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Presenters: Robert M. Gordon, Ph.D.

,
& Alan C. Tjeltveit, Ph.D.

1
Educational Objectives:
Learn about the ethical issues involved with making
and using a diagnosis, learn about the DSM-5, ICD-10
and PDM, and learn how to integrate these systems.
Goals:
Understand the ethical and risk issues involved in not
diagnosing accurately, identify the ethical issues
associated with how we (and others) use diagnoses,
and learn the difference between diagnosis as a label
of disease as compared to diagnosis as a means to
understand in order to better help.

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What we will NOT do today
Lecture you about the gross
ethical violations that many of
youthrough ignorance, malice,
or bothroutinely commit and

should STOP doing

Provide precise, foolproof, 100%


certain answers to all ethical
dilemmas
What We Will Do
Delineate general ethical principles and
specific ethical standards of relevance to any
diagnostic approach
Contend that the best ethical clinical practice
involves careful thought about diagnosis; there
are many ways to practice well
Discuss some ways of thinking that may help
you best practice in accord with professional
ethical principles and standards and your own
approaches to your practice and/or research
Diagnostic Systems
The DSMit is claimedis the Bible of diagnosis
NIMH Director Thomas Insel declared on April 29,
2013, that
While DSM has been described as a Bible for
the field, it is, at best, a dictionary
The DSMs weakness is its lack of validity
NIMH will be re-orienting its research away from
DSM categories
http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml
Thomas Insel
Director, NIMH
Official picture

Note what hes


leaning on

Source of photo: Herper, 2013


NIMHs alternative
Research Domain Criteria (RDoC)
http://www.nimh.nih.gov/research-funding/rdoc/nimh-
research-domain-criteria-rdoc.shtml
Draft Research Domain Criteria
Negative Valence Systems Working memory
Acute threat (fear) Cognitive (effortful) control
Potential threat (anxiety) Systems for Social Processes
Sustained threat Affiliation and attachment
Loss Social Communication
Frustrative nonreward Perception & Understanding of
Positive Valence Systems Self
Approach motivation Agency
Initial responsiveness to reward Self-Knowledge
Sustained responsiveness to Perception & Understanding of
reward Others
Reward learning Arousal and Regulatory Systems
Habit Arousal
Cognitive Systems Circadian Rhythms
Attention Sleep and wakefulness
Perception
Research Domain Criteria: Is anything
relevant to diagnosis left out?

Agency Narrative
Persons Meaning
The Self Spirituality
Personality Ethics
Relationships ?
Community
Culture
Research Domain Criteria
Some see this as praiseworthy scientific progress
The chair of the Psychiatry Department at Columbia
asserts that psychiatry needs to base its decisions more
on biology, and less on behavior (Herper, 2013)
Some psychologists see RDoC as either biological
reductionism or slanted toward biological causation
Given the current state of the research, the RDoC can
be read primarily as a promissory note, which is backed
up by an ideology which holds that:
1. Psychological problems are medical problems
2. Medical problems are, at root, biological problems
3. Real cures will only come at the root level
NIMH director & the American Psychiatric
Association president-elect, May 14, 2013
Today, the DSM [no number], along with the ICD
represents the best information currently available for
clinical diagnosis of mental disorders. Patients, families, and
insurers can be confident that effective treatments are
available and that the DSM is the key resource for delivering
the best available care. The National Institute of Mental
Health (NIMH) has not changed its position on DSM-5
[which was?]. As NIMH's Research Domain Criteria (RDoC)
project website states, "The diagnostic categories represented
in the DSM-IV [!] and the International Classification of
Diseases-10 (ICD-10, containing virtually identical disorder
codes) remain the contemporary consensus standard for how
mental disorders are diagnosed and treated.
http://www.nimh.nih.gov/news/science-news/2013/dsm-5-and-rdoc-shared-
interests.shtml?utm_source=govdelivery&utm_medium=email&utm_campaign=govdelivery , emendations by Rick Froman
Why does this matter?
Whatever diagnostic system we use
Behavior analytic
ICD: 9, 9-CM, 10, or (beginning in 2015) 11
DSM: IV-TR or 5
RDoC
we face ethical issues regarding diagnosis
The current controversy over the DSM-5 is an
opportunity to reflect deeply on diagnosis in
relationship to professional ethics
Case: Carlos
18-year-old high school junior (getting Cs) in the technical
track of an underfunded under-performing school district
in which 80% of the students are below the poverty line
Came from the Dominican Republic at 10 & mainstreamed
Tested as having an IQ of 69 at 12 (no IEP; unclear why)
Parents are divorced, one older brother is in prison
Has a girl friend (theyre in a band together)
After his best friend was killed in a car accident, he was
deeply depressed for 10 days (full range of symptoms)
Had pre-18 scrapes with the law (weapon & mj possession)
Wants to join the army after high school
What are the ethical issues associated with diagnosing Carlos?
Ethical Principles & Standards
Relevant to Diagnosis
Their intent is to guide and inspire psychologists
toward the very highest ethical ideals of the
profession
Principle A: Beneficence and Nonmaleficence
Psychologists strive to
benefit those with whom they work and
take care to do no harm
How can optimal diagnosis benefit
Better understanding/ Better research
assessment Combats client isolation
Better treatment: (Im not the only one)
what to do Helps connect individuals
how to be (e.g., patient) with others having similar
how to relate
problems (those whove
(relationship style) been there) so they can
receive
Better communication
social support
among professionals and
with clients challenge
How can diagnosis harm?
Diagnosis may
Harm clients
Harm family members and friends
Harm society
Harm may be (& probably usually is) unintentional
Harm may stem from a clients interpretation of the dx
Harm may stem from how others use and interpret
diagnoses
How may diagnosis harm?
Leads to less than optimal, Create unwarranted guilt or
ineffective, or harmful shame
treatment Focus attention away from
Leads to misunderstanding key dimensions of a
persons and their problems persons problems
Labels may stick Convince a person to accept
Stigma as natural (& hence
Damage a persons self- inevitable) what they can,
understanding in fact, change
Make it more difficult or
Decrease client
responsibility/motivation cost more to get health
to change and/or life insurance
How may diagnosis harm?
Result in not being hired
Job loss
Living down to
expectations associated
with a diagnosis
Increased health care costs
Increase expenses to
Clients
Employers
Society
?
Principle B: Fidelity and Responsibility
Psychologists are aware of their professional and
scientific responsibilities to society and to the specific
communities in which they work
Psychologists seek to manage conflicts of interest
that could lead to exploitation or harm
Standard 3. Human Relations
3.06 Conflict of Interest
Psychologists refrain from taking on a professional
role when personal, scientific, professional, legal,
financial or other interests or relationships could
reasonably be expected to (1) impair their objectivity,
competence or effectiveness in performing their
functions as psychologists

American Psychological Association. (2010). Ethical principles of


psychologists and code of conduct. Retrieved from
http://apa.org/ethics/code/index.aspx
Figure 1. Comparison of financial conflicts of interest among DSM-IV and DSM-5 task force and
work group members.

