Transcript Integrated Treatment Planning for Borderline Personality

Personality Disorders: Current Concepts
and Controversies
2006 Wolfe-Adler Lecture
Sheppard Pratt Health System
September 27, 2006
John M. Oldham, M.D.
Professor and Chairman
Department of Psychiatry and Behavioral Sciences
Medical University of South Carolina
[email protected]
Personality =
Temperament + Character
Hippocrates Classification
Element
Humor
Type
Style
Air
Blood
Sanguine
Hopeful
Enthusiastic
Optimistic
Earth
Black Bile
Melancholic
Sad
Fire
Yellow Bile
Choleric
Irascible
Irritable
Water
Phlegm
Phlegmatic
Apathetic
Slow
DIMENSIONAL
CATEGORICAL
Examples of Dimensional Systems
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Interpersonal Circumplex - Leary, Wiggins, Kiesler
Three factors - Eysenck & Eysenck
Four factors - Livesley et al., Clark et al.
Five factors - Costa & McCrae
Seven factors - Cloninger et al.
The Five-Factor Model of Personality
Neuroticism
Agreeableness
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Calm – Worrying
Even-tempered – Temperamental
Self-satisfied – Self-pitying
Comfortable – Self-conscious
Unemotional – Emotional
Hardy – Vulnerable
Ruthless – Soft-hearted
Suspicious – Trusting
Stingy – Generous
Antagonistic – Acquiescent
Critical – Lenient
Irritable – Good-natured
Extroversion
Conscientiousness
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Reserved – Affectionate
Loner – Joiner
Quiet – Talkative
Passive – Active
Sober – Fun-loving
Unfeeling – Passionate
Negligent – Conscientious
Lazy – Hardworking
Disorganized – Well-organized
Late – Punctual
Aimless – Ambitious
Quitting – Persevering
Openness to Experience
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Down-to-earth – Imaginative
Uncreative – Creative
Conventional – Original
Prefer routine – Prefer variety
Uncurious – Curious
Conservative – Liberal
Adapted from Costa & McCrae 1986
Three Major Brain Systems Influencing Stimulus –
Response Characteristics
Brain System
(Related Personality
Dimension)
Principal
Monoamine
Neuromodulator
Relevant Stimuli
Behavioral
Response
Behavioral activation
(novelty seeking)
Dopamine
Novelty
Exploratory pursuit
Potential reward
Appetitive approach
Potential relief of
monotony or
punishment
Active avoidance,
escape
Behavioral inhibition
(harm avoidance)
Serotonin
Conditioned signals
for punishment,
novelty, or frustrative
nonreward
Passive avoidance,
extinction
Behavioral
maintenance
(reward dependence)
Norepinephrine
Conditioned signals
for reward or relief of
punishment
Resistance to
extinction
Cloninger’s Seven-Factor Model
1. Temperament Domains (Moderately heritable, not greatly
influenced by family environment)
a. Novelty Seeking
b. Harm Avoidance
c. Reward Dependence
d. Persistence
2. Character Domains (Moderately influenced by family
environment, only weakly heritable)
a. Self-transcendence
b. Cooperativeness
c. Self-directedness
The DSM
Categorical System
DSM-I (1952)
Personality Pattern
Disturbance
Inadequate
Paranoid
Cyclothymic
Schizoid
Personality Trait
Disturbance
Emotionally unstable
Passive-aggressive
dependent type
aggressive type
Compulsive
Sociopathic Personality
Disturbance
Antisocial
Dyssocial
DSM-II (1968)
DSM-III (1980)
Axis I cyclothymic
disorder
Inadequate
Paranoid
Cyclothymic
Schizoid
Hysterical
Passive-aggressive
Obsessive-compulsive
Cluster A
Paranoid
Axis I cyclothymic
disorder
Cluster A
Paranoid
Schizoid
Schizotypal
Schizoid
Schizotypal
Cluster B
Histrionic
Antisocial
Borderline
Narcissistic
Cluster B
Histrionic
Antisocial
Borderline
Narcissistic
Cluster C
Compulsive
Avoidant
Dependent
Passive-aggressive
Cluster C
Obsessive-compulsive
Avoidant
Dependent
Asthenic
Antisocial
Explosive
Axis I intermittent
explosive disorder
DSM-III-R Appendix*
Self-defeating
Sadistic
Figure 1. Ontogeny of Personality Disorder Classification
indicates that category was discontinued.
