Examples of Dimensional Systems

1. Personality Disorders: Current ConceptsPersonality Disorders: Current Concepts
and Controversiesand Controversies
2006 Wolfe-Adler Lecture2006 Wolfe-Adler Lecture
Sheppard Pratt Health SystemSheppard Pratt Health System
September 27, 2006September 27, 2006
John M. Oldham, M.D.John M. Oldham, M.D.
Professor and ChairmanProfessor and Chairman
Department of Psychiatry and Behavioral SciencesDepartment of Psychiatry and Behavioral Sciences
Medical University of South CarolinaMedical University of South Carolina
oldhamj@musc.eduoldhamj@musc.edu

2. Personality =Personality =
Temperament + CharacterTemperament + Character

4. Hippocrates ClassificationHippocrates Classification
ElementElement HumorHumor TypeType StyleStyle
AirAir BloodBlood SanguineSanguine
HopefulHopeful
EnthusiasticEnthusiastic
OptimisticOptimistic
EarthEarth Black BileBlack Bile MelancholicMelancholic SadSad
FireFire Yellow BileYellow Bile CholericCholeric
IrascibleIrascible
IrritableIrritable
WaterWater PhlegmPhlegm PhlegmaticPhlegmatic
ApatheticApathetic
SlowSlow

5. DIMENSIONAL
CATEGORICAL

6. Examples of Dimensional SystemsExamples of Dimensional Systems
 Interpersonal Circumplex - Leary, Wiggins, KieslerInterpersonal Circumplex - Leary, Wiggins, Kiesler
 Three factors - Eysenck & EysenckThree factors - Eysenck & Eysenck
 Four factors - Livesley et al., Clark et al.Four factors - Livesley et al., Clark et al.
 Five factors - Costa & McCraeFive factors - Costa & McCrae
 Seven factors - Cloninger et al.Seven factors - Cloninger et al.

7. The Five-Factor Model of PersonalityThe Five-Factor Model of Personality
NeuroticismNeuroticism
 Calm – WorryingCalm – Worrying
 Even-tempered – TemperamentalEven-tempered – Temperamental
 Self-satisfied – Self-pityingSelf-satisfied – Self-pitying
 Comfortable – Self-consciousComfortable – Self-conscious
 Unemotional – EmotionalUnemotional – Emotional
 Hardy – VulnerableHardy – Vulnerable
ExtroversionExtroversion
 Reserved – AffectionateReserved – Affectionate
 Loner – JoinerLoner – Joiner
 Quiet – TalkativeQuiet – Talkative
 Passive – ActivePassive – Active
 Sober – Fun-lovingSober – Fun-loving
 Unfeeling – PassionateUnfeeling – Passionate
Openness to ExperienceOpenness to Experience
 Down-to-earth – ImaginativeDown-to-earth – Imaginative
 Uncreative – CreativeUncreative – Creative
 Conventional – OriginalConventional – Original
 Prefer routine – Prefer varietyPrefer routine – Prefer variety
 Uncurious – CuriousUncurious – Curious
 Conservative – LiberalConservative – Liberal
AgreeablenessAgreeableness
 Ruthless – Soft-heartedRuthless – Soft-hearted
 Suspicious – TrustingSuspicious – Trusting
 Stingy – GenerousStingy – Generous
 Antagonistic – AcquiescentAntagonistic – Acquiescent
 Critical – LenientCritical – Lenient
 Irritable – Good-naturedIrritable – Good-natured
ConscientiousnessConscientiousness
 Negligent – ConscientiousNegligent – Conscientious
 Lazy – HardworkingLazy – Hardworking
 Disorganized – Well-organizedDisorganized – Well-organized
 Late – PunctualLate – Punctual
 Aimless – AmbitiousAimless – Ambitious
 Quitting – PerseveringQuitting – Persevering
Adapted from Costa & McCrae 1986

8. Three Major Brain Systems Influencing Stimulus –Three Major Brain Systems Influencing Stimulus –
Response CharacteristicsResponse Characteristics
Brain SystemBrain System
(Related Personality(Related Personality
Dimension)Dimension)
PrincipalPrincipal
MonoamineMonoamine
NeuromodulatorNeuromodulator
Relevant StimuliRelevant Stimuli BehavioralBehavioral
ResponseResponse
Behavioral activationBehavioral activation
(novelty seeking)(novelty seeking)
DopamineDopamine NoveltyNovelty Exploratory pursuitExploratory pursuit
Potential rewardPotential reward Appetitive approachAppetitive approach
Potential relief ofPotential relief of
monotony ormonotony or
punishmentpunishment
Active avoidance,Active avoidance,
escapeescape
Behavioral inhibitionBehavioral inhibition
(harm avoidance)(harm avoidance)
SerotoninSerotonin Conditioned signalsConditioned signals
for punishment,for punishment,
novelty, or frustrativenovelty, or frustrative
nonrewardnonreward
Passive avoidance,Passive avoidance,
extinctionextinction
BehavioralBehavioral
maintenancemaintenance
(reward dependence)(reward dependence)
NorepinephrineNorepinephrine Conditioned signalsConditioned signals
for reward or relief offor reward or relief of
punishmentpunishment
Resistance toResistance to
extinctionextinction

9. Cloninger’s Seven-Factor ModelCloninger’s Seven-Factor Model
1.1. Temperament DomainsTemperament Domains (Moderately heritable, not greatly(Moderately heritable, not greatly
influenced by family environment)influenced by family environment)
a.a. Novelty SeekingNovelty Seeking
b.b. Harm AvoidanceHarm Avoidance
c.c. Reward DependenceReward Dependence
d.d. PersistencePersistence
2.2. Character DomainsCharacter Domains (Moderately influenced by family(Moderately influenced by family
environment, only weakly heritable)environment, only weakly heritable)
a.a. Self-transcendenceSelf-transcendence
b.b. CooperativenessCooperativeness
c.c. Self-directednessSelf-directedness