Cosgrove L, Krimsky S (2012) A Comparison of DSM-IV and DSM-5 Panel Members' Financial Associations with Industry: A Pernicious
Problem Persists. PLoS Med 9(3): e1001190. doi:10.1371/journal.pmed.1001190
http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001190
Principle C: Integrity
Psychologists seek to promote accuracy,
honesty, and truthfulness in the science,
teaching and practice of psychology
Insurance fraud?
Principle D: Justice
Psychologists recognize that fairness and
justice entitle all persons to access to and
benefit from the contributions of psychology
and to equal quality in the processes,
procedures and services being conducted by
psychologists. Psychologists exercise
reasonable judgment and take precautions to
ensure that their potential biases do not lead
to or condone unjust practices
Principle E: Respect for People's Rights and Dignity
Psychologists are aware that special safeguards may be
necessary to protect the rights and welfare of persons or
communities whose vulnerabilities impair autonomous
decision making
Psychologists are aware of and respect cultural, individual
and role differences, including those based on age, gender,
gender identity, race, ethnicity, culture, national origin,
religion, sexual orientation, disability, language and
socioeconomic status and consider these factors when
working with members of such groups
Psychologists try to eliminate the effect on their work of
biases based on those factors, and they do not knowingly
participate in or condone activities of others based upon
such prejudices
Standard 9. Assessment
9.01 Bases for Assessments
(a) Psychologists base the opinions contained in their
diagnostic statements on information sufficient to
substantiate their findings. (See also Standard 2.04,
Bases for Scientific and Professional Judgments.)
Standard 2. Competence
2.04 Bases for Scientific and Professional Judgments
Psychologists' work is based upon established
scientific and professional knowledge of the discipline
Exercise in Psychodiagnoses
Learn about:
Personality organization
Personality patterns
Strengths and weaknesses
Emergent symptoms
Cultural and Contexual issues
Issues related to ethical and risk issues
Countertransference and boundary issues
Contribute to the science of psychological taxonomy.
Participation is voluntary.
26
What Taxonomic Organization for
Mental and Behavioral Science?
Like a Biological
Like a Periodic Table?
Organization?

27
28
Start with a good diagnostic formulation
Once I have a good feel for the person, the work is
going well, I stop thinking diagnostically and
simply immerse myself in the unique relationship
that unfolds between me and the clientone can
throw away the book and savor individual
uniqueness.
Nancy McWilliams (2011) Psychoanalytic Diagnosis: Understanding
Personality Structure in the Clinical Process, Second Edition.

29
Main Reasons for Diagnosing
1. Its usefulness for treatment planning. Understanding
character styles help the therapist be more careful with
boundaries with a histrionic patient, more pursuant of
the flat affect with the obsessional person, and more
tolerant of silence with a schizoid client.
2. Its implications for prognosis. Realistic goals protect
patients from the demoralization and therapist from
burnout.

30
Why Diagnose?
3. Its value in enabling the therapist to convey empathy.
Once one knows that a depressed patient also has a
borderline rather neurotic level personality structure, the
therapist will not be surprised if during the second year of
treatment she makes a suicide gesture.
Or once a borderline client starts to have hope of real
change, that the borderline client often panics and flirts
with suicide in an effort to protect himself from
traumatic disappointment.

31
Why Diagnose?
4. Its role in reducing the probability that certain
easily frighten people will flee from treatment. It
is helpful for the therapist to communicate to
hypomanic or counter-dependent patients an
understanding of how hard it may be for them to
stay in therapy.

32
Why Diagnose?
5. Its value in risk management. Often therapists
mistakenly use a presenting symptom as the only
diagnosis and missed the borderline level of
personality or psychopathic personality and got
into trouble.
6. Its value in process and outcome research.

33
Risk Factors in Litigious Patients
Borderline Personality Organization
Psychopathic traits
History of acting out

34
I have often served as an expert witness in malpractice
cases where psychologists had missed the psychopathic
or borderline traits in patients.
The DSM classifies antisocial and borderline
personality disorders by precise and narrow symptoms.
This is often misleading. Psychopathy can be a complex
personality pattern that combines with or is obscured
by other personality patterns, and borderline can be
viewed as an entire level of personality organization
that can be applied to the various personality disorders.

Gordon, R.M., (2007) PDM Valuable in Identifying High-Risk Patients. The National Psychologist, 16, 6,
November/December, page 4.

35
Which Diagnostic Taxonomy
Should We Use?
DSM5?
ICD-10?
PDM?

36
DSM 5
The DSM 5 May 2013.
Research started in 1999.
The DSM makes the American Psychiatric Association
over $5 million a year, historically adding up to over
$100 million.

37
DSM-5 Moves from Multi-axial
system to a similar ICD 10 System

38
Main DSM 5 Categories
Neurodevelopmental Disorders
Schizophrenia Spectrum and Other Psychotic Disorders
Bipolar and Related Disorders
Depressive Disorders
Anxiety Disorders
Obsessive-Compulsive and Related Disorders
Trauma and Stressor Related Disorders
Dissociative Disorders
Somatic Symptom Disorders
Feeding and Eating Disorders
Elimination Disorders
Sleep-Wake Disorders
Sexual Dysfunctions
Gender Dysphoria
Disruptive, Impulse Control, and Conduct Disorders
Substance Use and Addictive Disorders
Neurocognitive Disorders
Personality Disorders
Paraphilic Disorders
Other Disorders
39
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Why Will DSM-5 Cost $199 a Copy?
By Allen Frances, M.D. 1/24/13 Huffington Post
DSM-5 has just announced its price -- an incredible $199
First, APA has sunk more than $25 million into DSM-5 and
wants to recoup as much of its investment as it can.
DSM-IV cost one fifth as much -- just $5 million -- of which half
came from external grants.
APA is probably counting on having captive buyers who are
forced to pay its price, however exorbitant it may be.
DSM-5 boycotts are sprouting up all over the place
The codes clinicians need for insurance purposes are available
for free on the internet
DSM-5 is so clunkily written, no teacher will ever want to assign
it to students
People are not likely to rush out to buy a ridiculously expensive
DSM-5 that has already been discredited as unsafe and
scientifically unsound.
41
DSM 5 Is Guide Not BibleIgnore Its Ten Worst
Changes
By Allen J. Frances, M.D. Psychology Today Dec 2 2012

More than fifty mental health professional associations


petitioned for an outside review of DSM 5 to provide an
independent judgment of its supporting evidence and to
evaluate the balance between its risks and benefits.
Professional journals, the press, and the public also
weighed in- expressing widespread astonishment about
decisions that sometimes seemed not only to lack
scientific support but also to defy common sense.

