A prototype matching approach to diagnosing personality disorders: toward DSM-V

Clinical utility of five dimensional systems for personality diagnosis: a "consumer preference" study

This study compares the clinical relevance and utility of five dimensional diagnostic systems for personality disorders that have been proposed for the forthcoming edition of DSM (DSM-V): (1) a criteria counting model based on current DSM-IV diagnostic criteria; (2) a prototype matching model based on current DSM-IV diagnostic criteria; (3) a prototype matching model based on the Shedler-Westen Assessment Procedure (SWAP); (4) the Five Factor Model; and (5) Cloninger's Psychobiological Model. A random national sample of psychiatrists and psychologists applied all 5 diagnostic systems to a patient in their care and rated the clinical utility of each system. The SWAP Prototype Matching and DSM-IV Prototype Matching models were judged most clinically useful and relevant. The Five Factor Model and Cloninger's Psychobiological Model were judged least useful. The prototype matching systems most faithfully capture the personality syndromes seen in clinical practice, and permit rich descriptions of diagnostic constructs without a proportionate increase in user effort. A prototype matching approach to personality diagnosis deserves consideration for DSM-V.

The relationship between the five-factor model and latent Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition personality disorder dimensions

This study compared the latent structure of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition personality disorders (PDs) with the 5-factor model (FFM) of general personality dimensions. The subjects in the study were 742 community-residing individuals who participated in the Hopkins Epidemiology of Personality Disorders Study. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition PD traits were assessed by psychologists using the International Personality Disorder Examination, and PD dimensions were derived previously using dichotomous factor analysis. The Revised NEO Personality Inventory, a measure of the FFM, was administered to all subjects. The relationship between the 2 sets of personality-related constructs was examined using a construct validity framework and also using Pearson correlation coefficients, multiple linear regression models, and spline regression models. The 5 PD factors each exhibited small to moderate correlations with several NEO dimensions; together, the NEO domain and facet scores explained a fifth to a third of the variance in PD dimensions. Examples of nonlinear relationships between the personality dimensions were identified. There is a modest correspondence between the PD dimensions and FFM traits, and the traits of FFM only partially explain the variance of the PDs. Dimensional measures of general personality may be a suitable alternative to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Whether additional maladaptive traits would better define the domain of PDs remains an important objective for future research.

[Validation of the "Assessment of DSM-IV Personality Disorders (ADP-IV)" Questionnaire]

OBJECTIVES

The "Assessment of DSM-IV Personality Disorders (ADP-IV)" represents a 94-item questionnaire that allows for a categorical and dimensional assessment of the DSM-IV personality disorders.

METHODS

Psychometric properties of the German ADP-IV were investigated in 400 psychotherapy outpatients and a community sample of 385 persons. The SCID-II interview and a standardised expert consensus rating were employed for the assessment of concurrent validity.

RESULTS

The ADP-IV showed satisfactory reliability; the median Cronbach's alpha for the subscales was .76 (range .65-.87), the median retest reliability .79 (range .37-.88). Factor analysis revealed an 11-factor solution that explained 49.4% of the variance. The median correlation of the dimensional ADP-IV subscale scores with the SCID-II and the expert consensus ratings were .51 (range: .34-.72) and .44 (range: .27-.62), respectively. The kappas for the chance corrected agreement of categorical ADP-IV diagnoses with the SCID-II diagnoses and the expert ratings were .35 and .29 for any personality disorder and a median of .37 and .30 for the specific personality disorders.

CONCLUSIONS

The ADP-IV shows satisfactory reliability and a validity that is comparable and partly superior to other self-rating instruments. The advantages of the instrument are its brevity, the inclusion of distress ratings, and the dimensional scoring that allows for the construction of detailed profiles of personality pathology. Moreover it is freely available in the internet: (http://zmkweb.uni-muenster.de/einrichtungen/proth/dienstleistungen/psycho/diag/index.html).

