Professional Documents
Culture Documents
,
& Alan C. Tjeltveit, Ph.D.
1
Educational Objectives:
Learn about the ethical issues involved with making
and using a diagnosis, learn about the DSM-5, ICD-10
and PDM, and learn how to integrate these systems.
Goals:
Understand the ethical and risk issues involved in not
diagnosing accurately, identify the ethical issues
associated with how we (and others) use diagnoses,
and learn the difference between diagnosis as a label
of disease as compared to diagnosis as a means to
understand in order to better help.
2
What we will NOT do today
Lecture you about the gross
ethical violations that many of
youthrough ignorance, malice,
or bothroutinely commit and
Agency Narrative
Persons Meaning
The Self Spirituality
Personality Ethics
Relationships ?
Community
Culture
Research Domain Criteria
Some see this as praiseworthy scientific progress
The chair of the Psychiatry Department at Columbia
asserts that psychiatry needs to base its decisions more
on biology, and less on behavior (Herper, 2013)
Some psychologists see RDoC as either biological
reductionism or slanted toward biological causation
Given the current state of the research, the RDoC can
be read primarily as a promissory note, which is backed
up by an ideology which holds that:
1. Psychological problems are medical problems
2. Medical problems are, at root, biological problems
3. Real cures will only come at the root level
NIMH director & the American Psychiatric
Association president-elect, May 14, 2013
Today, the DSM [no number], along with the ICD
represents the best information currently available for
clinical diagnosis of mental disorders. Patients, families, and
insurers can be confident that effective treatments are
available and that the DSM is the key resource for delivering
the best available care. The National Institute of Mental
Health (NIMH) has not changed its position on DSM-5
[which was?]. As NIMH's Research Domain Criteria (RDoC)
project website states, "The diagnostic categories represented
in the DSM-IV [!] and the International Classification of
Diseases-10 (ICD-10, containing virtually identical disorder
codes) remain the contemporary consensus standard for how
mental disorders are diagnosed and treated.
http://www.nimh.nih.gov/news/science-news/2013/dsm-5-and-rdoc-shared-
interests.shtml?utm_source=govdelivery&utm_medium=email&utm_campaign=govdelivery , emendations by Rick Froman
Why does this matter?
Whatever diagnostic system we use
Behavior analytic
ICD: 9, 9-CM, 10, or (beginning in 2015) 11
DSM: IV-TR or 5
RDoC
we face ethical issues regarding diagnosis
The current controversy over the DSM-5 is an
opportunity to reflect deeply on diagnosis in
relationship to professional ethics
Case: Carlos
18-year-old high school junior (getting Cs) in the technical
track of an underfunded under-performing school district
in which 80% of the students are below the poverty line
Came from the Dominican Republic at 10 & mainstreamed
Tested as having an IQ of 69 at 12 (no IEP; unclear why)
Parents are divorced, one older brother is in prison
Has a girl friend (theyre in a band together)
After his best friend was killed in a car accident, he was
deeply depressed for 10 days (full range of symptoms)
Had pre-18 scrapes with the law (weapon & mj possession)
Wants to join the army after high school
What are the ethical issues associated with diagnosing Carlos?
Ethical Principles & Standards
Relevant to Diagnosis
Their intent is to guide and inspire psychologists
toward the very highest ethical ideals of the
profession
Principle A: Beneficence and Nonmaleficence
Psychologists strive to
benefit those with whom they work and
take care to do no harm
How can optimal diagnosis benefit
Better understanding/ Better research
assessment Combats client isolation
Better treatment: (Im not the only one)
what to do Helps connect individuals
how to be (e.g., patient) with others having similar
how to relate
problems (those whove
(relationship style) been there) so they can
receive
Better communication
social support
among professionals and
with clients challenge
How can diagnosis harm?
Diagnosis may
Harm clients
Harm family members and friends
Harm society
Harm may be (& probably usually is) unintentional
Harm may stem from a clients interpretation of the dx
Harm may stem from how others use and interpret
diagnoses
How may diagnosis harm?
Leads to less than optimal, Create unwarranted guilt or
ineffective, or harmful shame
treatment Focus attention away from
Leads to misunderstanding key dimensions of a
persons and their problems persons problems
Labels may stick Convince a person to accept
Stigma as natural (& hence
Damage a persons self- inevitable) what they can,
understanding in fact, change
Make it more difficult or
Decrease client
responsibility/motivation cost more to get health
to change and/or life insurance
How may diagnosis harm?
