Ethical Issues Involved with Diagnosing


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Ethical issues related to diagnosis: Review of DSM-5, ICD-10, and the PDM

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  • “To date, there has been general consensus that the science is not yet well enough developed to permit neuroscience-based classification. However, at some point, it is necessary to instantiate such approaches if the field is ever to reach the point where advances in genomics, pathophysiology, and behavioral science can inform diagnosis in a meaningful way. ”
  • Negative Valence SystemsAcute threat (“fear”) Potential threat (“anxiety”) Sustained threat Loss Frustrative nonreward Positive Valence SystemsApproach motivationInitial responsiveness to reward Sustained responsiveness to reward Reward learning Habit Cognitive SystemsAttention PerceptionWorking memoryCognitive (effortful) controlSystems for Social ProcessesAffiliation and attachmentSocial CommunicationPerception & Understanding of SelfAgency Self-Knowledge Perception & Understanding of OthersArousal and Regulatory SystemsArousal Circadian Rhythms Sleep and wakefulness 
  • “To date, there has been general consensus that the science is not yet well enough developed to permit neuroscience-based classification. However, at some point, it is necessary to instantiate such approaches if the field is ever to reach the point where advances in genomics, pathophysiology, and behavioral science can inform diagnosis in a meaningful way. “
  • “To date, there has been general consensus that the science is not yet well enough developed to permit neuroscience-based classification. However, at some point, it is necessary to instantiate such approaches if the field is ever to reach the point where advances in genomics, pathophysiology, and behavioral science can inform diagnosis in a meaningful way. “
  • Hy and Sc have very low corrections .01- .15, Es and Sc moderate correlations, Es and Hy low to moderate correlations.
  • N=98 In hypothesis B.1., we predicted the Sc scale mean should be significantly larger than both the Hy and Es scale means for the psychotic level. Pairwise comparisons supported that prediction: Sc was significantly larger than Es (M = 85.77, SD = 19.55 vs. 34.31, SD = 6.78, p = .001) and significantly larger than Hy (M = 85.77, SD = 19.55 vs. 72.69, SD = 18.46, p = .017).In hypothesis B.2.for the borderline level, we predict that both the Sc scale mean and the Hy scale mean should not be significantly different (borderline as a mix of psychotic and neurotic features), but they both should be significantly larger than the Es scale mean. That prediction was supported: Sc and Hy were not significantly different, but Sc was significantly larger than Es (M = 62.21, SD = 12.31, vs. 43.58, SD = 10.25, p = .001) and Hy was also significantly larger than Es (64.21, SD = 12.31 vs. 43.58, SD = 10.25, p = .001). Finally, for the neurotic level, we predicted in hypothesis B.3. that the Es, Sc and Hy scales should all be in the normal-moderate range. There were significant mean differences between Es (M = 49.55, SD = 10.16) in comparison to both Hy (M = 59.85, SD = 12.15) and Sc,(M = 56.18, SD = 9.28). Hy and Sc were in the moderate range, and Ego strength moved up to the average range showing support for the prediction (see Figure 1 for the MMPI-2 scale means within each level). We next examined the pattern of means for each of the Hy, Sc, and Es scales separately across each of the three scale categories. A series of One-Way ANOVAs was used to test the hypothesized outcomes. For hypothesis C.1., we predicted significant mean differences for Hy across the psychotic, borderline, and neurotic scale categories, with the largest scale mean for psychotic followed by borderline and lastly the neurotic category (See Table 4 for the means and standard deviations). The ANOVA indicated that there were significant differences among the three scale categories on the Hy scale, F (2, 95) = 3.96, p < = .022, 2= .08. Scheffe post hoc tests indicated that patients rated as psychotic scored significantly higher on the Hy scales in comparison to patients rated as neurotic (M = 72.69 vs. M = 59.85, p = .023). Although in the predicted direction, there was no significance mean difference between patients rated as psychotic and those rated as borderline (M = 72.69 vs. 64.21, p = .154) nor was there significant mean differences between patients rated as borderline and those rated as neurotic (M = 64.21 vs. 59.85, p = .379).For hypothesis C.2., we predicted significant mean differences for Sc across the psychotic, borderline, and neurotic scale categories, with the largest scale mean for psychotic followed by borderline and lastly the neurotic category (see Table 4 for the means and standard deviations). The ANOVA indicated that there were significant differences among the three scale categories on the Sc scale, F (2, 95) = 26.15, p <.001, 2= .36. Scheffe post hoc tests indicated that patients rated as psychotic scored significantly higher on the Sc scale in comparison to those rated as borderline (M = 85.77 vs. 62.21, p = .001) and neurotic (M = 85.77 vs. 56.18, p = .001). There was no significant mean difference between patients rated as borderline versus neurotic (M = 62.21 vs. 56.18, p = .104).We predicted for hypothesis C.3., significant mean differences for Es across the psychotic, borderline, and neurotic scale categories, with the largest scale mean for neurotic, followed by borderline and lastly the psychotic category (see Table 4 for the means and standard deviations). This final ANOVA also found significant mean differences among the three scale categories on the Es scale, F (2, 95) = 11.506, p. = 001,2= .20. Scheffe post hoc tests indicated that patients rated as neurotic scored significantly higher on the Es scale in comparison to those rated as borderline (M = 49.55 vs. 43.58, p = .028), and psychotic (M = 49.55 vs. M = 34.31, p = .001). There was also a significance mean difference between patients rated as borderline and those rated as psychotic (M = 43.58 vs. 34.31, p = .012).