Classification for clinical practice: how to make ICD and DSM better able to serve clinicians

With DSM-V and ICD-11 on the horizon, now is an excellent time to consider options for improving their utility in clinical practice. A prerequisite for determining what can be done to improve their clinical utility is to establish a baseline from which to work. Surprisingly, there is virtually no information available that illuminates how clinicians actually use the DSM-IV and ICD-10 in clinical practice settings. Our first recommendation is for studies to be conducted that examine how the DSM-IV and ICD-10 is being used in the field and then to identify areas in need of improvement. We then propose two new diagnostic approaches to be considered that might significantly improve the system's clinical utility: (1) the addition of clinically useful dimensions (i.e., dimensions for indicating disorder severity, dimensions that cut across various disorders that would quantify symptoms of particular treatment-relevance such as psychosis, and dimensions to measure functioning) and (2) the augmentation of the DSM and ICD operationalized diagnostic criteria with the addition of a prototype-matching system that is likely to more closely conform to the way clinicians think about psychiatric diagnoses.

Dissociative symptom disorders in advanced nursing practice: background, treatment, and instrumentation to assess symptoms

Less well-known among the psychiatric disorders, dissociation is one of the most common underlying symptoms of individuals seeking mental health care (Maldonado, 2001). Closely associated with post-traumatic stress disorder, dissociation characteristics may include inconsistent consciousness, autobiographical forgetfulness, difficulties in self-regulation, regressions, alternate identities, disorganization in the development of a cohesive sense of self, depersonalization, and derealization (Trickett, Noll, Reiffman & Putnam, 2001). The major constructs and dimensions of the dissociative symptom disorders in adults are introduced. Several of the most prominent psychometric instruments that nurses and other mental health clinicians may use as adjuncts to diagnosis and treatment are described.

A Psychoanalytic Clinician Looks at Diagnostic Labels and Diagnostic Classification Systems

As psychoanalytic clinicians, we do not believe that assessment should be diagnosis based. However, we are supportive of attempts to create a diagnostic classification system that reflects something essential about human nature and also serves clinical purposes. In this article, we present a psychoanalytic diagnostic scheme that combines a more descriptive characterological diagnosis with a more structural level of personality organization diagnosis. The scheme is applied to a clinical case and then we discuss it in terms of the functions such a scheme provides for assessment.

The Shedler–Westen Assessment Procedure (SWAP): Making Personality Diagnosis Clinically Meaningful

There is a schism between science and practice in understanding and assessing personality. Approaches derived from the research laboratory often strike clinical practitioners as clinically naive and of dubious clinical relevance. Approaches derived from clinical observation and theory often strike empirical researchers as fanciful speculation. In this article, we describe an approach to personality designed to bridge the science-practice divide. The Shedler-Westen Assessment Procedure (SWAP; Shedler & Westen, 2004a, 2004b; Westen & Shedler, 1999a, 1999b) is an empirically rigorous diagnostic method that preserves the richness and complexity of clinical case description. In this article, we describe its use in diagnosis, case conceptualization, and treatment planning. We review evidence for reliability, validity, and clinical utility. Finally, in the article, we present a system for personality diagnosis, as an alternative to Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000) Axis II, that is empirically grounded, clinically relevant, and practical for routine use in both clinical and research contexts.

Personality judgment and personality pathology: self-other agreement in adolescents with conduct disorder

We examine two issues linking personality pathology and judgment of traits within the Five-Factor Model of personality. We hypothesize that pathology moderates self-other agreement--"target" participants with pathology should be less judgable than participants without pathology. In addition, we hypothesize that pathology could partially produce agreement across a variety of traits, particularly those traits fundamental to the pathology. In an adolescent sample including a group with Conduct Disorder (CD) and a Control group, we examine agreement between adolescents' self-reports and their mothers' informant reports. Using trait-centered and person-centered perspectives, we find support for both hypotheses. Results have implications for understanding the processes affecting personality judgment, for increasing integration of traditional personality research and personality pathology, and for personality assessment.

Under the axis II radar: clinically relevant personality constellations that escape DSM-IV diagnosis

Research suggests that personality pathology lies on a continuum from relatively severe to less severe and that subthreshold variants may not be adequately captured by axis II of DSM-IV. In this study, we used a measure of personality and psychopathology designed for experienced clinical observers (the SWAP-200) to derive subthreshold personality constellations in a sample of 159 psychotherapy patients who were high functioning but nevertheless suffered from maladaptive personality patterns. Using Q-factor analysis (an empirical clustering procedure), we identified 4 diagnostic groupings or SPC, which resembled the clinical concept of "neurotic styles": depressive, hostile-competitive, obsessive, and hysterical. The results of this study should stimulate further research on subthreshold personality configurations.

Depression research and treatment: Are we skating to where the puck is going to be?