10. The DSMThe DSM
Categorical SystemCategorical System

12. DSM-IV Personality DisordersDSM-IV Personality Disorders
A. Cluster A (odd/eccentric)A. Cluster A (odd/eccentric)
1.1. ParanoidParanoid
2.2. SchizoidSchizoid
3.3. SchizotypalSchizotypal
B. Cluster B (dramatic/emotional/impulsive)B. Cluster B (dramatic/emotional/impulsive)
1.1. AntisocialAntisocial
2.2. BorderlineBorderline
3.3. HistrionicHistrionic
4.4. NarcissisticNarcissistic
C. Cluster C (anxious/fearful)C. Cluster C (anxious/fearful)
1.1. AvoidantAvoidant
2.2. DependentDependent
3.3. Obsessive-CompulsiveObsessive-Compulsive
D. Personality Disorder Not Otherwise SpecifiedD. Personality Disorder Not Otherwise Specified

13. Connecting Order with DisorderConnecting Order with Disorder
- A Quantitative, Continuum Model- A Quantitative, Continuum Model

14. The Personality Style-PersonalityThe Personality Style-Personality
Disorder ContinuumDisorder Continuum

16. DSM-IV Definition of Personality DisorderDSM-IV Definition of Personality Disorder
A.A. An enduring pattern of inner experience andAn enduring pattern of inner experience and
behavior that deviates markedly from thebehavior that deviates markedly from the
expectations of the individual’s culture. This patternexpectations of the individual’s culture. This pattern
is manifested in two (or more) of the following areas:is manifested in two (or more) of the following areas:
1.1. Cognition (i.e., ways of perceiving andCognition (i.e., ways of perceiving and
interpreting self, other people, and events)interpreting self, other people, and events)
2.2. Affectivity (i.e., the range, intensity, ability,Affectivity (i.e., the range, intensity, ability,
appropriateness of emotional response)appropriateness of emotional response)
3.3. Interpersonal functioningInterpersonal functioning
4.4. Impulse controlImpulse control

17. DSM-IV Definition of Personality DisorderDSM-IV Definition of Personality Disorder
B.B. The enduring pattern is inflexible and pervasiveThe enduring pattern is inflexible and pervasive
across a broad range of personal and socialacross a broad range of personal and social
situations.situations.

18. DSM-IV Definition of Personality DisorderDSM-IV Definition of Personality Disorder
C.C. The enduring pattern leads to clinically significantThe enduring pattern leads to clinically significant
distress or impairment in social, occupational, ordistress or impairment in social, occupational, or
other important areas of functioning.other important areas of functioning.

19. DSM-IV Definition of Personality DisorderDSM-IV Definition of Personality Disorder
D.D. The pattern is stable and of long duration and itsThe pattern is stable and of long duration and its
onset can be traced back at least to adolescenceonset can be traced back at least to adolescence
or early adulthood.or early adulthood.

20. DSM-IV Definition of Personality DisorderDSM-IV Definition of Personality Disorder
E.E. The enduring pattern is not better accounted for asThe enduring pattern is not better accounted for as
a manifestation or consequence of another mentala manifestation or consequence of another mental
disorder.disorder.

21. DSM-IV Definition of Personality DisorderDSM-IV Definition of Personality Disorder
F.F. The enduring pattern is not due to the directThe enduring pattern is not due to the direct
physiological effects of a substance (e.g., a drug ofphysiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medicalabuse, a medication) or a general medical
condition (e.g., head trauma).condition (e.g., head trauma).

22. Prevalence of PDs in a Community SamplePrevalence of PDs in a Community Sample
(N=2053)(N=2053)
Overall – 13.4%Overall – 13.4%
Torgersen, Kringlen, Cramer, 2001Torgersen, Kringlen, Cramer, 2001

23. Prevalence of PDs in a Community SamplePrevalence of PDs in a Community Sample
(N=2053)(N=2053)
Personality DisorderPersonality Disorder Present PrevalencePresent Prevalence
ParanoidParanoid 2.42.4
SchizoidSchizoid 1.71.7
SchizotypalSchizotypal 0.60.6
AntisocialAntisocial 0.70.7
BorderlineBorderline 0.70.7
HistrionicHistrionic 2.02.0
NarcissisticNarcissistic 0.80.8
AvoidantAvoidant 5.05.0
DependentDependent 1.51.5
Obsessive-CompulsiveObsessive-Compulsive 2.02.0
Passive-AggressivePassive-Aggressive 1.71.7
Self-DefeatingSelf-Defeating 0.80.8
Torgersen, Kringlen, Cramer; 2001Torgersen, Kringlen, Cramer; 2001

24. AuthorsAuthors LocationLocation NN
Zimmerman & Coryell, 1989Zimmerman & Coryell, 1989 IowaIowa 797797
Black et al., 1992Black et al., 1992 IowaIowa 247247
Maier et al., 1992Maier et al., 1992 MainzMainz 452452
Moldin et al., 1994Moldin et al., 1994 New YorkNew York 303303
Klein et al., 1995Klein et al., 1995 New York StateNew York State 229229
Lenzenweger et al., 1997Lenzenweger et al., 1997 New York StateNew York State 258258
Torgersen et al., 2001Torgersen et al., 2001 OsloOslo 20532053
Samuels et al., 2002Samuels et al., 2002 BaltimoreBaltimore 742742
PD Prevalence StudiesPD Prevalence Studies
Torgersen, 2005

25. PD Prevalence Studies (n=5081)PD Prevalence Studies (n=5081)
Torgersen, 2005
PD Range Median Mean
Paranoid 0.0-2.2 1.25 1.48
Schizoid 0.0-1.6 0.65 0.96
Schizotypal 0.0-3.2 0.70 1.20
Antisocial 0.2-4.5 1.70 1.77
Borderline 0.0-3.2 1.45 1.16
Histrionic 0.4-3.2 1.85 1.77
Narcissistic 0.0-4.4 0.05 0.61
Avoidant 0.4-5.0 1.35 2.91
Dependent 0.4-1.8 1.30 1.24
Obsessive-Compulsive 0.0-9.3 1.95 2.09
Passive-Aggressive 0.0-10.5 1.80 1.99
Self-Defeating 0.0-0.83 0.40 0.74
Sadistic 0.0-0.19 0.10 0.17
Any PD 3.9-22.7 11.55 12.26