42
Fortunately, some of its most egregiously risky and
unsupportable proposals were eventually dropped
under great external pressure (most notably
'psychosis risk', mixed anxiety/depression, internet
and sex addiction, rape as a mental disorder,
'hebephilia', cumbersome personality ratings, and
sharply lowered thresholds for many existing
disorders).

43
1) Disruptive Mood Dysregulation Disorder will turn
temper tantrums into a mental disorder.
2) Normal grief will become Major Depressive Disorder.
3) The everyday forgetting characteristic of old age will
now be misdiagnosed as Minor Neurocognitive
Disorder.
4) DSM 5 will likely trigger a fad of Adult Attention
Deficit Disorder leading to widespread misuse of
stimulant drugs for performance enhancement and
recreation and contributing to the already large illegal
secondary market in diverted prescription drugs.
5) Excessive eating 12 times in 3 months is no longer just a
manifestation of gluttony but it is a psychiatric illness
called Binge Eating Disorder.
44
6) The changes in the DSM 5 definition of Autism will
result in lowered rates- perhaps by 50% according to
outside research groups.
7) First time substance abusers will be lumped in
definitionally in with hard core addicts despite their
very different treatment needs and prognosis and the
stigma this will cause.
8) Behavioral Addictions that eventually can spread to
make a mental disorder of everything we like to do a
lot. Watch out for careless overdiagnosis of internet
and sex addiction and the development of lucrative
treatment programs to exploit these new markets.
9) DSM 5 obscures the already fuzzy boundary been
Generalized Anxiety Disorder and the worries of
everyday life.
10) DSM 5 has opened the gate even further to the already
existing problem of misdiagnosis of PTSD in forensic
settings. 45
Neurodevelopmental Disorders
Intellectual Disability (Intellectual Developmental
Disorder)
Diagnostic criteria for intellectual disability
(intellectual developmental disorder) emphasize the
need for an assessment of both cognitive capacity (IQ)
and adaptive functioning.
Severity is determined by adaptive functioning rather
than IQ score. Moreover, a federal statue in the United
States (Public Law 111-256, Rosas Law) replaces the
term mental retardation with intellectual disability.
The term intellectual developmental disorder was
placed in parentheses to reflect the ICD-11 to be
released in 2015). 46
Intellectual Disability (Intellectual
Developmental Disorder)
DSM-IV criteria had required an IQ score of 70 as the
cutoff for diagnosis; the new criteria recommend IQ
testing and describe deficits in adaptive functioning
that result in failure to meet developmental and
sociocultural standards for personal independence
and social responsibility.
The new criteria also include severity measures for
mild, moderate, severe, and profound intellectual
disability.

47
Autism Spectrum Disorder (ASD)
Consolidation of DSM-IV criteria for autism, Aspergers,
childhood disintegrative disorder, and pervasive
developmental disorder-not otherwise specific (PDD-
NOS)into one diagnostic category called autism
spectrum disorder (ASD).
The new criteria describe two principal symptoms:
deficits in social communication and social interaction
and restrictive and repetitive behavior patterns

48
Communication Disorders
The DSM-5 communication disorders include:
language disorder
speech sound disorder
childhood-onset fluency disorder (a new name for
stuttering)
social (pragmatic) communication disorder, a new
condition for persistent difficulties in the social uses of
verbal and nonverbal communication.

49
Attention-Deficit/Hyperactivity Disorder
The same 18 symptoms are used as in DSM-IV
The onset criterion has been changed from symptoms
that caused impairment were present before age 7
years to several inattentive or hyperactive-impulsive
symptoms were present prior to age 12;
subtypes have been replaced with presentation
specifiers that map directly to the prior subtypes;
a comorbid diagnosis with autism spectrum disorder is
now allowed;
a symptom threshold change has been made for adults
with the cutoff for ADHD of five symptoms, instead of
six required for younger persons, 50
Specific Learning Disorder

Specific learning disorder combines the DSM-IV


diagnoses of reading disorder, mathematics disorder,
disorder of written expression, and learning disorder
not otherwise specified. Because learning deficits in
the areas of reading, written expression, and
mathematics commonly occur together, coded
specifiers for the deficit types in each area are
included.

51
Schizophrenia Spectrum and
Other Psychotic Disorders
Schizophrenia
Elimination of the special attribution of bizarre
delusions and Schneiderian first-rank auditory
hallucinations (e.g., two or more voices conversing).
The second change is the addition of a requirement in
Criterion A that the individual must have at least one
of these three symptoms: delusions, hallucinations,
and disorganized speech. At least one of these core
positive symptoms is necessary for a reliable
diagnosis of schizophrenia
52
Schizophrenia subtypes
The DSM-IV subtypes of schizophrenia (i.e., paranoid,
disorganized, catatonic, undifferentiated, and residual
types) are eliminated due to their limited diagnostic
stability, low reliability, and poor validity.
Instead, a dimensional approach to rating severity for
the core symptoms of schizophrenia.

53
Schizoaffective Disorder
The primary change to schizoaffective disorder is the
requirement that a major mood episode be present for
a majority of the disorders total duration after
Criterion A has been met.
It makes schizoaffective disorder a longitudinal
instead of a cross-sectional diagnosismore
comparable to schizophrenia, bipolar disorder, and
major depressive disorder, which are bridged by this
condition.

54
Delusional Disorder
Criterion A for delusional disorder no longer has the
requirement that the delusions must be nonbizarre. A
specifier for bizarre type delusions provides continuity
with DSM-IV. The demarcation of delusional disorder
from psychotic variants of obsessive-compulsive
disorder and body dysmorphic disorder is explicitly
noted with a new exclusion criterion, which states that
the symptoms must not be better explained by
conditions such as obsessive-compulsive or body
dysmorphic disorder with absent insight/delusional
beliefs.

