The DSM5, ICD-10 and PDM: Concepts of Personality, Ethics and
Validity
The DSM5, ICD-10-11 and PDM: Concepts of Personality, Ethics and
ValidityPPA Fall 2012 Ethics WorkshopWe have three competing
diagnostic systems of personality: DSM5, ICD10 and PDM. If we are
to ethically base our diagnoses on information and techniques
sufficient to substantiate their findings, then which do we use and
why?
Robert M. Gordon, Ph.D. ABPP in Clinical Psychology and
Psychoanalysis Janet Etzi, PsyD, Professor, Immaculata University
OutlineWhat is diagnosis and why diagnose?Case example of a ethical
and risk management issue over Dx.Big changes in DSM 5s Personality
Disorders.The ICD 10-PD and the ICD 11 PD,Participate in an
experiment on diagnostic formulation and learn more about Dx. The
PDM- a personality centered approach,Why Mental Functioning is
important to Dx,An Integration of the PDM, ICD or DSM.
The term Diagnosis is derived from Greek- meaning a
distinguishing, to perceive, to know thoroughly. Start with a good
diagnostic formulation Once I have a good feel for the person, the
work is going well, I stop thinking diagnostically and simply
immerse myself in the unique relationship that unfolds between me
and the clientone can throw away the book and savor individual
uniqueness. Nancy McWilliams (2011) Psychoanalytic Diagnosis:
Understanding Personality Structure in the Clinical Process, Second
Edition.Main Reasons for Diagnosing
1. Its usefulness for treatment planning. Understanding
character styles help the therapist be more careful with boundaries
with a histrionic patient, more pursuant of the flat affect with
the obsessional person, and more tolerant of silence with a
schizoid client. 2. Its implications for prognosis. Realistic goals
protect patients from the demoralization and therapist from
burnout.
Why Diagnose?3. Its value in enabling the therapist to convey
empathy. Once one knows that a depressed patient also has
aborderline rather neurotic level personality structure,
thetherapist will not be surprised if during the second year
oftreatment she makes a suicide gesture. Or once a borderlineclient
starts to have hope of real change, that the borderlineclient often
panics and flirts with suicide in an effort to protecthimself from
traumatic disappointment.
4. Its role in reducing the probability that certain easily
frighten peoplewill flee from treatment. It is helpful for the
therapist to communicate tohypomanic or counter-dependent patients
an understanding of how hardit may be for them to stay in
therapy.
Why Diagnose? 5. Its value in risk management. Often therapists
mistakenly use a presenting symptom as the only diagnosis and
missed the borderline level of personality or psychopathic
personality and got into trouble. 6. Its value in process and
outcome research.
Personality Structure and TreatmentMcWilliams points out that
for many neurotic level people, the best time to make
interpretations is when the patient is a state of emotional
arousal, so that the patient is less likely to intellectualize the
affect. With borderline clients, who also require a supportive
approach, the opposite consideration applies, because when they are
very upset, it is hard for them to take anything in.
9Why have competence in diagnoses?9.01 Bases for Assessments
(a) Psychologists base the opinions contained in their
recommendations, reports, and diagnostic or evaluative statements,
including forensic testimony, on information and techniques
sufficient to substantiate their findings. This includes interview,
assessments and diagnostic taxonomies that pass the Frye Test, i.e.
DSM, ICD and PDM.
9 I have often served as an expert witness in malpractice cases
where psychologists had missed the psychopathic or borderline
traits in patients. The DSM classifies antisocial and borderline
personality disorders by precise and narrow symptoms. This is often
misleading. Psychopathy can be a complex personality pattern that
combines with or is obscured by other personality patterns, and
borderline can be viewed as an entire level of personality
organization that can be applied to the various personality
disorders.
Gordon, R.M., (2007) PDM Valuable in Identifying High-Risk
Patients. The National Psychologist, 16, 6, November/December, page
4.10Risk Factors in Litigious PatientsBorderline Personality
OrganizationPsychopathic traitsHistory of acting out
11My Psychologist Abandoned Me! Patient claiming millions of
dollars in damagesMiddle age woman, with no history of
psychological problems seeks help after her husband commits
suicide.
Psychologist gives the Beck Depression Inventory, it shows
depression and the psychologist does CBT.
He is symptom focused in his orientation.
12Complaint to Licensing Board and Civil Suit for DamagesAt
first the patient is sweet and appreciative. Calls psychologist
frequently between sessions. Begins to stalk him and insist on an
outside relationship with him. At his rejection, she becomes
suicidal and requires hospitalizationPsychologist refers her to
other psychologists for treatment and does a termination session
with her.Later she sues for abandonment.He did not manage her as
someone with a dependent personality disorder at the borderline
level personality organization.
13Patient using sessions for sadomasochistic
gratificationConstantly testing the boundaries and insisting on
frequent phone contact between sessionsThreatening suicide, but
refusing to be cooperative with the treatment planIdealizing the
therapist and fearing his abandonment while devaluing the
treatmentInfuriating the therapist with complaints about his not
helping her, while she was resisting treatment (projective
identification)14Admission notes at first hospital stay soon after
start of treatment She was increasingly depressed and it seems that
despite treatment with antidepressants from her primary care doctor
and despite psychotherapy which had been started with Therapist Y
in the past three months, the patients overall condition had
continued to decline15Mental health outpatient note by subsequent
therapist Therapist Y suddenly stopped her treatment so she started
to harass him, follow him, follow him everywhere, go to his house,
hide in the bushes, in short she was stalking him. So he called 911
and she was in jail last month for one week. When she got out she
is going to sue Therapist Y for suddenly stopping her therapy
16Mental health outpatient note by subsequent therapist cont:AXIS
I: Posttraumatic stress disorder 309.81; AXIS II: Mixed personality
disorder with borderline and obsessive-compulsive components AXIS
V: Global assessment of functioning 55; highest in past 6517Whether
Therapist Y appropriately terminated his treatment of Patient
X.
The APA ethics committee and state licensing board hearing both
rejected Patient Xs complaint. She was not benefiting from
treatment and he was ethically bound to terminate treatment if the
patient is not benefiting. He gave her the names of other
therapists. He is not responsible if because of her psychopathology
she doesnt want other therapists and she doesnt want to get
better.
18Whether the treatment provided by Therapist Y was
appropriate.Yes it was. He appears to provide primarily cognitive
behavior therapy ... However, the problem was not that there was
inappropriate treatment but Ms. X was uncooperative and resistant
to treatment.