26. AXIS I / AXIS II

27. Phenomenologically Corresponding Axis I & Axis II Disorders, PotentialPhenomenologically Corresponding Axis I & Axis II Disorders, Potential
Biological Indexes, and Characteristic Traits (Core Vulnerabilities),Biological Indexes, and Characteristic Traits (Core Vulnerabilities),
Defenses and Coping Strategies of Dimensions of Personality DisordersDefenses and Coping Strategies of Dimensions of Personality Disorders
DimensionDimension Axis I DisorderAxis I Disorder Axis II DisorderAxis II Disorder Biological IndexesBiological Indexes Characteristic TraitsCharacteristic Traits Defenses andDefenses and
Coping StrategiesCoping Strategies
Cognitive/Cognitive/
PerceptualPerceptual
OrganizationOrganization
SchizophreniaSchizophrenia Odd clusterOdd cluster
(schizotypal PD)(schizotypal PD)
Eye movementEye movement
dysfunction*, continuousdysfunction*, continuous
performance task,performance task,
backward masking test*,backward masking test*,
plasma HVA*, CSFplasma HVA*, CSF
HVA*, evoked potentialHVA*, evoked potential
response, VBRresponse, VBR
Disorganization,Disorganization,
psychotic-likepsychotic-like
symptomssymptoms
Social isolation,Social isolation,
detachment,detachment,
guardednessguardedness
Impulsivity/Impulsivity/
AggressionAggression
ImpulseImpulse
disordersdisorders
Dramatic clusterDramatic cluster
(borderline &(borderline &
antisocial PDs)antisocial PDs)
CSF 5-HIAA*, responsesCSF 5-HIAA*, responses
to serotonergicto serotonergic
challenge, galvanic skinchallenge, galvanic skin
response*, continuousresponse*, continuous
performance taskperformance task
Readiness to action,Readiness to action,
irritability/irritability/
aggressionaggression
Externalization,Externalization,
dissociation,dissociation,
enactment,enactment,
repressionrepression
AffectiveAffective
InstabilityInstability
Major affectiveMajor affective
disordersdisorders
Dramatic clusterDramatic cluster
(borderline &(borderline &
possiblypossibly
histrionic PDs)histrionic PDs)
REM latency, responsesREM latency, responses
to cholinergicto cholinergic
challenges*, responseschallenges*, responses
to catecholamingericto catecholamingeric
challenges*challenges*
EnvironmentallyEnvironmentally
responsive, transientresponsive, transient
affective shiftsaffective shifts
ExaggeratedExaggerated
affectivity,affectivity,
“manipulativeness”,“manipulativeness”,
“splitting”“splitting”
Anxiety/Anxiety/
InhibitionInhibition
AnxietyAnxiety
disordersdisorders
Anxious clusterAnxious cluster
(avoidant PD)(avoidant PD)
Heart rate variability*,Heart rate variability*,
orienting responses,orienting responses,
responses to lactate andresponses to lactate and
yohimbineyohimbine
Autonomic arousal,Autonomic arousal,
fearfulness, inhibitionfearfulness, inhibition
Avoidant,Avoidant,
compulsive, andcompulsive, and
dependentdependent
behaviorsbehaviors
* Preliminary data are available in patients with personality disorder (PD)

28. Schizotypal

29. Schizotypal PDSchizotypal PD
↑ Dopamine [+ sx] (Coccaro & Siever, 2005)Dopamine [+ sx] (Coccaro & Siever, 2005)
↓ Dopamine [Dopamine [-- sx] (Siever & Davis, 2004)sx] (Siever & Davis, 2004)
↑ Ventricles (Siever, 1991)Ventricles (Siever, 1991)
↓ Cognitive functioning (Gold & Harvey, 1993)Cognitive functioning (Gold & Harvey, 1993)
↓ Working memory (Lees-Roitman et al., 1996)Working memory (Lees-Roitman et al., 1996)
↓ Verbal memory (Saykin et al., 1991)Verbal memory (Saykin et al., 1991)
↓ Sustained attention (Harvey et al., 1996)Sustained attention (Harvey et al., 1996)
↓ Arousal to stimuli (Siever, 1985)Arousal to stimuli (Siever, 1985)

30. Spectrum Model

31. Impulsive/Compulsive Spectrum of ControlImpulsive/Compulsive Spectrum of Control
Compulsive Impulsive
↑ Control ↓↓ Control
Inhibition Disinhibition

32. Impulsive DisordersImpulsive Disorders
Axis IIAxis II
 Borderline Personality DisorderBorderline Personality Disorder
 Antisocial Personality DisorderAntisocial Personality Disorder
Axis IAxis I
 Psychoactive Substance Use DisorderPsychoactive Substance Use Disorder
 BulimiaBulimia
 ParaphiliasParaphilias
 Impulsive Control Disorder NECImpulsive Control Disorder NEC

33. ANTISOCIALANTISOCIAL

34. Antisocial Personality Disorder (ASPD)Antisocial Personality Disorder (ASPD)
↓↓ Prefrontal gray matter volumePrefrontal gray matter volume
↓↓ Autonomic activity in ASPDAutonomic activity in ASPD
May underlie low arousal, poor fear conditioning, lackMay underlie low arousal, poor fear conditioning, lack
of conscience, and decision-making deficits in ASPDof conscience, and decision-making deficits in ASPD
Raine et al., 2000

35. Psychopathic Antisocial PD (P-ASPD)Psychopathic Antisocial PD (P-ASPD)
 Corpus Callosum in P-ASPD vs Controls:Corpus Callosum in P-ASPD vs Controls:
↑↑ white matter volumewhite matter volume
↑↑ lengthlength
↑↑ thicknessthickness
↑↑ functional interhemispheric connectivityfunctional interhemispheric connectivity
 May reflect atypical neurodevelopment, e.g.,May reflect atypical neurodevelopment, e.g.,
arrested early axonal pruning or ↑ white matterarrested early axonal pruning or ↑ white matter
myelinationmyelination
 May help explain affective deficitsMay help explain affective deficits
Raine et al., 2003

36. Malnutrition and Externalizing BehaviorMalnutrition and Externalizing Behavior
Malnutrition predisposes to neurocognitiveMalnutrition predisposes to neurocognitive
deficits, which predispose to persistentdeficits, which predispose to persistent
externalizing (antisocial and aggressive)externalizing (antisocial and aggressive)
behavior throughout childhood and adolescence.behavior throughout childhood and adolescence.
Liu et al., 2004