This paper critically reviews empirical findings regarding current key assumptions underlying the nature and treatment of depression which heavily rely on the DSM approach. This review shows that empirical evidence provides little support for these assumptions. In response to these findings, an etiologically based, biopsychosocial, dynamic interactionism model of depression is proposed. This model could foster further integration in research on depression and assist in the development of guidelines for the treatment of depression that are better informed by research findings and more congruent with complex clinical realities.

Eating disorders and personality: A methodological and empirical review

Methodological approaches utilized to evaluate models of the relationship between personality and eating disorders, as well as empirical support for each model, are reviewed. Limited prospective research suggests that negative emotionality, perfectionism, drive for thinness, poor interoceptive awareness, ineffectiveness, and obsessive-compulsive personality traits are likely predisposing factors. Limited family study research suggests that obsessive-compulsive personality disorder (OCPD) and anorexia nervosa share a common familial liability. Potential pathoplastic personality factors include Cluster B personality disorders and OCPD, which predict a poorer course and/or outcome, and histrionic personality traits and self-directedness, which predict a more favorable course and/or outcome. Future research should focus upon sophisticated prospective and family study research in order to best evaluate competing models of the eating disorder-personality relationship.

Clinical utility: a prerequisite for the adoption of a dimensional approach in DSM

A potential obstacle to implementing dimensional representations in the Diagnostic and Statistical Manual of Mental Disorders (DSM) is lack of data about clinical utility and user acceptability. Adopting a dimensional approach would likely complicate medical record keeping, create administrative and clinical barriers between mental disorders and medical conditions, require a massive retreating effort, disrupt research efforts (e.g., meta-analyses), and complicate clinicians' efforts to integrate prior clinical research using DSM categories into clinical practice. Efforts to empirically demonstrate the clinical utility of dimensional alternatives should be a prerequisite for their future implementation in order to establish that their advantages outweigh the disadvantages. Approaches to promote user acceptability and the development of an empirical database include dimensionalizing existing DSM categories and including research dimensions in the DSM appendix.

Personality constellations in patients with a history of childhood sexual abuse

Although childhood sexual abuse (CSA) appears to have an impact on personality, it does not affect all survivors the same way. The goal of this study was to identify common personality patterns in women with a history of CSA. A national sample of randomly selected psychologists and psychiatrists described 74 adult female patients with a history of CSA and a comparison group of 74 without CSA using the Shedler-Westen Assessment Procedure-200 (SWAP-200), a Q-sort procedure for assessing personality pathology. Q-factor analysis identified four personality constellations among abuse survivors: Internalizing Dysregulated, High Functioning Internalizing, Externalizing Dysregulated, and Dependent. The four groups differed on diagnostic, adaptive functioning, and developmental history variables, providing initial support for the validity of this classification. The data have potential methodological and treatment implications.

The borderline personality diagnosis in adolescents: gender differences and subtypes

BACKGROUND

This study aimed to identify personality features characterizing adolescent girls and boys with borderline personality disorder (BPD) and to see whether meaningful patterns of heterogeneity exist among adolescents diagnosed with the disorder.

METHODS

Two hundred and ninety-four randomly selected doctoral-level clinicians described adolescent patients using Axis II rating scales and the Shedler-Westen Assessment Procedure-200 for Adolescents (SWAP-200-A). We used the SWAP-200-A to provide empirically derived descriptions of female and male adolescents meeting DSM-IV criteria for BPD (who differed substantially in their profiles), and used Q-factor analysis to identify naturally occurring groupings of female patients based on shared personality features.

RESULTS

The symptoms and phenomenology of adolescent girls with BPD are similar to those of adults. Adolescent boys meeting BPD criteria have a more aggressive, disruptive, antisocial presentation. Although Ns did not permit further analysis of the data on adolescent boys, Q-analysis isolated four clinically coherent subgroups of girls with BPD: high-functioning internalizing, histrionic, depressive internalizing, and angry externalizing.

CONCLUSIONS

BPD in female adolescents resembles DSM-IV BPD as defined for adults. The operating characteristics of the DSM-IV criteria for adolescent boys require further investigation. Empirically derived subgroups are similar to those identified in recent research with adult females. Differences across subgroups on internalizing and externalizing Child Behavior Checklist (CBCL) scales provide preliminary data on the validity of subgroups and raise questions about the place of BPD among internalizing and externalizing spectrum disorders.

