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Story of Personality in the DSM
Story of one of themost profound
measurement
debacles of modernhistory.
The DSM-IV Manual
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What is the DSM-IV?
The Diagnostic andStatistical Manual of Mental
disorders.American Psychiatric
Association.Considered a world standard.
Describes all officially
recognized mental
disorders.
The DSM-IV Manual
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Achieved Modern Form in 1980
In 1970s, professional status of psychiatrywas in trouble.
Mission of DSM-III: Reliability.
Adopted prototypal model.Adopted multiaxial model.
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The Structure of the DSM:
Multiaxial Model: Lines of Causality in Psychopathology
Axis I:
Clinical
Syndromes
Anxiety, Depression =
Fever, Cough
Axis II: Personality
Disorders
Histrionic, Sadistic =
Immune System
Axis IV: Psychosocial
Environment
Marriage, Money =
Infectious Agents
Multiaxial model is anintrinsically integrative
conception.
Provides a model of how
psychopathology emerges
and is perpetuated.
Specifically requires us to
develop an integrative
conception of the patient
that transcends a list of
diagnoses.
Interactionof Axis IV
and Axis II
produces
Axis I
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The Personality Disorders
Schizoid Avoidant Dependent
Histrionic Narcissistic Antisocial
Compulsive
Schizotypal Borderline
Paranoid
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Arbitrary Diagnostic Boundaries
DSM-III (1980) adopted behaviorally specificcriteria sets in order to increase diagnostic
reliability.
No justifications for any diagnostic thresholds.Dramatic changes in prevalence rates across DSMs
Schizotypal prevalence dropped from 11% to 1%
from DSM-III to III-R
This is like publishing a test with no external validitystudies.
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Massive Comorbidity of PDs
PD constructs are useless when patientsreceive four or five diagnoses.
Structured interviews consistently find extensive
co-morbidity of PDs.This situation has existed in DSM-III, published
in 1980 (nearly 30 years)
Examples of co-morbidities
Narcissistic and Antisocial
Borderline, Histrionic, and Dependent
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PDNOS is most used Diagnosis
In other words, existing PD categories dont
provide adequate coverage.
The majority of patients with personality
pathologyare currently undiagnosable onAxis II. Westen & Arkowitz-Weston (1998)
Can a taxonomy endure when its constructs
fail to diagnose over half the patients?
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DSM-IV PDs Represented as Diseases
May fall on separate Axis, but still
diagnosed as diseases.
Disease assumes a focal point or single
cause from which the disorder emanates.
Personality disorders are disorders of the
entire matrix of the person.
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Borderline PD, Criteria 1 to 4
No standardization of diagnostic criteria.Different types, and different levels of inference.
As diseases, diagnostic criteria are simply markers of
disease.
DSM Diagnostic Criterion
Behavioral 1. frantic efforts to avoid real or imagined abandonment
Psychodynamic 2. a pattern of unstable and intense interpersonalrelationships characterized by alternating between extremesof idealization and devaluation
Psychodynamic 3. identity disturbance: markedly and persistently unstableself image or sense of self
Trait 4. impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, recklessdriving, binge eating)
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Borderline PD, Criteria 5 to 9DSM Diagnostic Criterion
Behavioral 5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
Emotional 6. affective instability due to a marked reactivity of mood(e.g., intense episodic dysphoria, irritability, or anxiety usuallylasting a few hours and only rarely more than a few days)
Psychodynamic 7. chronic feelings of emptiness
Emotional 8. inappropriate, intense anger or difficulty controlling anger(e.g., frequent displays of temper, constant anger, recurrentphysical fights)
9. transient, stress-related paranoid ideation or severedissociative symptoms
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The Essential Insight
Personalitydisorders consist of
personality traits.
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Six Trait Domains
Negative Emotionality: Experiences a wide range of negative emotions(e.g., anxiety, depression, guilt-shame, worry, etc.), and the behavioral andinterpersonal manifestations of those experiences.
Introversion: Withdrawal from other people, ranging from intimate
relationships to the world at large; restricted affective experience and
expression; limited hedonic capacity.
Antagonism: Exhibits diverse manifestations of antipathy toward others,and a correspondingly exaggerated sense of self-importance.
Disinhibition: Diverse manifestations of being present- (vs. future- or past-)
oriented, so that behavior is driven by current internal and external stimuli,
rather than by past learning and consideration of future consequences.
Compulsivity: The tendency to think and act according to a narrowly
defined and unchanging ideal, and the expectation that this ideal should
be adhered to by everyone.
Schizotypy: Exhibits a range of odd or unusual behaviors and cognitions,
including both process (e.g., perception) and content (e.g., beliefs).
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The Structure of PP in DSM-V
A set of typesoperationalizedin terms of astandard set of
traits. Prototypes
operationalizedas traits.
Trait 1
Trait 2
And so on
Trait 1
Trait 2
And so on
Trait 1
Trait 2
And so on
PD
PD
PD
PD
PD
Narrower Tendency
Typical Behavior
Typical Feeling
Tier 1 Tier 2 Tier 3
PD
PD
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Tier 2: Six Broad TraitTier 2: Six Broad Trait
Dimensions, with FacetsDimensions, with Facets
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Negative Emotionality
Negative Emotionality
Emotional Lability
Anxiousness
Submissiveness
Separation Insecurity
DSM-V
Pessimism
Low Self-Esteem
Guilt-Shame
Self-Harm
Depressivity
Suspiciousness
Negative Emotionality:
Experiences a wide range of
negative emotions, and the
behavioral and interpersonalmanifestations of those
experiences.