37. The Gradations of AntisocialityThe Gradations of Antisociality
 Some antisocial personality traits insufficient to meet DSM criteria; someSome antisocial personality traits insufficient to meet DSM criteria; some
antisocial traits occurring in another personality disorderantisocial traits occurring in another personality disorder
 Explosive/Irritable Personality Disorder with some antisocial traitsExplosive/Irritable Personality Disorder with some antisocial traits
 Malignant NarcissismMalignant Narcissism
 Antisocial Personality Disorder, with property crimes onlyAntisocial Personality Disorder, with property crimes only
 Sexual Offenses without violence (viz., voyeurism, exhibitionism, frotteurism)Sexual Offenses without violence (viz., voyeurism, exhibitionism, frotteurism)
 Antisocial Personality Disorder, with violent felonies. (There may be someAntisocial Personality Disorder, with violent felonies. (There may be some
psychopathic traits, but insufficient to meet Hare’s PCL-R criteria: score >29)psychopathic traits, but insufficient to meet Hare’s PCL-R criteria: score >29)
 Psychopathy without violence (viz., con-artists, financial scams)Psychopathy without violence (viz., con-artists, financial scams)
 Psychopathy with violent crimesPsychopathy with violent crimes
 Psychopathy with sadistic control (viz., unlawful imprisonment of a kidnapPsychopathy with sadistic control (viz., unlawful imprisonment of a kidnap
victim while awaiting ransom)victim while awaiting ransom)
 Psychopathy with violent sadism and murder, but no prolonged torturePsychopathy with violent sadism and murder, but no prolonged torture
 Psychopathy with prolonged torture followed by murderPsychopathy with prolonged torture followed by murder
Stone, 2000

38. TreatabilityTreatability
 Presence ofPresence of
– Adequate motivationAdequate motivation
– Ability to take seriously the nature of one’sAbility to take seriously the nature of one’s
antisocial attitudes and behaviorsantisocial attitudes and behaviors
 Absence ofAbsence of
– Pathological lying/deceitfulnessPathological lying/deceitfulness
– Conning/manipulativenessConning/manipulativeness
– Lack of remorse or guiltLack of remorse or guilt
– Callousness/lack of compassionCallousness/lack of compassion
Stone, 2002

39. PsychopathyPsychopathy
 Kraeplin (1915) – Psychopathic personalitiesKraeplin (1915) – Psychopathic personalities
 Cleckley (1940) – PsychopathCleckley (1940) – Psychopath
 Hare PCL-RHare PCL-R

40. PCL-R Factor-I ItemsPCL-R Factor-I Items
 Glibness, superficial charmGlibness, superficial charm
 Grandiose sense of self worthGrandiose sense of self worth
 Pathological lyingPathological lying
 Conning/manipulativeConning/manipulative
 Lack of remorse or guiltLack of remorse or guilt
 Shallow affectShallow affect
 Callous/lack of empathyCallous/lack of empathy
 Failure to accept responsibility for one’s actionsFailure to accept responsibility for one’s actions
Black, 1999

41. Example of Offender RecidivismExample of Offender Recidivism
3 Year Reconviction3 Year Reconviction
PCL-RPCL-R > 30> 30 75%75%
PCL-RPCL-R 20-2920-29 50%50%
PCL-RPCL-R 0-190-19 25%25%
Hemphill et al., 1998

42. Predictors of ASPDPredictors of ASPD
Preschool child’s inability to inhibit socially inappropriatePreschool child’s inability to inhibit socially inappropriate
behavior predicts later asocial behavior, andbehavior predicts later asocial behavior, and
undercontrolled behavior in school-age children is theundercontrolled behavior in school-age children is the
best predictor of adult antisocial behavior. Thisbest predictor of adult antisocial behavior. This
association may be the most reliable relation betweenassociation may be the most reliable relation between
characteristics in young children and latercharacteristics in young children and later
psychopathology.psychopathology.
From Kagan J, Zentner M, Early childhood predictors of adult
psychopathology. Harvard Review of Psychiatry, 1996.

43. Is ASPD Genetic?Is ASPD Genetic?
 Genetic factors do play a significant role inGenetic factors do play a significant role in
antisocial behaviorantisocial behavior
 Twin studies show genetic factors to be particularlyTwin studies show genetic factors to be particularly
important in AS behavior with early-onsetimportant in AS behavior with early-onset
hyperactivityhyperactivity
 Genetic factors least influential in adolescent onsetGenetic factors least influential in adolescent onset
delinquencydelinquency

44. JIMMY, SIXTH-GENERATION PAIN IN THE ASS

45. BORDERLINE

46. Borderline Personality Disorder (DSM-IV)Borderline Personality Disorder (DSM-IV)
1.1. Frantic efforts to avoid real or imagined abandonment. Note: doFrantic efforts to avoid real or imagined abandonment. Note: do
not include suicidal or self-mutilating behavior covered in Criterionnot include suicidal or self-mutilating behavior covered in Criterion
5.5.
2.2. A pattern of unstable and intense interpersonal relationshipsA pattern of unstable and intense interpersonal relationships
characterized by alternating between extremes of idealization andcharacterized by alternating between extremes of idealization and
devaluation.devaluation.
3.3. Identity disturbance: markedly and persistently unstable self-imageIdentity disturbance: markedly and persistently unstable self-image
or sense of self.or sense of self.
4.4. Impulsivity in at least two areas that are potentially self-damagingImpulsivity in at least two areas that are potentially self-damaging
(e.g., spending, sex, substance abuse, reckless driving, binge(e.g., spending, sex, substance abuse, reckless driving, binge
eating). Note: do not include suicidal or self-mutilating behavioreating). Note: do not include suicidal or self-mutilating behavior
covered in Criterion 5.covered in Criterion 5.
A pervasive pattern of instability of interpersonal relationships, self-
image, and affects, and marked impulsivity beginning by early adulthood
and present in a variety of contexts as indicated by five (or more) of the
following:

47. Borderline Personality Disorder (DSM-IV)Borderline Personality Disorder (DSM-IV)
5.5. Recurrent suicidal behavior, gestures, or threats, or self-mutilatingRecurrent suicidal behavior, gestures, or threats, or self-mutilating
behavior.behavior.
6.6. Affective instability due to a marked reactivity of mood (e.g., intenseAffective instability due to a marked reactivity of mood (e.g., intense
episodic dysphoria, irritability, or anxiety usually lasting a few hoursepisodic dysphoria, irritability, or anxiety usually lasting a few hours
and only rarely more than a few days).and only rarely more than a few days).
7.7. Chronic feelings of emptiness.Chronic feelings of emptiness.
8.8. Inappropriate, intense anger or difficulty controlling anger (e.g.,Inappropriate, intense anger or difficulty controlling anger (e.g.,
frequent displays of temper, constant anger, recurrent physicalfrequent displays of temper, constant anger, recurrent physical
fights).fights).
9.9. Transient, stress-related paranoid ideation or severe dissociativeTransient, stress-related paranoid ideation or severe dissociative
symptoms.symptoms.
A pervasive pattern of instability of interpersonal relationships, self-
image, and affects, and marked impulsivity beginning by early adulthood
and present in a variety of contexts as indicated by five (or more) of the
following:

48. Heterogeneity of BPDHeterogeneity of BPD
 DSM-IV - defined BPD is an extremelyDSM-IV - defined BPD is an extremely
heterogeneous construct (Est. 256 varieties)heterogeneous construct (Est. 256 varieties)
 Mix of unstable, stress-induced symptomsMix of unstable, stress-induced symptoms
and stable personality characteristicsand stable personality characteristics
(i.e., dimensional traits)(i.e., dimensional traits)

49. BPD as a Personality Disorder Emerging From theBPD as a Personality Disorder Emerging From the
Interaction of Underlying Genetically-Based TraitsInteraction of Underlying Genetically-Based Traits
Impulsive aggression and affective instability = heritableImpulsive aggression and affective instability = heritable
endophenotypes that would contribute significantly toendophenotypes that would contribute significantly to
development of BPDdevelopment of BPD
Siever et al., 2002Siever et al., 2002

50. Heritability of BPDHeritability of BPD
 Twin study (Torgersen et al. 2000)Twin study (Torgersen et al. 2000)
 Novelty seeking (Cloninger, 2005)Novelty seeking (Cloninger, 2005)
 Impulsivity (New and Siever, 2002)Impulsivity (New and Siever, 2002)

51. Childhood Abuse and BPDChildhood Abuse and BPD
 Severe childhood traumaSevere childhood trauma →→ persistent serotonergic disturbancepersistent serotonergic disturbance
 Dose/response correlation (age of onset, frequency, seriousness)Dose/response correlation (age of onset, frequency, seriousness)
 Only males showOnly males show ↓↓ serotonin andserotonin and ↑↑ aggression oraggression or ↑↑ impulsivityimpulsivity
 Sustained childhood abuseSustained childhood abuse →→
– Hyporesponsiveness of 5-HT systemHyporesponsiveness of 5-HT system
– Hyper-responsiveness of HPA systemHyper-responsiveness of HPA system
(correlated with sustained abuse,(correlated with sustained abuse, notnot BPD pathology)BPD pathology)
 To know what characterizes BPD, must correct for chronicTo know what characterizes BPD, must correct for chronic
childhood traumachildhood trauma
 Possibly faulty attachment in genetically vulnerable childrenPossibly faulty attachment in genetically vulnerable children →→
selected by abusersselected by abusers →→ sustained abusesustained abuse →→ HPA disturbancesHPA disturbances →→
↑↑susceptibility to stress and stress-related disorders (e.g. BPD,susceptibility to stress and stress-related disorders (e.g. BPD,
MDD)MDD)
Rinne, T, ISSPD, Florence, 2003Rinne, T, ISSPD, Florence, 2003

52. MRI in Patients with BPDMRI in Patients with BPD
16% reduction in volume of hippocampus16% reduction in volume of hippocampus
8% reduction in volume of amygdala in BPD patients8% reduction in volume of amygdala in BPD patients
vs. healthy controlsvs. healthy controls
Not clearly related to traumaNot clearly related to trauma
(results only significant for total BPD group [with and(results only significant for total BPD group [with and
without hx of trauma])without hx of trauma])
Driessen et al., 2000Driessen et al., 2000

53. MRI in Patients with BPDMRI in Patients with BPD
↓↓ Volume hippocampus andVolume hippocampus and
amygdala (Schmahl et al, 2003;amygdala (Schmahl et al, 2003;
Rusch et al., 2003)Rusch et al., 2003)

54. PET and BPDPET and BPD
BPD patients vs ControlsBPD patients vs Controls
•• frontal and prefrontal hypermetabolismfrontal and prefrontal hypermetabolism
•• hippocampus and cuneus hypometabolismhippocampus and cuneus hypometabolism
= limbic and prefrontal dysfunction, implicated in= limbic and prefrontal dysfunction, implicated in
regulation of emotionregulation of emotion
Juengling et al., 2003

55. Implications of Imaging Studies in BPDImplications of Imaging Studies in BPD
 Abnormalities in prefrontal,Abnormalities in prefrontal,
corticostriatal, and limbic networkscorticostriatal, and limbic networks
 Perhaps related to lowered serotoninPerhaps related to lowered serotonin
neurotransmission and behavioralneurotransmission and behavioral
disinhibition.disinhibition.
Johnson et al., 2003Johnson et al., 2003

56. Neurocognitive Deficits in BPDNeurocognitive Deficits in BPD
BPD patients vs ControlsBPD patients vs Controls
→→ delayed, maladaptive choicesdelayed, maladaptive choices
→→ impulsive, disinhibited responsesimpulsive, disinhibited responses
→→ impairment in planningimpairment in planning
suggest complex impairments in cognitivesuggest complex impairments in cognitive
processes involving frontal lobesprocesses involving frontal lobes
Bazanis et al., 2002

57. Continuity of Treatment for Patients withContinuity of Treatment for Patients with
Personality DisordersPersonality Disorders
Collaborative Longitudinal PersonalityCollaborative Longitudinal Personality
Disorders StudyDisorders Study
Donna S. Bender, Ph.D.Donna S. Bender, Ph.D.
Andrew E. Skodol, M.D.Andrew E. Skodol, M.D.
John M. Oldham, M.D.John M. Oldham, M.D.
Ingrid R. Dyck, M.P.H.Ingrid R. Dyck, M.P.H.
Regina T. Dolan, Ph.D.Regina T. Dolan, Ph.D.
M. Tracie Shea, Ph.D.M. Tracie Shea, Ph.D.
John G. Gunderson, M.D.John G. Gunderson, M.D.
Charles Sanislow, Ph.D.Charles Sanislow, Ph.D.