[Psychotherapeutic treatment of personality disorders]

Treating patients with personality disorders presents a major challenge due to their maladaptive interpersonal styles which affect the therapeutic relationship. A number of therapeutic approaches using psychodynamic, behavioural, and other origins have been developed to treat patients with personality disorders, most of them dealing with borderline personality disorder. Overall, only a few controlled therapy studies have been carried out to document therapy effectiveness. However, available research indicates that psychotherapy has substantial effects even in personality disorders. From a vast literature based on case reports, therapeutic recommendations are presented for specific personality disorders.

Personality disorder research agenda for the DSM-V

The American Psychiatric Association is sponsoring a series of international conferences to set a research agenda for the development of the next edition of the diagnostic manual. The first conference in this series, "Dimensional Models of Personality Disorder: Etiology, Pathology, Phenomenology, and Treatment," was devoted to reviewing the existing research and setting a future research agenda that would be most effective in leading the field toward a dimensional classification of personality disorder. The purpose of this article, authored by the Steering Committee of this conference, was to provide a summary of the conference papers and their recommendations for research. Covered herein are the reviews and recommendations concerning alternative dimensional models of personality disorder, behavioral genetics and gene mapping, neurobiological mechanisms, childhood antecedents, cross-cultural issues, Axes I and II continuity, coverage and cutoff points for diagnosis, and clinical utility.

Clinical utility of dimensional models for personality pathology

Clinical utility is defined as the extent to which the DSM assists clinical decision makers in fulfilling the various clinical functions of a psychiatric classification system. Distinction is made between elements of diagnostic validity that are more or less conditional to utility (i.e., coverage, and consistency with etiology and prognosis) and components of clinical utility in the narrow sense of the term (i.e., user acceptability and accuracy, communication, reliability, subtlety, and clinical decision making). Clinical utility is often considered the driving force behind the respective revisions of the DSM system, yet it has been difficult if not impossible to obtain reasonable levels of clinical utility within categorical classifications of personality disorders. This paper presents evidence that a dimensional diagnostic system will substantially improve clinical utility, especially with respect to coverage, reliability, subtlety, and clinical decision making. In addition, some evidence suggests that the purely dimensional models outperform the so-called hybrid models (i.e., dimensional profiling of categories) with respect to coverage, consistency with etiology, subtlety, and clinical decision making. Several research options that might inform future revisions, including the choice or development of a dimensional classification, are suggested.

Dimensional models of personality disorder: coverage and cutoffs

Two major challenges that must be addressed by dimensional models, if they are to be considered viable alternatives to the present categorical system for diagnosing personality disorders, involve the issues of coverage and cutoffs. Several dimensional models of personality and personality pathology are evaluated with these issues in mind. There is growing consensus for the relevance of at least four higher-order domains of personality functioning that are clearly related to personality pathology: neuroticism/negative affectivity/emotional dysregulation, extraversion/positive emotionality, dissocial/antagonistic behavior, and constraint/compulsivity/conscientiousness. A proposal for developing a dimensionally based diagnostic system for personality disorders incorporating these higher-order traits is offered.

Categorical and Dimensional Models of Personality Disorder

We review major categorical and dimensional models of personality pathology, highlighting advantages and disadvantages of these approaches. Several analytic and methodological approaches to the question of the categorical versus dimensional status of constructs are discussed, including taxometric analyses, latent class analyses, and multivariate genetic analyses. Based on our review, we advocate a dimensional approach to classifying personality pathology. There is converging evidence that four major domains of personality are relevant to personality pathology: neuroticism/negative affectivity/emotional dysregulation; extraversion/positive emotionality; dissocial/antagonistic behavior; and constraint/compulsivity/conscientiousness. Finally, we discuss how dimensional approaches might be integrated into the diagnostic system, as well as some of the major issues that must be addressed in order for dimensional approaches to gain wide acceptance.

Alternative dimensional models of personality disorder: finding a common ground

The recognition of the many limitations of the categorical model of personality disorder classification has led to the development of quite a number of alternative proposals for a dimensional classification. The purpose of this article is to suggest that future research work toward the integration of these alternative proposals within a common hierarchical structure. An illustration of a potential integration is provided using the constructs assessed within existing dimensional models. Suggestions for future research that will help lead toward a common, integrative dimensional model of personality disorder are provided.

Assessing adolescent personality pathology

BACKGROUND

Personality pathology constitutes a major form of psychopathology in adolescents.