DSM-IV (1994)
Axis I intermittent
explosive disorder
DSM-IV Appendix
Passive-aggressive
Depressive
DSM-IV Personality Disorders
A. Cluster A (odd/eccentric)
1. Paranoid
2. Schizoid
3. Schizotypal
B. Cluster B (dramatic/emotional/impulsive)
1. Antisocial
2. Borderline
3. Histrionic
4. Narcissistic
C. Cluster C (anxious/fearful)
1. Avoidant
2. Dependent
3. Obsessive-Compulsive
D. Personality Disorder Not Otherwise Specified
Connecting Order with Disorder
- A Quantitative, Continuum Model
The Personality Style-Personality
Disorder Continuum
DSM-IV Definition of Personality Disorder
A. An enduring pattern of inner experience and
behavior that 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, ability,
appropriateness of emotional response)
3. Interpersonal functioning
4. Impulse control
DSM-IV Definition of Personality Disorder
B. The enduring pattern is inflexible and pervasive
across a broad range of personal and social
situations.
DSM-IV Definition of Personality Disorder
C. The enduring pattern leads to clinically significant
distress or impairment in social, occupational, or
other important areas of functioning.
DSM-IV Definition of Personality Disorder
D. The pattern is stable and of long duration and its
onset can be traced back at least to adolescence
or early adulthood.
DSM-IV Definition of Personality Disorder
E. The enduring pattern is not better accounted for as
a manifestation or consequence of another mental
disorder.
DSM-IV Definition of Personality Disorder
F. The enduring pattern is not due to the direct
physiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medical
condition (e.g., head trauma).
Prevalence of PDs in a Community Sample
(N=2053)
Overall – 13.4%
Torgersen, Kringlen, Cramer, 2001
Prevalence of PDs in a Community Sample
(N=2053)
Personality Disorder
Paranoid
Schizoid
Schizotypal
Antisocial
Borderline
Histrionic
Narcissistic
Avoidant
Dependent
Obsessive-Compulsive
Passive-Aggressive
Self-Defeating
Present Prevalence
2.4
1.7
0.6
0.7
0.7
2.0
0.8
5.0
1.5
2.0
1.7
0.8
Torgersen, Kringlen, Cramer; 2001
PD Prevalence Studies
Authors
Location
N
Zimmerman & Coryell, 1989
Iowa
797
Black et al., 1992
Iowa
247
Maier et al., 1992
Mainz
452
Moldin et al., 1994
New York
303
Klein et al., 1995
New York State
229
Lenzenweger et al., 1997
New York State
258
Torgersen et al., 2001
Oslo
2053
Samuels et al., 2002
Baltimore
742
Torgersen, 2005
PD Prevalence Studies (n=5081)
PD
Range
Median
Mean
Paranoid
0.0-2.2
1.25
1.48
Schizoid
0.0-1.6
0.65
0.96
Schizotypal
0.0-3.2
0.70
1.20
Antisocial
0.2-4.5
1.70
1.77
Borderline
0.0-3.2
1.45
1.16
Histrionic
0.4-3.2
1.85
1.77
Narcissistic
0.0-4.4
0.05
0.61
Avoidant
0.4-5.0
1.35
2.91
Dependent
0.4-1.8
1.30
1.24
Obsessive-Compulsive
0.0-9.3
1.95
2.09
Passive-Aggressive
0.0-10.5
1.80
1.99
Self-Defeating
0.0-0.83
0.40
0.74
Sadistic
0.0-0.19
0.10
0.17
Any PD
3.9-22.7
11.55
12.26
Torgersen, 2005
AXIS I / AXIS II
Phenomenologically Corresponding Axis I & Axis II Disorders, Potential