19
20Throw Away Occams Razor (law of parsimony)
Clinicians should follow the general rule of recording as many
diagnoses as are necessary to cover the clinical picture.
Hickam's Dictum: "Patients can have as many diseases as they
damn well please" John Hickam, MD.
When recording more than one diagnosis, it is usually best to
give the main diagnosis, and to label any others as subsidiary or
additional diagnoses. The DSM-IV was originally published in 1994
and listed more than 250 mental disorders.
The DSM-IV is based on five different dimensions. Axis I:
Clinical Syndromes clinical symptoms that cause significant
impairment Axis II: Personality and Mental Retardation long-term
problems that are overlooked in the presence of Axis I disorders
Axis III: Medical Conditions physical and medical conditions that
may influence or worsen Axis I and Axis II disorders Axis IV:
Psychosocial and Environmental ProblemsAxis V: Global Assessment of
Functioningclient's overall level of functioning DSM 5The DSM 5 is
due May 2013 and will supersede the DSM-IV which was last revised
in 2000.Research started in 1999.The DSM makes the American
Psychiatric Association over $5 million a year, historically adding
up to over $100 million.DSM IVs problem of temporal instability
The average short-term test-retest reliabilities of .54 for
specific PDs and .56 for any PD (Zimmerman, 1994) suggest large
transient error of measurement; (Chmielewski & Watson, 2009)
when using structured interviews.
Longer term test-retest reliabilities of .51 for any PD and .34
for specific PDs, and the finding of significant diagnostic change
over as little as 6 months (Shea et al., 2002), indicate diagnostic
instability that is inconsistent with the relative stability of
personality traits (Roberts & DelVecchio, 2000). By making PD
diagnoses more trait-based and dimensional, the DSM-5 is expected
to reduce temporal instability.DSM IV Axis II Poor convergent
validity Meta-analytic convergence between structured interviews,
and between structured interviews and personality questionnaires,
respectively, was .27 for specific PDs and .29 for any PD (Clark et
al., 1997).In contrast, the proposed DSM- 5 personality trait set
is based on an extensive research literature whose origins are more
than half a century old (e.g., Cattell, 1946), culminating in
recent years in a consensual, highly robust personality trait
hierarchical structure (Markon et al., 2005) that has a high degree
of convergent and discriminant validity across a wide range of
measures, primarily questionnaires (OConnor, 2002b), but also
encompassing structured interviews (Stepp et al., 2005).
(But- If a simpler construct has more stability and convergent
validity- does it also mean that it has more generalizable validity
to complex personality structures?)
DSM-5 Moves from Multi-axial system to a similar ICD 10
System
DSM-5 changes to the approach used by ICD 10, with Axes I, II,
and III into one axis.
Axis IV and Axis V may also copy ICD 10 (making the dimensional
ratings specific to the diagnosis)
Main DSM 5 Categories Neurodevelopmental DisordersSchizophrenia
Spectrum and Other Psychotic DisordersBipolar and Related
DisordersDepressive DisordersAnxiety DisordersObsessive-Compulsive
and Related DisordersTrauma and Stressor Related
DisordersDissociative DisordersSomatic Symptom DisordersFeeding and
Eating DisordersElimination DisordersSleep-Wake DisordersSexual
DysfunctionsGender DysphoriaDisruptive, Impulse Control, and
Conduct DisordersSubstance Use and Addictive
DisordersNeurocognitive DisordersPersonality DisordersParaphilic
DisordersOther DisordersDSM 5 Changes to Personality Disorder
The personality domain in DSM-5 is intended to describe the
personality characteristics of all patients, whether they have a
personality disorder or not.
Five Factor Model and the DSM 5 PD The proposed model represents
an extension of the Five Factor Model (FFM; Costa & Widiger,
2002) of personality that encompasses the more maladaptive
personality variants necessary to capture features of PDs. The 5
domain/25 trait model includes 5 broad, higher-order personality
trait domains negative affectivity, detachment, antagonism,
disinhibition, and psychoticism each comprised of from 3 to 9
lower-order, more specific trait facets that help flesh out the
domains (e.g., manipulativeness and callousness are specific facets
in the antagonism domain).
DSM 5 two dimensional assessments The proposed DSM-5 model
consists of two dimensional assessments: 1) a personality pathology
severity scale, the Levels of Personality Functioning, and 2) a 5
domain/25 facet pathological personality trait assessment.
Combined, these assessments redefine the core features of a PD and
provide the information needed to rate the major diagnostic
inclusion criteria for six specific PD categories and for a
diagnosis of personality disorder-trait specified (PD-TS) to
replace PD not otherwise specified (PDNOS). Guide to Implementation
of Assessment of Personality Pathology
1. Is impairment in personality functioning (self and
interpersonal) present or not? 2. If so, rate the level of
impairment in self (identity or self-direction) and interpersonal
(empathy or intimacy) functioning on the Levels of Personality
Functioning Scale (0-4). 3. Is one of the 6 defined types present?
(antisocial, avoidant, borderline, narcissistic,
obsessive-compulsive, and schizotypal) If so, record the type and
the severity of impairment.
5. If not, is PD-Trait Specified present? (negative affectivity,
detachment, antagonism, disinhibition vs. compulsivity, and
psychoticism) If so, record PDTS, identify and list the trait
domain(s) that are applicable, and record the severity of
impairment on Clinicians Trait Rating Form (0-3).
7. If a PD is present and a detailed personality profile is
desired and would be helpful in the case conceptualization,
evaluate the trait facets. 8. If neither a specific PD type nor
PDTS is present, evaluate the trait domains and/or the trait
facets, if these are relevant and helpful in the case
conceptualization.Revised General Criteria for Personality
Disorder
The essential features of a personality disorder are impairments
in personality (self and interpersonal) functioning and the
presence of pathological personality traits. To diagnose a
personality disorder, the following criteria must be met:
A. Significant impairments in self (identity or self-direction)
and interpersonal (empathy or intimacy) functioning.
B. One or more pathological personality trait domains or trait
facets.
C. The impairments in personality functioning and the
individuals personality trait expression are relatively stable
across time and consistent across situations.
D. The impairments in personality functioning and the
individuals personality trait expression are not better understood
as normative for the individuals developmental stage or
socio-cultural environment.
E. The impairments in personality functioning and the
individuals personality trait expression are not solely due to the
direct physiological effects of a substance (e.g., a drug of abuse,
medication) or a general medical condition (e.g., severe head
trauma).