AIMS

To examine the reliability and validity of a Q-sort instrument for assessing adolescent personality pathology designed for clinically experienced informants.

METHOD

A sample of 294 randomly selected psychiatrists and psychologists each provided data on a current patient, aged 14-18 years. Clinicians completed several measures, including the Shedler-Westen Assessment Procedure for Adolescents (SWAP-200-A).

RESULTS

Factor analysis identified II dimensions of adolescent personality: psychopathology/malignant narcissism, dysphoria/inhibition, psychological health, histrionic sexualisation, schizotypy, sexual conflict, emotional dysregulation, anxious obsessionality, peer rejection, delinquent behaviour and attentional dysregulation. These correlated in predicted ways with a range of criterion variables, including measures of adaptive functioning, Axis II pathology, the Five Factor Model and the Child Behavior Checklist.

CONCLUSIONS

The SWAP-200-A shows promise as an instrument for assessing personality pathology in adolescents. Trait dimensions such as delinquent behaviour and emotional dysregulation may prove useful additions to a classification of personality.

Searching for a Developmental Typology of Personality and Its Relations to Antisocial Behavior: A Longitudinal Study of a Representative Sample of Men

The search for an empirically based personality typology has regained the interest of researchers. To date, however, the empirical inquiries were mainly cross-sectional. In this study, an empirically based developmental typology of personality was identified using data from a prospective longitudinal study of a representative sample of men assessed on four occasions from adolescence to midlife. Cluster analyses were performed on measures of Disinhibition, Negative Emotionality, and Extraversion. Four developmental types of personality were identified. The first was characterized by average scores in the three traits in adolescence that decreased rapidly until midlife (38%). The second was similar, but, instead, displayed increases in Extraversion during adulthood (32%). The third type showed high scores in Disinhibition and Negative Emotionality in adolescence that decreased progressively until midlife (23%). The fourth type was characterized by average scores in the three traits during adolescence followed by important increases in Negative Emotionality and decreases in Extraversion during adulthood (7%). These four developmental types of personality seemed to be related to known antisocial behavior trajectories.

In praise of clinical judgment: Meehl's forgotten legacy

Although Paul E. Meehl demonstrated the limits of informal aggregation of data and prognostication by presumed experts, he remained convinced that clinical experience confers expertise of some kind. The authors explore this forgotten side of Meehl's legacy by reconsidering the validity of clinical judgment in its natural context, everyday clinical work. Three domains central to clinical practice are examined: diagnosis, interpretation of meaning, and intervention. It is argued that a more sanguine picture of clinical expertise emerges when the focus shifts from prediction at high levels of inference to (a) judgments at a moderate level of inference, (b) contexts for which clinical training and experience are likely to confer expertise, and (c) conditions that optimize the expression of that expertise (e.g., use of instruments designed for expert observers). The authors conclude by examining domains in which clinical judgment could prove useful in knowledge generation (e.g., hypothesis generation, identification of falsifying instances, item development).

Etiology of borderline personality disorder: disentangling the contributions of intercorrelated antecedents

A substantial body of research points to several variables relevant to the etiology of borderline personality disorder (BPD), notably childhood physical and sexual abuse, childhood family environment, and familial aggregation of both internalizing and externalizing disorders. However, these variables tend to be correlated, and few studies have examined them simultaneously. A national sample of randomly selected psychologists and psychiatrists described 524 adult patients with personality disorders. Family environment, parental psychopathology, and history of abuse all independently predicted BPD symptoms in multiple regression analyses. Sexual abuse contributed to the prediction of BPD symptoms over and above family environment, although family environmental factors such as instability partially mediated the effect. The results converge with recent studies using very different samples and methodologies.

Measuring disordered personality functioning: to love and to work reprised

OBJECTIVE

Current limitations to diagnosing and measuring the personality disorders encouraged a set of studies seeking to provide an alternate approach to modeling and measuring disordered personality function.

METHOD

A large set of self-reported descriptors of disordered personality function were factor analyzed in a sample of patients with clinician-diagnosed personality dysfunction, generating 11 lower-order and two higher-order constructs. Subjects and non-clinical controls also completed a measure of personality styles underpinning formalized personality disorder groupings. Properties of the refined self-report (SR) measure were assessed in an independent sample of patients with a clinically diagnosed personality disorder.