Biological Indexes, and Characteristic Traits (Core Vulnerabilities),
Defenses and Coping Strategies of Dimensions of Personality Disorders
Dimension
Axis I Disorder
Axis II Disorder
Biological Indexes
Characteristic Traits
Defenses and
Coping Strategies
Cognitive/
Perceptual
Organization
Schizophrenia
Odd cluster
(schizotypal PD)
Eye movement
dysfunction*, continuous
performance task,
backward masking test*,
plasma HVA*, CSF
HVA*, evoked potential
response, VBR
Disorganization,
psychotic-like
symptoms
Social isolation,
detachment,
guardedness
Impulsivity/
Aggression
Impulse
disorders
Dramatic cluster
(borderline &
antisocial PDs)
CSF 5-HIAA*, responses
to serotonergic
challenge, galvanic skin
response*, continuous
performance task
Readiness to action,
irritability/
aggression
Externalization,
dissociation,
enactment,
repression
Affective
Instability
Major affective
disorders
Dramatic cluster
(borderline &
possibly
histrionic PDs)
REM latency, responses
to cholinergic
challenges*, responses
to catecholamingeric
challenges*
Environmentally
responsive, transient
affective shifts
Exaggerated
affectivity,
“manipulativeness”,
“splitting”
Anxiety/
Inhibition
Anxiety
disorders
Anxious cluster
(avoidant PD)
Heart rate variability*,
orienting responses,
responses to lactate and
yohimbine
Autonomic arousal,
fearfulness, inhibition
Avoidant,
compulsive, and
dependent
behaviors
* Preliminary data are available in patients with personality disorder (PD)
Schizotypal
Schizotypal PD


Dopamine [+ sx] (Coccaro & Siever, 2005)
Dopamine [- sx] (Siever & Davis, 2004)
 Ventricles (Siever, 1991)
 Cognitive functioning (Gold & Harvey, 1993)
 Working memory (Lees-Roitman et al., 1996)
 Verbal memory (Saykin et al., 1991)
 Sustained attention (Harvey et al., 1996)
 Arousal to stimuli (Siever, 1985)
Spectrum Model
Impulsive/Compulsive Spectrum of Control
Compulsive
 Control
Inhibition
Impulsive
 Control
Disinhibition
Impulsive Disorders
Axis II
 Borderline Personality Disorder
 Antisocial Personality Disorder
Axis I
 Psychoactive Substance Use Disorder
 Bulimia
 Paraphilias
 Impulsive Control Disorder NEC
ANTISOCIAL
Antisocial Personality Disorder (ASPD)
 Prefrontal gray matter volume
 Autonomic activity in ASPD
May underlie low arousal, poor fear conditioning, lack
of conscience, and decision-making deficits in ASPD
Raine et al., 2000
Psychopathic Antisocial PD (P-ASPD)
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Corpus Callosum in P-ASPD vs Controls:
 white matter volume
 length
 thickness
 functional interhemispheric connectivity
 May reflect atypical neurodevelopment, e.g.,
arrested early axonal pruning or ↑ white matter
myelination
 May help explain affective deficits
Raine et al., 2003
Malnutrition and Externalizing Behavior
Malnutrition predisposes to neurocognitive
deficits, which predispose to persistent
externalizing (antisocial and aggressive)
behavior throughout childhood and adolescence.
