Advantages and limitations in current classification of Personality Disorders pointing to the future

1
Advantages and limitations in current
classification of Personality Disorders-
pointing to the future

• WPA Athens, 12.-15. March, 2005
• Erik Simonsen, chair WPA PD Section on PD
• E-mail rfes_at_ra.dk

2
The Categorical approachadvantages

• Consistent with medical diagnoses
• Familiar to clinicians and easy to use
• Clinical decisions are binary
• Some evidence (Borderline, Schizotypal,
  Psychopathy)
• Historically well-etablished typologies
• Restore the unity of self , constitute patient as
  a person

3
Limitations of Existing Diagnostic Categories

• Excessive Diagnostic Co-Occurence
• Inadequate Coverage
• Heterogeneity within diagnoses
• Arbitrary and unstable diagnostic boundaries

4
The dimensional approachadvantages

• No information lost
• Permits graded description of psychopathology
• Encourage representation of individuality because
  of its comprehensive nature
• Permits assessment of unusual cases
• Better way of measuring more subtle aspects
• Permit detailed description of specific
  components of psychopathology that facilitates
  treatment planning

5
Limitations of dimensional approach

• No well-established system (competing models)
• Can become a closed system
• Personality structure is a dynamic, highly
  interelated and coordinated system
• Fractionate the intrinsic unity of personality
  into separate rows and coloums of uncoordinated
  traits
• Some kind of grouping needed for communication

6
APA/NIMH DSM V Research planning conference 1999

• important that consideration be given to
  advantages and disadvantages of basing part or
  all DSM-V on dimensions rather than categories
• If dimensional system of personality performs
  well and is acceptable to clinicians it might be
  appropriate to explore dimensional approaches in
  other domains
• Nomenclature Work Group
• (Rounsaville, Alarcon, Andrews, Jackson,
  Kendell, Kendler (2002)

7
Personality DisorderLaunch conference,
Washington 2.-3. december 2004sponsored by a
grant NIH (APA/WHO)

• Alternative dimensional models
• Papers will published in
• 2 special issues of Journal of Personality
  Disorder (2005)
• (Widiger Simonsen Alternative models)
• a book by American Psychiatric Association Press
  (2006)
• ed. Widiger, Simonsen, Krueger, Livesley,
  Verheul

8
Eighteen Proposals

• A Dimensional profile of existing or modified
  categories
• Oldham Skodol (2000)
• Tyrer Johnson (1996)
• Westen Shedler (2000)
• B Dimensional reorganization of personality
  disorder symptoms
• 3 clusters
• Livesley (2003)
• Clark (1993)
• Harkness McNulty (1994)
• Shedler Westen (2004-a)
• C Clinical spectra models
• Siever Davis (1991)
• Krueger (1999)
• D. Integration with general personality
  functioning
• Eysenck (1967)
• Zuckerman (1991)
• Tyrer Alexander (1979)
• Millon (1981)
• Cloninger (2000)

9
Four dimensional based approaches

• A Dimensional profiles of existing or modified
  categories
• B Dimensional reorganization of personality
  disorder symptoms
• C Clinical spectra symptoms
• D Integration with general functioning

10
A. Dimensional Profile of PDDiagnostic Categories

• Tyrer and Johnson (1996)
• Oldham and Skodol (2000)
• Westen and Shedler (2000)

11
Oldham and Skodol (2000)

• 10 DSM/ICD personality disorder constructs
• (e.g., borderline, avoidant, antisocial,
  schizotypal, paranoid, narcissistic, etc.)
• Each classified along six levels
• Prototypic (all criteria met)
• Moderately present (one or more above threshold)
• Threshold (just meets cutoff point for diagnosis)
• Subthreshold (one criterion short of cutoff
  point)
• Traits (1-3 criteria)
• Absent (no criteria are present)
• Extensive personality disorder
• Three or more at or above threshold

12
B. Clinical spectra models

• Siever and Davis (1991)
• Krueger (internalization externalization)

13
The spectrum disorders

• Trait vulnerabilities become symptoms, prodromes
  and disorders/illnesses
• Traits becomes, DSM -Axis II personality
• and DSM-Axis I syndrome
• i.e. introvert- schizotypal-schizophrenia, shy
  -avoidant-social phobia, perfectionism-compulsive-
  OCD.

14
C Dimensional reorganization of Personality
Disorder Symptoms

• The three cluster of DSM-IV (1980)
• Twelve factors of Clark (1993)
• Personality Psychopathology Five (1995)
• Eighteen factors of Livesley (2003)
• Shedler and Westen 12 Factor Model (2004)

15
Four-Factors of Personality Disorder
Compulsive Traits
Anxious -Dependent Traits
Antisocial Traits
Socially Withdrawn Traits
16
D Dimensional models of general personality
functioning

• Eysenck three factor model (1967)
• Tyrers four dimension/twenty-four traits (1979)
• Millons three polarities (1981)
• Kernbergs personality organization (1975)
• Zuckermans Five-Factor model (1991)
• Costa and McCrae Five factor model (1992)
• Benjamin and Kieslers Interpersonal Circumplex
  (1996)
• Tellegen, Watson, Clarks three factors (1999)
• Cloninger four temperaments/three character
  (2000)

17
Five-Factor Model NEO-PI-R

• Neuroticism
• Extraversion
• Openness to experience
• Agreeableness
• Conscientiousness
• Costa McCrae, 1992

18
Finding the common Broad Domains
First Second Third Fourth Fifth DAPP-BQ -Inh
ibition Dissocial Compulsivity Emotional
Dysregulation NEOPIR Extraversion Antagonism C
onscientiousness Neuroticism Openness SNAP
MPQ Positive Affectivity (Negative
Affectivity) Constraint Negative
Affectivity PSY-5 Positive Emotionality Aggress
iveness Constraint Negative Emotionality Psychot
icism IPC Agency Communion MCMI -Withdrawn
Aggressiveness Constraint Neuroticism EPQ Extra
version
Psychoticism Neuroticism ZKPQ Sociability,
Acivity Aggression-Hostility -Impulsive Neuroti
cism PAS -Withdrawn Antisocial,
-Dependent Inhibited Siever/Davis (-Inhibition)
Aggression-Impulsive
Affective Instability, Anxious
Inhibition Cog-Percep TCI -Cooperative
ness Persistence Harm Avoidance Self-Transcend
Reward Dependence -Novelty Seeking
Self-Directdness
Widiger Simonsen, 2005
19
Higher order domains

• Extroversion
• Aggression
• Constraint
• Emotional dysregulation

• Introversion
• Dependency
• Impulsivity
• Emotional stability

20
Different aspects of validityof the dimensional
systems

• Behavioral Genetics
• Neurobiology
• Childhood antecedents
• Cross-cultural application
• Axis I/II resolution
• Coverage
• Clinical Utility
• see Special Journal PD issue and APA book

21
Conclusions

• Different dimensional approaches should be
  investigated for their clinical utility and
  validity
• Consensus should be achieved for a common ground
  (role of the WPA Sections?)
• Clinicians from all over the world should be
  involved in field trials for clinical utility
  (role of the WPA Sections?)
• Then the ICD/APA decision of whether to follow
• - continue categorical,
• - a hybrid,
• - an alternative dimensional
• - a combination