RESULTS

Limitations in 'cooperativeness' and 'coping' formed the higher-order constructs defining disordered personality function, with these constructs relevant to all personality styles. Analyses of SR, corroborative witness (CW) and clinician-rated data in an independent sample supported measuring disordered personality function by our derived 20-item SR measure, and exposed limitations to clinician-based assessment.

CONCLUSION

Study findings build to a multi-axial strategy for measuring personality disorder, involving separate dimensional assessment of both disordered personality function and of personality style.

Effect of patient sex, clinician sex, and sex role on the diagnosis of Antisocial Personality Disorder: Models of underpathologizing and overpathologizing biases

This study examined the influence of patient sex and clinician sex and sex role for a case, meeting minimum diagnostic criteria for Antisocial Personality Disorder, in which patient sex was varied. The purpose was to provide an in-depth evaluation of the process by which patient sex and characteristics of clinicians may contribute to bias in personality disorder diagnoses. Psychologists (N = 167) read two cases, including the target case, and provided symptom ratings and diagnoses. A sex-unspecified condition served as a baseline to assess for over- and underpathologizing bias, and diagnoses based on the symptom ratings were compared to assigned diagnoses. Clinician sex role was assessed using the Bem Sex Role Inventory-Short Form. Results revealed that bias occurred when the patient's sex (female) was inconsistent with the gender weighting of the symptoms in the case (masculine), but the direction of the bias was consistent with sex roles (underdiagnosis of sex-role-inconsistent diagnoses, overdiagnosis of sex-role-consistent diagnoses). Path models of over- and underdiagnostic bias were developed using structural equation modeling. Patient sex had a direct effect on diagnostic ratings whereas clinician sex role had an indirect effect through symptom ratings.

Dimensions of personality disorders in offenders

BACKGROUND

Owing to criticisms of current concepts of personality disorders such as high comorbidity, criteria overlap and arbitrary thresholds of categorical diagnoses, a dimensional assessment is proposed that considers interrelations between different personality disorders. Results of previous factor analyses using dimensional personality disorder scores have indicated that one underlying dimension shows strong similarities to the concept of psychopathy and is similarly related to criminal recidivism.

AIM

The authors examined the underlying dimensions of ICD-10 personality disorders, to analyse their association with criminal behaviour in general, and with specific criminal history variables.

METHOD

Study samples included 105 offenders and 80 non-criminal controls. Personality disorders were measured using a clinical structured interview (IPDE), measures of personality using self-report (NEO-FFI, IPC, HDHQ), and criminal history variables obtained from court records.

RESULTS

Three underlying personality disorder factors could be identified, which showed identical structures in both the forensic and the non-forensic sample. Factor 1 comprised emotionally unstable, histrionic, paranoid and dissocial traits and showed strong similarity to the construct of psychopathy. Factor 2 was defined by anankastic personality disorder scores and an inverse relation to schizoid personality features. Factor 3 showed high negative loadings of anxious and dependent personality disorders. Self-report measures of personality and criminal history variables yielded different associations with the three PD dimensions. Offenders with high scores on factor 1 were highly aggressive, violent and impulsive.

CONCLUSIONS

The findings generally replicated previous analyses using DSM-III personality disorder scores. Differences can be explained by the different constructs of personality disorders included in ICD-10. Although a diagnosis of psychopathy is not currently included in these diagnostic systems, the authors' findings indicate that a highly inter-related pattern of personality disorder scores constitutes psychopathic personality disorder and can be used to identify impulsive, hostile and violent offenders.

Assessing progress in analysis interminable

A case study is provided of a schizoid patient in her mid-sixties who in a lengthy analysis had made significant clinical improvement. The treating analyst's impression of clinical improvement was independently verified through systematic analysis of transcripts of audiotapes of thirty-six sessions over a four-year period of treatment. The patient showed significant improvement on measures of character pathology, object relations, mentalization, and superego anxiety. The results suggest that some patients with entrenched character pathology who seem to be in analysis interminable may still make clinically significant improvement. It is suggested that the scientific status of psychoanalysis would be greatly enhanced if the anecdotal evidence generated in private practice were supported by independent verification. The current study illustrates one methodology, "case study plus," for providing independent verification while retaining the richness of the traditional case study.