58. Collaborative Longitudinal PersonalityCollaborative Longitudinal Personality
Disorders Study (CLPS)Disorders Study (CLPS)
• 5 Collaborative Sites5 Collaborative Sites
Brown (Shea), Columbia (Skodol), HarvardBrown (Shea), Columbia (Skodol), Harvard
(Gunderson),Yale (McGlashan), Texas A&M (Morey)(Gunderson),Yale (McGlashan), Texas A&M (Morey)
• 668 Patients Recruited Originally (+65)668 Patients Recruited Originally (+65)
STPD (N= 86), BPD (N=175), AVPD (N= 158),STPD (N= 86), BPD (N=175), AVPD (N= 158),
OCPD (N= 154), MDD and no PD (N= 95)OCPD (N= 154), MDD and no PD (N= 95)
• Followed Longitudinally for >8 YearsFollowed Longitudinally for >8 Years
To determine the stability of symptoms, diagnoses,To determine the stability of symptoms, diagnoses,
dimensions, and functioning and to determine thedimensions, and functioning and to determine the
predictors of clinical coursepredictors of clinical course

59. Utilization of Psychosocial TreatmentsUtilization of Psychosocial Treatments

60. Mean Lifetime Months of OutpatientMean Lifetime Months of Outpatient
Treatment ReceivedTreatment Received
0
10
20
30
40
50
60
70
80
STPD BPD AVPD OCPD MDD
Self-Help
Family
Group
Individual

61. Mean Lifetime Weeks of ResidentialMean Lifetime Weeks of Residential
Treatment ReceivedTreatment Received
0
5
10
15
20
25
30
35
40
STPD BPD AVPD OCPD MDD
Halfway Hse.
Psych. Hosp.
Day Tmt.

62. Utilization of PsychopharmocologicUtilization of Psychopharmocologic
TreatmentsTreatments

63. Utilization of Psychiatric Medications:Utilization of Psychiatric Medications:
LifetimeLifetime
0
10
20
30
40
50
60
70
80
Percent
of Group
STPD BPD AVPD OCPD MDD
Antianxiety
Mood Stabilizer
Antipsychotic
Antidepressant

64. APA Practice Guidelines Work Group onAPA Practice Guidelines Work Group on
Borderline Personality DisordersBorderline Personality Disorders
John Oldham, M.D. (Chair)John Oldham, M.D. (Chair)
Glen Gabbard, M.D.Glen Gabbard, M.D.
Marcia Goin, M.D., Ph.D.Marcia Goin, M.D., Ph.D.
John Gunderson, M.D.John Gunderson, M.D.
Paul Soloff, M.D.Paul Soloff, M.D.
David Spiegel, M.D.David Spiegel, M.D.
Michael Stone, M.D.Michael Stone, M.D.
Katherine Phillips, M.D.Katherine Phillips, M.D.

65. Part A: Treatment RecommendationsPart A: Treatment Recommendations
for Patients with Borderline Personality Disorderfor Patients with Borderline Personality Disorder
II.II. Formulation and Implementation of a Treatment PlanFormulation and Implementation of a Treatment Plan
E.E. Specific Treatment Strategies for the Clinical Features ofSpecific Treatment Strategies for the Clinical Features of
Borderline Personality DisorderBorderline Personality Disorder
1.1. PsychotherapyPsychotherapy
2.2. Pharmacotherapy and other somatic treatmentsPharmacotherapy and other somatic treatments

66. Partial Hospital PsychoanalyticPartial Hospital Psychoanalytic
PsychotherapyPsychotherapy
 BPD patients (n = 38)BPD patients (n = 38)
 Randomized controlled design:Randomized controlled design:
– Partial hospital vs. Standard treatmentPartial hospital vs. Standard treatment
 18 months, psychoanalytic individual & group therapy18 months, psychoanalytic individual & group therapy
↓↓ suicidal actssuicidal acts
↓↓ self-mutilatory actsself-mutilatory acts
↓↓ depressive symptomsdepressive symptoms
↓↓ hospital patient dayshospital patient days
↑↑ social and interpersonal functioningsocial and interpersonal functioning
 36 month, maintained gains36 month, maintained gains
Bateman & Fonagy, AJP, 1999Bateman & Fonagy, AJP, 1999
Bateman & Fonagy, AJP, 2001Bateman & Fonagy, AJP, 2001

67. Dialectical Behavior TherapyDialectical Behavior Therapy
↓↓ Frequency and severity of parasuicidal episodesFrequency and severity of parasuicidal episodes
↓↓ Therapy attritionTherapy attrition
↓↓ Number of psychiatric inpatient daysNumber of psychiatric inpatient days
 Improved scores on measures of anger, interviewer-Improved scores on measures of anger, interviewer-
related global social adjustment, and Globalrelated global social adjustment, and Global
Assessment ScaleAssessment Scale
 Improved self-rating on overall social adjustmentImproved self-rating on overall social adjustment
 One-year maintenance of treatment gainsOne-year maintenance of treatment gains
-Linehan et al, Arch Gen Psychiatry 1991-Linehan et al, Arch Gen Psychiatry 1991
-Linehan et al, Arch Gen Psychiatry 1993-Linehan et al, Arch Gen Psychiatry 1993
-Linehan et al, Am J Psychiatry 1994-Linehan et al, Am J Psychiatry 1994

68. Symptom-OrientedSymptom-Oriented
Psychopharmacology for BPDPsychopharmacology for BPD
1.1. Cognitive/Perceptual SymptomsCognitive/Perceptual Symptoms
2.2. Affective Dysregulation: MoodAffective Dysregulation: Mood
3.3. Affective Dysregulation: AnxietyAffective Dysregulation: Anxiety
4.4. Impulsive Behavioral DyscontrolImpulsive Behavioral Dyscontrol
From Paul Soloff

69. Algorithm for the Treatment ofAlgorithm for the Treatment of
Cognitive-Perceptual Symptoms in BPDCognitive-Perceptual Symptoms in BPD

70. Algorithm for the Treatment of Impulsive-Algorithm for the Treatment of Impulsive-
Behavioral Symptoms in BPDBehavioral Symptoms in BPD

71. Algorithm for the Treatment of AffectiveAlgorithm for the Treatment of Affective
Dysregulation in BPDDysregulation in BPD