Liu et al., 2004
The Gradations of Antisociality
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Some antisocial personality traits insufficient to meet DSM criteria; some
antisocial traits occurring in another personality disorder
Explosive/Irritable Personality Disorder with some antisocial traits
Malignant Narcissism
Antisocial Personality Disorder, with property crimes only
Sexual Offenses without violence (viz., voyeurism, exhibitionism, frotteurism)
Antisocial Personality Disorder, with violent felonies. (There may be some
psychopathic traits, but insufficient to meet Hare’s PCL-R criteria: score >29)
Psychopathy without violence (viz., con-artists, financial scams)
Psychopathy with violent crimes
Psychopathy with sadistic control (viz., unlawful imprisonment of a kidnap
victim while awaiting ransom)
Psychopathy with violent sadism and murder, but no prolonged torture
Psychopathy with prolonged torture followed by murder
Stone, 2000
Treatability
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Presence of
– Adequate motivation
– Ability to take seriously the nature of one’s
antisocial attitudes and behaviors
Absence of
– Pathological lying/deceitfulness
– Conning/manipulativeness
– Lack of remorse or guilt
– Callousness/lack of compassion
Stone, 2002
Psychopathy
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Kraeplin (1915) – Psychopathic personalities
Cleckley (1940) – Psychopath
Hare PCL-R
PCL-R Factor-I Items
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Glibness, superficial charm
 Grandiose sense of self worth
 Pathological lying
 Conning/manipulative
 Lack of remorse or guilt
 Shallow affect
 Callous/lack of empathy
 Failure to accept responsibility for one’s actions
Black, 1999
Example of Offender Recidivism
3 Year Reconviction
PCL-R
PCL-R
PCL-R
> 30
20-29
0-19
75%
50%
25%
Hemphill et al., 1998
Predictors of ASPD
Preschool child’s inability to inhibit socially inappropriate
behavior predicts later asocial behavior, and
undercontrolled behavior in school-age children is the
best predictor of adult antisocial behavior. This
association may be the most reliable relation between
characteristics in young children and later
psychopathology.
From Kagan J, Zentner M, Early childhood predictors of adult
psychopathology. Harvard Review of Psychiatry, 1996.
Is ASPD Genetic?
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Genetic factors do play a significant role in
antisocial behavior
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Twin studies show genetic factors to be particularly
important in AS behavior with early-onset
hyperactivity
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Genetic factors least influential in adolescent onset
delinquency
JIMMY, SIXTH-GENERATION PAIN IN THE ASS
BORDERLINE
Borderline Personality Disorder (DSM-IV)
A pervasive pattern of instability of interpersonal relationships, selfimage, and affects, and marked impulsivity beginning by early adulthood
and present in a variety of contexts as indicated by five (or more) of the
following:
1. Frantic efforts to avoid real or imagined abandonment. Note: do not
include suicidal or self-mutilating behavior covered in Criterion 5.
2. A pattern of unstable and intense interpersonal relationships
characterized by alternating between extremes of idealization and
devaluation.
3. Identity disturbance: markedly and persistently unstable self-image
or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging
(e.g., spending, sex, substance abuse, reckless driving, binge
eating). Note: do not include suicidal or self-mutilating behavior
covered in Criterion 5.
Borderline Personality Disorder (DSM-IV)
A pervasive pattern of instability of interpersonal relationships, selfimage, and affects, and marked impulsivity beginning by early adulthood
and present in a variety of contexts as indicated by five (or more) of the
following:
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating
behavior.
6. Affective instability due to a marked reactivity of mood (e.g., intense
episodic dysphoria, irritability, or anxiety usually lasting a few hours
and only rarely more than a few days).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger (e.g.,
frequent displays of temper, constant anger, recurrent physical
fights).
9. Transient, stress-related paranoid ideation or severe dissociative
symptoms.
Heterogeneity of BPD
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DSM-IV - defined BPD is an extremely
heterogeneous construct (Est. 256 varieties)
 Mix of unstable, stress-induced symptoms
and stable personality characteristics
(i.e., dimensional traits)
BPD as a Personality Disorder Emerging From the
Interaction of Underlying Genetically-Based Traits
Impulsive aggression and affective instability = heritable
endophenotypes that would contribute significantly to
development of BPD
Siever et al., 2002
Heritability of BPD
Twin study (Torgersen et al. 2000)
 Novelty seeking (Cloninger, 2005)
 Impulsivity (New and Siever, 2002)
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Childhood Abuse and BPD
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Severe childhood trauma  persistent serotonergic disturbance
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Dose/response correlation (age of onset, frequency, seriousness)
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Only males show  serotonin and  aggression or  impulsivity
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Sustained childhood abuse 
– Hyporesponsiveness of 5-HT system
– Hyper-responsiveness of HPA system
(correlated with sustained abuse, not BPD pathology)
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To know what characterizes BPD, must correct for chronic
childhood trauma

Possibly faulty attachment in genetically vulnerable children 
selected by abusers  sustained abuse  HPA disturbances 
susceptibility to stress and stress-related disorders (e.g. BPD,
MDD)
Rinne, T, ISSPD, Florence, 2003
MRI in Patients with BPD
16% reduction in volume of hippocampus
8% reduction in volume of amygdala in BPD patients
vs. healthy controls
Not clearly related to trauma
(results only significant for total BPD group [with and
without hx of trauma])
Driessen et al., 2000
MRI in Patients with BPD
↓ Volume hippocampus and amygdala
(Schmahl et al, 2003; Rusch et al.,
2003)
PET and BPD
BPD patients vs Controls
• frontal and prefrontal hypermetabolism
• hippocampus and cuneus hypometabolism
= limbic and prefrontal dysfunction, implicated in
regulation of emotion
Juengling et al., 2003
Implications of Imaging Studies in BPD
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Abnormalities in prefrontal,
corticostriatal, and limbic networks
 Perhaps related to lowered serotonin
neurotransmission and behavioral
disinhibition.