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Catatonia
In DSM-5, catatonia may be diagnosed as a specifier
for depressive, bipolar, and psychotic disorders

56
Bipolar and Related Disorders
Bipolar Disorders
Criterion A for manic and hypomanic episodes now includes an
emphasis on changes in activity and energy as well as mood. The DSM-
IV diagnosis of bipolar I disorder, mixed episode, requiring that the
individual simultaneously meet full criteria for both mania and major
depressive episode, has been removed. Instead, a new specifier, with
mixed features, has been added that can be applied to episodes of
mania or hypomania when depressive features are present, and to
episodes of depression in the context of major depressive disorder or
bipolar disorder when features of mania/hypomania are present.
Other Specified Bipolar and Related Disorder
categorization for individuals with a past history of a major depressive
disorder who meet all criteria for hypomania except the duration
criterion (i.e., at least 4 consecutive days). A second condition
constituting an other specified bipolar and related disorder is that too
few symptoms of hypomania are present to meet criteria for the full
bipolar II syndrome, although the duration is sufficient at 4 or more
days.
Anxious Distress Specifier
57
Depressive Disorders
DSM-5 contains several new depressive disorders,
including disruptive mood dysregulation disorder and
premenstrual dysphoric disorder.
To address concerns about potential overdiagnosis and
overtreatment of bipolar disorder in children, a new
diagnosis, disruptive mood dysregulation disorder, is
included for children up to age 18 years who exhibit
persistent irritability and frequent episodes of extreme
behavioral dyscontrol.
Finally, DSM-5 conceptualizes chronic forms of depression
in a somewhat modified way. What was referred to as
dysthymia in DSM-IV now falls under the category of
persistent depressive disorder, which includes both
chronic major depressive disorder and the previous
dysthymic disorder.
58
Bereavement
In DSM-IV, there was an exclusion criterion for a major
depressive episode that was applied to depressive symptoms
lasting less than 2 months following the death of a loved one
(i.e., the bereavement exclusion). This exclusion is omitted in
DSM-5. 1, to remove the implication that bereavement
typically lasts only 2 months when both physicians and grief
counselors recognize that the duration is more commonly 12
years. 2, bereavement is recognized as a severe psychosocial
stressor that can precipitate a major depressive episode in a
vulnerable individual, and an increased risk for persistent
complex bereavement disorder, which is now in Conditions
for Further Study in DSM-5 Section III. 3, bereavement-related
major depression is most likely to occur in individuals with past
personal and family histories of major depressive episodes. It is
genetically influenced and is associated with similar
personality characteristics, patterns of comorbidity, and risks
of chronicity and/or recurrence as nonbereavement-related
major depressive episodes
59
Anxiety Disorders

The DSM-5 chapter on anxiety disorder no longer


includes obsessive-compulsive disorder (which is
included with the obsessive-compulsive and related
disorders) or posttraumatic stress disorder and acute
stress disorder (which is included with the trauma-
and stressor-related disorders). However, the
sequential order of these chapters in DSM-5 reflects
the close relationships among them.

60
PTSD
The 3 clusters of DSM-IV symptoms will be divided into 4
clusters in DSM-5: intrusion symptoms, avoidance
symptoms, arousal/reactivity symptoms and negative mood
and cognitions.
Criterion A2 (requiring fear, helplessness or horror happen
right after the trauma) will be removed.
The diagnosis is proposed to move from the class of anxiety
disorders into a new class of "trauma and stressor-related
disorders."
PTSD assessment measures, such as the CAPS and the PCL,
are being revised by the National Center for PTSD to be
made available upon the release of DSM-5.
61
Somatic Symptom and Related Disorders
The DSM-5 classification reduces the number of these
disorders and subcategories. Diagnoses of somatization
disorder, hypochondriasis, pain disorder, and
undifferentiated somatoform disorder have been
removed.

62
The International Classification of
Diseases ICD
The ICD is currently the most widely used statistical
classification system for diseases in the world.
This is in fact the official diagnostic system for mental
disorders in the US.
The ICD-10, was developed in 1992.
ICD-11 is currently being researched and should be
ready in 2015.

63
ICD History
The first international conference to revise the
International Classification of Causes of Death convened
in 1900; with revisions occurring every ten-years
thereafter.
In 1948, the World Health Organization (WHO)
assumed responsibility for preparing and publishing the
revisions to the ICD every ten-years. WHO sponsored
the seventh and eighth revisions in 1957 and 1968,
respectively. It later become clear that the established
ten-year interval between revisions was too short.
The America Psychiatric Association has long lobbied
against the use of the ICD (but due to federal law is
forced to work with the ICD). 64
ICD is Required by HIPPA
The deadline for the United States to begin using
Clinical Modification ICD-10-Clinical Modification
(CM) is currently October 1, 2014.
The deadline was previously October 1, 2011. The
transition to ICD-10 is required for everyone covered
by the Health Insurance Portability Accountability Act
(HIPAA), Medicare and Medicaid.

65
ICD-10 MENTAL AND BEHAVIOURAL DISORDERS consists of 10
main groups:

F0: Due to known physiological conditions


F1: Due to use of psychoactive substances
F2: Schizophrenia, schizotypal and delusional disorders
F3: Mood [affective] disorders
F4: Anxiety, dissociative, stress-related and somatoform
disorders
F5: Behavioural syndromes associated with physiological
disturbances and physical factors
F6: Disorders of personality and behaviour in adult persons
F7: Intellectual disabilities
F8: Pervasive and specific developmental disorders
F9: Behavioural and emotional disorders with onset usually
occurring in childhood and adolescence
In addition, a group of "unspecified mental disorders". 66
F60 Specific personality disorders
F60.0 Paranoid personality disorder
F60.1 Schizoid personality disorder
F60.2 Antisocial personality disorder
F60.3 Borderline personality disorder
F60.4 Histrionic personality disorder
F60.5 Obsessive-Compulsive personality disorder
F60.6 Avoidant personality disorder
F60.7 Dependent personality disorder
F60.8 Other specific personality disorders
F60.81 Narcissistic personality disorder
F60.89 Other specific personality disorder
F60.9 Personality disorder, unspecified
67
ICD-11 Survey Overview
2155 global psychologists participated in the WHO and
International Union of Psychological Sciences (IUPsyS)
Recruited through 23 IUPsyS member national
psychological associations in 23 countries
10 low and middle-income countries
Administered in 5 languages (English, Spanish, French,
German, Turkish)
Parallel to survey conducted by WHO and World Psychiatric
Association (WPA) of 4887 psychiatrists in 44 countries

68
ICD-11 2015
ICD-11 will draw on research about how clinicians
conceptualize mental disorders in hopes of creating a
more intuitive and psychological classification system.

ICD-11 will be available for free on the Internet (ICD-9


and 10 apps are free).

