METHOD: A total of 496 experienced psychiatrists and psychologists used the Shedler-Westen Assessment Procedure-200 (SWAP-200) to describe current patients diagnosed with axis II personality disorders. The SWAP-200 is an assessment tool that allows clinicians to provide detailed, clinically rich descriptions of patients in a systematic and quantifiable form. A statistical technique, Q-analysis, was used to identify naturally occurring groupings of patients with personality disorders, based on shared psychological features. The resulting groupings represent an empirically derived personality disorder taxonomy. RESULTS: The analysis found 11 naturally occurring diagnostic categories, some of which resembled current axis II categories and some of which did not. The findings suggest that axis II falls short in its attempt to "carve nature at the joints": In some cases it puts patients who are psychologically dissimilar in the same diagnostic category, and in others it makes diagnostic distinctions where none likely exist. It also fails to recognize a large category of patients best characterized as having a dysphoric personality constellation. The empirically derived classification system appears to be more faithful to the clinical data and to avoid many problems inherent in the current axis II taxonomy. CONCLUSIONS: The approach presented here may be helpful in refining the existing taxonomy of personality disorders and moving toward a system of classification that lies on a firmer clinical and empirical foundation. In addition, it can help to bridge the gap that often exists between research and clinical approaches to personality pathology.
Factor Analysis, Statistical↗
The scientific status of unconscious processes: is Freud really dead?
At regular intervals for over half a century, critiques of Freud and psychoanalysis have emerged in the popular media and in intellectual circles, usually declaring that Freud has died some new and agonizing death, and that the enterprise he created should be buried along with him like the artifacts in the tomb of an Egyptian king. Although the critiques take many forms, a central claim has long been that unconscious processes, like other psychoanalytic constructs, lack any basis in scientific research. In recent years, however, a large body of experimental research has emerged in a number of independent literatures. This work documents the most fundamental tenet of psychoanalysis--that much of mental life is unconscious, including cognitive, affective, and motivational processes. This body of research suggests some important revisions in the psychoanalytic understanding of unconscious processes, but it also points to the conclusion that, based on controlled scientific investigations alone (that is, without even considering clinical data), the repeated broadside attacks on psychoanalysis are no longer tenable.
Cause of Death↗
Limitations of axis II in diagnosing personality pathology in clinical practice.
OBJECTIVE: DSM-IV's axis II is limited to severe personality disturbances, posing difficulty for diagnosing less severe but nonetheless clinically significant personality pathology. The authors examined the percentage of patients treated in clinical practice for personality pathology who are diagnosable with DSM-IV. METHOD: Psychiatrists and psychologists from a random national sample provided diagnostic data on 714 patients treated for enduring, maladaptive personality patterns. RESULTS: Only 39.4% of the patients had diagnosable axis II disorders. This percentage was relatively stable across clinicians' theoretical orientations and did not vary substantially when axis I diagnosis was controlled for. CONCLUSIONS: DSM-IV cannot be used to diagnose most patients being treated for personality problems. The range of axis II should be broadened to encompass the range of personality pathology seen in clinical practice.
Adult↗
Refining the measurement of axis II: a Q-sort procedure for assessing personality pathology.
The measurement of personality disorders (PDs) has proven to be a difficult enterprise. This article describes two initial studies of the validity and reliability of the Shedler-Westen Assessment Procedure (SWAP), a Q-sort procedure that quantifies clinical judgment, which may be useful both for assessing personality pathology and for empirically refining Axis II categories and diagnostic criteria. In the first study, 153 clinicians from a random national sample used a version of the Q-sort to describe either a prototype or actual patient with either a borderline, antisocial, histrionic, or narcissistic personality disorder. Correlations between aggregated prototype and actual patient profiles provided evidence for convergent and discriminant validity, and a cluster-analytic procedure (Q-factor analysis) produced revised criteria for the four disorders that minimized the problem of comorbidity. In Study 2, a pilot sample of patients were interviewed using a clinical research interview that mirrors the way clinicians assess personality and PDs. The study yielded promising results with respect to the possibility of obtaining reliable Q-sort descriptions based on an interview that resembles a clinical interview rather than the direct-question format used in current Axis II structured interviews. It also produced strong correlations between Q-sort descriptions made by interview and those made independently by the treating clinician, further supporting the validity of the instrument. The findings suggest the potential utility of the SWAP as a measure of PDs and as a method for empirically refining Axis II categories and criteria.
Adult↗
Affect regulation and affective experience: individual differences, group differences, and measurement using a Q-sort procedure.