  • Of the 61 practitioners surveyed, 80% held doctorates and 20% held masters degrees. Fifty-two percent of the respondents were women. Most of the participating practitioners’ primary theoretical orientations were other than psychodynamic: Psychodynamic (44%), Eclectic (21%), Cognitive-Behavioral (15%), Humanistic/existential (13%), and Systems (3%). Practitioners rated on 7-point scales (1 = Not at all helpful; 7 = Very helpful) how helpful the PDC was in improving both their understanding of their patients and in treatment planning beyond their ICD and DSM diagnosis. Practitioners were also asked to rate how helpful specific scales of the PDC were in understanding their patients. Seventy-nine percent of the practitioners rated the PDC as “helpful-very helpful” in improving their understanding of their patient beyond their ICD or DSM diagnosis, 67% rated the PDC as “helpful-very helpful” in the treatment planning of their patient beyond their ICD or DSM diagnosis, 84% rated the PDC’s level of Personality Structure Scale as “helpful-very helpful” in understanding their patient, 72% rated Dominate Personality Patterns and Disorders Scale as “helpful-very helpful” in understanding their patient, 79% rated the Mental Functioning Scale as “helpful-very helpful” in understanding their patient, and 50% rated the Cultural/Contextual Dimension as “helpful-very helpful” in understanding their patient. In comparison to the above PDC scales, only 31% rated the ICD or DSM symptoms as “helpful-very helpful” in understanding their patient
  • Ethical Issues Involved with Diagnosing

    1. 1. Presenters: Robert M. Gordon, Ph.D.,& Alan C. Tjeltveit, Ph.D.1
    2. 2. Educational Objectives:Learn about the ethical issues involved with makingand using a diagnosis, learn about the DSM-5, ICD-10and PDM, and learn how to integrate these systems.Goals:Understand the ethical and risk issues involved in notdiagnosing accurately, identify the ethical issuesassociated with how we (and others) use diagnoses,and learn the difference between diagnosis as a labelof disease as compared to diagnosis as a means tounderstand in order to better help.2
    3. 3.  Lecture you about the grossethical violations that many ofyou—through ignorance, malice,or both—routinely commit andshould STOP doing Provide precise, foolproof, 100%certain answers to all ethicaldilemmasWhat we will NOT do today
    4. 4. What We Will Do Delineate general ethical principles andspecific ethical standards of relevance to anydiagnostic approach Contend that the best ethical clinical practiceinvolves careful thought about diagnosis; thereare many ways to practice well Discuss some ways of thinking that may helpyou best practice in accord with professionalethical principles and standards and your ownapproaches to your practice and/or research
    5. 5. Diagnostic Systems The DSM—it is claimed—is the Bible of diagnosis NIMH Director Thomas Insel declared on April 29,2013, that “While DSM has been described as a „Bible‟ forthe field, it is, at best, a dictionary” The DSM‟s “weakness is its lack of validity” “NIMH will be re-orienting its research away fromDSM categories”
    6. 6. Thomas InselDirector, NIMHOfficial pictureNote what he’sleaning onSource of photo: Herper, 2013
    7. 7. NIMH’s alternative Research Domain Criteria (RDoC)
    8. 8. Draft Research Domain CriteriaNegative Valence SystemsAcute threat (“fear”)Potential threat (“anxiety”)Sustained threatLossFrustrative nonrewardPositive Valence SystemsApproach motivationInitial responsiveness to rewardSustained responsiveness torewardReward learningHabitCognitive SystemsAttentionPerceptionWorking memoryCognitive (effortful) controlSystems for Social ProcessesAffiliation and attachmentSocial CommunicationPerception & Understanding ofSelfAgencySelf-KnowledgePerception & Understanding ofOthersArousal and Regulatory SystemsArousalCircadian RhythmsSleep and wakefulness
    9. 9. Research Domain Criteria: Is anythingrelevant to diagnosis left out? Agency Persons The Self Personality Relationships Community Culture Narrative Meaning Spirituality Ethics ?
    10. 10. Research Domain Criteria Some see this as praiseworthy scientific progress The chair of the Psychiatry Department at Columbiaasserts that “psychiatry needs to base its decisions moreon biology, and less on behavior” (Herper, 2013) Some psychologists see RDoC as either biologicalreductionism or slanted toward biological causation Given the current state of the research, the RDoC canbe read primarily as a promissory note, which is backedup by an ideology which holds that:1. Psychological problems are medical problems2. Medical problems are, at root, biological problems3. Real cures will only come at the root level
    11. 11. NIMH director & the American PsychiatricAssociation president-elect, May 14, 2013 Today, the … DSM [no number], along with the ICDrepresents the best information currently available forclinical diagnosis of mental disorders. Patients, families, andinsurers can be confident that effective treatments areavailable and that the DSM is the key resource for deliveringthe best available care. The National Institute of MentalHealth (NIMH) has not changed its position on DSM-5[which was?]. As NIMHs Research Domain Criteria (RDoC)project website states, "The diagnostic categories representedin the DSM-IV [!] and the International Classification ofDiseases-10 (ICD-10, containing virtually identical disordercodes) remain the contemporary consensus standard for howmental disorders are diagnosed and treated.” , emendations by Rick Froman
    12. 12. 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 RDoCwe face ethical issues regarding diagnosis The current controversy over the DSM-5 is anopportunity to reflect deeply on diagnosis inrelationship to professional ethics
    13. 13. Case: Carlos 18-year-old high school junior (getting Cs) in the technicaltrack of an underfunded “under-performing” school districtin 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 (they’re in a band together) After his best friend was killed in a car accident, he wasdeeply 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 schoolWhat are the ethical issues associated with diagnosing Carlos?
    14. 14. Ethical Principles & StandardsRelevant to Diagnosis “Their intent is to guide and inspire psychologiststoward the very highest ethical ideals of theprofession” Principle A: Beneficence and Nonmaleficence“Psychologists strive to benefit those with whom they work and take care to do no harm”
    15. 15. How can optimal diagnosis benefit Better understanding/assessment Better treatment: what to do how to be (e.g., patient) how to relate(relationship style) Better communicationamong professionals andwith clients Better research Combats client isolation(“I’m not the only one”) Helps connect individualswith others having similarproblems (those who’ve“been there”) so they canreceive social support challenge
    16. 16. 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 client’s interpretation of the dx Harm may stem from how others use and interpretdiagnoses
    17. 17. How may diagnosis harm? Leads to less than optimal,ineffective, or harmfultreatment Leads to misunderstandingpersons and their problems Labels may stick Stigma Damage a person’s self-understanding Decrease clientresponsibility/motivationto change Create unwarranted guilt orshame Focus attention away fromkey dimensions of aperson’s problems Convince a person to acceptas natural (& henceinevitable) what they can,in fact, change Make it more difficult orcost more to get healthand/or life insurance
    18. 18. How may diagnosis harm? Result in not being hired Job loss Living down toexpectations associatedwith a diagnosis Increased health care costs Increase expenses to Clients Employers Society ?
    19. 19. Principle B: Fidelity and Responsibility “Psychologists … are aware of their professional andscientific responsibilities to society and to the specificcommunities in which they work” “Psychologists … seek to manage conflicts of interestthat could lead to exploitation or harm”
    20. 20. Standard 3. Human Relations3.06 Conflict of Interest “Psychologists refrain from taking on a professionalrole when personal, scientific, professional, legal,financial or other interests or relationships couldreasonably be expected to (1) impair their objectivity,competence or effectiveness in performing theirfunctions as psychologists”American Psychological Association. (2010). Ethical principles ofpsychologists and code of conduct. Retrieved from
    21. 21. Figure 1. Comparison of financial conflicts of interest among DSM-IV and DSM-5 task force andwork group members.Cosgrove L, Krimsky S (2012) A Comparison of DSM-IV and DSM-5 Panel Members Financial Associations with Industry: A PerniciousProblem Persists. PLoS Med 9(3): e1001190. doi:10.1371/journal.pmed.1001190
    22. 22. Principle C: Integrity “Psychologists seek to promote accuracy,honesty, and truthfulness in the science,teaching and practice of psychology” Insurance fraud?
