The DSM5, ICD-10-11 and PDM: Concepts of Personality, Ethics and Validity

1. The DSM5, ICD-10-11 and PDM: Concepts of Personality, Ethics and Validity PPA Fall 2012 Ethics Workshop We 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

2. Outline • What is diagnosis and why diagnose? • Case example of a ethical and risk management issue over Dx. • Big changes in DSM 5’s 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.

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

4. Start with a good diagnostic formulation “Once I have a good feel for the person, the work is going well, I stop thinking diagnostically and simply immerse myself in the unique relationship that unfolds between me and the client…one can throw away the book and savor individual uniqueness.” Nancy McWilliams (2011) Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process, Second Edition.

5. 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.”

6. 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. 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.

7. 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. It’s value in process and outcome research.

8. Personality Structure and Treatment • McWilliams 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.

9. Why 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.

10. “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.

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

12. “My Psychologist Abandoned Me!”Patient claiming millions of dollars in damages • Middle 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.

13. Complaint to Licensing Board and Civil Suit for Damages • At 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 hospitalization • Psychologist 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.

14. Patient using sessions for sadomasochistic gratification • Constantly testing the boundaries and insisting on frequent phone contact between sessions • Threatening suicide, but refusing to be cooperative with the treatment plan • Idealizing the therapist and fearing his abandonment while devaluing the treatment • Infuriating the therapist with complaints about his not helping her, while she was resisting treatment (projective identification)

15. Admission 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 patient’s overall condition had continued to decline…”

16. Mental 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…”

17. Mental health outpatient note by subsequent therapist con’t: • “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 65…”

18. Whether Therapist Y appropriately terminated his treatment of Patient X. “The APA ethics committee and state licensing board hearing both rejected Patient X’s 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 doesn’t want other therapists and she doesn’t want to get better.”

19. “Whether 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.”

21. Throw Away Occam’s Razor (law of parsimony) • Clinicians should follow the general rule of recording as many diagnoses as are necessary to cover the clinical picture. • Hickam's Dictum: "Patients can have as many diseases as they damn well please" John Hickam, MD. • When recording more than one diagnosis, it is usually best to give the main diagnosis, and to label any others as subsidiary or additional diagnoses.

22. 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 Problems Axis V: Global Assessment of Functioning client's overall level of functioning

23. DSM 5 • The 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.

24. DSM IV’s 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.

25. DSM IV Axis IIPoor 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 (O’Connor, 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?)

26. 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)

27. 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

28. DSM 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.

29. 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).

30. 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).

31. 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.

32. 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 individual’s personality trait expression are relatively stable across time and consistent across situations. D. The impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s developmental stage or socio-cultural environment. E. The impairments in personality functioning and the individual’s 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).

34. 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 functioningimpairment, ranging from no impairment, i.e., healthy functioning (Level = 0) to extreme impairment (Level = 4)

40. 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 Disorder • T 01 Obsessive-Compulsive Personality Disorder • T 02 Avoidant Personality Disorder • T 03 Schizotypal Personality Disorder • T 04 Antisocial Personality Disorder (Dyssocial Personality Disorder) • T 05 Narcissistic Personality Disorder • T 06 Personality Disorder Trait Specified

41. DSM5: 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.  AND 2.   Impairments in interpersonal functioning (a or b): a.   Empathy: Lack of concern for feelings, needs, or suffering of others; lack of remorse after hurting or mistreating another. b.   Intimacy: Incapacity for mutually intimate relationships, as exploitation is a primary means of relating to others, including by deceit and coercion; use of dominance or intimidation to control others.

42. B.   Pathological personality traits in the following domains: 1.   Antagonism, characterized by: a.   Manipulativeness b.   Deceitfulness c.   Callousness d.   Hostility 2.   Disinhibition, characterized by: a.   Irresponsibility b.   Impulsivity c.   Risk taking

43. DSM 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 abandonment • A pattern of unstable and intense interpersonal relationships-"splitting" • Identity disturbance: unstable self-image • Impulsivity in at least two areas that are potentially self-damaging • Recurrent suicidal behavioror self-mutilating behavior • Affective instability • Chronic feelings of emptiness • Inappropriate, intense anger or difficulty controlling anger • Paranoid ideation or dissociative symptoms

44. DSM 5: T 00 Borderline Personality Disorder- now Degree A.   Significant impairments in personality functioning manifest by: 1.  Impairments in self functioning (a or b): a. Identity: Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress.  b.Self-direction: Instability in goals, aspirations, values, or career plans. AND  2.   Impairments in interpersonal functioning (a or b): a.   Empathy b.   Intimacy B.  Pathological personality traits in the following domains: 1.   Negative Affectivity, characterized by: a.   Emotional lability b.   Anxiousness c.   Separation insecurity d.   Depressivity 2.   Disinhibition, characterized by: a.   Impulsivity b.   Risk taking 3.   Antagonism, characterized by: a.   Hostility

45. 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.

46. 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.

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

49. Rate the twenty-five specific trait facets comprising the five domains Negative Affectivity • Emotional lability • Anxiousness • Separation insecurity • Perseveration • Submissiveness • Hostility • Depressivity • Suspiciousness

50. Detachment • Restricted affectivity • Withdrawal • Anhedonia • Intimacy avoidance