First- If there is impairment in personality functioning (self
and interpersonal) then- rate the level of impairment in self and
interpersonal functioning on the Levels of Personality Functioning
Scale. Five levels of self-interpersonal functioning impairment,
ranging from no impairment, i.e., healthy functioning (Level = 0)
to extreme impairment (Level = 4)
Is one of the 6 defined types present?If so, record the type and
the severity of impairment.
The six specific types are as follows:T 00 Borderline
Personality DisorderT 01 Obsessive-Compulsive Personality DisorderT
02 Avoidant Personality DisorderT 03 Schizotypal Personality
DisorderT 04 Antisocial Personality Disorder (Dyssocial Personality
Disorder)T 05 Narcissistic Personality DisorderT 06 Personality
Disorder Trait SpecifiedDSM5: T 04 Antisocial Personality Disorder
(Dyssocial Personality Disorder)
A. Significant impairments in personality functioning manifest
by:1. Impairments in self functioning (a or b):a. Identity:
Ego-centrism; self-esteem derived from personal gain, power, or
pleasure.b. Self-direction: Goal-setting based on personal
gratification; absence of prosocial internal standards associated
with failure to conform to lawful or culturally normative ethical
behavior.AND2. Impairments in interpersonal functioning (a or b):a.
Empathy: Lack of concern for feelings, needs, or suffering of
others; lack of remorse after hurting or mistreating another.b.
Intimacy: Incapacity for mutually intimate relationships, as
exploitation is a primary means of relating to others, including by
deceit and coercion; use of dominance or intimidation to control
others.
B. Pathological personality traits in the following domains:1.
Antagonism, characterized by: a. Manipulativeness b. Deceitfulness
c. Callousness d. Hostility2. Disinhibition, characterized by: a.
Irresponsibility b. Impulsivity c. Risk takingDSM IV- BPD
Criteria-no more needing at least 5 BPD as indicated by at least 5
of the following: Frantic efforts to avoid real or imagined
abandonmentA pattern of unstable and intense interpersonal
relationships-"splitting" Identity disturbance: unstable self-image
Impulsivity in at least two areas that are potentially
self-damagingRecurrent suicidal behavior or self-mutilating
behavior Affective instability Chronic feelings of emptiness
Inappropriate, intense anger or difficulty controlling anger
Paranoid ideation or dissociative symptomsDSM 5: T 00 Borderline
Personality Disorder- now Degree
A. Significant impairments in personality functioning manifest
by: 1. Impairments in self functioning (a or b): a. Identity:
Markedly impoverished, poorly developed, or unstable self-image,
often associated with excessive self-criticism; chronic feelings of
emptiness; dissociative states under stress. b. Self-direction:
Instability in goals, aspirations, values, or career plans.AND2.
Impairments in interpersonal functioning (a or b): a. Empathy b.
IntimacyB. Pathological personality traits in the following
domains: 1. Negative Affectivity, characterized by: a. Emotional
lability b. Anxiousness c. Separation insecurity d. Depressivity 2.
Disinhibition, characterized by: a. Impulsivity b. Risk taking3.
Antagonism, characterized by: a. Hostility
DSM 5 PERSONALITY TRAIT RATING FORM If not one of 6 types, then
is PD-Trait Specified present? If so, record PDTS, identify and
list the trait domain(s) that are applicable, and record the
severity of impairment.
If a PD is present and a detailed personality profile is desired
and would be helpful in the case conceptualization, evaluate the
trait facets.
DSM-5 CLINICIANS PERSONALITY TRAIT RATING FORM Depending on the
role of personality in patients clinical pictures, you may rate
their traits in one of three ways: (1) just the five broad trait
domains for a personality overview, (2) all trait facets for a
comprehensive personality profile, or (3) the five trait domains,
followed by the component trait facets comprising each of those
domains for which the characteristics describe the patient with
degree of fit:0=Very little, 1= Mildly, 2= Moderately, 3=
Extremely
Please rate patients usual personality, what they are like most
of the time.
Rate the five trait domains and the specific trait facets
comprising the domains 0=Very little, 1= Mildly, 2= Moderately, 3=
ExtremelyNegative Affectivity Detachment Antagonism Disinhibition
Psychoticism
Rate the twenty-five specific trait facets comprising the five
domains Negative AffectivityEmotional lability Anxiousness
Separation insecurity Perseveration Submissiveness Hostility
Depressivity Suspiciousness
Detachment Restricted affectivityWithdrawal Anhedonia Intimacy
avoidance
Antagonism Manipulativeness Deceitfulness Grandiosity Attention
seeking Callousness
Disinhibition Irresponsibility Impulsivity Distractibility Risk
taking (lack of) Rigid perfectionism
Psychoticism Unusual beliefs and experiences Eccentricity
Cognitive and Perceptual dysregulation
The only two non-US members of the DSM-5 Personality Disorders
Work group (Roel Verheul and John Livesley) resigned in April
2012:
First, the proposed classification is unnecessarily complex,
incoherent, and inconsistent. Second, the proposal displays a truly
stunning disregard for evidence. The current proposal represents
the worst possible outcome: it displays almost total discontinuity
with DSM-IV while failing to improve validity and clinical utility
of the classification.
54The International Classification of DiseasesThe ICD is
currently the most widely used statistical classification system
for diseases in the world.This is in fact the official diagnostic
system for mental disorders in the US.The ICD-10, was developed in
1992. ICD-11 is planned for 2015.
ICD is Required by HIPPAThe deadline for the United States to
begin using Clinical Modification ICD-10-Clinical Modification (CM)
is currently October 1, 2014. The deadline was previously October
1, 2011, then October 1, 2013.ICD vs DSM-IV A survey of 205
psychiatrists, from 66 different countries across all continents,
found that ICD-10 was more frequently used and more valued in
clinical practice and training. The DSM-IV was more valued for
research, but less clear to mental health professionals, policy
makers, patients and families. (Mezzich JE., 2002). Neurosis and
Psychosis in ICD 10
The traditional division between neurosis and psychosis has not
been used in ICD-10. However, the term "neurotic" is still used for
instance, in "Neurotic, stress-related and somatoform disorders".
"Psychotic" has been retained as a convenient descriptive term, as
in Acute and transient psychotic disorders. The use of neurotic or
psychotic does not involve assumptions about psychodynamic
mechanisms.
ICD-10 mental and behavioural disorders and consists of 10 main
groups:
F0: Organic, including symptomatic, mental disorders F1: Mental
and behavioural disorders due to use of psychoactive substances F2:
Schizophrenia, schizotypal and delusional disorders F3: Mood
[affective] disorders F4: Neurotic, stress-related and somatoform
disorders F5: Behavioural syndromes associated with physiological
disturbances and physical factors F6: Disorders of personality and
behaviour in adult persons F7: Mental retardation F8: Disorders of
psychological development F9: Behavioural and emotional disorders
with onset usually occurring in childhood and adolescence In
addition, a group of "unspecified mental disorders".
