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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.
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 and Axis II produces Axis I
Axis IV: Psychosocial Environment Axis II: Personality Disorders Axis I: Clinical Syndromes
Anxiety, Depression = Fever, Cough
Multiaxial model is an intrinsically 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.
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)
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
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 Psychodynamic 1. frantic efforts to avoid real or imagined abandonment 2. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation 3. identity disturbance: markedly and persistently unstable self image or sense of self 4. impulsivity in at least two areas that are potentially selfdamaging (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 Emotional 5. recurrent suicidal behavior, gestures, or threats, or selfmutilating behavior 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) 7. chronic feelings of emptiness 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 PD PD PD PD PD PD Trait 1 Trait 2 And so on… Trait 1 Trait 2 And so on… Trait 1 Trait 2 And so on… Typical Behavior Typical Feeling
A set of types operationalized in terms of a standard set of traits. Prototypes operationalized as traits.
Tier 2: Six Broad Trait Dimensions, with Facets
DSM-V Negative Emotionality Emotional Lability Anxiousness Submissiveness Separation Insecurity Pessimism Low Self-Esteem Guilt-Shame Self-Harm Depressivity Suspiciousness
Negative Emotionality: Experiences a wide range of negative emotions, and the behavioral and interpersonal manifestations of those experiences.
NEO Agreeableness versus DSM-V Antagonism
Five Factor Model Agreeableness Trust Straightforwardness Altruism Compliance Modesty Tender-Mindedness Antagonism: Exhibits diverse manifestations of antipathy toward others, and a correspondingly exaggerated sense of self-importance. DSM-V Antagonism Callousness Manipulativeness Narcissism Histrionism Hostility Aggression Oppositionality Deceitfulness
Good Construct Definitions
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
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
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 Antisocial Deceitfulness Narcissism Histrionism Disinhibition Irresponsibility Recklessness Impulsivity
DSM-V Narcissist not necessarily disinhibited.
Borderline, Dependent, and Histrionic in DSM-V
Emotional Lability Negative Emotionality Self-Harm Separation Insecurity Anxiousness Low Self-Esteem Borderline Depressivity Histrionism Submissiveness Hostility Antagonism Aggression Impulsivity Schizotypy Dissociation Proneness Histrionic Dependent
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.
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.
Much more empirically driven. The committees will be hungry for data. Any researcher could influence the DSM.
Current Scales are Classical Test Theory
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.
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 people to make my decisions for me.
205. People often take 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. 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.
Potential for most improvement in functioning.
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.
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