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Controversy in Personality Disorder Assessment

Controversy in Personality Disorder Assessment. As evidenced by Borderline Personality Disorder. What is a Personality Disorder?.

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Controversy in Personality Disorder Assessment

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  1. Controversy in Personality Disorder Assessment As evidenced by Borderline Personality Disorder

  2. What is a Personality Disorder? • According to the DSM-IV-TR, Personality Traits are “enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts.

  3. What is a Personality Disorder? • Personality is said to be disordered when it deviates markedly from cultural expectations, it is inflexible, and pervasive across situations, is stable and of long duration and causes clinically significant distress or impairment. (DSM-IV-TR)

  4. How are Personality Disorders Measured? • FFM (NEO-PI-R and others) • MMPI • DSM • Rorschach • Just to give some examples

  5. Personality Disorder Controversy • Just as with many DSM diagnoses, there is much controversy over Personality Disorders and the ways in which they are understood, assessed, and treated.

  6. Categorical vs. Dimensional Approach to Understanding • Huprich and Bornstein • Widiger and Lowe define the types of disorders for which DSM style categorical approach works best, and how PDs don’t fit into this model. • Bernstein ‘07 looks ahead to PDs in the DSM-V • 74% of PD experts prefer a categorical approach • Co-morbidity (With both other PDs and Axis I disorders)

  7. Problems in Personality Disorder Assessment • Many assessment measures rely on self-report, which can prove problematic. (Huprich and Ganellen) • Terminology is that of abstract constructs, and the patient may not understand the terms, or may not understand them in the same way the clinician does • All patients may intentionally or unconsciously misrepresent themselves in self-reports, but this is especially problematic when working with Personality disordered individuals who may not have an accurate self-concept, and may not think their personality is disordered

  8. Problems in Personality Disorder Assessment • Similarly, reports from others connected to the patient may not be trustworthy, either. • Agreement problems between informants • Understanding of concepts and terminology • Reporter’s own personality pathology might interfere

  9. Stability • Of diagnoses over time • Based on DSM-IV criteria, diagnoses have not been shown to be stable over a 12 month period.

  10. Other Methodological Issues • Problems with patient vs. non-patient samples. (Huprich and Bornstein ‘07) • Most measures look at behavior not at the underlying psychological constructs, which can each get at different presentations of a disorder. (Shedler&Westen) • Most do not take clinical expertise into account. (Shedler & Westen)

  11. Treatment • Treatment of personality disorder can vary greatly depending on the theoretical orientation used • Treatment also varies considerably by particular PD, so we’ll talk about this in terms of Borderline PD later.

  12. Borderline Personality Disorder • Borderline Personality Disorder is characterized by “instability in interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early adulthood and is present in a viariety of contexts.” (DSM-IV-TR)

  13. Assessment of Borderline Personality Disorder • Terminology problematic (“intense” etc.) • Self-image is disturbed with BLPD (DSM criterion 3) and mood is extremely labile (DSM Criterion 6) • Problems in assessing suicidality as imminent as it may be with BLPD (DSM criterion 5) • Transient dissociative/Paranoid ideation sx (criterion 9)

  14. Assessment of Borderline Personality Disorder • Reports from others are also likely to be biased/inaccurate • Idealization/Devaluation Criterion 2

  15. BLPD as dimensional, not categorical • Taxometric analysis shows that BLPD is better conceptualized as a continuous entity, not a latent category. • Bernstein ‘07 says that experts on PD want to do away with the term “Borderline” in the DSM-V • Only 31% want to see it kept

  16. Gender and Ethical Bias • Delphin article

  17. How to effectively treat • DBT and CBT • What treatment from a developmental/attachment, or analytic perspective? • Medication from a biological perspective

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