ICD 10 Disorders of adult personality and behavior
F60 Specific personality disorders F60.0 Paranoid personality
disorder F60.1 Schizoid personality disorder F60.2 Dissocial
personality disorder F60.3 Emotionally unstable personality
disorder .30 Impulsive type .31 Borderline type F60.4 Histrionic
personality disorder F60.5 Anankastic personality disorder (i.e.
OCPD)F60.6 Anxious [avoidant] personality disorder F60.7 Dependent
personality disorder F60.8 Other specific personality disorders
F60.9 Personality disorder, unspecified
F61 Mixed and other personality disorders F61.0 Mixed
personality disorders F61.1 Troublesome personality changes F60.2
Dissocial personality disorder
(a) callous unconcern for the feelings of others;(b) gross and
persistent attitude of irresponsibility and disregard for social
norms, rules and obligations;(c) incapacity to maintain enduring
relationships, though having no difficulty in establishing them;(d)
very low tolerance to frustration and a low threshold for discharge
of aggression, including violence;(e) incapacity to experience
guilt or to profit from experience, particularly punishment;(f)
marked proneness to blame others, or to offer plausible
rationalizations, for the behavior that has brought the patient
into conflict with society. There may also be persistent
irritability as an associated feature. Conduct disorder during
childhood and adolescence, may support the diagnosis. Includes:
amoral, antisocial, asocial, psychopathic, and sociopathic
personality (disorder) Excludes: conduct disorders, emotionally
unstable personality disorder.
ICD 10 and Borderline
After initial hesitation, a brief description of borderline
personality disorder (F60.31) was finally included as a subcategory
of emotionally unstable personality disorder (F60.3), again in the
hope of stimulating investigations.
F60.3 Emotionally unstable personality disorder marked tendency
to act impulsively without consideration of the consequences,
together with affective instability. The ability to plan ahead may
be minimal, and outbursts of intense anger may often lead to
violence or "behavioral explosions"; F60.30 Impulsive typeemotional
instability and lack of impulse control, Outbursts of violence or
threatening behavior are common, particularly in response to
criticism by others. Includes: explosive and aggressive personality
(disorder) Excludes: dissocial personality disorder (F60.2) F60.31
Borderline typethe patient's own self-image, aims, and internal
preferences (including sexual) are often unclear or disturbed.
There are usually chronic feelings of emptiness; intense and
unstable relationships may cause repeated emotional crises and may
be associated with excessive efforts to avoid abandonment and a
series of suicidal threats or acts of self-harm (although these may
occur without obvious precipitants). Includes: borderline
personality (disorder) ICD-11 Survey OverviewDeveloped for
psychologists by WHO and International Union of Psychological
Sciences (IUPsyS)Parallel to survey conducted by WHO and World
Psychiatric Association (WPA) of 4887 psychiatrists in 44
countries2155 global psychologists participatedRecruited through 23
IUPsyS member national psychological associations in 23 countries
10 low and middle-income countriesAdministered in 5 languages
(English, Spanish, French, German, Turkish)Dr. Geoffrey M. Reed
World Health Organization2 September 2010WPA International
Congress64ICD-11 2015ICD-11 will draw on research about how
clinicians conceptualize mental disorders in hopes of creating a
more intuitive and psychological classification system.ICD-11 will
be available for free on the Internet.A study of nearly 5,000
psychiatrists in 44 countries sponsored by WHO, more than 70
percent of the world's psychiatrists use ICD while just 23 percent
turn to the DSM. The same pattern is found among psychologists
globally.
Psychologists Role in Making Diagnoses% ParticipantsPurpose of
Classification% Participants2 September 2010WPA International
CongressDr. Geoffrey M. Reed World Health Organization67Number
ofCategories Desired% Participants2 September 2010WPA International
CongressDr. Geoffrey M. Reed World Health Organization68Strict
Criteria vs.Flexible Guidance% Participants2 September 2010WPA
International CongressDr. Geoffrey M. Reed World Health
Organization69A Dimensional Component% ParticipantsICD-10 and
DSM-IV Categories Used Most Often (Why they couldnt get rid of
Borderline)ICD-10%DSM-IV% Depressive Episode71% Major Depressive
Disorder60% Generalized Anxiety Disorder48% Generalized Anxiety
Disorder59% Social Phobia46% Post-Traumatic Stress Disorder42%
Mixed Anxiety and Depressive Disorder44% Adjustment Disorders41%
Recurrent Depressive Disorder44% Attention-Deficit/Hyperactivity
Disorder38% Post-Traumatic Stress Disorder42% Obsessive-Compulsive
Disorder37% Borderline Personality Disorder 42% Social Phobia37%
Adjustment Disorder42% Borderline Personality Disorder34% Specific
(Isolated) Phobias41% Single Major Depressive Episode34%
Hyperkinetic (Attention Deficit) Disorder34% Panic Disorder without
Agoraphobia32% Obsessive-Compulsive Disorder34% Bipolar I
Disorder27% Bipolar Affective Disorder28% Alcohol-Related
Disorders26%A diagnostic framework that attempts to characterize
the whole person--the depth as well as the surface of emotional,
cognitive, and social functioning; from healthy to disturbed in a
mixed categorical -dimensional system
Psychodynamic Theory as a Complex Adaptive System-temperament,
affects, cognitions, development, traumas, defenses, fantasies,
attachments all interacting at various levels of consciousness.
73Kernbergs (1976, 1984) Differentiation of Personality
Organization Neurotic Borderline PsychoticIdentity + -
-Integration
Defensive + - -Operations
Reality + +/- -TestingGordon and Stoffey recent research
supports that these factors contribute most to personality
organization.