Result in not being hired
Job loss
Living down to
expectations associated
with a diagnosis
Increased health care costs
Increase expenses to
Clients
Employers
Society
?
Principle B: Fidelity and Responsibility
Psychologists are aware of their professional and
scientific responsibilities to society and to the specific
communities in which they work
Psychologists seek to manage conflicts of interest
that could lead to exploitation or harm
Standard 3. Human Relations
3.06 Conflict of Interest
Psychologists refrain from taking on a professional
role when personal, scientific, professional, legal,
financial or other interests or relationships could
reasonably be expected to (1) impair their objectivity,
competence or effectiveness in performing their
functions as psychologists
Cosgrove L, Krimsky S (2012) A Comparison of DSM-IV and DSM-5 Panel Members' Financial Associations with Industry: A Pernicious
Problem Persists. PLoS Med 9(3): e1001190. doi:10.1371/journal.pmed.1001190
http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001190
Principle C: Integrity
Psychologists seek to promote accuracy,
honesty, and truthfulness in the science,
teaching and practice of psychology
Insurance fraud?
Principle D: Justice
Psychologists recognize that fairness and
justice entitle all persons to access to and
benefit from the contributions of psychology
and to equal quality in the processes,
procedures and services being conducted by
psychologists. Psychologists exercise
reasonable judgment and take precautions to
ensure that their potential biases do not lead
to or condone unjust practices
Principle E: Respect for People's Rights and Dignity
Psychologists are aware that special safeguards may be
necessary to protect the rights and welfare of persons or
communities whose vulnerabilities impair autonomous
decision making
Psychologists are aware of and respect cultural, individual
and role differences, including those based on age, gender,
gender identity, race, ethnicity, culture, national origin,
religion, sexual orientation, disability, language and
socioeconomic status and consider these factors when
working with members of such groups
Psychologists try to eliminate the effect on their work of
biases based on those factors, and they do not knowingly
participate in or condone activities of others based upon
such prejudices
Standard 9. Assessment
9.01 Bases for Assessments
(a) Psychologists base the opinions contained in their
diagnostic statements on information sufficient to
substantiate their findings. (See also Standard 2.04,
Bases for Scientific and Professional Judgments.)
Standard 2. Competence
2.04 Bases for Scientific and Professional Judgments
Psychologists' work is based upon established
scientific and professional knowledge of the discipline
Exercise in Psychodiagnoses
Learn about:
Personality organization
Personality patterns
Strengths and weaknesses
Emergent symptoms
Cultural and Contexual issues
Issues related to ethical and risk issues
Countertransference and boundary issues
Contribute to the science of psychological taxonomy.
Participation is voluntary.
26
What Taxonomic Organization for
Mental and Behavioral Science?
Like a Biological
Like a Periodic Table?
Organization?
27
28
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.
29
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.
30
Why Diagnose?
3. Its value in enabling the therapist to convey empathy.
Once one knows that a depressed patient also has a
borderline rather neurotic level personality structure, the
therapist will not be surprised if during the second year of
treatment she makes a suicide gesture.
Or once a borderline client starts to have hope of real
change, that the borderline client often panics and flirts
with suicide in an effort to protect himself from
traumatic disappointment.
31
Why Diagnose?
4. Its role in reducing the probability that certain
easily frighten people will flee from treatment. It
is helpful for the therapist to communicate to
hypomanic or counter-dependent patients an
understanding of how hard it may be for them to
stay in therapy.
32
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.
33
Risk Factors in Litigious Patients
Borderline Personality Organization
Psychopathic traits
History of acting out
34
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.
35
Which Diagnostic Taxonomy
Should We Use?
DSM5?
ICD-10?
PDM?
36
DSM 5
The DSM 5 May 2013.
Research started in 1999.
The DSM makes the American Psychiatric Association
over $5 million a year, historically adding up to over
$100 million.