Johnson et al., 2003
Neurocognitive Deficits in BPD
BPD patients vs Controls
 delayed, maladaptive choices
 impulsive, disinhibited responses
 impairment in planning
suggest complex impairments in cognitive
processes involving frontal lobes
Bazanis et al., 2002
Continuity of Treatment for Patients with
Personality Disorders
Collaborative Longitudinal Personality
Disorders Study
Donna S. Bender, Ph.D.
Andrew E. Skodol, M.D.
John M. Oldham, M.D.
Ingrid R. Dyck, M.P.H.
Regina T. Dolan, Ph.D.
M. Tracie Shea, Ph.D.
John G. Gunderson, M.D.
Charles Sanislow, Ph.D.
Collaborative Longitudinal Personality
Disorders Study (CLPS)
• 5 Collaborative Sites
Brown (Shea), Columbia (Skodol), Harvard
(Gunderson),Yale (McGlashan), Texas A&M (Morey)
• 668 Patients Recruited Originally (+65)
STPD (N= 86), BPD (N=175), AVPD (N= 158),
OCPD (N= 154), MDD and no PD (N= 95)
• Followed Longitudinally for >8 Years
To determine the stability of symptoms, diagnoses,
dimensions, and functioning and to determine the
predictors of clinical course
Utilization of Psychosocial Treatments
Mean Lifetime Months of Outpatient
Treatment Received
80
70
60
Self-Help
Family
Group
Individual
50
40
30
20
10
0
STPD
BPD
AVPD
OCPD
MDD
Mean Lifetime Weeks of Residential
Treatment Received
40
35
30
25
Halfway Hse.
Psych. Hosp.
Day Tmt.
20
15
10
5
0
STPD
BPD
AVPD
OCPD
MDD
Utilization of Psychopharmocologic
Treatments
Utilization of Psychiatric Medications:
Lifetime
80
Antianxiety
70
Mood Stabilizer
60
Antipsychotic
50
Percent
of Group 40
Antidepressant
30
20
10
0
STPD
BPD
AVPD
OCPD
MDD
APA Practice Guidelines Work Group on
Borderline Personality Disorders
John Oldham, M.D. (Chair)
Glen Gabbard, M.D.
Marcia Goin, M.D., Ph.D.
John Gunderson, M.D.
Paul Soloff, M.D.
David Spiegel, M.D.
Michael Stone, M.D.
Katherine Phillips, M.D.
Part A: Treatment Recommendations
for Patients with Borderline Personality Disorder
II. Formulation and Implementation of a Treatment Plan
E. Specific Treatment Strategies for the Clinical Features of
Borderline Personality Disorder
1. Psychotherapy
2. Pharmacotherapy and other somatic treatments
Partial Hospital Psychoanalytic
Psychotherapy
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BPD patients (n = 38)
Randomized controlled design:
– Partial hospital vs. Standard treatment
18 months, psychoanalytic individual & group therapy
 suicidal acts
 self-mutilatory acts
 depressive symptoms
 hospital patient days
 social and interpersonal functioning
36 month, maintained gains
Bateman & Fonagy, AJP, 1999
Bateman & Fonagy, AJP, 2001
Dialectical Behavior Therapy
 Frequency and severity of parasuicidal episodes
 Therapy attrition
 Number of psychiatric inpatient days
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Improved scores on measures of anger, interviewerrelated global social adjustment, and Global
Assessment Scale
Improved self-rating on overall social adjustment
One-year maintenance of treatment gains
-Linehan et al, Arch Gen Psychiatry 1991
-Linehan et al, Arch Gen Psychiatry 1993
-Linehan et al, Am J Psychiatry 1994
Symptom-Oriented
Psychopharmacology for BPD
1.