74How can we conceptualize borderline more accurately? Kernbergs
Levels of Personality Organization1- Normal flexibility and
adaptation2- Neurotic level of personality organization3-
Borderline level of personality organization: High level borderline
Low level borderline4- Psychotic level of personality
7575Borderline Personality OrganizationBasic Characteristics-
KernbergIdentity Diffusion No integrated concept of selfNo
integrated concept of significant others
Primitive Defenses Splitting Idealization/devaluation Projective
identification Omnipotent control Denial Variable Reality
Testing
7676PDM System The PDM uses a multi dimensional approach to
describe the intricacies of the patient's overall functioning and
ways of engaging in the therapeutic process. It begins with a
classification of the spectrum of personality patterns and
disorders, then offers a "profile of mental functioning" covering
in more detail the patient's capacities, and finally considers
symptom patterns, with emphasis on the patient's subjective
experience.The Psychodynamic Diagnostic ManualOver-all level of
personality organization (Healthy, Neurotic or
Borderline)Personality patterns and disorders (Temperament,
conflicts, affects, cognitions and defensives)Specific capacities
of mental functioning (learning, relationships, self regard,
affective experience, internal representations, differentiation and
integration, psychological mindedness, a sense of morality)The
subjective experience of symptoms78Dimension I: Personality
Patterns and Disorders The PDM classification of personality
patterns has been placed first in the PDM system because of the
accumulating evidence that symptoms or problems cannot be
understood, assessed, or treated in the absence of an understanding
of the mental life of the person who has the symptoms. Dimension
II: Mental Functioning The second PDM dimension offers a more
detailed description of emotional functioning-the capacities that
contribute to an individual's personality and overall level of
psychological health or pathology. Dimension III: Manifest Symptoms
and Concerns Dimension III presents symptom patterns in terms of
the patient's personal experience of his or her prevailing
difficulties. The patient may evidence a few or many patterns,
which may or may not be related, and which should be seen in the
context of the person's personality and mental functioning. Types
of Personality DisordersP101. Schizoid Personality DisordersP102.
Paranoid Personality Disorders
P103. Psychopathic (Antisocial) Personality DisordersP103.1
Passive/Parasitic P103.2 Aggressive
P104. Narcissistic Personality DisordersP104.1
Arrogant/EntitledP104.2 Depressed/Depleted
P105. Sadistic and Sadomasochistic Personality DisordersP105.1
Intermediate Manifestation: Sadomasochistic Personality
Disorders
P106. Masochistic (Self-Defeating) Personality DisordersP106.1
Moral MasochisticP106.2 Relational Masochistic
P107. Depressive Personality DisordersP107.1 IntrojectiveP107.2
Anaclitic P107.3 Converse Manifestation: Hypomanic Personality
Disorder
P108. Somatizing Personality Disorders
P109. Dependent Personality DisordersP109.1 Passive-Aggressive
Versions of Dependent Personality DisordersP109.2 Converse
Manifestation: Counterdependent Personality Disorders
P110. Phobic (Avoidant) Personality DisordersP110.1 Converse
Manifestation: Counterphobic Personality Disorders
P111. Anxious Personality Disorders P112. Obsessive-Compulsive
Personality DisordersP112.1 ObsessiveP112.2 Compulsive
P113. Hysterical (Histrionic) Personality DisordersP113.1
InhibitedP113.2 Demonstrative or Flamboyant
P114. Dissociative Personality Disorders (Dissociative Identity
Disorder/Multiple Personality Disorder)
P115. Mixed/Other
The P Axis- Personality Disorders Considers the Following
Factors:
Temperamental, Thematic, Affective, Cognitive, and Defense
patterns 86Psychopathic, Sociopathic, Antisocial or Dissocial?The
DSM-IV-TR states that psychopathy and sociopathy are obsolete
synonyms for Antisocial Personality Disorder.
The World Health Organization stance in its ICD-10 refers to
psychopathy, sociopathy, antisocial personality, asocial
personality, and amoral personality as synonyms for Dissocial
Personality Disorder.
The PDM uses Psychopathic to relate to the personality not just
symptoms, and considers all the terms as basically
interchangeable.
8787Psychopathy and Narcissism Otto Kernberg (2004) believed
psychopathy should fall under a spectrum of pathological
narcissism, that ranged from narcissistic personality on the low
end, malignant narcissism in the middle, and psychopathy at the
high end.
8888P103. Psychopathic (Antisocial) Personality Disorder P103.1
Passive/Parasitic P103.2 AggressiveContributing
constitutional-maturational patterns: aggressiveness, high
threshold for emotional stimulation
Central tension/preoccupation: Manipulating/being
manipulated
Central affects: Rage, envy
Characteristic pathogenic belief about self: I can make anything
happen
Characteristic pathogenic belief about others: Everyone is
selfish, manipulative, dishonest
Central ways of defending: Reaching for omnipotent control
8989Aggressive SubtypeExplosiveActively predatoryOften
violent
9090Passive/Parasitic SubtypeMore dependentLess aggressive,
usually non-violentManipulatorCon artist
9191Psychopathic P.D. (PDM)Not all psychopaths are antisocial.
Many are successful and social in certain roles (intelligence, law
enforcement, attorney, clergy, etc.)Want power for its own
sakePleasure in exploiting and duping othersGood at reading the
emotions of others, but not their ownLacking a moral center of
gravityLose interest in people once no longer useful to themLack of
remorseNeed high external stimulationOrganized mainly at the
borderline level, and often combines with other personality
disorders or patterns (Paranoid, Sadistic, Narcissistic, etc.)
92Robert Hare, Ph.D. author of Snakes in Suits: When Psychopaths
Go to Work found that psychopathic traits are common to many
CEOs.
He describes psychopaths as Intraspecies predators
93Why the Psychopath is a risk in treatmentThey are very hard to
detect.They are con artists. They are experts at sizing you up and
exploiting your issues.They can be charming one moment, and
dangerous the next.They can seduce you and then destroy your
career.They will make false claims against you for the money.
94What to do?Be aware of the diagnosis- Learn the PDM!Keep
strict boundaries and ground rules,Use frequent clarifications of
roles and rules of therapy, Use confrontations to help with impulse
containment, Take protective notes,Get a consult,If you are
frightened or uncomfortable, you do not have to treat the patient.
Refer to a more appropriate facility.