37
DSM-5 Moves from Multi-axial
system to a similar ICD 10 System
38
Main DSM 5 Categories
Neurodevelopmental Disorders
Schizophrenia Spectrum and Other Psychotic Disorders
Bipolar and Related Disorders
Depressive Disorders
Anxiety Disorders
Obsessive-Compulsive and Related Disorders
Trauma and Stressor Related Disorders
Dissociative Disorders
Somatic Symptom Disorders
Feeding and Eating Disorders
Elimination Disorders
Sleep-Wake Disorders
Sexual Dysfunctions
Gender Dysphoria
Disruptive, Impulse Control, and Conduct Disorders
Substance Use and Addictive Disorders
Neurocognitive Disorders
Personality Disorders
Paraphilic Disorders
Other Disorders
39
40
Why Will DSM-5 Cost $199 a Copy?
By Allen Frances, M.D. 1/24/13 Huffington Post
DSM-5 has just announced its price -- an incredible $199
First, APA has sunk more than $25 million into DSM-5 and
wants to recoup as much of its investment as it can.
DSM-IV cost one fifth as much -- just $5 million -- of which half
came from external grants.
APA is probably counting on having captive buyers who are
forced to pay its price, however exorbitant it may be.
DSM-5 boycotts are sprouting up all over the place
The codes clinicians need for insurance purposes are available
for free on the internet
DSM-5 is so clunkily written, no teacher will ever want to assign
it to students
People are not likely to rush out to buy a ridiculously expensive
DSM-5 that has already been discredited as unsafe and
scientifically unsound.
41
DSM 5 Is Guide Not BibleIgnore Its Ten Worst
Changes
By Allen J. Frances, M.D. Psychology Today Dec 2 2012
42
Fortunately, some of its most egregiously risky and
unsupportable proposals were eventually dropped
under great external pressure (most notably
'psychosis risk', mixed anxiety/depression, internet
and sex addiction, rape as a mental disorder,
'hebephilia', cumbersome personality ratings, and
sharply lowered thresholds for many existing
disorders).
43
1) Disruptive Mood Dysregulation Disorder will turn
temper tantrums into a mental disorder.
2) Normal grief will become Major Depressive Disorder.
3) The everyday forgetting characteristic of old age will
now be misdiagnosed as Minor Neurocognitive
Disorder.
4) DSM 5 will likely trigger a fad of Adult Attention
Deficit Disorder leading to widespread misuse of
stimulant drugs for performance enhancement and
recreation and contributing to the already large illegal
secondary market in diverted prescription drugs.
5) Excessive eating 12 times in 3 months is no longer just a
manifestation of gluttony but it is a psychiatric illness
called Binge Eating Disorder.
44
6) The changes in the DSM 5 definition of Autism will
result in lowered rates- perhaps by 50% according to
outside research groups.
7) First time substance abusers will be lumped in
definitionally in with hard core addicts despite their
very different treatment needs and prognosis and the
stigma this will cause.
8) Behavioral Addictions that eventually can spread to
make a mental disorder of everything we like to do a
lot. Watch out for careless overdiagnosis of internet
and sex addiction and the development of lucrative
treatment programs to exploit these new markets.
9) DSM 5 obscures the already fuzzy boundary been
Generalized Anxiety Disorder and the worries of
everyday life.
10) DSM 5 has opened the gate even further to the already
existing problem of misdiagnosis of PTSD in forensic
settings. 45
Neurodevelopmental Disorders
Intellectual Disability (Intellectual Developmental
Disorder)
Diagnostic criteria for intellectual disability
(intellectual developmental disorder) emphasize the
need for an assessment of both cognitive capacity (IQ)
and adaptive functioning.
Severity is determined by adaptive functioning rather
than IQ score. Moreover, a federal statue in the United
States (Public Law 111-256, Rosas Law) replaces the
term mental retardation with intellectual disability.
The term intellectual developmental disorder was
placed in parentheses to reflect the ICD-11 to be
released in 2015). 46
Intellectual Disability (Intellectual
Developmental Disorder)
DSM-IV criteria had required an IQ score of 70 as the
cutoff for diagnosis; the new criteria recommend IQ
testing and describe deficits in adaptive functioning
that result in failure to meet developmental and
sociocultural standards for personal independence
and social responsibility.
The new criteria also include severity measures for
mild, moderate, severe, and profound intellectual
disability.
47
Autism Spectrum Disorder (ASD)
Consolidation of DSM-IV criteria for autism, Aspergers,
childhood disintegrative disorder, and pervasive
developmental disorder-not otherwise specific (PDD-
NOS)into one diagnostic category called autism
spectrum disorder (ASD).