2.
3.
4.
Cognitive/Perceptual Symptoms
Affective Dysregulation: Mood
Affective Dysregulation: Anxiety
Impulsive Behavioral Dyscontrol
From Paul Soloff
Algorithm for the Treatment of
Cognitive-Perceptual Symptoms in BPD
Algorithm for the Treatment of ImpulsiveBehavioral Symptoms in BPD
Algorithm for the Treatment of Affective
Dysregulation in BPD
New Directions
The Effectiveness of Psychodynamic Therapy and
Cognitive Behavior Therapy in the Treatment of
Personality Disorders: A Meta-Analysis

Both psychodynamic therapy and cognitive behavior
therapy are effective treatments of personality disorders

For psychodynamic therapy, the effect sizes indicate
long-term rather than short-term change in personality
disorders (mean follow-up period = 1.5 years [78 weeks]
vs CBT mean follow-up = 13 weeks)
Leichsenring F, Leibing E, Am J
Psychiatry 2003; 160:1223-1232
Biology in the Service of Psychotherapy

Psychotherapy can induce robust changes in
brain function that are detectable with
neuroimaging.
Etkin et al., 2005
Biology in the Service of Psychotherapy
Areas decreased after vs. before treatment
amygdala
cognitive-behavioral therapy
citalopram
From Furmark et al., 2002.
Biology in the Service of Psychotherapy

Identification of brain regions associated with
deficits of impulse control in patients with BPD
may be useful to predict a patient’s ability to
respond to psychotherapy and recover.
Etkin et al., 2005
Toward a New Model
of PDs for DSM-V
Categorical vs. Dimensional Models:
Advantages and Disadvantages
Limitations of categorical model
• Excessive diagnostic co-occurrence, i.e., most patients meet criteria
for more than one PD.
• Heterogeneity among persons with the same diagnosis, e.g., there are
256 ways to meet criteria for BPD.
• Arbitrary diagnostic thresholds, i.e., no empirical rationale for boundary
with “normal” personality functioning.
• Inadequate coverage, e.g., PDNOS is the most frequently used
diagnosis.
Limitations of dimensional models
• Unfamiliar to those trained in medical model, i.e., communication of
much information via single diagnostic concept.
• More complex and difficult to use, e.g., up to 30 dimensions to
describe personality.
• Little empirical information on treatment or other clinical implications of
scale elevations or on cut-points for clinical decision-making.
Personality Disorders and the
Research Agenda for DSM-V
• “There is a clear need for dimensional models to be
developed and their utility compared with that of existing
typologies in one or more limited fields, such as
personality. If a dimensional system performs well and is
acceptable to clinicians, it might be appropriate to
explore dimensional approaches in other domains (e.g.,
psychotic or mood disorders)” (Rounsaville et al., 2002).
• Thus, personality disorders are “test case” for return to a
dimensional approach to the diagnosis of mental
disorders in DSM-V.
18 Alternative Proposals for a
Dimensional Model of Personality Disorders
• Proposals to provide dimensional representation of
existing constructs.
• Proposals to provide dimensional reorganization of
diagnostic criteria.
• Proposals to integrate Axes II and I with respect to
common spectra.
• Proposals to integrate Axis II with dimensional models of
general personality structure.