69
Purpose of Classification
Q9 - From your perspective, which is the single, most
important purpose of a diagnostic classification system?
50%

39%
40%
33%
% Participants

30%

20% 16%

10%
3% 5% 4%

0%
Communication Communication Inform Facilitate Basis for Other
among between treatment and research generating
clinicians clinicians and management national health
patients decisions statistics

70
Number of Categories Desired
Q10 - In clinical settings, how many diagnostic categories
should a classification system contain to be most useful
for mental health professionals?
60%
50%
50%
% Participants

40% 35%
30%

20%
11%
10% 4%
0%
10 to 30 31 to 100 101 to 200 More than 200

71
ICD-10 and DSM-IV
Categories Used Most Often
ICD-10 % DSM-IV %

Depressive Episode 71% Major Depressive Disorder 60%

Generalized Anxiety Disorder 48% Generalized Anxiety Disorder 59%

Social Phobia 46% Post-Traumatic Stress Disorder 42%

Mixed Anxiety and Depressive Disorder 44% Adjustment Disorders 41%

Recurrent Depressive Disorder 44% Attention-Deficit/Hyperactivity Disorder 38%

Post-Traumatic Stress Disorder 42% Obsessive-Compulsive Disorder 37%

Borderline Personality Disorder 42% Social Phobia 37%

Adjustment Disorder 42% Borderline Personality Disorder 34%

Specific (Isolated) Phobias 41% Single Major Depressive Episode 34%

Hyperkinetic (Attention Deficit) Disorder 34% Panic Disorder without Agoraphobia 32%

Obsessive-Compulsive Disorder 34% Bipolar I Disorder 27%

Bipolar Affective Disorder 28% Alcohol-Related Disorders 26%


72
Categories With the
Lowest Ease of Use
ICD-10 EOU DSM-IV EOU
Asperger's Syndrome 0.50 Dissociative Disorders 0.48

Dissociative [Conversion] Disorders 0.50 Impulse Control Disorders 0.50

Schizoaffective Disorder 0.51 Schizotypal Personality Disorder 0.54

Schizotypal Disorder 0.51 Schizoaffective Disorder 0.54

Somatoform Disorders 0.52 Asperger's Disorder 0.56

Borderline Personality Disorder 0.56 Somatoform Disorders 0.56

Hyperkinetic (Attention Deficit) Disorder 0.56 Primary Sleep Disorders 0.58

Delirium 0.58 Bipolar II Disorder 0.58

MBDs due to Use of Volatile Solvents 0.58 Tic disorders 0.59

Habit and Impulse Disorders 0.59 Brief Psychotic Disorder 0.60

MBDs due to Use of Hallucinogens 0.60 Vascular Dementia 0.60

Bipolar Affective Disorder 0.60 Sexual Dysfunctions 0.60

Mixed Anxiety and Depressive Disorder 0.60 Autistic Disorder 0.61

Adjustment Disorder 0.60 Delusional Disorder 0.62


73
Categories With the
Lowest Goodness of Fit
ICD-10 GOF DSM-IV GOF
Dissociative [Conversion] Disorders 0.45 Schizotypal Personality Disorder 0.44

Asperger's Syndrome 0.45 Dissociative Disorders 0.45

Hyperkinetic (Attention Deficit) Disorder 0.50 Somatoform Disorders 0.47

Schizoaffective Disorder 0.51 Asperger's Disorder 0.48

Somatoform Disorders 0.51 Impulse Control Disorders 0.48

Borderline Personality Disorder 0.51 Schizoaffective Disorder 0.49

MBDs Due to Use of Hallucinogens 0.52 Primary Sleep Disorders 0.51

Schizotypal Disorder 0.53 Tic disorders 0.53

Vascular Dementia 0.53 Bipolar II Disorder 0.53

Dissocial (Antisocial) Personality Disorder 0.55 Borderline Personality Disorder 0.54

Adjustment Disorder 0.55 Autistic Disorder 0.54

Habit and Impulse Disorders 0.55 Brief Psychotic Disorder 0.55

Mixed Anxiety and Depressive Disorder 0.56 Sexual Dysfunctions 0.56


74
ICD 10 / ICD 11 Schizotypal Disorder
An enduring pattern of unusual speech, perceptions, beliefs
and behaviors that are not of sufficient intensity to meet the
requirements of schizophrenia. 3 or 4 of the following:
Constricted affect, the individual appearing cold and aloof.
Behaviour or appearance which is odd, eccentric, or peculiar.
Poor rapport with others, tendency towards social withdrawal.
Unusual beliefs, magical thinking or paranoid ideation
Unusual perceptual distortions
Suspiciousness or paranoid ideas
Occasional transient psychotic episodes
Vague, circumstantial, stereotyped thinking
Obsessive ruminations
Not met diagnostic criteria for schizophrenia
75
DSM-IV Schizotypal Personality
Disorder
A pervasive pattern of social and interpersonal deficits
marked by acute discomfort with, and reduced capacity
for, close relationships as well as by cognitive or perceptual
distortions and eccentricities of behavior
5 or more of the following:

(1) ideas of reference


(2) odd beliefs or magical thinking
(3) unusual perceptual experiences
(4) odd thinking and speech (e.g., vague, circumstantial)
(5) suspiciousness or paranoid ideation
(6) inappropriate or constricted affect
(7) behavior or appearance that is odd, eccentric, or peculiar
(8) lack of close friends or confidants other than first-degree relatives
(9) excessive social anxiety 76
DSM-5 Schizotypal Personality Disorder
A. Significant impairments in personality functioning:
1. Impairments in self functioning (a or b):
a. Identity: Confused boundaries between self and others;
b. Self-direction: Unrealistic or incoherent goals;
AND
2. Impairments in interpersonal functioning (a or b):
a. Empathy: Difficulty understanding impact of behaviors on others;
b. Intimacy: Marked impairments in developing close relationships.
B. Pathological personality traits in the following domains:
1. Psychoticism, characterized by:
a. Eccentricity
b. Cognitive and perceptual dysregulation:
c. Unusual beliefs and experiences
2. Detachment, characterized by:
a. Restricted affectivity
b. Withdrawal
3. Negative Affectivity, characterized by:
a. Suspiciousness
77
DSM-5 Schizotypal Personality Disorder
The only two non-US members of the DSM-5
Personality Disorders Work group (Roel Verheul
and John Livesley) resigned in April 2012:

First, the proposed classification is unnecessarily


complex, incoherent, and inconsistent. Second, the
proposal displays a truly stunning disregard for
evidence.
The current proposal represents the worst possible
outcome: it displays almost total discontinuity with
DSM-IV while failing to improve validity and clinical
utility of the classification.
78
A diagnostic framework that attempts to characterize the
whole person--the depth as well as the surface of
emotional, cognitive, and social functioning; from
healthy to disturbed in a mixed categorical -dimensional
system

79
Psychodynamic Theory as a Complex Adaptive System-
interaction, interdependence and diversity of constructs
(temperament, affects, cognitions, development, traumas, defenses, fantasi
es, attachments), emergences (symptoms), tails (one event can move
the entire central tendency) and tipping points (break downs).