The new criteria describe two principal symptoms:
deficits in social communication and social interaction
and restrictive and repetitive behavior patterns
48
Communication Disorders
The DSM-5 communication disorders include:
language disorder
speech sound disorder
childhood-onset fluency disorder (a new name for
stuttering)
social (pragmatic) communication disorder, a new
condition for persistent difficulties in the social uses of
verbal and nonverbal communication.
49
Attention-Deficit/Hyperactivity Disorder
The same 18 symptoms are used as in DSM-IV
The onset criterion has been changed from symptoms
that caused impairment were present before age 7
years to several inattentive or hyperactive-impulsive
symptoms were present prior to age 12;
subtypes have been replaced with presentation
specifiers that map directly to the prior subtypes;
a comorbid diagnosis with autism spectrum disorder is
now allowed;
a symptom threshold change has been made for adults
with the cutoff for ADHD of five symptoms, instead of
six required for younger persons, 50
Specific Learning Disorder
51
Schizophrenia Spectrum and
Other Psychotic Disorders
Schizophrenia
Elimination of the special attribution of bizarre
delusions and Schneiderian first-rank auditory
hallucinations (e.g., two or more voices conversing).
The second change is the addition of a requirement in
Criterion A that the individual must have at least one
of these three symptoms: delusions, hallucinations,
and disorganized speech. At least one of these core
positive symptoms is necessary for a reliable
diagnosis of schizophrenia
52
Schizophrenia subtypes
The DSM-IV subtypes of schizophrenia (i.e., paranoid,
disorganized, catatonic, undifferentiated, and residual
types) are eliminated due to their limited diagnostic
stability, low reliability, and poor validity.
Instead, a dimensional approach to rating severity for
the core symptoms of schizophrenia.
53
Schizoaffective Disorder
The primary change to schizoaffective disorder is the
requirement that a major mood episode be present for
a majority of the disorders total duration after
Criterion A has been met.
It makes schizoaffective disorder a longitudinal
instead of a cross-sectional diagnosismore
comparable to schizophrenia, bipolar disorder, and
major depressive disorder, which are bridged by this
condition.
54
Delusional Disorder
Criterion A for delusional disorder no longer has the
requirement that the delusions must be nonbizarre. A
specifier for bizarre type delusions provides continuity
with DSM-IV. The demarcation of delusional disorder
from psychotic variants of obsessive-compulsive
disorder and body dysmorphic disorder is explicitly
noted with a new exclusion criterion, which states that
the symptoms must not be better explained by
conditions such as obsessive-compulsive or body
dysmorphic disorder with absent insight/delusional
beliefs.
55
Catatonia
In DSM-5, catatonia may be diagnosed as a specifier
for depressive, bipolar, and psychotic disorders
56
Bipolar and Related Disorders
Bipolar Disorders
Criterion A for manic and hypomanic episodes now includes an
emphasis on changes in activity and energy as well as mood. The DSM-
IV diagnosis of bipolar I disorder, mixed episode, requiring that the
individual simultaneously meet full criteria for both mania and major
depressive episode, has been removed. Instead, a new specifier, with
mixed features, has been added that can be applied to episodes of
mania or hypomania when depressive features are present, and to
episodes of depression in the context of major depressive disorder or
bipolar disorder when features of mania/hypomania are present.
Other Specified Bipolar and Related Disorder
categorization for individuals with a past history of a major depressive
disorder who meet all criteria for hypomania except the duration
criterion (i.e., at least 4 consecutive days). A second condition
constituting an other specified bipolar and related disorder is that too
few symptoms of hypomania are present to meet criteria for the full
bipolar II syndrome, although the duration is sufficient at 4 or more
days.
Anxious Distress Specifier
57
Depressive Disorders
DSM-5 contains several new depressive disorders,
including disruptive mood dysregulation disorder and
premenstrual dysphoric disorder.
To address concerns about potential overdiagnosis and
overtreatment of bipolar disorder in children, a new
diagnosis, disruptive mood dysregulation disorder, is
included for children up to age 18 years who exhibit
persistent irritability and frequent episodes of extreme
behavioral dyscontrol.
Finally, DSM-5 conceptualizes chronic forms of depression
in a somewhat modified way. What was referred to as
dysthymia in DSM-IV now falls under the category of
persistent depressive disorder, which includes both
chronic major depressive disorder and the previous
dysthymic disorder.