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NEO Agreeableness versus DSM-V Antagonism
Agreeableness
Trust
Straightforwardness
Altruism
Compliance
Modesty
Tender-Mindedness
Five Factor Model DSM-V
Antagonism
Callousness
Manipulativeness
Narcissism
Histrionism
Hostility
Aggression
Oppositionality
Deceitfulness
Antagonism:
Exhibits diversemanifestations of
antipathy toward
others, and a
correspondingly
exaggerated sense
of self-importance.
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Good Construct Definitions
SubmissivenessSubservience and unassertiveness
Advice and reassurance seeking
Lack of confidence in decision-making;subordination of ones needs to those of
others
Adaptation of ones behavior to the interests
and desires of others
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Personality Types in DSM-VPersonality Types in DSM-V
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The PDs Reconceptualized
DSM-IV PDs now re-conceptualized as acollection of personality traits.The PDs can only be operationalized in terms of
the 37 traits.
Each PD is some subset of the 37.
If you want the PDs to include more content,
then you have to argue for numbers 38, 39, 40
and so on.
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First Important Consequence
The PDs can be compared and contrastedin terms of the 37.In DSM-IV, you might have ideas about the
relationships between the PDs, but these were
literary inferences not officially recognized.
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Antisocial and Narcissistic in DSM-V
Callousness
Aggression
Antagonism
Manipulativeness
Hostility
Deceitfulness
Narcissism
Irresponsibility
Recklessness
Impulsivity
Antisocial
Histrionism
Narcissism
Disinhibition DSM-V Narcissistnot necessarilydisinhibited.
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Antagonism
Negative
Emotionality
Borderline, Dependent, and Histrionic in DSM-V
Emotional Lability
Self-Harm
Separation Insecurity
Anxiousness
Low Self-Esteem
Depressivity
Hostility
Aggression
Impulsivity
Histrionism
Dependent
Dissociation PronenessSchizotypy
Submissiveness
BorderlineHistrionic
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Psychology Moves to Forefront
Psychiatrists diagnose.
Psychologists measure.Psychologists know what to do with traits.
Continuity between normality and pathology.
This is the moment in history where
measurement enters the DSM.
Possible to measure personality pathology for
first time.
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New Inventories
Older instruments just dont allow assessment ofthe 37 pathological traits.MMPI-2 and MMPI-2-RF better suited for Axis I.
MCMI-III at least has the PDs
But the MCMI-III is too short to assess 37 traits. With the Grossman Facet scales, Millon is following his
own system of traits.
The FFM is geared toward normal personality.
Some FFM facet parallel DSM-V, others are unique.Does not include Schizotypy at all.
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Measurement versus Authority
Changes the way the personality pathology willbe revised in future DSMs.
Past DSMsRevised based on expert consensus.
Measurement came later.
Future DSMsMuch more empirically driven.
The committees will be hungry for data.Any researcher could influence the DSM.
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Current Scales are Classical Test Theory
DAPP-BQ Submissiveness 1. If I am pressured, I will usually give in. 16. I usually go along with other people's suggestions.
48. I go along with what other people want even when its not what I want.
50. In a discussion, I usually end up agreeing with the other persons point of view.
53. I hesitate to express opinions that I think others will disagree with.
77. I try to get other people to make my decisions for me.
124. I need people to tell me what to do. 133. I doubt my own ability to do the right thing without advice from other people.
152. I tend to follow other people's wishes.
155. I tend to believe what people say without question.
177. I find it hard to resist persuasive people.
205. People often take advantage of me.
213. I am easily fooled by others. 220. I am not very good at being assertive with others.
224. I let people walk all over me.
256. I feel unsure about my decisions until I check them out with others.
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0 1 2-1-2-3 3
Eventually,
Logits will
replace
diagnosticthresholds
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The Logistic Curve and Therapy
Rasch model isa probabilisticGuttman model
The Logisticcurve gives usappropriatetargets for
therapy. 205. Peopleoften takeadvantage of
me.
77. I try to get otherpeople to make my
decisions for me.
Hierarchy of items = Hierarchy of
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Hierarchy of items = Hierarchy of
Therapeutic Goals
1. If I am pressured, I will usually give in.
16. I usually go along with other people's suggestions.
48. I go along with what other people want even when its
not what I want.
50. In a discussion, I usually end up agreeing with the other
persons point of view.
53. I hesitate to express opinions that I think others willdisagree with.
77. I try to get other people to make my decisions for me.
124. I need people to tell me what to do.
133. I doubt my own ability to do the right thing without
advice from other people.
152. I tend to follow other people's wishes. 155. I tend to believe what people say without question.
177. I find it hard to resist persuasive people.
Item
Difficu
lties
Potential formost
improvement
in
functioning.
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Conclusion
DSM-V marks the moment thatmeasurement enters psychiatry.
This promises a vigorous future role for
psychologists.
And finally links measurement to
psychotherapy.Cant do this in classical test theory.