80
PDMs Current Taxonomy
Personality Patterns and Disorders

Mental Functioning

Manifest Symptoms and Concerns


81
Types of Personality Disorders or Patterns

P101. Schizoid Personality Disorders


P102. Paranoid Personality Disorders

P103. Psychopathic (Antisocial) Personality Disorders


P103.1 Passive/Parasitic
P103.2 Aggressive

P104. Narcissistic Personality Disorders


P104.1 Arrogant/Entitled
P104.2 Depressed/Depleted

P105. Sadistic and Sadomasochistic Personality Disorders


P105.1 Intermediate Manifestation: Sadomasochistic Personality
Disorders

P106. Masochistic (Self-Defeating) Personality Disorders


P106.1 Moral Masochistic
82
P106.2 Relational Masochistic
P107. Depressive Personality Disorders
P107.1 Introjective
P107.2 Anaclitic
P107.3 Converse Manifestation: Hypomanic Personality
Disorder

P108. Somatizing Personality Disorders

P109. Dependent Personality Disorders


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

P110. Phobic (Avoidant) Personality Disorders


P110.1 Converse Manifestation: Counterphobic Personality
Disorders

P111. Anxious Personality Disorders


83
P112. Obsessive-Compulsive Personality Disorders
P112.1 Obsessive
P112.2 Compulsive

P113. Hysterical (Histrionic) Personality Disorders


P113.1 Inhibited
P113.2 Demonstrative or Flamboyant

P114. Dissociative Personality Disorders (Dissociative


Identity Disorder/Multiple Personality Disorder)

P115. Mixed/Other

84
Capacity for Regulation, Attention, and Learning

Capacity for Relationships (Including Depth, Range, and


Consistency)
Quality of Internal Experience (Level of Confidence and Self-
Regard)
Affective Experience, Expression, and Communication

Defensive Patterns and Capacities

Capacity to Form Internal Representations

Capacity for Differentiation and Integration

Self-Observing Capacities (Psychological-Mindedness)

Capacity for Internal Standards and Ideals: A Sense of Morality

85
Symptom Patterns: The Subjective Experience - S Axis

S301. Adjustment Disorders


S302. Anxiety Disorders
S302.1 Psychic Trauma and Posttraumatic Stress Disorder
S302.2 Phobias
S302.3 Obsessive-Compulsive Disorders
S303. Dissociative Disorders
S304. Mood Disorders
S304.1 Depressive Disorders
S304.2 Bipolar Disorders
S305. Somatoform (Somatization) Disorders
S306. Eating Disorders
S307. Psychogenic Sleep Disorders
S308. Sexual and Gender Identity Disorders
S308.1 Sexual Disorders
S308.2 Paraphilias
S308.3 Gender Identity Disorders
S309. Factitious Disorders
S310. Impulse Control Disorders
S311. Addictive/Substance Abuse Disorders
S312. Psychotic Disorders
S313. Mental Disorders Based on a General Medical Condition

86
Classification of Child and Adolescent Mental Health Disorders
Profile of Mental Functioning for Children and
Adolescents - MCA Axis
Capacity for Regulation, Attention, and Learning
Capacity for Relationships (Including Depth, Range, and
Consistency)
Quality of Internal Experience (Level of Confidence and
Self-Regard)
Affective Experience, Expression, and Communication
Defensive Patterns and Capacities
Capacity to Form Internal Representations
Capacity for Differentiation and Integration
Self-Observing Capacities (Psychological-Mindedness)
Capacity for Internal Standards and Ideals: Sense of
Morality
Summary of Child and Adolescent Mental Functioning
87
Child and Adolescent Personality Patterns and Disorders - PCA Axis

Developmental Aspects of Emerging Personality Patterns

PCA101. Fearful of Closeness/Intimacy (Schizoid) Personality


Disorders
PCA102. Suspicious/Distrustful Personality Disorders
PCA103. Sociopathic (Antisocial) Personality Disorders
PCA104. Narcissistic Personality Disorders
PCA105. Impulsive/Explosive Personality Disorders
PCA106. Self-Defeating Personality Disorders
PCA107. Depressive Personality Disorders
PCA108. Somatizing Personality Disorders
PCA109. Dependent Personality Disorders
PCA110. Avoidant/Constricted Personality Disorders
PCA110.1 Counterphobic Personality Disorders
PCA111. Anxious Personality Disorders
PCA112. Obsessive-Compulsive Personality Disorders
PCA113. Histrionic Personality Disorders
PCA114. Dysregulated Personality Disorders
PCA115. Mixed/Other
88
Child and Adolescent Symptom Patterns: The Subjective Experience
Anxiety Disorders
SCA301. Anxiety Disorders
SCA302. Phobias
SCA303. Obsessive-Compulsive Disorders
SCA304. Somatization (Somatoform) Disorders
Affect/Mood Disorders
SCA305. Prolonged Mourning/Grief Reaction
SCA306. Depressive Disorders
SCA307. Bipolar Disorders
SCA308. Suicidality
Disruptive Behavior Disorders
SCA309. Conduct Disorders
SCA310. Oppositional-Defiant Disorders
SCA311. Substance Abuse Related Disorders
Reactive Disorders
SCA312. Psychic Trauma and Posttraumatic Stress Disorder
SCA313. Adjustment Disorders (other than developmental)
Disorders of Mental Functioning
SCA314. Motor Skills Disorders
SCA315. Tic Disorders
SCA316. Psychotic Disorders
SCA317. Neuropsychological Disorders
SCA317.1 Visual-Spatial Processing Disorders
SCA317.2 Language and Auditory Processing Disorders
SCA317.3 Memory Impairments
SCA317.4 Attention Deficit/Hyperactivity Disorder (AD/HD)
SCA317.5 Executive Function Disorders
89
SCA317.6 Severe Cognitive Deficits
Child and Adolescent Symptom Patterns: The Subjective Experience
SCA318. Learning Disorders
SCA318.1 Reading Disorders
SCA318.2 Mathematics Disorders
SCA318.3 Disorders of Written Expression
SCA318.4 Nonverbal Learning Disabilities
SCA318.5 Social-Emotional Learning Disabilities
Psychophysiologic Disorders
SCA319. Bulimia
SCA320. Anorexia
Developmental Disorders
SCA321. Regulatory Disorders
SCA322. Feeding Problems of Childhood
SCA323. Elimination Disorders
SCA323.1 Encopresis
SCA323.2 Enuresis
SCA324. Sleep Disorders
SCA325. Attachment Disorders
SCA326. Pervasive Developmental Disorders
SCA326.1 Autism
SCA326.2 Aspergers Syndrome
SCA326.3 Pervasive Developmental Disorder (PDD) Not Otherwise Specified
Other Disorders
SCA327. Gender Identity Disorders