    23. 23. Principle D: Justice “Psychologists recognize that fairness andjustice entitle all persons to access to andbenefit from the contributions of psychologyand to equal quality in the processes,procedures and services being conducted bypsychologists. Psychologists exercisereasonable judgment and take precautions toensure that their potential biases … do not leadto or condone unjust practices”
    24. 24. Principle E: Respect for Peoples Rights and Dignity “Psychologists are aware that special safeguards may benecessary to protect the rights and welfare of persons orcommunities whose vulnerabilities impair autonomousdecision making” “Psychologists are aware of and respect cultural, individualand role differences, including those based on age, gender,gender identity, race, ethnicity, culture, national origin,religion, sexual orientation, disability, language andsocioeconomic status and consider these factors whenworking with members of such groups” “Psychologists try to eliminate the effect on their work ofbiases based on those factors, and they do not knowinglyparticipate in or condone activities of others based uponsuch prejudices”
    25. 25. Standard 9. Assessment9.01 Bases for Assessments (a) “Psychologists base the opinions contained in their …diagnostic … statements … on information … sufficient tosubstantiate their findings. (See also Standard 2.04,Bases for Scientific and Professional Judgments.)”Standard 2. Competence2.04 Bases for Scientific and Professional Judgments “Psychologists work is based upon establishedscientific and professional knowledge of the discipline”
    26. 26. Exercise in PsychodiagnosesLearn 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
    27. 27. What Taxonomic Organization forMental and Behavioral Science?Like a BiologicalOrganization?Like a Periodic Table?27
    28. 28. 28
    29. 29. Start with a good diagnostic formulation“Once I have a good feel for the person, the work isgoing well, I stop thinking diagnostically andsimply immerse myself in the unique relationshipthat unfolds between me and the client…one canthrow away the book and savor individualuniqueness.”Nancy McWilliams (2011) Psychoanalytic Diagnosis: UnderstandingPersonality Structure in the Clinical Process, Second Edition.29
    30. 30. Main Reasons for Diagnosing1. Its usefulness for treatment planning. “Understandingcharacter styles help the therapist be more careful withboundaries with a histrionic patient, more pursuant ofthe flat affect with the obsessional person, and moretolerant of silence with a schizoid client.”2. Its implications for prognosis. “Realistic goals protectpatients from the demoralization and therapist fromburnout.”30
    31. 31. Why Diagnose?3. Its value in enabling the therapist to convey empathy.Once one knows that a depressed patient also has aborderline rather neurotic level personality structure, thetherapist will not be surprised if during the second year oftreatment she makes a suicide gesture.Or once a borderline client starts to have hope of realchange, that the borderline client often panics and flirtswith suicide in an effort to protect himself fromtraumatic disappointment.31
    32. 32. Why Diagnose?4. Its role in reducing the probability that certaineasily frighten people will flee from treatment. Itis helpful for the therapist to communicate tohypomanic or counter-dependent patients anunderstanding of how hard it may be for them tostay in therapy.32
    33. 33. Why Diagnose?5. Its value in risk management. Often therapistsmistakenly use a presenting symptom as the onlydiagnosis and missed the borderline level ofpersonality or psychopathic personality and gotinto trouble.6. It’s value in process and outcome research.33
    34. 34. Risk Factors in Litigious PatientsBorderline Personality OrganizationPsychopathic traitsHistory of acting out34
    35. 35. “I have often served as an expert witness in malpracticecases where psychologists had missed the psychopathicor borderline traits in patients.The DSM classifies antisocial and borderlinepersonality disorders by precise and narrow symptoms.This is often misleading. Psychopathy can be a complexpersonality pattern that combines with or is obscuredby other personality patterns, and borderline can beviewed as an entire level of personality organizationthat 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
    36. 36. Which Diagnostic TaxonomyShould We Use?DSM5?ICD-10?PDM?36
    37. 37. DSM 5 The DSM 5 May 2013. Research started in 1999. The DSM makes the American Psychiatric Associationover $5 million a year, historically adding up to over$100 million.37
    38. 38. DSM-5 Moves from Multi-axialsystem to a similar ICD 10 System38
    39. 39. 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 Disorders39
    40. 40. 40
    41. 41. Why Will DSM-5 Cost $199 a Copy?By Allen Frances, M.D. 1/24/13 Huffington PostDSM-5 has just announced its price -- an incredible $199 First, APA has sunk more than $25 million into DSM-5 andwants to recoup as much of its investment as it can. DSM-IV cost one fifth as much -- just $5 million -- of which halfcame from external grants. APA is probably counting on having captive buyers who areforced 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 availablefor free on the internet DSM-5 is so clunkily written, no teacher will ever want to assignit to students People are not likely to rush out to buy a ridiculously expensiveDSM-5 that has already been discredited as unsafe andscientifically unsound.41
    42. 42. DSM 5 Is Guide Not Bible—Ignore Its Ten WorstChangesBy Allen J. Frances, M.D. Psychology Today Dec 2 2012 More than fifty mental health professional associationspetitioned for an outside review of DSM 5 to provide anindependent judgment of its supporting evidence and toevaluate the balance between its risks and benefits.Professional journals, the press, and the public alsoweighed in- expressing widespread astonishment aboutdecisions that sometimes seemed not only to lackscientific support but also to defy common sense.42
    43. 43.  Fortunately, some of its most egregiously risky andunsupportable proposals were eventually droppedunder great external pressure (most notablypsychosis risk, mixed anxiety/depression, internetand sex addiction, rape as a mental disorder,hebephilia, cumbersome personality ratings, andsharply lowered thresholds for many existingdisorders).43
    44. 44. 1) Disruptive Mood Dysregulation Disorder will turntemper tantrums into a mental disorder.2) Normal grief will become Major Depressive Disorder.3) The everyday forgetting characteristic of old age willnow be misdiagnosed as Minor NeurocognitiveDisorder.4) DSM 5 will likely trigger a fad of Adult AttentionDeficit Disorder leading to widespread misuse ofstimulant drugs for performance enhancement andrecreation and contributing to the already large illegalsecondary market in diverted prescription drugs.5) Excessive eating 12 times in 3 months is no longer just amanifestation of gluttony but it is a psychiatric illnesscalled Binge Eating Disorder.44