Parental bonding and personality pathology assessed by clinician report

The present study focused on the link between parental bonding and personality pathology. We developed a clinician-report version of the Parental Bonding Instrument (PBI; Parker, Tupling, and Brown, 1979), which 203 clinicians applied to a randomly selected patient in their care. The goal of the study was to examine the reliability and validity of a clinician-report PBI, and to provide a preliminary examination of the relation between personality disorder (PD) symptoms and parental bonding in a national sample of patients in treatment in the community. Factor analysis yielded two factors (parental rejection/care and parental overprotection) for each parent, which had high internal consistency (coefficient alphas all >.80). The factor structure of the clinician-report measure strongly resembled the factor structure of the widely used self-report instrument. Parental bonding as assessed by clinician report showed coherent patterns of association with PD diagnoses, which resembled those found in other samples. Maternal rejection/care showed a particular link to borderline PD (BPD), and remained a significant predictor of BPD along with sexual abuse and physical abuse in multiple regression analysis. These data, along with others from recent studies using clinicians as informants, suggest that clinicians can provide reliable and valid data when their observations are quantified using psychometrically sound instruments. Clinician-report methods may provide a useful complement to studies of personality disorders that rely primarily on self-reports or structured interviews.

Dimensional versus categorical classification of prototypic and nonprototypic cases of personality disorder

This study examined interrater reliability and ratings of confidence and clinical utility (professional communication, case conceptualization, treatment planning) of categorical and dimensional approaches to diagnosing prototypic and nonprototypic personality disorder cases. Two national samples of psychologists (n = 93, n = 92) participated. Interrater reliability was higher for prototypic cases than nonprototypic cases for the categorical system, but similar for prototypic and nonprototypic cases using dimensional ratings. Across cases, interrater reliability and confidence were highest for the categorical model, hybrid models, and the five-factor model. However, ratings of clinical utility were highest for the categorical and the hybrid models, even when interrater reliability was inadequate, suggesting clinician preference for a classification based on the existing categories. Mean ratings for the prototypic cases supported the theorized relationships between the dimensional models and the personality disorders. Reasons for these findings and implications for moving towards a dimensional model of personality disorder are discussed.

Assessing personality disorders using a systematic clinical interview: evaluation of an alternative to structured interviews

The aim of this study was to assess interrater reliability and provide initial data bearing on the validity of a method of assessing personality disorders (PDs) that does not presume that patients can accurately self-report personality pathology. In a sample of 24 outpatients, two clinician-judges independently applied the Shedler-Westen Assessment Procedure-200 (SWAP-200; Westen & Shedler, 1999a, 2000), a 200-item Q-sort procedure for assessing personality pathology, to data from the Clinical Diagnostic Interview (Westen, 2002), a systematic clinical interview that mirrors and standardizes methods used by experienced clinicians to diagnose personality. In 16 of the 24 cases, the treating clinician also independently described the patient using the SWAP-200 Q-sort, based on longitudinal knowledge of the patient over the course of treatment, blind to the interview data. Interrater reliability was uniformly high, with median correlations between interviewers at r > .80. Interviewer-treating clinician correlations were also high, with median convergent validity coefficients at r > .80. Diagnostic overlap (discriminant validity) was moderate for dimensional DSM-IV diagnoses, reflecting extensive comorbidity among disorders, but minimal for empirically derived diagnoses identified in prior research. Treating clinicians' dimensional PD diagnoses using this method also strongly predicted interviewer-rated measures of adaptive functioning. The findings provide preliminary support for the reliability and validity of an alternative to structured interviews for diagnosing personality pathology, and suggest that the way to improve validity of personality diagnosis may not be to minimize clinical inference but to quantify it using psychometric instruments.

Quantifying clinical judgment in the assessment of adolescent psychopathology: Reliability, validity, and factor structure of the Child Behavior Checklist for clinician report

The aim of this study was to assess the reliability and validity of the Child Behavior Checklist (CBCL) as completed by doctoral-level clinicians in the treatment of adolescents. We asked 294 randomly selected, experienced psychiatrists and psychologists to describe a patient aged 14 to 18 in treatment for personality pathology. Clinicians completed the CBCL (parent-report version) and measures of adaptive functioning, personality pathology, and family and developmental history, which served as criterion variables to test the validity of the CBCL as completed by clinicians. Most CBCL scales demonstrated acceptable reliability. Validity estimates were impressive, and the data revealed clinically meaningful associations between specific CBCL scale scores and developmental and family history variables. Confirmatory factor analysis showed that the factorial structure of the clinician-report CBCL resembled that of the parent-report CBCL, with the exception of a substantially lower correlation between higher order internalizing and externalizing factors. The data suggest that clinical judgment can be both reliable and valid when quantified using psychometrically sound instruments.