90
Disorders of Infancy and Early Childhood Axis I - Primary Axis

IEC100 Series- Interactive Disorders


IEC101. Anxiety Disorders
IEC102. Developmental Anxiety Disorders
IEC103. Disorders of Emotional Range and Stability
IEC104. Disruptive Behavior and Oppositional Disorders
IEC105. Depressive Disorders
IEC106. Mood Dysregulation: A Unique Type of Interactive and Mixed
Regulatory-Sensory Processing Disorder Characterized by Bipolar Patterns
IEC107. Attentional Disorders
IEC108. Prolonged Grief Reaction
IEC109. Reactive Attachment Disorders
IEC110. Traumatic Stress Disorders
IEC111. Adjustment Disorders
IEC112. Gender Identity Disorders
IEC113. Selective Mutism
IEC114. Sleep Disorders
IEC115. Eating Disorders
IEC116. Elimination Disorders

91
IEC200 Series - Regulatory-Sensory Processing Disorders (RSPD)
Clinical Evidence and Prevalence of Regulatory-Sensory Processing
Differences
Sensory Modulation Difficulties (Type I)
IEC201. Overresponsive, Fearful, Anxious Pattern
IEC202. Overresponsive, Negative, Stubborn Pattern
IEC203. Underresponsive, Self-Absorbed Pattern
IEC203.1 Self-Absorbed and Difficult-to-Engage Type
IEC203.2 Self-Absorbed and Creative Type
IEC204. Active, Sensory Seeking Pattern
Sensory Discrimination Difficulties (Type II) and Sensory-Based Motor
Difficulties (Type III)
IEC205. Inattentive, Disorganized Pattern
IEC205.1 With Sensory Discrimination Difficulties
IEC205.2 With Postural Control Difficulties
IEC205.3 With Dyspraxia
IEC205.4 With Combinations of All Three
IEC206. Compromised School and/or Academic Performance Pattern
IEC206.1 With Sensory Discrimination Difficulties
IEC206.2 With Postural Control Difficulties
IEC206.3 With Dyspraxia
IEC206.4 With Combinations of All Three
Contributing Sensory Discrimination and Sensory-Based Motor Difficulties

92
IEC207. Mixed Regulatory-Sensory Processing Patterns
IEC207.1 Attentional Problems
IEC207.2 Disruptive Behavioral Problems
IEC207.3 Sleep Problems
IEC207.4 Eating Problems
IEC207.5 Elimination Problems
IEC207.6 Selective Mutism
IEC207.7 Mood Dysregulation, including Bipolar Patterns
IEC207.8 Other Emotional and Behavioral Problems Related to
Mixed Regulatory-Sensory Processing Difficulties
IEC207.9 Mixed Regulatory-Sensory Processing Patterns where
Behavioral or Emotional Problems Are Not Yet In Evidence
IEC300 Series - Neurodevelopmental Disorders of Relating and
Communicating
IEC301. Type I: Early Symbolic, with Constrictions
IEC302. Type II: Purposeful Problem-Solving, with Constrictions
IEC303. Type III: Intermittently Engaged and Purposeful
IEC304. Type IV: Aimless and Unpurposeful
Other Neurodevelopmental Disorders (Including Genetic and Metabolic
Syndromes)

93
Reactions to the PDM

The PDM was introduced to 192 psychologists in a

several ethics and MMPI-2 workshops

(65 Psychodynamic, 76 CBT and 51 Other)

Overall the psychologists gave the PDM a 90%

favorable rating.

Gordon, R.M. (2009). Reactions to the Psychodynamic Diagnostic Manual (PDM) by Psychodynamic, CBT
and Other Non- Psychodynamic Psychologists. Issues in Psychoanalytic Psychology, 31,1, 55-62.
94
Nancy McWilliams ( 2011) Psychoanalytic
Diagnosis: Understanding Personality Structure in
the Clinical Process

McWilliams taxonomy is fundamentally based on


two dimensions:
1. Personality Organization and
2. Character Organization.

Gordon, R.M. (2013) book review in Division/Review and at Amazon books

95
Robert M. Gordon and Robert F. Bornstein (2012)

96
PDC Is A User Friendly Guide to
the Adult Section of the PDM
Short- 3pages
Easy- all scales are 1-10
Intuitive and Empirical
Categorical and Dimensional
Flexible-can do part or all
Integrates with the DSM and ICD
Good Reliability and Construct Validity-preliminary field
evidence (Gordon and Stoffey 2013 in press)

97
PDCs Taxonomy: From Larger to Smaller Units
Personality Organization
Personality Patterns

Mental Functioning

ICD Symptoms

Cultural-Contextual Issues

98
Clinical Example Using the PDC
Bana is a 28 year old woman from Syria. Her husband was killed in the
war and she has no children. Her brother was able to get her to the US this
year.
1. Level of Personality Organization- is 7 (Neurotic Level). Her capacity
scores are mainly in the 6-9 range. Her lowest rating is in Affect Tolerance
(5) which may be due to her PTSD. She is a good candidate for PDT.
2. Personality Patterns or Disorders- mainly Hysterical/Inhibited type
at the Moderate level of severity (6) with some obsessional and dependent
features.
3. Mental Functioning- most of the 9 capacities are in the high range.
She has a masters in education, her marriage was good, she has average self
esteem, she can go from inhibited to overly excited expression of affect, her
favored defenses are repression and intellectualization, she has a warm
relationship with her mother and both sets of grandparents, her father was
killed when she was a child, good level of differentiation and integration,
very insightful and excellent moral reasoning.
4. Manifest Symptoms- ICD-10: (F43.1) Post-traumatic stress disorder
5. Cultural, Contextual Issues- recent death of husband, war trauma,
loss of father, leaving much of her family and friends behind, immigration
fears and guilt.
99
Testing Dimensional and Categorical
Qualities of Personality Organization
Hysteria scale and Schizophrenia scale correlate
.01 with male sample and .15 with female sample.
They are independent representations of very
different character structures.

The Ego Strength scale measures responsiveness to


psychotherapy. I found that the Es scale significantly
increased (p<.001, Cohens d = .80) after an average of
3 years of PDT for 55 borderline patients
(Gordon, 2001).

100
Testing Dimensional and Categorical
Qualities of Personality Organization with 3 Scales

(L+Pa+Sc)-(Hy+Pt)

Es

Sc, Hy and Es
101
MMPI-2 Hysteria-Hy, Schizophrenia-Sc, and Ego Strength-Es
Scales within the Psychotic, Borderline, and Neurotic
Categories of the Personality Organization Scale
Psychotic (ratings 1-3, n = 13), Borderline (4-6, n = 52), and Neurotic (7-10, n = 33).
Psychotic: Sc >> Hy>> Es; Borderline: (Sc ~ Hy) >> Es; Neurotic: (Sc ~ Hy) > Es all in the average to moderate range.