95Profile of Mental Functioning - M Axis
Capacity for Regulation, Attention, and Learning
Capacity for Relationships (Including Depth, Range, and
Consistency)
Quality of Internal Experience (Level of Confidence and
Self-Regard)
Affective Experience, Expression, and Communication
Defensive Patterns and Capacities
Capacity to Form Internal Representations
Capacity for Differentiation and Integration
Self-Observing Capacities (Psychological-Mindedness)
Capacity for Internal Standards and Ideals: A Sense of Morality
Summary of Basic Mental Functioning Scale M201. Optimal Age- and
Phase-Appropriate Mental CapacitiesM202. Reasonable Age- and
Phase-Appropriate Mental CapacitiesM203. Age- and Phase-Appropriate
Capacities M204. Mild Constrictions and InflexibilityM204.1
Encapsulated character formationsM204.2 Encapsulated symptom
formationsM205. Moderate Constrictions and Alterations in Mental
FunctioningM206. Major Constrictions and Alterations in Mental
FunctioningM207. Defects in Integration and Organization and/or
Differentiation of Self- and Object RepresentationsM208. Major
Defects in Basic Mental Functions Psychodiagnostic Chart (PDC)An
Integration of the Psychodynamic Diagnostic Manual (PDM), ICD and
DSM
Robert M. Gordon and Robert F. BornsteinGoal of the PDC To offer
a person-based nosology by integrating the PDM, ICD and DSM; this
integrated nosology may be used for: better diagnoses, treatment
formulations, progress reports, outcome assessment, research on
personality and psychopathology. USE Our overarching aim is to make
psychodiagnoses more useful to the practitioner by combining the
symptom-focused ICD or DSM with the full range and depth of human
mental functioning addressed by the PDM.
How to Use The clinician must perform (or have access to)
diagnostic interview data and psychological assessment data to
derive optimal ratings. We recognize that this is not always
feasible, and in many instances the clinician will code an initial
impression, then re-assess as additional information accrues. If
this is used for progress notes, there will be opportunities to
re-assess and revise the persons diagnosis as well. The validity of
this chart can be enhanced with the integration of relevant
psychological tests.
Scoring For consistency and ease of scoring, all dimensional
ratings go from most disturbed (1) to healthy (10). We advise
against using ratings of 10 except in unusual circumstances.
Psychodiagnostic Chart1. PERSONALITY STRUCTURELEVEL OF
PERSONALITY STRUCTUREWe start with the overall personality
structure or severity, ranging from psychotic to healthy. The PDM
uses seven mental capacities to assess level of severity. Three
steps are involved:Rate each capacity using the 1-10 scale. Review
the definitions of personality structure (healthy, neurotic,
borderline and psychotic)Indicate the overall level of personality
structure. For example, a 3 would be a low functioning borderline
structure; an 8 would be a high functioning neurotic structure.
1. Level of Personality Structure
Please rate each capacity from 1 to 10; ratings range from Most
Disturbed (1) to Most Healthy (10).1. Identity: ability to view
self in complex, stable, and accurate ways 2. Object Relations:
ability to maintain intimate, stable, and satisfying relationships
3. Affect Tolerance: ability to experience the full range of
age-expected affects
4. Affect Regulation: ability to regulate impulses and affects
with flexibility in using defenses or coping strategies
5. Superego Integration: ability to use a consistent and mature
moral sensibility 6. Reality Testing: ability to appreciate
conventional notions of what is realistic 7. Ego Resilience:
ability to respond to stress resourcefully and to recover from
painful events without undue difficulty
1. Level of Personality Structure- RatingHealthy Personality-
characterized by 9-10 scores, life problems never get out of hand
and enough flexibility to accommodate to challenging realities.
Neurotic Level- characterized by mainly 6-8 scores, rigidity and
limited range of defenses and coping mechanisms, basically a good
sense of identity, healthy intimacies, good reality testing, fair
resiliency, fair affect tolerance and regulation, favors
repression.
Borderline Level- characterized by mainly 3-5 scores, recurrent
relational problems, difficulty with affect tolerance and
regulation, poor impulse control, poor sense of identity, poor
resiliency, favors primitive defenses such as denial, splitting and
projective identification.
Psychotic Level- characterized by mainly 1-2 scores, delusional
thinking, sometimes hallucinations, poor reality testing and mood
regulation, extreme difficulty functioning in work and
relationships.Overall Personality StructureBased on the 7 ratings
above, rate persons overall personality structure from 1
(Psychotic) to 10 (Healthy)
2. Dominant Personality Patterns or Disorders
These are relatively stable ways of thinking, feeling, behaving
and relating to others. Normal level temperaments and traits (e.g.,
extroversion) do not involve impairment, while personality
disorders involve impairment at the neurotic, borderline, or severe
(psychotic) level. You may substitute ICD or DSM personality
disorders for those of the PDM. If the person does not have a
personality disorder, but a maladaptive trait or personality style,
then rate the trait or style as mild (e.g., obsessional traits-8).
Check off as many as apply.
2. Personality Patterns or Disorders- Scoring Review the P axis
in the PDM for the personality patterns most descriptive of your
client (or use the PDP, SWAP, OPD, etc.). Begin by checking off as
many descriptors that apply. Then decide on the most dominant
personality patterns or disorders, and the level of severity
(1-10).
PDM Categories:SchizoidParanoidPsychopathic (antisocial);
Subtypes - passive/parasitic or aggressiveNarcissistic; Subtypes -
arrogant/entitled or depressed/depleted;Sadistic (and intermediate
manifestation, sadomasochistic)Masochistic (self-defeating);
Subtypes - moral masochistic or relational masochisticDepressive;
Subtypes - introjective or anaclitic; Converse manifestation -
hypomanicSomatizingDependent (and passive-aggressive versions of
dependent); Converse manifestation - counterdependentPhobic
(avoidant); Converse manifestation -
counterphobicAnxiousObsessive-compulsive; Subtypes - obsessive or
compulsiveHysterical (histrionic); Subtypes - inhibited or
demonstrative/ flamboyantDissociativeMixed/other Rate: Dominate
Personality Disorder or Maladaptive Traits & Overall Severity
of Impairment
3. MENTAL FUNCTIONING
Rate (1-10) the 9 different mental capacities according to the
level of maturation or functioning.
3. Mental Functioning
1. Capacity for Attention, Memory, Learning, and Intelligence 2.
Capacity for Relationships and Intimacy (including depth, range,
and consistency) 3. Quality of Internal Experience (level of
confidence and self-regard) 4. Affective Comprehension, Expression,
and Communication 5. Level of Defensive or Coping Patterns 1-2:
Psychotic level (e.g., delusional projection, psychotic denial,
psychotic distortion) 3-5: Borderline level (e.g., splitting,
projective identification, idealization/devaluation, denial, acting
out) 6-8: Neurotic level (e.g., repression, reaction formation,
rationalization, displacement, undoing) 9-10: Healthy level (e.g.,
anticipation, sublimation, altruism, and humor)6. Capacity to Form
Internal Representations (sense of self and others are realistic
and guiding)7. Capacity for Differentiation and Integration (self,
others, time, internal experiences and external reality are all
well distinguished) 8. Self-Observing Capacity (psychological
mindedness) 9. Realistic sense of Morality
4. ICD, DSM or PDM SYMPTOMS
Symptoms are considered in the context of: 1. level of
personality structure, 2. personality pattern or disorder 3. mental
functioning.