This article describes the development of, and preliminary findings with, the Affect Regulation and Experience Q-Sort (the AREQ), an observer-based assessment of affect regulation and experience. In Study 1, 31 clinicians provided Q-sort descriptions of 90 patients. Factor scores correlated in predicted ways with criteria such as suicide attempts and hospitalizations, as well as with clinicians' ratings of functioning in a variety of domains. Correlations between prototype Q-sorts and actual Q-sort profiles for patients sharing a diagnosis (dysthymia, borderline personality disorder, and narcissistic personality disorder) also provided evidence for convergent and discriminant validity. The data also suggested the importance of distinguishing 2 kinds of negative affect that have very different correlates. Study 2 showed that the AREQ can be applied reliably using an interview that avoids many of the problems of self-report.
Adult↗
Divergences between clinical and research methods for assessing personality disorders: implications for research and the evolution of axis II.
OBJECTIVE: The purpose of this study was to examine the extent to which instruments for assessing axis II diverge from clinical diagnostic processes. METHOD: Subjects in the first study were 52 clinicians with experience in assessment and treatment of patients with personality disorders, who were surveyed about the methods they use in clinical practice to make diagnoses and other aspects of the diagnostic process. A second study replicated the major findings with a random national sample of 1,901 experienced psychiatrists and psychologists. RESULTS: Whereas current instruments rely primarily on direct questions derived from DSM-IV, clinicians of every theoretical persuasion found direct questions useful for assessing axis I disorders but only marginally so for axis II. They made axis II diagnoses, instead, by listening to patients describe interpersonal interactions and observing their behavior with the interviewer. In contrast to findings with current research instruments, most patients with personality disorders in clinical practice receive only one axis II diagnosis, and if they receive more than one, one is considered primary. Clinicians reported treating a substantial number of patients for enduring personality patterns that current axis II instruments do not assess, many of which meet neither axis I nor axis II criteria, notably problems with relatedness, work, self-esteem, and chronic subclinical depressive traits. CONCLUSIONS: Measurements of axis II were constructed by using a model derived from axis I instruments that diverges from clinical diagnostic procedures in a way that may be problematic for the assessment of personality disorders and the development of a more clinically and empirically sound taxonomy.
Algorithms↗
Towards a clinically and empirically sound theory of motivation.
The author outlines a theory of motivation that attempts to integrate psychoanalytic theory with current psychological thinking and research. Emotions and other sensory feeling states are evolved mechanisms for channelling behaviour in directions that foster adaptation. The avoidance of unpleasant states and pursuit of pleasant ones leads to goal-directed mental and behavioural processes, including defences and compromise formations. Affects provide a flexible motivational mechanism in humans, as they become associated with representations of perceived, feared, wished-for, or otherwise valued states through the interaction of environmental events and highly specific naturally-selected biological proclivities. This reconceptualisation of motivation points towards a resolution of a contradiction in Freud's models of affect and motivation between a theory of drive-reduction and a theory of affect regulation, and of the apparent contradiction between motivational models that emphasise either sexual desire or relational needs. The model also has implications for the theory of transference, since it suggests that neutrality is not the feature of the analytic situation that evokes meaningful transferential processes.
Adaptation, Psychological↗
A clinical-empirical model of personality: life after the Mischelian ice age and the NEO-lithic era.
A theory of personality should lead to both accurate prediction and interpretive understanding. Aside from its empirical uses, a personality theory should provide a grammar that allows personality psychologists to infer meaning from overt behavior with more sophistication than a layperson, and the best laboratory for testing the interpretive utility of a personality theory remains the clinic. With respect to the appropriate data for constructing and evaluating theories of personality, an overreliance on questionnaire data is problematic for several reasons: It assumes that understanding people requires no training, it mistakes research on the conscious self-concept for research on personality, it conflates implicit and explicit knowledge, it fails to address defensive biases, and it lacks interrater reliability. Consideration of both empirical and clinical data points to three questions that define the elements of personality necessary for a comprehensive assessment of an individual: (a) What psychological resources--cognitive, affective, and behavioral dispositions--does the individual have at his or her disposal? (b) What does the person wish for, fear, and value, and how do these motives combine and conflict? (c) How does the person experience the self and others, and to what extent can the individual enter into intimate relationships?
Affect↗
Maternal empathy, family chaos, and the etiology of borderline personality disorder.