    45. 45. 6) The changes in the DSM 5 definition of Autism willresult in lowered rates- perhaps by 50% according tooutside research groups.7) First time substance abusers will be lumped indefinitionally in with hard core addicts despite theirvery different treatment needs and prognosis and thestigma this will cause.8) Behavioral Addictions that eventually can spread tomake a mental disorder of everything we like to do alot. Watch out for careless overdiagnosis of internetand sex addiction and the development of lucrativetreatment programs to exploit these new markets.9) DSM 5 obscures the already fuzzy boundary beenGeneralized Anxiety Disorder and the worries ofeveryday life.10) DSM 5 has opened the gate even further to the alreadyexisting problem of misdiagnosis of PTSD in forensicsettings. 45
    46. 46. Neurodevelopmental DisordersIntellectual Disability (Intellectual DevelopmentalDisorder) Diagnostic criteria for intellectual disability(intellectual developmental disorder) emphasize theneed for an assessment of both cognitive capacity (IQ)and adaptive functioning. Severity is determined by adaptive functioning ratherthan IQ score. Moreover, a federal statue in the UnitedStates (Public Law 111-256, Rosa’s Law) replaces theterm “mental retardation” with intellectual disability. The term intellectual developmental disorder wasplaced in parentheses to reflect the ICD-11 to bereleased in 2015). 46
    47. 47. Intellectual Disability (IntellectualDevelopmental Disorder) DSM-IV criteria had required an IQ score of 70 as thecutoff for diagnosis; the new criteria recommend IQtesting and describe “deficits in adaptive functioningthat result in failure to meet developmental andsociocultural standards for personal independenceand social responsibility.” The new criteria also include severity measures formild, moderate, severe, and profound intellectualdisability.47
    48. 48. Autism Spectrum Disorder (ASD) Consolidation of DSM-IV criteria for autism, Asperger’s,childhood disintegrative disorder, and pervasivedevelopmental disorder-not otherwise specific (PDD-NOS)—into one diagnostic category called autismspectrum disorder (ASD). The new criteria describe two principal symptoms:“deficits in social communication and social interaction”and “restrictive and repetitive behavior patterns”48
    49. 49. Communication Disorders The DSM-5 communication disorders include: language disorder speech sound disorder childhood-onset fluency disorder (a new name forstuttering) social (pragmatic) communication disorder, a newcondition for persistent difficulties in the social uses ofverbal and nonverbal communication.49
    50. 50. Attention-Deficit/Hyperactivity Disorder The same 18 symptoms are used as in DSM-IV The onset criterion has been changed from “symptomsthat caused impairment were present before age 7years” to “several inattentive or hyperactive-impulsivesymptoms were present prior to age 12”; subtypes have been replaced with presentationspecifiers that map directly to the prior subtypes; a comorbid diagnosis with autism spectrum disorder isnow allowed; a symptom threshold change has been made for adultswith the cutoff for ADHD of five symptoms, instead ofsix required for younger persons, 50
    51. 51. Specific Learning Disorder Specific learning disorder combines the DSM-IVdiagnoses of reading disorder, mathematics disorder,disorder of written expression, and learning disordernot otherwise specified. Because learning deficits inthe areas of reading, written expression, andmathematics commonly occur together, codedspecifiers for the deficit types in each area areincluded.51
    52. 52. Schizophrenia Spectrum andOther Psychotic Disorders Schizophrenia Elimination of the special attribution of bizarredelusions and Schneiderian first-rank auditoryhallucinations (e.g., two or more voices conversing). The second change is the addition of a requirement inCriterion A that the individual must have at least oneof these three symptoms: delusions, hallucinations,and disorganized speech. At least one of these core“positive symptoms” is necessary for a reliablediagnosis of schizophrenia52
    53. 53. Schizophrenia subtypes The DSM-IV subtypes of schizophrenia (i.e., paranoid,disorganized, catatonic, undifferentiated, and residualtypes) are eliminated due to their limited diagnosticstability, low reliability, and poor validity. Instead, a dimensional approach to rating severity forthe core symptoms of schizophrenia.53
    54. 54. Schizoaffective Disorder The primary change to schizoaffective disorder is therequirement that a major mood episode be present fora majority of the disorder’s total duration afterCriterion A has been met. It makes schizoaffective disorder a longitudinalinstead of a cross-sectional diagnosis—morecomparable to schizophrenia, bipolar disorder, andmajor depressive disorder, which are bridged by thiscondition.54
    55. 55. Delusional Disorder Criterion A for delusional disorder no longer has therequirement that the delusions must be nonbizarre. Aspecifier for bizarre type delusions provides continuitywith DSM-IV. The demarcation of delusional disorderfrom psychotic variants of obsessive-compulsivedisorder and body dysmorphic disorder is explicitlynoted with a new exclusion criterion, which states thatthe symptoms must not be better explained byconditions such as obsessive-compulsive or bodydysmorphic disorder with absent insight/delusionalbeliefs.55
    56. 56. Catatonia In DSM-5, catatonia may be diagnosed as a specifierfor depressive, bipolar, and psychotic disorders56
    57. 57. Bipolar and Related DisordersBipolar Disorders Criterion A for manic and hypomanic episodes now includes anemphasis on changes in activity and energy as well as mood. The DSM-IV diagnosis of bipolar I disorder, mixed episode, requiring that theindividual simultaneously meet full criteria for both mania and majordepressive episode, has been removed. Instead, a new specifier, “withmixed features,” has been added that can be applied to episodes ofmania or hypomania when depressive features are present, and toepisodes of depression in the context of major depressive disorder orbipolar disorder when features of mania/hypomania are present.Other Specified Bipolar and Related Disorder categorization for individuals with a past history of a major depressivedisorder who meet all criteria for hypomania except the durationcriterion (i.e., at least 4 consecutive days). A second conditionconstituting an other specified bipolar and related disorder is that toofew symptoms of hypomania are present to meet criteria for the fullbipolar II syndrome, although the duration is sufficient at 4 or moredays.Anxious Distress Specifier57
    58. 58. Depressive Disorders DSM-5 contains several new depressive disorders,including disruptive mood dysregulation disorder andpremenstrual dysphoric disorder. To address concerns about potential overdiagnosis andovertreatment of bipolar disorder in children, a newdiagnosis, disruptive mood dysregulation disorder, isincluded for children up to age 18 years who exhibitpersistent irritability and frequent episodes of extremebehavioral dyscontrol. Finally, DSM-5 conceptualizes chronic forms of depressionin a somewhat modified way. What was referred to asdysthymia in DSM-IV now falls under the category ofpersistent depressive disorder, which includes bothchronic major depressive disorder and the previousdysthymic disorder.58