58
Bereavement
In DSM-IV, there was an exclusion criterion for a major
depressive episode that was applied to depressive symptoms
lasting less than 2 months following the death of a loved one
(i.e., the bereavement exclusion). This exclusion is omitted in
DSM-5. 1, to remove the implication that bereavement
typically lasts only 2 months when both physicians and grief
counselors recognize that the duration is more commonly 12
years. 2, bereavement is recognized as a severe psychosocial
stressor that can precipitate a major depressive episode in a
vulnerable individual, and an increased risk for persistent
complex bereavement disorder, which is now in Conditions
for Further Study in DSM-5 Section III. 3, bereavement-related
major depression is most likely to occur in individuals with past
personal and family histories of major depressive episodes. It is
genetically influenced and is associated with similar
personality characteristics, patterns of comorbidity, and risks
of chronicity and/or recurrence as nonbereavement-related
major depressive episodes
59
Anxiety Disorders
60
PTSD
The 3 clusters of DSM-IV symptoms will be divided into 4
clusters in DSM-5: intrusion symptoms, avoidance
symptoms, arousal/reactivity symptoms and negative mood
and cognitions.
Criterion A2 (requiring fear, helplessness or horror happen
right after the trauma) will be removed.
The diagnosis is proposed to move from the class of anxiety
disorders into a new class of "trauma and stressor-related
disorders."
PTSD assessment measures, such as the CAPS and the PCL,
are being revised by the National Center for PTSD to be
made available upon the release of DSM-5.
61
Somatic Symptom and Related Disorders
The DSM-5 classification reduces the number of these
disorders and subcategories. Diagnoses of somatization
disorder, hypochondriasis, pain disorder, and
undifferentiated somatoform disorder have been
removed.
62
The International Classification of
Diseases ICD
The 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 currently being researched and should be
ready in 2015.
63
ICD History
The first international conference to revise the
International Classification of Causes of Death convened
in 1900; with revisions occurring every ten-years
thereafter.
In 1948, the World Health Organization (WHO)
assumed responsibility for preparing and publishing the
revisions to the ICD every ten-years. WHO sponsored
the seventh and eighth revisions in 1957 and 1968,
respectively. It later become clear that the established
ten-year interval between revisions was too short.
The America Psychiatric Association has long lobbied
against the use of the ICD (but due to federal law is
forced to work with the ICD). 64
ICD is Required by HIPPA
The 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. The
transition to ICD-10 is required for everyone covered
by the Health Insurance Portability Accountability Act
(HIPAA), Medicare and Medicaid.
65
ICD-10 MENTAL AND BEHAVIOURAL DISORDERS consists of 10
main groups:
68
ICD-11 2015
ICD-11 will draw on research about how clinicians
conceptualize mental disorders in hopes of creating a
more intuitive and psychological classification system.
69
Purpose of Classification
Q9 - From your perspective, which is the single, most
important purpose of a diagnostic classification system?
50%
39%
40%
33%
% Participants
30%
20% 16%
10%
3% 5% 4%
0%
Communication Communication Inform Facilitate Basis for Other
among between treatment and research generating
clinicians clinicians and management national health
patients decisions statistics
70
Number of Categories Desired
Q10 - In clinical settings, how many diagnostic categories
should a classification system contain to be most useful
for mental health professionals?
60%
50%
50%
% Participants
40% 35%
30%
20%
11%
10% 4%
0%
10 to 30 31 to 100 101 to 200 More than 200
71
ICD-10 and DSM-IV
Categories Used Most Often
ICD-10 % DSM-IV %
Hyperkinetic (Attention Deficit) Disorder 34% Panic Disorder without Agoraphobia 32%
79
Psychodynamic Theory as a Complex Adaptive System-
interaction, interdependence and diversity of constructs
(temperament, affects, cognitions, development, traumas, defenses, fantasi
es, attachments), emergences (symptoms), tails (one event can move
the entire central tendency) and tipping points (break downs).