72. New DirectionsNew Directions

73. The Effectiveness of Psychodynamic Therapy andThe Effectiveness of Psychodynamic Therapy and
Cognitive Behavior Therapy in the Treatment ofCognitive Behavior Therapy in the Treatment of
Personality Disorders: A Meta-AnalysisPersonality Disorders: A Meta-Analysis
 Both psychodynamic therapy and cognitive behaviorBoth psychodynamic therapy and cognitive behavior
therapy are effective treatments of personality disorderstherapy are effective treatments of personality disorders
 For psychodynamic therapy, the effect sizes indicateFor psychodynamic therapy, the effect sizes indicate
long-term rather than short-term change in personalitylong-term rather than short-term change in personality
disorders (mean follow-up period = 1.5 years [78 weeks]disorders (mean follow-up period = 1.5 years [78 weeks]
vs CBT mean follow-up = 13 weeks)vs CBT mean follow-up = 13 weeks)
Leichsenring F, Leibing E, Am J
Psychiatry 2003; 160:1223-1232

74. Biology in the Service of PsychotherapyBiology in the Service of Psychotherapy
 Psychotherapy can induce robust changes inPsychotherapy can induce robust changes in
brain function that are detectable withbrain function that are detectable with
neuroimagingneuroimaging..
Etkin et al., 2005

75. Biology in the Service of PsychotherapyBiology in the Service of Psychotherapy
From Furmark et al., 2002.
amygdala
cognitive-behavioral therapy citalopram
Areas decreased after vs. before treatment

76. Biology in the Service of PsychotherapyBiology in the Service of Psychotherapy
 Identification of brain regions associated withIdentification of brain regions associated with
deficits of impulse control in patients with BPDdeficits of impulse control in patients with BPD
may be useful to predict a patient’s ability tomay be useful to predict a patient’s ability to
respond to psychotherapy and recover.respond to psychotherapy and recover.
Etkin et al., 2005

77. Toward a New Model
of PDs for DSM-V

78. Categorical vs. Dimensional Models:Categorical vs. Dimensional Models:
Advantages and DisadvantagesAdvantages and Disadvantages
Limitations of categorical model
• Excessive diagnostic co-occurrence, i.e., most patients meet criteriaExcessive diagnostic co-occurrence, i.e., most patients meet criteria
for more than one PD.for more than one PD.
• Heterogeneity among persons with the same diagnosis, e.g., there areHeterogeneity among persons with the same diagnosis, e.g., there are
256 ways to meet criteria for BPD.256 ways to meet criteria for BPD.
• Arbitrary diagnostic thresholds, i.e., no empirical rationale for boundaryArbitrary diagnostic thresholds, i.e., no empirical rationale for boundary
with “normal” personality functioning.with “normal” personality functioning.
• Inadequate coverage, e.g., PDNOS is the most frequently usedInadequate coverage, e.g., PDNOS is the most frequently used
diagnosis.diagnosis.
Limitations of dimensional models
• Unfamiliar to those trained in medical model, i.e., communication ofUnfamiliar to those trained in medical model, i.e., communication of
much information via single diagnostic concept.much information via single diagnostic concept.
• More complex and difficult to use, e.g., up to 30 dimensions toMore complex and difficult to use, e.g., up to 30 dimensions to
describe personality.describe personality.
• Little empirical information on treatment or other clinical implications ofLittle empirical information on treatment or other clinical implications of
scale elevations or on cut-points for clinical decision-making.scale elevations or on cut-points for clinical decision-making.

79. Personality Disorders and thePersonality Disorders and the
Research Agenda for DSM-VResearch Agenda for DSM-V
• ““There is a clear need for dimensional models to beThere is a clear need for dimensional models to be
developed and their utility compared with that of existingdeveloped and their utility compared with that of existing
typologies in one or more limited fields, such astypologies in one or more limited fields, such as
personality. If a dimensional system performs well andpersonality. If a dimensional system performs well and
is acceptable to clinicians, it might be appropriate tois acceptable to clinicians, it might be appropriate to
explore dimensional approaches in other domains (e.g.,explore dimensional approaches in other domains (e.g.,
psychotic or mood disorders)” (Rounsaville et al., 2002).psychotic or mood disorders)” (Rounsaville et al., 2002).
• Thus, personality disorders are “test case” for return to aThus, personality disorders are “test case” for return to a
dimensional approach to the diagnosis of mentaldimensional approach to the diagnosis of mental
disorders in DSM-V.disorders in DSM-V.

80. 18 Alternative Proposals for a18 Alternative Proposals for a
Dimensional Model of Personality DisordersDimensional Model of Personality Disorders
• Proposals to provide dimensional representation ofProposals to provide dimensional representation of
existing constructs.existing constructs.
• Proposals to provide dimensional reorganization ofProposals to provide dimensional reorganization of
diagnostic criteria.diagnostic criteria.
• Proposals to integrate Axes II and I with respect toProposals to integrate Axes II and I with respect to
common spectra.common spectra.
• Proposals to integrate Axis II with dimensional models ofProposals to integrate Axis II with dimensional models of
general personality structure.general personality structure.

81. 18 Alternative Proposals for a18 Alternative Proposals for a
Dimensional Model of Personality DisordersDimensional Model of Personality Disorders
• Proposals to provide dimensionalProposals to provide dimensional
representation of existing constructs:representation of existing constructs:
Oldham & Skodol (2000)Oldham & Skodol (2000) Any instrumentAny instrument
Tyrer & Johnson (1996)Tyrer & Johnson (1996) Personality AssessmentPersonality Assessment
Schedule (PAS)Schedule (PAS)
Westen & Schedler (2000)Westen & Schedler (2000) S&W AssessmentS&W Assessment
Procedure (SWAP-200)Procedure (SWAP-200)
(Widiger & Simonsen:(Widiger & Simonsen: JPDJPD, 2005), 2005)

82. Dimensional Representation ofDimensional Representation of
DSM-IV PD CategoriesDSM-IV PD Categories
Summary TermSummary Term Number of Criteria MetNumber of Criteria Met
• Absent (1)Absent (1) 00
• Traits (2)Traits (2) 1, 2, or 31, 2, or 3
• Subthreshold (3)Subthreshold (3) 3 or 43 or 4
• Threshold (4)Threshold (4) 4 or 54 or 5
• Pervasive (5)Pervasive (5) 5, 6, 7, or 85, 6, 7, or 8
• Prototypic (6)Prototypic (6) 7, 8, or 97, 8, or 9
Oldham & Skodol:Oldham & Skodol: JPDJPD, 2000, 2000