Relationship between attachment patterns and personality pathology in adolescents

OBJECTIVE

To explore the relationship between attachment status and personality pathology in a large clinical sample of adolescents.

METHOD

Two hundred ninety-four randomly selected psychiatrists and psychologists were each asked to provide data on a patient (aged 14-18 years) in treatment for maladaptive personality patterns. Clinicians completed several measures including a clinician-report attachment questionnaire, several measures of personality pathology, and a clinician-report version of the Child Behavior Checklist.

RESULTS

In both dimensional and categorical analyses, secure attachment was negatively correlated with personality pathology and positively correlated with healthy functioning, whereas disorganized/unresolved attachment was strongly associated with multiple forms of personality pathology. Anxious/ambivalent attachment tended to be associated with measures of withdrawal, internalization, and introversion. Avoidant attachment style was not associated with any single form of personality pathology.

CONCLUSION

The marked association between unresolved attachment and more severe psychopathology in adolescents, the lack of construct validity of avoidant personality disorder in adolescents, and the broader relations among attachment, personality, and psychopathology are discussed.

Measuring the core features of personality disorders in substance abusers using the Temperament and Character Inventory (TCI)

Personality disorders (PDs) are still classified through categorical taxonomies that are at odds with current research findings. Dimensional models provide a suitable alternative for measuring individual differences. However, as they have traditionally lacked a clear definition of the "disorder" construct, the clinical utility of these models has been limited. This study tests whether Cloninger's dimensional model is able to capture two domains: the features that differentiate PD subtypes from each other and the common core features underlying all PDs. Seventy-four drug dependent patients were independently assessed using the SCID-II and Cloninger's TCI. There was a slight relationship between TCI temperament dimensions and the DSM personality disorder subtypes, but the association was not specific enough to allow differential diagnosis. The character dimension Self-Directedness was strongly associated with the presence and severity of all PDs, irrespective of subtype, correctly classifying 77% of subjects. Character dimensions are a reliable, valid and low-cost tool for detecting PDs in drug abusers and may help to provide an operational definition of the common core features underlying all PDs.

Assessment is not enough: the SPA should participate in constructing a comprehensive clinical science of personality. Society of Personality Assessment

Several proposals for a comprehensive clinical science of personality are enumerated in this Klopfer award article, namely (a) the need to integrate the study of personality within a framework of universal principles from which its theories can be derived, its categories organized, its assessment tools constructed, and its therapeutic interventions designed; (b) the wisdom of conceptualizing personality disorders, not as discrete "disease entities" but as psychological prototypes; (c) the shift from the Diagnostic and Statistical Manual of Mental Disorders Axis I to Axis II distinction to a 3-part complexity continuum demarcated by simple reactions, complex syndromes, and personality patterns; (d) the utility of expanding the range and comparability of routinely appraised clinical domains; and (e) the refining and differentiation of personality style and personality pathology subtypes.

Avoidant personality disorder: current status and future directions

Avoidant Personality Disorder (APD) is the topic of a growing body of research literature. In this article, we review empirical studies of APD with the goals of identifying the themes that underlie this work and pointing to new directions for future research. In particular, we recommend that future studies evaluate several unique factors postulated by personality theorists to be central to this condition.

Determinants of diagnostic prototypicality judgments of the personality disorders

We evaluated the impact of three factors that have been suggested to be important determinants of the diagnostic process pertaining to personality disorders: (a) the number of features representative of a personality disorder category; (b) the extent to which those features are typical of the category, and (c) the dominance or proportion of category features to the total number of features. Thirty-two clinical psychologists evaluated 12 profiles of hypothetical patients in which these factors were varied factorially. The results revealed strong effects of typicality and dominance, but no effects for number. Implications for the assessment and classification of personality disorders are discussed.

The role of personality in the onset of eating disorders and treatment implications

The relationship of personality and eating disorders is largely unclear. The development of well-specified conceptual models of this relationship, developments in family history, behavior genetic and prospective longitudinal research methodology, and careful consideration of how trait constructs may interact with state variables to produce or maintain eating disorders all will help to advance this area of research.