Here you may use the symptoms that may be the focus of the chief
complaint and necessary for third party reimbursement. However, you
treat the person, not just the symptoms. 5. Cultural, Contextual,
and Other Relevant Considerations This is a qualitative section
where the practitioner may write how cultural or contextual factors
contribute to symptoms, better explain symptoms and/or degree of
suffering. Importance of a Psychodynamic Understanding of
PersonalityThe PDM was introduced to 192 psychologists in a several
ethics and MMPI-2 workshops(65 Psychodynamic, 76 CBT and 51
Other)Over all the psychologists gave the PDM a 90% favorable
rating.
Gordon, R.M. (2009). Reactions to the Psychodynamic Diagnostic
Manual (PDM) by Psychodynamic, CBT and Other Non- Psychodynamic
Psychologists. Issues in Psychoanalytic Psychology, 31,1,
55-62.
114What Do Practitioners Want in a Diagnostic Taxonomy?
Comparing the PDM with DSM and ICDFifty practitioners have taken
the survey to date, with 80% of respondents having doctorates and
20% masters degrees; 54% were women. Half of the respondents
identified themselves as Psychodynamic (50%); the rest were
Eclectic (22%), Cognitive-Behavioral (12%), Humanistic/Existential
(10%), Systems (4%), and Other (2%).
(Bornstein, R.F. and Gordon, R.M. 2012, in press, What Do
Practitioners Want in a Diagnostic Taxonomy? Comparing the PDM with
DSM and ICD. Division Review: A Quarterly Psychoanalytic Forum)
68% rated PDM Personality Structure as helpful-very helpful.58%
rated PDM Mental Functioning as helpful-very helpful.44% rated PDM
Dominant Personality Patterns or Disorders as helpful-very
helpful.18% rated DSM GAF scores as helpful-very helpful.14% rated
ICD or DSM symptoms as helpful-very helpful.Finally, Use the ICD
and integrate it with the PDMFor better risk managementFor more
empathy and better treatment formulationFor insurance
requirements
Thank you. GAF From 11/27/00 to 3/28/05
WhenDateGAF (current)WhenDateGAF (current)
Before11/27/0050After3/18/0355
Before4/3/0140After4/17/0365
Before4/23/0150After5/5/0360
Before5/23/0160After6/5/0360
Before8/22/0160After7/8/0365
Before10/17/0160After8/5/0362.5
Before11/27/0160After8/10/0365
Before1/23/0265After8/21/0360
Before4/30/0250After10/2/0360
Before6/4/0235After10/8/0365
Before6/10/0260After10/30/0360
Before7/5/0260After11/25/0360
Before9/5/0260After12/24/0360
Before12/16/0265After1/20/0460
Before2/24/0330After2/18/0455
BeforeAverage:53.67After3/31/0457.5
St. dev.:10.93After4/28/0455
After6/30/0455
After3/28/0555
Average:59.74
St. dev.:3.62
When looking at patients DSM Axis V GAF scores over a period of
about 4.5 years, while seeing Dr. Y (before termination) and after,
we see no injury. In fact, she becomes more stable and improved
over time. PAGE 3
General Criteria for a Personality Disorder General Criteria for
a Personality Disorder
DSM-IV DSM-5 Criteria - Revised June 2011
1. An enduring pattern of inner experience and behavior the
deviates markedly from the expectations of the individual's
culture. This pattern is manifested in two (or more) of the
following areas: 1. Cognition (i.e., ways of perceiving and
interpreting self, other people and events) 2. Affectivity (i.e.,
the range, intensity, liability, and appropriateness of emotional
response) 3. Interpersonal functioning 4. Impulse control 2. The
enduring pattern is inflexible and pervasive across a broad range
of personal and social situations. 3. The enduring pattern leads to
clinically significant distress or impairment in social,
occupational, or other important areas of functioning. 4. The
pattern is stable and of long duration, and its onset can be traced
back at least to adolescence or early adulthood. 5. The enduring
pattern is not better accounted for as a manifestation or
consequence of another mental disorder. 6. The enduring pattern is
not due to the direct physiological effects of a substance (e.g., a
drug abuse, a medication) or a general medical condition (e.g.,
head trauma). The essential features of a personality disorder are
impairments in personality (self and interpersonal) functioning and
the presence of pathological personality traits. To diagnose a
personality disorder, the following criteria must be met: 1.
Significant impairments in self (identity or self-direction) and
interpersonal (empathy or intimacy) functioning. 2. One or more
pathological personality trait domains or trait facets. 3. The
impairments in personality functioning and the individuals
personality trait expression are relatively stable across time and
consistent across situations. 4. The impairments in personality
functioning and the individuals personality trait expression are
not better understood as normative for the individuals
developmental stage or socio- cultural environment. 5. The
impairments in personality functioning and the individuals
personality trait expression are not solely due to the direct
physiological effects of a substance (e.g., a drug of abuse,
medication) or a general medical condition (e.g., severe head
trauma).
SELF INTERPERSONAL
LevelIdentitySelf-DirectionEmpathyIntimacy
0-Ongoing awareness of a unique self; maintains role-appropriate
boundaries. -Consistent and self-regulated positive self-esteem,
with accurate self-appraisal. -Capable of experiencing, tolerating
and regulating a full range of emotions.-Sets and aspires to
reasonable goals based on a realistic assessment of personal
capacities.-Utilizes appropriate standards of behavior, attaining
fulfillment in multiple realms. -Can reflect on, and make
constructive meaning of, internal experience.-Capable of accurately
understanding others experiences and motivations in most
situations. -Comprehends and appreciates others perspectives, even
if disagreeing. -Is aware of the effect of own actions on
others.-Maintains multiple satisfying and enduring relationships in
personal and community life. -Desires and engages in a number of
caring, close and reciprocal relationships.-Strives for cooperation
and mutual benefit and flexibly responds to a range of others
ideas, emotions and behaviors.