80
PDMs Current Taxonomy
Personality Patterns and Disorders
Mental Functioning
P115. Mixed/Other
84
Capacity for Regulation, Attention, and Learning
85
Symptom Patterns: The Subjective Experience - S Axis
86
Classification of Child and Adolescent Mental Health Disorders
Profile of Mental Functioning for Children and
Adolescents - MCA 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: Sense of
Morality
Summary of Child and Adolescent Mental Functioning
87
Child and Adolescent Personality Patterns and Disorders - PCA Axis
90
Disorders of Infancy and Early Childhood Axis I - Primary Axis
91
IEC200 Series - Regulatory-Sensory Processing Disorders (RSPD)
Clinical Evidence and Prevalence of Regulatory-Sensory Processing
Differences
Sensory Modulation Difficulties (Type I)
IEC201. Overresponsive, Fearful, Anxious Pattern
IEC202. Overresponsive, Negative, Stubborn Pattern
IEC203. Underresponsive, Self-Absorbed Pattern
IEC203.1 Self-Absorbed and Difficult-to-Engage Type
IEC203.2 Self-Absorbed and Creative Type
IEC204. Active, Sensory Seeking Pattern
Sensory Discrimination Difficulties (Type II) and Sensory-Based Motor
Difficulties (Type III)
IEC205. Inattentive, Disorganized Pattern
IEC205.1 With Sensory Discrimination Difficulties
IEC205.2 With Postural Control Difficulties
IEC205.3 With Dyspraxia
IEC205.4 With Combinations of All Three
IEC206. Compromised School and/or Academic Performance Pattern
IEC206.1 With Sensory Discrimination Difficulties
IEC206.2 With Postural Control Difficulties
IEC206.3 With Dyspraxia
IEC206.4 With Combinations of All Three
Contributing Sensory Discrimination and Sensory-Based Motor Difficulties
92
IEC207. Mixed Regulatory-Sensory Processing Patterns
IEC207.1 Attentional Problems
IEC207.2 Disruptive Behavioral Problems
IEC207.3 Sleep Problems
IEC207.4 Eating Problems
IEC207.5 Elimination Problems
IEC207.6 Selective Mutism
IEC207.7 Mood Dysregulation, including Bipolar Patterns
IEC207.8 Other Emotional and Behavioral Problems Related to
Mixed Regulatory-Sensory Processing Difficulties
IEC207.9 Mixed Regulatory-Sensory Processing Patterns where
Behavioral or Emotional Problems Are Not Yet In Evidence
IEC300 Series - Neurodevelopmental Disorders of Relating and
Communicating
IEC301. Type I: Early Symbolic, with Constrictions
IEC302. Type II: Purposeful Problem-Solving, with Constrictions
IEC303. Type III: Intermittently Engaged and Purposeful
IEC304. Type IV: Aimless and Unpurposeful
Other Neurodevelopmental Disorders (Including Genetic and Metabolic
Syndromes)
93
Reactions to the PDM
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.
94
Nancy McWilliams ( 2011) Psychoanalytic
Diagnosis: Understanding Personality Structure in
the Clinical Process
95
Robert M. Gordon and Robert F. Bornstein (2012)
96
PDC Is A User Friendly Guide to
the Adult Section of the PDM
Short- 3pages
Easy- all scales are 1-10
Intuitive and Empirical
Categorical and Dimensional
Flexible-can do part or all
Integrates with the DSM and ICD
Good Reliability and Construct Validity-preliminary field
evidence (Gordon and Stoffey 2013 in press)
97
PDCs Taxonomy: From Larger to Smaller Units
Personality Organization
Personality Patterns
Mental Functioning
ICD Symptoms
Cultural-Contextual Issues
98
Clinical Example Using the PDC
Bana is a 28 year old woman from Syria. Her husband was killed in the
war and she has no children. Her brother was able to get her to the US this
year.
1. Level of Personality Organization- is 7 (Neurotic Level). Her capacity
scores are mainly in the 6-9 range. Her lowest rating is in Affect Tolerance
(5) which may be due to her PTSD. She is a good candidate for PDT.
2. Personality Patterns or Disorders- mainly Hysterical/Inhibited type
at the Moderate level of severity (6) with some obsessional and dependent
features.
3. Mental Functioning- most of the 9 capacities are in the high range.
She has a masters in education, her marriage was good, she has average self
esteem, she can go from inhibited to overly excited expression of affect, her
favored defenses are repression and intellectualization, she has a warm
relationship with her mother and both sets of grandparents, her father was
killed when she was a child, good level of differentiation and integration,
very insightful and excellent moral reasoning.
4. Manifest Symptoms- ICD-10: (F43.1) Post-traumatic stress disorder
5. Cultural, Contextual Issues- recent death of husband, war trauma,
loss of father, leaving much of her family and friends behind, immigration
fears and guilt.