    59. 59. Bereavement In DSM-IV, there was an exclusion criterion for a majordepressive episode that was applied to depressive symptomslasting less than 2 months following the death of a loved one(i.e., the bereavement exclusion). This exclusion is omitted inDSM-5. 1, to remove the implication that bereavementtypically lasts only 2 months when both physicians and griefcounselors recognize that the duration is more commonly 1–2years. 2, bereavement is recognized as a severe psychosocialstressor that can precipitate a major depressive episode in avulnerable individual, and an increased risk for persistentcomplex bereavement disorder, which is now in Conditionsfor Further Study in DSM-5 Section III. 3, bereavement-relatedmajor depression is most likely to occur in individuals with pastpersonal and family histories of major depressive episodes. It isgenetically influenced and is associated with similarpersonality characteristics, patterns of comorbidity, and risksof chronicity and/or recurrence as non–bereavement-relatedmajor depressive episodes59
    60. 60. Anxiety Disorders The DSM-5 chapter on anxiety disorder no longerincludes obsessive-compulsive disorder (which isincluded with the obsessive-compulsive and relateddisorders) or posttraumatic stress disorder and acutestress disorder (which is included with the trauma-and stressor-related disorders). However, thesequential order of these chapters in DSM-5 reflectsthe close relationships among them.60
    61. 61. PTSD The 3 clusters of DSM-IV symptoms will be divided into 4clusters in DSM-5: intrusion symptoms, avoidancesymptoms, arousal/reactivity symptoms and negative moodand cognitions. Criterion A2 (requiring fear, helplessness or horror happenright after the trauma) will be removed. The diagnosis is proposed to move from the class of anxietydisorders into a new class of "trauma and stressor-relateddisorders." PTSD assessment measures, such as the CAPS and the PCL,are being revised by the National Center for PTSD to bemade available upon the release of DSM-5.61
    62. 62. Somatic Symptom and Related DisordersThe DSM-5 classification reduces the number of thesedisorders and subcategories. Diagnoses of somatizationdisorder, hypochondriasis, pain disorder, andundifferentiated somatoform disorder have beenremoved.62
    63. 63. The International Classification ofDiseases ICD The ICD is currently the most widely used statisticalclassification system for diseases in the world. This is in fact the official diagnostic system for mentaldisorders in the US. The ICD-10, was developed in 1992. ICD-11 is currently being researched and should beready in 2015.63
    64. 64. ICD History The first international conference to revise theInternational Classification of Causes of Death convenedin 1900; with revisions occurring every ten-yearsthereafter. In 1948, the World Health Organization (WHO)assumed responsibility for preparing and publishing therevisions to the ICD every ten-years. WHO sponsoredthe seventh and eighth revisions in 1957 and 1968,respectively. It later become clear that the establishedten-year interval between revisions was too short. The America Psychiatric Association has long lobbiedagainst the use of the ICD (but due to federal law isforced to work with the ICD). 64
    65. 65. ICD is Required by HIPPA The deadline for the United States to begin usingClinical Modification ICD-10-Clinical Modification(CM) is currently October 1, 2014. The deadline was previously October 1, 2011. Thetransition to ICD-10 is required for everyone coveredby the Health Insurance Portability Accountability Act(HIPAA), Medicare and Medicaid.65
    66. 66. ICD-10 MENTAL AND BEHAVIOURAL DISORDERS consists of 10main groups:F0: Due to known physiological conditionsF1: Due to use of psychoactive substancesF2: Schizophrenia, schizotypal and delusional disordersF3: Mood [affective] disordersF4: Anxiety, dissociative, stress-related and somatoformdisordersF5: Behavioural syndromes associated with physiologicaldisturbances and physical factorsF6: Disorders of personality and behaviour in adult personsF7: Intellectual disabilitiesF8: Pervasive and specific developmental disordersF9: Behavioural and emotional disorders with onset usuallyoccurring in childhood and adolescenceIn addition, a group of "unspecified mental disorders". 66
    67. 67. F60 Specific personality disordersF60.0 Paranoid personality disorderF60.1 Schizoid personality disorderF60.2 Antisocial personality disorderF60.3 Borderline personality disorderF60.4 Histrionic personality disorderF60.5 Obsessive-Compulsive personality disorderF60.6 Avoidant personality disorderF60.7 Dependent personality disorderF60.8 Other specific personality disordersF60.81 Narcissistic personality disorderF60.89 Other specific personality disorderF60.9 Personality disorder, unspecified67
    68. 68. ICD-11 Survey Overview 2155 global psychologists participated in the WHO andInternational Union of Psychological Sciences (IUPsyS) Recruited through 23 IUPsyS member nationalpsychological 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 PsychiatricAssociation (WPA) of 4887 psychiatrists in 44 countries68
    69. 69. ICD-11 2015 ICD-11 will draw on research about how cliniciansconceptualize mental disorders in hopes of creating amore intuitive and psychological classification system. ICD-11 will be available for free on the Internet (ICD-9and 10 apps are free).69
    70. 70. Purpose of Classification%Participants33%16%39%3% 5% 4%0%10%20%30%40%50%CommunicationamongcliniciansCommunicationbetweenclinicians andpatientsInformtreatment andmanagementdecisionsFacilitateresearchBasis forgeneratingnational healthstatisticsOtherQ9 - From your perspective, which is the single, mostimportant purpose of a diagnostic classification system?70
    71. 71. Number of Categories Desired%Participants35%50%11%4%0%10%20%30%40%50%60%10 to 30 31 to 100 101 to 200 More than 200Q10 - In clinical settings, how many diagnostic categoriesshould a classification system contain to be most usefulfor mental health professionals?71
    72. 72. ICD-10 and DSM-IVCategories Used Most OftenICD-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
    73. 73. Categories With theLowest Ease of UseICD-10 EOU DSM-IV EOUAspergers Syndrome 0.50 Dissociative Disorders 0.48Dissociative [Conversion] Disorders 0.50 Impulse Control Disorders 0.50Schizoaffective Disorder 0.51 Schizotypal Personality Disorder 0.54Schizotypal Disorder 0.51 Schizoaffective Disorder 0.54Somatoform Disorders 0.52 Aspergers Disorder 0.56Borderline Personality Disorder 0.56 Somatoform Disorders 0.56Hyperkinetic (Attention Deficit) Disorder 0.56 Primary Sleep Disorders 0.58Delirium 0.58 Bipolar II Disorder 0.58MBDs due to Use of Volatile Solvents 0.58 Tic disorders 0.59Habit and Impulse Disorders 0.59 Brief Psychotic Disorder 0.60MBDs due to Use of Hallucinogens 0.60 Vascular Dementia 0.60Bipolar Affective Disorder 0.60 Sexual Dysfunctions 0.60Mixed Anxiety and Depressive Disorder 0.60 Autistic Disorder 0.61Adjustment Disorder 0.60 Delusional Disorder 0.6273