83. PROPOSALPROPOSAL
Axis II: Personality Disorder TraitsAxis II: Personality Disorder Traits
and Personality Disordersand Personality Disorders
Instructions:Instructions: Personality disorder traits or personalityPersonality disorder traits or personality
disorders are identified according to the number ofdisorders are identified according to the number of
criteria met, as specified in each personality diagnosis,criteria met, as specified in each personality diagnosis,
utilizing the following categories:utilizing the following categories:
-- AbsentAbsent
- Traits- Traits
- Subthreshold features- Subthreshold features
- Threshold- Threshold
- Moderate- Moderate
- Prototype- Prototype

84. PROPOSAL (continued)PROPOSAL (continued)
Instructions (continued):Instructions (continued): If a patient is at or aboveIf a patient is at or above
threshold for up to two PDs, the diagnosis or diagnosesthreshold for up to two PDs, the diagnosis or diagnoses
should be made. If a patient is at or above threshold forshould be made. If a patient is at or above threshold for
three or more PDs, the patient’s diagnosis should be:three or more PDs, the patient’s diagnosis should be:
Extensive Personality Disorder, characterized by:Extensive Personality Disorder, characterized by:
(A, B, C) components,(A, B, C) components,
subcategorized as traits, subthreshold, threshold,subcategorized as traits, subthreshold, threshold,
moderate, or prototypemoderate, or prototype

85. EXAMPLE #1EXAMPLE #1
DiagnosisDiagnosis CategoriesCategories Number ofNumber of
CriteriaCriteria
Paranoid PDParanoid PD AbsentAbsent
TraitsTraits
SubthresholdSubthreshold
ThresholdThreshold
ModerateModerate
PrototypePrototype
00
1-21-2
33
44
5-65-6
77

86. EXAMPLE #2EXAMPLE #2
DiagnosisDiagnosis ComponentsComponents Categories ofCategories of
CriteriaCriteria
NumberNumber
Extensive PDExtensive PD BorderlineBorderline
ParanoidParanoid
NarcissisticNarcissistic
PrototypePrototype
ModerateModerate
ThresholdThreshold
99
55
55
Histrionic featuresHistrionic features
SchizotypalSchizotypal
SubthresholdSubthreshold
TraitsTraits
33
33

87. Personality Disorders Over TimePersonality Disorders Over Time

88. ““Remission” Rates of PDs Over 2 Years byRemission” Rates of PDs Over 2 Years by
Different Definitions of RemissionDifferent Definitions of Remission
(Grilo et al:(Grilo et al: JCCPJCCP, 2004), 2004)
PersonalityPersonality
DisorderDisorder
2 months2 months <<
2 criteria2 criteria
12 months12 months <<
2 criteria2 criteria
BelowBelow
threshold onthreshold on
blind re-testblind re-test
STPDSTPD 33%33% 23%23% 61%61%
BPDBPD 42%42% 28%28% 56%56%
AVPDAVPD 47%47% 31%31% 50%50%
OCPDOCPD 55%55% 38%38% 60%60%

89. Mean Proportion of Criteria Met for PDMean Proportion of Criteria Met for PD
Groups Over Two YearsGroups Over Two Years
(Grilo et al:(Grilo et al: JCCPJCCP, 2004), 2004)
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
Baseline 6 months 1 year 2 years
STPD
BPD
AVPD
OCPD

90. Probability of Remission of PDs Over 6 Years byProbability of Remission of PDs Over 6 Years by
Different Definitions of RemissionDifferent Definitions of Remission
PersonalityPersonality
DisorderDisorder
2 months2 months <<
2 criteria2 criteria
12 months12 months << 22
criteriacriteria
STPDSTPD .74.74 .67.67
BPDBPD .77.77 .66.66
AVPDAVPD .79.79 .68.68
OCPDOCPD .89.89 .82.82
Skodol, AE (Unpublished)

91. Probability of PD Relapse After 6 YearsProbability of PD Relapse After 6 Years
STPDSTPD BPDBPD AVPDAVPD OCPDOCPD
2+ month2+ month
remissionremission
.02.02 .16.16 .29.29 .27.27
12+ month12+ month
remissionremission
.00.00 .07.07 .17.17 .17.17
Skodol, AE (Unpublished)

92. Persistence of Functional Impairment inPersistence of Functional Impairment in
Personality DisordersPersonality Disorders
Axis V (GAFS) Ratings Over 2 Years
50
60
70
Baseline 1 year 2 year
Time of Assessment
STPD
BPD
AVPD
OCPD
MDD
Skodol et al: Psychol Med, 2005

93. Toward a New Model of PDsToward a New Model of PDs
• Personality disorders show consistency as syndromesPersonality disorders show consistency as syndromes
over time, but rates of improvement that are inconsistentover time, but rates of improvement that are inconsistent
with DSM-IV definitionswith DSM-IV definitions
• Functional impairment in PDs is more stable thanFunctional impairment in PDs is more stable than
psychopathologypsychopathology
• Some PD criteria are more stable than othersSome PD criteria are more stable than others
• Personality traits are more stable than personalityPersonality traits are more stable than personality
disorders, predict stability and change, and are associateddisorders, predict stability and change, and are associated
with outcome over timewith outcome over time
• PDs may be “hybrids” of more stablePDs may be “hybrids” of more stable personalitypersonality traitstraits
and less stableand less stable symptomatic behaviorssymptomatic behaviors

94. Toward a New Model of PDs:Toward a New Model of PDs:
Diagnostic and Treatment ImplicationsDiagnostic and Treatment Implications
• Redefine personality disorders in terms of trait andRedefine personality disorders in terms of trait and
symptom componentssymptom components
• Reconceptualize course of personality disorders asReconceptualize course of personality disorders as
waxing and waning, depending on circumstanceswaxing and waning, depending on circumstances
• Delay definitive PD diagnosis until late 20s?Delay definitive PD diagnosis until late 20s?
• Convey more optimistic prognosis to younger patientsConvey more optimistic prognosis to younger patients
and their familiesand their families
• Focus treatment more on attaining adequateFocus treatment more on attaining adequate
psychosocial functioningpsychosocial functioning

95. Psychopathology Over Time: HypotheticalPsychopathology Over Time: Hypothetical
Data for One SubjectData for One Subject
from Pfohl B, 1999from Pfohl B, 1999

96. DIMENSIONAL
CATEGORICAL