SELF INTERPERSONAL
LevelIdentitySelf-DirectionEmpathyIntimacy
1-Relatively intact sense of self, with some decrease in clarity
of boundaries when strong emotions and mental distress are
experienced.-Self-esteem diminished at times, with overly critical
or somewhat distorted self-appraisal.-Strong emotions may be
distressing, associated with a restriction in range of emotional
experience.-Excessively goal-directed, somewhat goal-inhibited, or
conflicted about goals. -May have an unrealistic or socially
inappropriate set of personal standards, limiting some aspects of
fulfillment. -Able to reflect upon internal experiences, but may
overemphasize a single (e.g., intellectual, emotional) type of
self-knowledge.-Somewhat compromised in ability to appreciate and
understand others experiences; may tend to see others as having
unreasonable expectations or a wish for control.-Although capable
of considering and understanding different perspectives, resists
doing so.-Inconsistent is awareness of effect of own behavior on
others.-Able to establish enduring relationships in personal and
community life, with some limitations on degree of depth and
satisfaction.-Capacity and desire to form intimate and reciprocal
relationships, but may be inhibited in meaningful expression and
sometimes constrained if intense emotions or conflicts arise.
-Cooperation may be inhibited by unrealistic standards; somewhat
limited in ability to respect or respond to others ideas, emotions
and behaviors.
SELF INTERPERSONAL
LevelIdentitySelf-DirectionEmpathyIntimacy
2-Excessive dependence on others for identity definition, with
compromised boundary delineation. -Vulnerable self-esteem
controlled by exaggerated concern about external evaluation, with a
wish for approval. Sense of incompleteness or inferiority, with
compensatory inflated, or deflated, self-appraisal. -Emotional
regulation depends on positive external appraisal. Threats to
self-esteem may engender strong emotions such as rage or
shame.-Goals are more often a means of gaining external approval
than self-generated, and thus may lack coherence and/or stability.
-Personal standards may be unreasonably high (e.g., a need to be
special or please others) or low (e.g., not consonant with
prevailing social values). Fulfillment is compromised by a sense of
lack of authenticity. -Impaired capacity to reflect upon internal
experience. -Hyper-attuned to the experience of others, but only
with respect to perceived relevance to self. -Excessively
self-referential; significantly compromised ability to appreciate
and understand others experiences and to consider alternative
perspectives.-Generally unaware of or unconcerned about effect of
own behavior on others, or unrealistic appraisal of own
effect.-Capacity and desire to form relationships in personal and
community life, but connections may be largely superficial.
-Intimate relationships are largely based on meeting
self-regulatory and self-esteem needs, with an unrealistic
expectation of being perfectly understood by others. -Tends not to
view relationships in reciprocal terms, and cooperates
predominantly for personal gain.
SELF INTERPERSONAL
LevelIdentitySelf-DirectionEmpathyIntimacy
3-A weak sense of autonomy/agency; experience of a lack of
identity, or emptiness. Boundary definition is poor or rigid: may
be over identification with others, overemphasis on independence
from others, or vacillation between these. -Fragile self-esteem is
easily influenced by events, and self-image lacks coherence.
Self-appraisal is un-nuanced: self-loathing, self-aggrandizing, or
an illogical, unrealistic combination. -Emotions may be rapidly
shifting or a chronic, unwavering feeling of despair.-Difficulty
establishing and/or achieving personal goals. -Internal standards
for behavior are unclear or contradictory. Life is experienced as
meaningless or dangerous. -Significantly compromised ability to
reflect upon and understand own mental processes. -Ability to
consider and understand the thoughts, feelings and behavior of
other people is significantly limited; may discern very specific
aspects of others experience, particularly vulnerabilities and
suffering. -Generally unable to consider alternative perspectives;
highly threatened by differences of opinion or alternative
viewpoints. -Confusion or unawareness of impact of own actions on
others; often bewildered about peoples thoughts and actions, with
destructive motivations frequently misattributed to others.-Some
desire to form relationships in community and personal life is
present, but capacity for positive and enduring connection is
significantly impaired.-Relationships are based on a strong belief
in the absolute need for the intimate other(s), and/or expectations
of abandonment or abuse. Feelings about intimate involvement with
others alternate between fear/rejection and desperate desire for
connection. -Little mutuality: others are conceptualized primarily
in terms of how they affect the self (negatively or positively);
cooperative efforts are often disrupted due to the perception of
slights from others.
SELF INTERPERSONAL
LevelIdentitySelf-DirectionEmpathyIntimacy
4-Experience of a unique self and sense of agency/autonomy are
virtually absent, or are organized around perceived external
persecution. Boundaries with others are confused or lacking. -Weak
or distorted self-image easily threatened by interactions with
others; significant distortions and confusion around
self-appraisal. -Emotions not congruent with context or internal
experience. Hatred and aggression may be dominant affects, although
they may be disavowed and attributed to others. -Poor
differentiation of thoughts from actions, so goal-setting ability
is severely compromised, with unrealistic or incoherent goals.
-Internal standards for behavior are virtually lacking. Genuine
fulfillment is virtually inconceivable. -Profound inability to
constructively reflect upon own experience. Personal motivations
may be unrecognized and/or experienced as external to
self.-Pronounced inability to consider and understand others
experience and motivation. -Attention to others' perspectives
virtually absent (attention is hypervigilant, focused on
need-fulfillment and harm avoidance). -Social interactions can be
confusing and disorienting.-Desire for affiliation is limited
because of profound disinterest or expectation of harm. Engagement
with others is detached, disorganized or consistently negative.
-Relationships are conceptualized almost exclusively in terms of
their ability to provide comfort or inflict pain and suffering.
-Social/interpersonal behavior is not reciprocal; rather, it seeks
fulfillment of basic needs or escape from pain.
2010 American Psychiatric Association. All Rights Reserved. See
Terms & Conditions of Use for more information
Provisional map of specific core criteria (facet traits) into
personality trait domains Personality Domains
I. Negative Affectivity II. Detachment III. Antagonism IV.
Disinhibition V. Psychoticism
Core criteria (facet traits) 1. Emotional Lability X 2.
Anxiousness X 3. Separation Insecurity X 4. Perseveration X 5.
Submissiveness X 6. Hostility X X 7. Restricted Affectivity (- X) X
8. Depressivity X X 9. Suspiciousness X X 10. Withdrawal X 11.
Anhedonia X 12. Intimacy Avoidance X 13. Manipulativeness X 14.
Deceitfulness X 15. Grandiosity X 16. Attention Seeking X 17.
Callousness X 18. Irresponsibility X 19. Impulsivity X 20. Rigid
Perfectionism (- X) 21. Distractibility X 22. Risk Taking X 23.
Unusual Beliefs & Experiences X 24. Eccentricity X 25.
Cognitive and Perceptual Dysregulation X Note. X means that this
core criterion is one way in which a broad personality domain is
manifested in specific persons, and provisional data suggest the
specific connections seen above. Sometimes, core criteria are
connected with more than one domain, and this is indicated when
more than one X appears in a given row. (-X) means that the absence
of the core criterion is indicative of a specific personality
domain.