99
Testing Dimensional and Categorical
Qualities of Personality Organization
Hysteria scale and Schizophrenia scale correlate
.01 with male sample and .15 with female sample.
They are independent representations of very
different character structures.
100
Testing Dimensional and Categorical
Qualities of Personality Organization with 3 Scales
(L+Pa+Sc)-(Hy+Pt)
Es
Sc, Hy and Es
101
MMPI-2 Hysteria-Hy, Schizophrenia-Sc, and Ego Strength-Es
Scales within the Psychotic, Borderline, and Neurotic
Categories of the Personality Organization Scale
Psychotic (ratings 1-3, n = 13), Borderline (4-6, n = 52), and Neurotic (7-10, n = 33).
Psychotic: Sc >> Hy>> Es; Borderline: (Sc ~ Hy) >> Es; Neurotic: (Sc ~ Hy) > Es all in the average to moderate range.
90
85
80
75
70 Hy
65
60
Sc
55
50
45 Es
40
35
30
103
Percent of Practitioners Rating the PDC Dimensions as
HelpfulVery Helpful in Understanding Their Patient
90
84
79
80
72
70
60
50
50
40
31
30
20
10
0
Levels of Personality Structure
Dominant Personality Patterns
Mental Functioning ICD or DSM Symptoms
Cultural/Contextual Dimensi
104
Current PDM Study
Data collected from 13 workshops from
Nov. 2012- July 2013.
105
Psychodynamic Diagnostic Prototypes
(PDP)
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PDP narrative description
P105.1 Intermediate Manifestation:
Sadomasochistic Personality Disorders
Some individuals alternate between sadistic and sadomasochistic
attitudes and behaviors (Kernberg, 1988). Patients with this psychology
are much more emotionally alive and capable of attachment than those
with primary psychopathic, narcissistic, or sadistic personality structures.
Their relationships, however, are intense and explosive. Sometimes they
let themselves be dominated to an extreme extent, and sometimes they
viciously attack the person to whom they previously capitulated. They tend
to see themselves as victims of others aggression whose only choices are
to surrender their will entirely or to fight back belligerently. The help-
rejecting complainer described by Frank and his colleagues
(Frank, Margolin, Nash, Stone, Varon & Ascher, 1952) is one version of
this psychology. In psychotherapy, such patients tend to alternate between
attacking the therapist and feeling insulted and demeaned by him or her.
Because sadomasochistic personality disorder is found at the borderline
level of severity, treatment considerations include those for borderline
patients generally. 107
The validation of Psychodynamic Diagnostic Prototypes
(PDP; Gazzillo, Lingiardi, Del Corno, 2010)
108
Hypotheses
1. Norms for PDP and PDC
2. Concurrent validity between PDP and PDC
3. How PDM Dx inform about boundaries and
countertransference issues
4. How theoretical orientation affects value of various
taxa (PO, PD, MF, Symptoms, Context)
5. Which PD are commonly found at which level of PO.
109
1. Level of Personality Structure
Please rate each capacity from 1 to 10; ratings range from Most Disturbed (1) to Most
Healthy (10).
4. Affect Regulation: ability to regulate impulses and affects with flexibility in using
defenses or coping strategies
Healthy 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.
111
2. Personality Patterns or Disorders- Scoring
112
PDM Categories:
Schizoid
Paranoid
Psychopathic (antisocial); Subtypes - passive/parasitic or aggressive
Narcissistic; Subtypes - arrogant/entitled or depressed/depleted;
Sadistic (and intermediate manifestation, sadomasochistic)
Masochistic (self-defeating); Subtypes - moral masochistic or relational
masochistic
Depressive; Subtypes - introjective or anaclitic; Converse manifestation -
hypomanic
Somatizing
Dependent (and passive-aggressive versions of dependent); Converse
manifestation - counterdependent
Phobic (avoidant); Converse manifestation - counterphobic
Anxious
Obsessive-compulsive; Subtypes - obsessive or compulsive
Hysterical (histrionic); Subtypes - inhibited or demonstrative/ flamboyant
Dissociative
Mixed/other
Rate: Dominate Personality Disorder or Maladaptive Traits & Overall Severity of
Impairment 113
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
114
4. ICD or DSM 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.
115
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.
116
For Free Copies:
For copies of the PDP and PDC, search for:
Psychodiagnostic Chart
117
In addition, use whatever system is
most helpful to you in understanding
and helping the client/patient
118