90

85

80

75

70 Hy
65

60
Sc
55

50

45 Es
40

35

30

Psychotic Borderline Neurotic


102
Example of a Psychotic Level
Personality: Schizotypal
In ICD-10, Schizotypal disorder is classified as a
clinical disorder associated with schizophrenia
rather than a personality disorder as with DSM-IV
and 5.
It is not in the PDM.

103
Percent of Practitioners Rating the PDC Dimensions as
HelpfulVery Helpful in Understanding Their Patient
90
84
79
80

72
70

60

50
50

40

31
30

20

10

0
Levels of Personality Structure
Dominant Personality Patterns
Mental Functioning ICD or DSM Symptoms
Cultural/Contextual Dimensi
104
Current PDM Study
Data collected from 13 workshops from
Nov. 2012- July 2013.

Estimated N= 500+ practitioners and


doctoral students

Lead researcher Robert M. Gordon

105
Psychodynamic Diagnostic Prototypes
(PDP)

Francesco Gazzillo, PhD


Department of Dynamic and Clinical Psychology
Sapienza University of Rome

106
PDP narrative description
P105.1 Intermediate Manifestation:
Sadomasochistic Personality Disorders
Some individuals alternate between sadistic and sadomasochistic
attitudes and behaviors (Kernberg, 1988). Patients with this psychology
are much more emotionally alive and capable of attachment than those
with primary psychopathic, narcissistic, or sadistic personality structures.
Their relationships, however, are intense and explosive. Sometimes they
let themselves be dominated to an extreme extent, and sometimes they
viciously attack the person to whom they previously capitulated. They tend
to see themselves as victims of others aggression whose only choices are
to surrender their will entirely or to fight back belligerently. The help-
rejecting complainer described by Frank and his colleagues
(Frank, Margolin, Nash, Stone, Varon & Ascher, 1952) is one version of
this psychology. In psychotherapy, such patients tend to alternate between
attacking the therapist and feeling insulted and demeaned by him or her.
Because sadomasochistic personality disorder is found at the borderline
level of severity, treatment considerations include those for borderline
patients generally. 107
The validation of Psychodynamic Diagnostic Prototypes
(PDP; Gazzillo, Lingiardi, Del Corno, 2010)

The Prototypic Assessment


of the Psychodynamic Diagnostic Prototype

5 Very good match (patient exemplifies this disorder; prototypical case)


4 Good match (patient has this disorder; diagnosis applies)
3 Moderate match (patient has significant features of this disorder)
2 Slight match (patient has minor features of this disorder)
1 No match (description does not apply)

The evaluation of all 21 disorders takes about 10-30 minutes

108
Hypotheses
1. Norms for PDP and PDC
2. Concurrent validity between PDP and PDC
3. How PDM Dx inform about boundaries and
countertransference issues
4. How theoretical orientation affects value of various
taxa (PO, PD, MF, Symptoms, Context)
5. Which PD are commonly found at which level of PO.

109
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
110
1. Level of Personality Structure- Rating

Healthy Personality- characterized by 9-10 scores, life problems never get out of hand
and enough flexibility to accommodate to challenging realities.

Neurotic Level- characterized by mainly 6-8 scores, rigidity and limited range of
defenses and coping mechanisms, basically a good sense of identity, healthy
intimacies, good reality testing, fair resiliency, fair affect tolerance and
regulation, favors repression.

Borderline Level- characterized by mainly 3-5 scores, recurrent relational


problems, difficulty with affect tolerance and regulation, poor impulse control, poor
sense of identity, poor resiliency, favors primitive defenses such as denial, splitting
and projective identification.

Psychotic Level- characterized by mainly 1-2 scores, delusional thinking, sometimes


hallucinations, poor reality testing and mood regulation, extreme difficulty
functioning in work and relationships.

Overall Personality Structure


Based on the 7 ratings above, rate persons overall personality structure from 1
(Psychotic) to 10 (Healthy)

111
2. Personality Patterns or Disorders- Scoring

Review the P axis in the PDM for the personality


patterns most descriptive of your client (use the PDP).
Begin by checking off as many descriptors that apply.
Then decide on the most dominant personality
patterns or disorders, and the level of severity (1-10).

112
PDM Categories:

Schizoid
Paranoid
Psychopathic (antisocial); Subtypes - passive/parasitic or aggressive
Narcissistic; Subtypes - arrogant/entitled or depressed/depleted;
Sadistic (and intermediate manifestation, sadomasochistic)
Masochistic (self-defeating); Subtypes - moral masochistic or relational
masochistic
Depressive; Subtypes - introjective or anaclitic; Converse manifestation -
hypomanic
Somatizing
Dependent (and passive-aggressive versions of dependent); Converse
manifestation - counterdependent
Phobic (avoidant); Converse manifestation - counterphobic
Anxious
Obsessive-compulsive; Subtypes - obsessive or compulsive
Hysterical (histrionic); Subtypes - inhibited or demonstrative/ flamboyant
Dissociative
Mixed/other
Rate: Dominate Personality Disorder or Maladaptive Traits & Overall Severity of
Impairment 113
3. Mental Functioning
1. Capacity for Attention, Memory, Learning, and Intelligence
2. Capacity for Relationships and Intimacy (including depth, range, and
consistency)
3. Quality of Internal Experience (level of confidence and self-regard)
4. Affective Comprehension, Expression, and Communication
5. Level of Defensive or Coping Patterns
1-2: Psychotic level (e.g., delusional projection, psychotic denial, psychotic
distortion)
3-5: Borderline level (e.g., splitting, projective
identification, idealization/devaluation, denial, acting out)
6-8: Neurotic level (e.g., repression, reaction
formation, rationalization, displacement, undoing)
9-10: Healthy level (e.g., anticipation, sublimation, altruism, and humor)
6. Capacity to Form Internal Representations (sense of self and others are realistic
and guiding)
7. Capacity for Differentiation and Integration (self, others, time, internal
experiences and
external reality are all well distinguished)
8. Self-Observing Capacity (psychological mindedness)
9. Realistic sense of Morality
114
4. ICD or DSM SYMPTOMS
Symptoms are considered in the context of:
1. level of personality structure,
2. personality pattern or disorder
3. mental functioning.

Here you may use the symptoms that may be the focus
of the chief complaint and necessary for third party
reimbursement.

115
5. Cultural, Contextual, and Other
Relevant Considerations
This is a qualitative section where the practitioner may
write how cultural or contextual factors contribute to
symptoms.

116
For Free Copies:
For copies of the PDP and PDC, search for:

Psychodiagnostic Chart

117
In addition, use whatever system is
most helpful to you in understanding
and helping the client/patient
118