    74. 74. Categories With theLowest Goodness of FitICD-10 GOF DSM-IV GOFDissociative [Conversion] Disorders 0.45 Schizotypal Personality Disorder 0.44Aspergers Syndrome 0.45 Dissociative Disorders 0.45Hyperkinetic (Attention Deficit) Disorder 0.50 Somatoform Disorders 0.47Schizoaffective Disorder 0.51 Aspergers Disorder 0.48Somatoform Disorders 0.51 Impulse Control Disorders 0.48Borderline Personality Disorder 0.51 Schizoaffective Disorder 0.49MBDs Due to Use of Hallucinogens 0.52 Primary Sleep Disorders 0.51Schizotypal Disorder 0.53 Tic disorders 0.53Vascular Dementia 0.53 Bipolar II Disorder 0.53Dissocial (Antisocial) Personality Disorder 0.55 Borderline Personality Disorder 0.54Adjustment Disorder 0.55 Autistic Disorder 0.54Habit and Impulse Disorders 0.55 Brief Psychotic Disorder 0.55Mixed Anxiety and Depressive Disorder 0.56 Sexual Dysfunctions 0.5674
    75. 75. An enduring pattern of unusual speech, perceptions, beliefsand behaviors that are not of sufficient intensity to meet therequirements 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 ideationUnusual perceptual distortionsSuspiciousness or paranoid ideasOccasional transient psychotic episodesVague, circumstantial, stereotyped thinkingObsessive ruminationsNot met diagnostic criteria for schizophreniaICD 10 / ICD 11 Schizotypal Disorder75
    76. 76. A pervasive pattern of social and interpersonal deficitsmarked by acute discomfort with, and reduced capacityfor, close relationships as well as by cognitive or perceptualdistortions 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 anxietyDSM-IV Schizotypal PersonalityDisorder76
    77. 77. DSM-5 Schizotypal Personality DisorderA. 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;AND2. 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. Eccentricityb. Cognitive and perceptual dysregulation:c. Unusual beliefs and experiences2. Detachment, characterized by:a. Restricted affectivityb. Withdrawal3. Negative Affectivity, characterized by:a. Suspiciousness77
    78. 78. DSM-5 Schizotypal Personality DisorderThe only two non-US members of the DSM-5Personality Disorders Work group (Roel Verheuland John Livesley) resigned in April 2012:“First, the proposed classification is unnecessarilycomplex, incoherent, and inconsistent. … Second, theproposal displays a truly stunning disregard forevidence.The current proposal represents the worst possibleoutcome: it displays almost total discontinuity withDSM-IV while failing to improve validity and clinicalutility of the classification.”78
    79. 79. A diagnostic framework that attempts to characterize thewhole person--the depth as well as the surface ofemotional, cognitive, and social functioning; fromhealthy to disturbed in a mixed categorical -dimensionalsystem79
    80. 80. Psychodynamic Theory as a Complex Adaptive System-interaction, interdependence and diversity of constructs(temperament, affects, cognitions, development, traumas, defenses, fantasies, attachments), emergences (symptoms), tails (one event can movethe entire central tendency) and tipping points (break downs).80
    81. 81. PDM’s Current TaxonomyManifest Symptoms and ConcernsMental FunctioningPersonality Patterns and Disorders81
    82. 82. Types of Personality Disorders or PatternsP101. Schizoid Personality DisordersP102. Paranoid Personality Disorders P103. Psychopathic (Antisocial) Personality DisordersP103.1 Passive/ParasiticP103.2 Aggressive P104. Narcissistic Personality DisordersP104.1 Arrogant/EntitledP104.2 Depressed/Depleted P105. Sadistic and Sadomasochistic Personality DisordersP105.1 Intermediate Manifestation: Sadomasochistic PersonalityDisorders P106. Masochistic (Self-Defeating) Personality DisordersP106.1 Moral MasochisticP106.2 Relational Masochistic 82
    83. 83.  P107. Depressive Personality DisordersP107.1 IntrojectiveP107.2 AnacliticP107.3 Converse Manifestation: Hypomanic PersonalityDisorder P108. Somatizing Personality Disorders P109. Dependent Personality DisordersP109.1 Passive-Aggressive Versions of Dependent PersonalityDisordersP109.2 Converse Manifestation: CounterdependentPersonality Disorders P110. Phobic (Avoidant) Personality DisordersP110.1 Converse Manifestation: Counterphobic PersonalityDisorders P111. Anxious Personality Disorders83
    84. 84.  P112. Obsessive-Compulsive Personality DisordersP112.1 ObsessiveP112.2 Compulsive P113. Hysterical (Histrionic) Personality DisordersP113.1 InhibitedP113.2 Demonstrative or Flamboyant P114. Dissociative Personality Disorders (DissociativeIdentity Disorder/Multiple Personality Disorder) P115. Mixed/Other84
    85. 85.  Capacity for Regulation, Attention, and Learning Capacity for Relationships (Including Depth, Range, andConsistency) 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 Morality85
    86. 86. Symptom Patterns: The Subjective Experience - S Axis S301. Adjustment DisordersS302. Anxiety DisordersS302.1 Psychic Trauma and Posttraumatic Stress DisorderS302.2 PhobiasS302.3 Obsessive-Compulsive DisordersS303. Dissociative DisordersS304. Mood DisordersS304.1 Depressive DisordersS304.2 Bipolar DisordersS305. Somatoform (Somatization) DisordersS306. Eating DisordersS307. Psychogenic Sleep DisordersS308. Sexual and Gender Identity DisordersS308.1 Sexual DisordersS308.2 ParaphiliasS308.3 Gender Identity DisordersS309. Factitious DisordersS310. Impulse Control DisordersS311. Addictive/Substance Abuse DisordersS312. Psychotic DisordersS313. Mental Disorders Based on a General Medical Condition86
    87. 87. Classification of Child and Adolescent Mental Health DisordersProfile of Mental Functioning for Children andAdolescents - MCA Axis Capacity for Regulation, Attention, and Learning Capacity for Relationships (Including Depth, Range, andConsistency) Quality of Internal Experience (Level of Confidence andSelf-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 ofMorality Summary of Child and Adolescent Mental Functioning87
    88. 88. Child and Adolescent Personality Patterns and Disorders - PCA AxisDevelopmental Aspects of Emerging Personality PatternsPCA101. Fearful of Closeness/Intimacy (Schizoid) PersonalityDisordersPCA102. Suspicious/Distrustful Personality DisordersPCA103. Sociopathic (Antisocial) Personality DisordersPCA104. Narcissistic Personality DisordersPCA105. Impulsive/Explosive Personality DisordersPCA106. Self-Defeating Personality DisordersPCA107. Depressive Personality DisordersPCA108. Somatizing Personality DisordersPCA109. Dependent Personality DisordersPCA110. Avoidant/Constricted Personality DisordersPCA110.1 Counterphobic Personality DisordersPCA111. Anxious Personality DisordersPCA112. Obsessive-Compulsive Personality DisordersPCA113. Histrionic Personality DisordersPCA114. Dysregulated Personality DisordersPCA115. Mixed/Other88
