Story of Personality in the DSM

 Story of one of the

most profound
measurement
debacles of modern
history.

The DSM-IV Manual

 What is the DSM-IV?
 The Diagnostic and
Statistical Manual of Mental
disorders.
American Psychiatric
Association.
Considered a world standard.
 Describes all “officially
recognized” mental
disorders.

The DSM-IV Manual

 Achieved Modern Form in 1980
 In 1970s, professional status of psychiatry
was in trouble.
 Mission of DSM-III: Reliability.
Adopted prototypal model.
Adopted multiaxial model.
 The Structure of the DSM:
Multiaxial Model: Lines of Causality in Psychopathology

Interaction
of Axis IV  Multiaxial model is an
Axis IV: Psychosocial
and Axis II intrinsically integrative
Environment
conception.
produces
Axis I Axis II: Personality  Provides a model of how
Disorders psychopathology emerges
and is perpetuated.
Axis I:  Specifically requires us to
Clinical
develop an integrative
Syndromes
conception of the patient
that transcends a list of
Anxiety, Depression = diagnoses.
Fever, Cough

Histrionic, Sadistic =
Immune System

Marriage, Money =
Infectious Agents
 The Personality Disorders
 Schizoid
 Avoidant
 Dependent
 Histrionic
 Narcissistic
 Antisocial
 Compulsive
 Schizotypal
 Borderline
 Paranoid
Arbitrary Diagnostic Boundaries
 DSM-III (1980) adopted behaviorally specific
criteria 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 validity
studies.
 Massive Comorbidity of PDs

 PD constructs are useless when patients

receive 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
 PDNOS is most used Diagnosis
 In other words, existing PD categories don’t
provide adequate coverage.
 “The majority of patients with personality
pathology…are currently undiagnosable on
Axis II.” Westen & Arkowitz-Weston (1998)
 Can a taxonomy endure when it’s constructs
fail to diagnose over half the patients?
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.
 Borderline PD, Criteria 1 to 4
DSM Diagnostic Criterion
Behavioral 1. frantic efforts to avoid real or imagined abandonment
Psychodynamic 2. a pattern of unstable and intense interpersonal
relationships characterized by alternating between extremes
of idealization and devaluation
Psychodynamic 3. identity disturbance: markedly and persistently unstable
self image or sense of self
Trait 4. impulsivity in at least two areas that are potentially self-
damaging (e.g., spending, sex, substance abuse, reckless
driving, binge eating)

 No standardization of diagnostic criteria.

 Different types, and different levels of inference.
 As diseases, diagnostic criteria are simply markers of
disease.
 Borderline PD, Criteria 5 to 9
DSM 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 usually
lasting 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, recurrent
physical fights)
9. transient, stress-related paranoid ideation or severe
dissociative symptoms
 The Essential Insight

 Personality
disorders consist of
personality traits.
 Six Trait Domains
 Negative Emotionality: Experiences a wide range of negative emotions
(e.g., anxiety, depression, guilt-shame, worry, etc.), and the behavioral and
interpersonal 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).
 The Structure of PP in DSM-V
Tier 1 Tier 2 Tier 3

Narrower Tendency

PD Trait 1 Typical Behavior

Trait 2 Typical Feeling
PD
And so on…
PD
 A set of types
operationalized
Trait 1
PD in terms of a
Trait 2 standard set of
PD And so on… traits.
 Prototypes
PD Trait 1
operationalized
as traits.
PD Trait 2

And so on…
 Tier 2: Six Broad Trait
Dimensions, with Facets
 Negative Emotionality
DSM-V

Negative Emotionality
Negative Emotionality:
Emotional Lability
Experiences a wide range of
Anxiousness negative emotions, and the
Submissiveness behavioral and interpersonal
Separation Insecurity manifestations of those
Pessimism experiences.
Low Self-Esteem

Guilt-Shame

Self-Harm

Depressivity

Suspiciousness
 NEO Agreeableness versus DSM-V Antagonism

Five Factor Model Antagonism: DSM-V

Exhibits diverse
manifestations of
Agreeableness Antagonism
antipathy toward
others, and a
Trust Callousness
correspondingly
exaggerated sense
Straightforwardness Manipulativeness
of self-importance.
Altruism Narcissism

Compliance Histrionism

Modesty Hostility

Tender-Mindedness Aggression

Oppositionality

Deceitfulness
 Good Construct Definitions

 Submissiveness
Subservience and unassertiveness
Advice and reassurance seeking
Lack of confidence in decision-making;
subordination of one’s needs to those of
others
Adaptation of one’s behavior to the interests
and desires of others
Personality Types in DSM-V
 The PDs Reconceptualized
 DSM-IV PDs now re-conceptualized as a
collection 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.
 First Important Consequence
 The PDs can be compared and contrasted
in 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.
 Antisocial and Narcissistic in DSM-V
Antagonism

Callousness

Aggression

Manipulativeness

Hostility

Deceitfulness
Antisocial Narcissism
Narcissism
Histrionism
 DSM-V Narcissist
Disinhibition not necessarily
Irresponsibility
disinhibited.

Recklessness

Impulsivity
 Borderline, Dependent, and Histrionic in DSM-V
Emotional Lability
Negative Self-Harm
Emotionality
Separation Insecurity Dependent
Anxiousness

Low Self-Esteem
Histrionic
Borderline Depressivity
Histrionism

Submissiveness

Hostility
Antagonism Aggression

Impulsivity

Schizotypy Dissociation Proneness

 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.
 New Inventories
 Older instruments just don’t allow assessment of
the 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.
 Measurement versus Authority

 Changes the way the personality pathology will

be revised in future DSMs.
 Past DSMs
Revised based on expert consensus.
Measurement came later.
 Future DSMs
Much more empirically driven.
The committees will be hungry for data.
Any researcher could influence the DSM.
 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 it’s not what I want.
 50. In a discussion, I usually end up agreeing with the other person’s 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.
-3 -2 -1 0 1 2 3

Eventually,
Logits will
replace
diagnostic
thresholds
 The Logistic Curve and Therapy
 Rasch model is
a probabilistic
Guttman model
 The Logistic
curve gives us
appropriate
targets for
therapy. 77. I try to get other 205. People
people to make my often take
decisions for me. advantage of
me.
 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 it’s
not what I want.
 50. In a discussion, I usually end up agreeing with the other
person’s point of view.
Difficulties

 53. I hesitate to express opinions that I think others will Potential for
disagree with.
most
Item

 77. I try to get other people to make my decisions for me.

improvement
 124. I need people to tell me what to do.
in
 133. I doubt my own ability to do the right thing without
functioning.
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.
 Conclusion
 DSM-V marks the moment that
measurement enters psychiatry.
 This promises a vigorous future role for
psychologists.
 And finally links measurement to
psychotherapy.
Can’t do this in classical test theory.