Psychoanalytic writers have traced the etiology of borderline personality disorder (BPD) to be a preoedipal disturbance in the mother-child relationship. Despite the prevalence of theories focusing on the role of mothering in the development of BPD, few empirical studies have tested the hypothesis that borderlines were the recipients of unempathic mothering. The current preliminary study compared 13 mothers of borderline adolescents with 13 mothers of normal adolescents. This study found that mothers of borderlines tended to conceive of their children egocentrically, as need-gratifying objects, rather than as individuals with distinct and evolving personalities. This study also found that the mothers of borderlines reported raising their daughters in extremely chaotic families struggling to cope with multiple hardships, including divorce and financial worries. The stressful environmental circumstances reported by the mothers likely affected the borderline daughters directly as well as the mothers' ability to parent effectively and empathically. The results of this study suggest that, as predicted by psychoanalytic theory, a problematic mother-child relationship may play a significant role in the genesis of borderline pathology; however, the life circumstances that contextualize the mother-child relationship also need to be considered when accounting for the etiology of BPD.
Adolescent↗
The quality of depression in adolescents with borderline personality disorder.
OBJECTIVE: The quality of depression in borderline adolescent girls was compared with the quality of depression in depressed, nonborderline girls. Psychoanalytic theories led us to expect signs of anaclitic depression in borderlines as well as a depressive sense of being "all bad." METHOD: Quality of depression was examined by means of Rorschach content analysis and the Depressive Experiences Questionnaire (DEQ). Borderline girls were expected to show greater Rorschach imagery pertaining to oral dependency and oral aggression than would depressed, nonborderline control girls. The borderline diagnosis was based on the Diagnostic Interview for Borderlines. DSM-III-R criteria were used to diagnose depression. Subjects were psychiatric inpatients, ages 14 to 18 years. RESULTS: As expected, it was found that borderline girls scored significantly higher than did controls on Rorschach scales of oral dependency; borderlines scored significantly higher on DEQ factors of dependency and self-criticism. Significant DEQ items reflected the borderlines' abandonment fears. CONCLUSIONS: This study provides empirical support for anaclitic depression in borderline adolescents, and suggests the presence of underlying fears in borderlines of being fundamentally evil or bad.
Adolescent↗
Clinical assessment of object relations and social cognition using stories told to the picture arrangement subtest of the WAIS-R.
For many years clinicians have supplemented the Wechsler Adult Intelligence Scale-Revised (WAIS-R; Wechsler, 1981) Picture Arrangement (PA) subtest by asking subjects to "tell the story" made by the sequence of cards. Doing so allows assessment of the underlying reasoning behind the subject's response and adds a projective element to the task. This article describes a method for systematically assessing several dimensions of object relations and social cognition from the stories subjects tell to the PA subtest. Six scales, which have been validated in several studies, are described: Episode Integration, Accuracy of Causal Attributions, Affect-Tone of Relationship Paradigms, Capacity for Emotional Investment in Relationships and Moral Standards, Complexity of Representations, and Accuracy of Character Ascriptions. Evidence for convergent and discriminant validity is presented by comparing PA scale scores of reliably diagnosed borderline inpatients, depressed inpatients, and normal comparison subjects, with scores from self-report instruments measuring symptomatology and social adjustment. Clinical use of the scales is then illustrated by applying them to PA story texts of a borderline patient and a normal subject.
Adult↗
Malevolence, splitting, and parental ratings by borderlines.
Malevolent object relations as well as splitting have long been considered by psychodynamic theorists as central features of borderline personality disorder. We tested the hypotheses that borderlines would a) perceive their parents more negatively than both nonborderline major depressive patients and nonpatient normal controls, and b) split their representations of their parents into opposites more than the comparison subjects. Borderlines (N = 31), who were identified by the Diagnostic Interview for Borderlines, Research Diagnostic Criteria major depressives (N = 15), and nonpatient controls (N = 14) were asked to rate each parent on the Adjective Check List (ACL; Gough and Heilbrun, 1983). Seven ACL scales were studied: Favorable, Unfavorable, Critical Parent, Nurturing Parent, Nurturance, Aggression, and Dominance. Correlations were performed between scores for mother and father on the various scales for each of the three cohorts. Analysis of variance and one-way t-tests with Bonferroni correction were used to test group differences. Borderlines rated their parents, especially their fathers, not only as more unfavorable on negative scales than depressives or normals, but as less favorable on positive scales than the comparison groups. Analysis of covariance revealed that a significant portion of the variance in father scores, but not in mother scores, was related to age of respondent and history of sexual abuse. While borderlines did not appear to split their parents into one good and one bad parent, they did show significantly less correlation between parents on the Favorable scale when compared with either depressives or normal subjects. The results imply that borderlines have a greater tendency to view the world in negative, malevolent ways than to split their object representations.
Adult↗