    89. 89. Child and Adolescent Symptom Patterns: The Subjective Experience Anxiety DisordersSCA301. Anxiety DisordersSCA302. PhobiasSCA303. Obsessive-Compulsive DisordersSCA304. Somatization (Somatoform) DisordersAffect/Mood DisordersSCA305. Prolonged Mourning/Grief ReactionSCA306. Depressive DisordersSCA307. Bipolar DisordersSCA308. SuicidalityDisruptive Behavior DisordersSCA309. Conduct DisordersSCA310. Oppositional-Defiant DisordersSCA311. Substance Abuse Related DisordersReactive DisordersSCA312. Psychic Trauma and Posttraumatic Stress DisorderSCA313. Adjustment Disorders (other than developmental)Disorders of Mental FunctioningSCA314. Motor Skills DisordersSCA315. Tic DisordersSCA316. Psychotic DisordersSCA317. Neuropsychological DisordersSCA317.1 Visual-Spatial Processing DisordersSCA317.2 Language and Auditory Processing DisordersSCA317.3 Memory ImpairmentsSCA317.4 Attention Deficit/Hyperactivity Disorder (AD/HD)SCA317.5 Executive Function DisordersSCA317.6 Severe Cognitive Deficits 89
    90. 90. Child and Adolescent Symptom Patterns: The Subjective Experience SCA318. Learning DisordersSCA318.1 Reading DisordersSCA318.2 Mathematics DisordersSCA318.3 Disorders of Written ExpressionSCA318.4 Nonverbal Learning DisabilitiesSCA318.5 Social-Emotional Learning DisabilitiesPsychophysiologic DisordersSCA319. BulimiaSCA320. AnorexiaDevelopmental DisordersSCA321. Regulatory DisordersSCA322. Feeding Problems of ChildhoodSCA323. Elimination DisordersSCA323.1 EncopresisSCA323.2 EnuresisSCA324. Sleep DisordersSCA325. Attachment DisordersSCA326. Pervasive Developmental DisordersSCA326.1 AutismSCA326.2 Asperger’s SyndromeSCA326.3 Pervasive Developmental Disorder (PDD) Not Otherwise SpecifiedOther DisordersSCA327. Gender Identity Disorders90
    91. 91. Disorders of Infancy and Early Childhood – Axis I - Primary Axis IEC100 Series- Interactive DisordersIEC101. Anxiety DisordersIEC102. Developmental Anxiety DisordersIEC103. Disorders of Emotional Range and StabilityIEC104. Disruptive Behavior and Oppositional DisordersIEC105. Depressive DisordersIEC106. Mood Dysregulation: A Unique Type of Interactive and MixedRegulatory-Sensory Processing Disorder Characterized by Bipolar PatternsIEC107. Attentional DisordersIEC108. Prolonged Grief ReactionIEC109. Reactive Attachment DisordersIEC110. Traumatic Stress DisordersIEC111. Adjustment DisordersIEC112. Gender Identity DisordersIEC113. Selective MutismIEC114. Sleep DisordersIEC115. Eating DisordersIEC116. Elimination Disorders91
    92. 92.  IEC200 Series - Regulatory-Sensory Processing Disorders (RSPD)Clinical Evidence and Prevalence of Regulatory-Sensory ProcessingDifferencesSensory Modulation Difficulties (Type I)IEC201. Overresponsive, Fearful, Anxious PatternIEC202. Overresponsive, Negative, Stubborn PatternIEC203. Underresponsive, Self-Absorbed PatternIEC203.1 Self-Absorbed and Difficult-to-Engage TypeIEC203.2 Self-Absorbed and Creative TypeIEC204. Active, Sensory Seeking PatternSensory Discrimination Difficulties (Type II) and Sensory-Based MotorDifficulties (Type III)IEC205. Inattentive, Disorganized PatternIEC205.1 With Sensory Discrimination DifficultiesIEC205.2 With Postural Control DifficultiesIEC205.3 With DyspraxiaIEC205.4 With Combinations of All ThreeIEC206. Compromised School and/or Academic Performance PatternIEC206.1 With Sensory Discrimination DifficultiesIEC206.2 With Postural Control DifficultiesIEC206.3 With DyspraxiaIEC206.4 With Combinations of All ThreeContributing Sensory Discrimination and Sensory-Based Motor Difficulties92
    93. 93.  IEC207. Mixed Regulatory-Sensory Processing PatternsIEC207.1 Attentional ProblemsIEC207.2 Disruptive Behavioral ProblemsIEC207.3 Sleep ProblemsIEC207.4 Eating ProblemsIEC207.5 Elimination ProblemsIEC207.6 Selective MutismIEC207.7 Mood Dysregulation, including Bipolar PatternsIEC207.8 Other Emotional and Behavioral Problems Related to Mixed Regulatory-Sensory Processing DifficultiesIEC207.9 Mixed Regulatory-Sensory Processing Patterns whereBehavioral or Emotional Problems Are Not Yet In Evidence IEC300 Series - Neurodevelopmental Disorders of Relating andCommunicatingIEC301. Type I: Early Symbolic, with ConstrictionsIEC302. Type II: Purposeful Problem-Solving, with ConstrictionsIEC303. Type III: Intermittently Engaged and PurposefulIEC304. Type IV: Aimless and UnpurposefulOther Neurodevelopmental Disorders (Including Genetic and MetabolicSyndromes)93
    94. 94. Reactions to the PDM The PDM was introduced to 192 psychologists in aseveral 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, CBTand Other Non- Psychodynamic Psychologists. Issues in Psychoanalytic Psychology, 31,1, 55-62.94
    95. 95. Nancy McWilliams ( 2011) PsychoanalyticDiagnosis: Understanding Personality Structure inthe Clinical ProcessMcWilliams’ taxonomy is fundamentally based ontwo dimensions:1. Personality Organization and2. Character Organization. Gordon, R.M. (2013) book review in Division/Review and at Amazon books95
    96. 96. Robert M. Gordon and Robert F. Bornstein (2012)96
    97. 97. PDC Is A User Friendly Guide tothe 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 fieldevidence (Gordon and Stoffey 2013 in press)97
    98. 98. PDC’s Taxonomy: From Larger to Smaller UnitsCultural-Contextual IssuesICD SymptomsMental FunctioningPersonality PatternsPersonality Organization98
    99. 99. Clinical Example Using the PDC“Bana” is a 28 year old woman from Syria. Her husband was killed in thewar and she has no children. Her brother was able to get her to the US thisyear.1. Level of Personality Organization- is 7 (Neurotic Level). Her capacityscores 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 typeat the Moderate level of severity (6) with some obsessional and dependentfeatures.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 selfesteem, she can go from inhibited to overly excited expression of affect, herfavored defenses are repression and intellectualization, she has a warmrelationship with her mother and both sets of grandparents, her father waskilled 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 disorder5. Cultural, Contextual Issues- recent death of husband, war trauma,loss of father, leaving much of her family and friends behind, immigrationfears and guilt.99
    100. 100. Testing Dimensional and CategoricalQualities of Personality Organization Hysteria scale and Schizophrenia scale correlate.01 with male sample and .15 with female sample.They are independent representations of verydifferent character structures. The Ego Strength scale measures responsiveness topsychotherapy. I found that the Es scale significantlyincreased (p<.001, Cohen’s d = .80) after an average of3 years of PDT for 55 borderline patients(Gordon, 2001).100
    101. 101. Testing Dimensional and CategoricalQualities of Personality Organization with 3 Scales(L+Pa+Sc)-(Hy+Pt)EsSc, Hy and Es101
    102. 102. 30354045505560657075808590Psychotic Borderline NeuroticHyScEsMMPI-2 Hysteria-Hy, Schizophrenia-Sc, and Ego Strength-EsScales within the Psychotic, Borderline, and NeuroticCategories of the Personality Organization ScalePsychotic (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.102