18 Alternative Proposals for a
Dimensional Model of Personality Disorders
• Proposals to provide dimensional
representation of existing constructs:
Oldham & Skodol (2000)
Any instrument
Tyrer & Johnson (1996)
Personality Assessment
Schedule (PAS)
S&W Assessment
Procedure (SWAP-200)
Westen & Schedler (2000)
(Widiger & Simonsen: JPD, 2005)
Dimensional Representation of
DSM-IV PD Categories
Summary Term
• Absent (1)
• Traits (2)
• Subthreshold (3)
• Threshold (4)
• Pervasive (5)
• Prototypic (6)
Number of Criteria Met
0
1, 2, or 3
3 or 4
4 or 5
5, 6, 7, or 8
7, 8, or 9
Oldham & Skodol: JPD, 2000
PROPOSAL
Axis II: Personality Disorder Traits
and Personality Disorders
Instructions: Personality disorder traits or personality
disorders are identified according to the number of
criteria met, as specified in each personality diagnosis,
utilizing the following categories:
- Absent
- Traits
- Subthreshold features
- Threshold
- Moderate
- Prototype
PROPOSAL (continued)
Instructions (continued): If a patient is at or above
threshold for up to two PDs, the diagnosis or diagnoses
should be made. If a patient is at or above threshold for
three or more PDs, the patient’s diagnosis should be:
Extensive Personality Disorder, characterized by:
(A, B, C) components,
subcategorized as traits, subthreshold, threshold,
moderate, or prototype
EXAMPLE #1
Diagnosis
Categories
Paranoid PD
Absent
Traits
Subthreshold
Threshold
Moderate
Prototype
Number of
Criteria
0
1-2
3
4
5-6
7
EXAMPLE #2
Diagnosis
Components
Extensive PD Borderline
Paranoid
Narcissistic
Categories of Number
Criteria
Prototype
Moderate
Threshold
Histrionic features Subthreshold
Schizotypal
Traits
9
5
5
3
3
Personality Disorders Over Time
“Remission” Rates of PDs Over 2 Years by
Different Definitions of Remission
(Grilo et al: JCCP, 2004)
Personality
Disorder
2 months <
2 criteria
12 months <
2 criteria
Below
threshold on
blind re-test
STPD
33%
23%
61%
BPD
42%
28%
56%
AVPD
47%
31%
50%
OCPD
55%
38%
60%
Mean Proportion of Criteria Met for PD
Groups Over Two Years
(Grilo et al: JCCP, 2004)
0.8
0.7
0.6
0.5
STPD
BPD
AVPD
OCPD
0.4
0.3
0.2
0.1
0
Baseline
6 months
1 year
2 years
Probability of Remission of PDs Over 6 Years by
Different Definitions of Remission
Personality
Disorder
2 months <
2 criteria
12 months < 2
criteria
STPD
.74
.67
BPD
.77
.66
AVPD
.79
.68
OCPD
.89
.82
Skodol, AE (Unpublished)
Probability of PD Relapse After 6 Years
STPD
BPD
AVPD
OCPD
2+ month
remission
.02
.16
.29
.27
12+ month
remission
.00
.07
.17
.17
Skodol, AE (Unpublished)
Persistence of Functional Impairment in
Personality Disorders
Axis V (GAFS) Ratings Over 2 Years
70
STPD
BPD
AVPD
OCPD
MDD
60
50
Baseline
1 year
2 year
Time of Assessment
Skodol et al: Psychol Med, 2005
Toward a New Model of PDs
• Personality disorders show consistency as syndromes
over time, but rates of improvement that are inconsistent
with DSM-IV definitions
• Functional impairment in PDs is more stable than
psychopathology
• Some PD criteria are more stable than others
• Personality traits are more stable than personality
disorders, predict stability and change, and are
associated with outcome over time
• PDs may be “hybrids” of more stable personality traits
and less stable symptomatic behaviors
Toward a New Model of PDs:
Diagnostic and Treatment Implications
• Redefine personality disorders in terms of trait and
symptom components
• Reconceptualize course of personality disorders as
waxing and waning, depending on circumstances
• Delay definitive PD diagnosis until late 20s?
• Convey more optimistic prognosis to younger patients
and their families
• Focus treatment more on attaining adequate
psychosocial functioning
Psychopathology Over Time: Hypothetical
Data for One Subject
from Pfohl B, 1999
DIMENSIONAL
CATEGORICAL