    103. 103. Example of a Psychotic LevelPersonality: Schizotypal In ICD-10, Schizotypal disorder is classified as aclinical disorder associated with schizophreniarather than a personality disorder as with DSM-IVand 5. It is not in the PDM.103
    104. 104. Percent of Practitioners Rating the PDC Dimensions as“Helpful—Very Helpful” in Understanding Their Patient84727931500102030405060708090Levels of Personality StructureDominant Personality PatternsMental Functioning ICD or DSM SymptomsCultural/Contextual Dimensi104
    105. 105. Current PDM StudyData collected from 13 workshops fromNov. 2012- July 2013.Estimated N= 500+ practitioners anddoctoral studentsLead researcher Robert M. Gordon105
    106. 106. Psychodynamic Diagnostic Prototypes(PDP)Francesco Gazzillo, PhDDepartment of Dynamic and Clinical Psychology«Sapienza» University of Rome106
    107. 107. PDP narrative descriptionP105.1 Intermediate Manifestation:Sadomasochistic Personality DisordersSome individuals alternate between sadistic and sadomasochisticattitudes and behaviors (Kernberg, 1988). Patients with this psychologyare much more emotionally alive and capable of attachment than thosewith primary psychopathic, narcissistic, or sadistic personality structures.Their relationships, however, are intense and explosive. Sometimes theylet themselves be dominated to an extreme extent, and sometimes theyviciously attack the person to whom they previously capitulated. They tendto see themselves as victims of others‟ aggression whose only choices areto 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 ofthis psychology. In psychotherapy, such patients tend to alternate betweenattacking the therapist and feeling insulted and demeaned by him or her.Because sadomasochistic personality disorder is found at the borderlinelevel of severity, treatment considerations include those for borderlinepatients generally. 107
    108. 108. The validation of Psychodynamic Diagnostic Prototypes(PDP; Gazzillo, Lingiardi, Del Corno, 2010)The Prototypic Assessmentof the Psychodynamic Diagnostic Prototype5 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 minutes108
    109. 109. Hypotheses1. Norms for PDP and PDC2. Concurrent validity between PDP and PDC3. How PDM Dx inform about boundaries andcountertransference issues4. How theoretical orientation affects value of varioustaxa (PO, PD, MF, Symptoms, Context)5. Which PD are commonly found at which level of PO.109
    110. 110. 1. Level of Personality StructurePlease rate each capacity from 1 to 10; ratings range from Most Disturbed (1) to MostHealthy (10).1. Identity: ability to view self in complex, stable, and accurate ways2. Object Relations: ability to maintain intimate, stable, and satisfying relationships3. Affect Tolerance: ability to experience the full range of age-expected affects4. Affect Regulation: ability to regulate impulses and affects with flexibility in usingdefenses or coping strategies5. Superego Integration: ability to use a consistent and mature moral sensibility6. Reality Testing: ability to appreciate conventional notions of what is realistic7. Ego Resilience: ability to respond to stress resourcefully and to recover frompainful events without undue difficulty110
    111. 111. 1. Level of Personality Structure- RatingHealthy Personality- characterized by 9-10 scores, life problems never get out of handand enough flexibility to accommodate to challenging realities.Neurotic Level- characterized by mainly 6-8 scores, rigidity and limited range ofdefenses and coping mechanisms, basically a good sense of identity, healthyintimacies, good reality testing, fair resiliency, fair affect tolerance andregulation, favors repression.Borderline Level- characterized by mainly 3-5 scores, recurrent relationalproblems, difficulty with affect tolerance and regulation, poor impulse control, poorsense of identity, poor resiliency, favors primitive defenses such as denial, splittingand projective identification.Psychotic Level- characterized by mainly 1-2 scores, delusional thinking, sometimeshallucinations, poor reality testing and mood regulation, extreme difficultyfunctioning in work and relationships.Overall Personality StructureBased on the 7 ratings above, rate person’s overall personality structure from 1(Psychotic) to 10 (Healthy)111
    112. 112. 2. Personality Patterns or Disorders- ScoringReview the P axis in the PDM for the personalitypatterns most descriptive of your client (use the PDP).Begin by checking off as many descriptors that apply.Then decide on the most dominant personalitypatterns or disorders, and the level of severity (1-10).112
    113. 113. PDM Categories:SchizoidParanoidPsychopathic (antisocial); Subtypes - passive/parasitic or aggressiveNarcissistic; Subtypes - arrogant/entitled or depressed/depleted;Sadistic (and intermediate manifestation, sadomasochistic)Masochistic (self-defeating); Subtypes - moral masochistic or relationalmasochisticDepressive; Subtypes - introjective or anaclitic; Converse manifestation -hypomanicSomatizingDependent (and passive-aggressive versions of dependent); Conversemanifestation - counterdependentPhobic (avoidant); Converse manifestation - counterphobicAnxiousObsessive-compulsive; Subtypes - obsessive or compulsiveHysterical (histrionic); Subtypes - inhibited or demonstrative/ flamboyantDissociativeMixed/otherRate: Dominate Personality Disorder or Maladaptive Traits & Overall Severity ofImpairment 113
    114. 114. 3. Mental Functioning1. Capacity for Attention, Memory, Learning, and Intelligence2. Capacity for Relationships and Intimacy (including depth, range, andconsistency)3. Quality of Internal Experience (level of confidence and self-regard)4. Affective Comprehension, Expression, and Communication5. Level of Defensive or Coping Patterns1-2: Psychotic level (e.g., delusional projection, psychotic denial, psychoticdistortion)3-5: Borderline level (e.g., splitting, projectiveidentification, idealization/devaluation, denial, acting out)6-8: Neurotic level (e.g., repression, reactionformation, 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 realisticand guiding)7. Capacity for Differentiation and Integration (self, others, time, internalexperiences andexternal reality are all well distinguished)8. Self-Observing Capacity (psychological mindedness)9. Realistic sense of Morality114
    115. 115. 4. ICD or DSM SYMPTOMSSymptoms are considered in the context of:1. level of personality structure,2. personality pattern or disorder3. mental functioning.Here you may use the symptoms that may be the focusof the chief complaint and necessary for third partyreimbursement.115
    116. 116. 5. Cultural, Contextual, and OtherRelevant ConsiderationsThis is a qualitative section where the practitioner maywrite how cultural or contextual factors contribute tosymptoms.116
    117. 117. For Free Copies: For copies of the PDP and PDC, search for:“Psychodiagnostic Chart”117
    118. 118. In addition, use whatever system ismost helpful to you in understandingand helping the client/patient118