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Relating DSM-5 section II and section III personality disorder diagnostic classification systems to treatment planning
Relating DSM-5 Section II and Section III Personality Disorder Diagnostic Classification Systems to Treatment Planning Leslie C. Morey, Kathryn T. Benson PII: DOI: Reference:
S0010-440X(15)30338-2 doi: 10.1016/j.comppsych.2016.03.010 YCOMP 51650
To appear in:
Comprehensive Psychiatry
Please cite this article as: Morey Leslie C., Benson Kathryn T., Relating DSM-5 Section II and Section III Personality Disorder Diagnostic Classification Systems to Treatment Planning, Comprehensive Psychiatry (2016), doi: 10.1016/j.comppsych.2016.03.010
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Running head: DIAGNOSTIC CLASSIFICATION AND TREATMENT PLANNING
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Relating DSM-5 Section II and Section III Personality Disorder Diagnostic Classification Systems to
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Treatment Planning
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Leslie C. Morey
Kathryn T. Benson
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Texas A&M University
Author Note Correspondence concerning this article should be addressed to Leslie C. Morey, Department of Psychology, Texas A&M University, College Station, TX 77843-4235. E-mail: [email protected]
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Abstract
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Background: Beginning with DSM-III, the inclusion of a ―personality‖ axis was designed to encourage
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awareness of personality disorders and the treatment-related implications of individual differences, but since that time there is little accumulated evidence that the personality disorder categories provide
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substantial treatment-related guidance. The DSM-5 Personality and Personality Disorders Work Group sought to develop an Alternative Model for personality disorder, and this study examined whether this
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model is more closely related to clinicians‘ decision-making processes than the traditional categorical
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personality disorder diagnoses. Procedures: A national sample of 337 clinicians provided complete personality disorder diagnostic information and several treatment-related clinical judgments about one of Findings:
The dimensional concepts of the DSM-5 Alternative Model for personality
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their patients.
disorders demonstrated stronger relationships than categorical DSM-IV/DSM-5 Section II diagnoses to 10
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of 11 clinical judgments regarding differential treatment planning, optimal treatment intensity, and longterm prognosis. Conclusions: The constructs of the DSM-5 Alternative Model for personality disorders
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may provide more clinically useful information for treatment planning than the official categorical
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personality disorder diagnostic system retained in DSM-5 Section II.
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Treatment Planning
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1. Introduction
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Relating DSM-5 Section II and Section III Personality Disorder Diagnostic Classification Systems to
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One of the primary purposes of a classification system in mental health is to provide concepts useful for treatment planning and intervention [1]. In particular, one of the hopes for the inclusion of a
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―personality‖ axis in the diagnostic system, beginning with DSM-III, was that a consideration of important individual differences would lead to more refined treatment selection [2]. However, the
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literature on the utility of the personality disorder system for treatment assignment is quite limited; although individuals with personality disorders often have worse outcomes than those without PD in
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response to established treatment, there is often little suggestion that any particular PD construct predicts superior treatment response to any particular treatment approach [3]. In order to more precisely evaluate
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specificity of treatment effects and to assess fidelity of application, researchers have developed
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‗manualized‘ treatments for PD such as psychodynamic psychotherapy [4], Dialectical Behavior Therapy [5], and object relations/interpersonal approaches [6]. At present, the only traditional personality disorder included in the APA Division 12 ―list of empirically supported treatments‖ is Borderline Personality Disorder (BPD), and yet the treatments described for BPD are typically those elaborated for the other personality disorders as well (e.g., schema-focused therapy) [7]. It is likely that clinicians treating individuals with PDs make complex choices in selecting interventions that take account of numerous cognitive, behavioral, interpersonal, and dynamic factors, but for the most part the extant categories of personality disorder provide little guidance for such choices. As such, the personality disorders section of the DSM has often been criticized as lacking in clinical utility[8].
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Given this and numerous other problems with the extant personality disorder diagnostic system,
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such as extensive co-occurrence of PDs, heterogeneity among patients receiving the same PD diagnosis,
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and limited reliability and validity of the concepts[9], the DSM-5 Personality and Personality Disorders Work Group sought to develop an approach to the Personality Disorders section of DSM-5 that might
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rectify some of these problems [10,11]. A study endorsed by two influential PD research organizations (the Association for Research on Personality Disorders and the International Society for the Study of
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Personality Disorders), found that most PD experts surveyed thought that the DSM-IV-TR categorical
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approach to PDs should be replaced, and that a ―hybrid‖ categorical-dimensional approach to PD diagnosis was the most desirable alternative to DSM-IV-TR [12]. The Work Group proposed a novel,
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hybrid model for the assessment and diagnosis of personality pathology that centers around dimensional evaluations of 1) the severity of impairment in core personality (self and interpersonal) functioning and 2)
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25 pathological personality trait "facets" organized into 5 broad trait "domains." This "Alternative Model" was approved by the DSM-5 Task Force, and was intended for inclusion in Section II of DSM-5,
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"Diagnostic Criteria and Codes." However, the Board of Trustees of the American Psychiatric
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Association voted to put the new model in Section III of the manual-- "Emerging Measures and Models," and to continue with the identical categories and criteria from DSM-IV for the personality disorders in DSM-5 Section II (to avoid confusion, this latter classification will be labeled as the ―DSM-IV‖ system in this paper even though it was retained verbatim in DSM-5 Section II). The Board‘s decision appeared to be related to the presence of considerable resistance from some PD clinicians and researchers to the substantial changes represented by the Alternative Model [13]. Among the most cited concerns was a feared loss of clinical utility resulting from a move toward a more dimensional representation of personality problems. For example, a commentary by Shedler et al. [14] stated that ―the proposed system for classifying personality disorders is too complicated, includes a traitbased approach to diagnosis without an adequate clinical rationale, and omits personality syndromes that
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have significant clinical utility,‖ [p. 1026] while Clarkin and Huprich [15] wrote that the Alternative
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Model ―does not often meet criteria for clinical relevance‖ [p. 202]. However, the concerns expressed by
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such writers were offered in the absence of relevant data. Verheul [8] observed that there have been few studies supporting the clinical utility of the extant model. Those studies that had been done typically
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compared clinical utility ratings provided by clinicians diagnosing cases, using the DSM approach to cases described by the normative Five-Factor (FFM) trait model. Such studies obtained mixed results
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that variously supported the DSM [16–18] or the FFM or other dimensional approaches [19, 20]. In
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summarizing the results of these and other studies, Mullins-Sweatt and Lengel [21] noted that it is important to compare diagnostic systems using comparable methods of assessment; when such studies are
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conducted, the FFM has been found to demonstrate equivalent or better clinical utility than the DSM categorical model, calling into question whether use of a dimensional approach would indeed result in a
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significance loss of acceptability or perceived clinical utility. One of the first studies of the perceived clinical utility of the DSM-5 Alternative Model (hereafter
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referred to as DSM-5-AM) was conducted by Morey et al. [22], who conducted a survey of 337 mental
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health clinicians (26% psychiatrists, 63% psychologists, and 11% other professional disciplines), each of whom evaluated one of their patients on all personality disorder features listed in DSM-IV-TR and DSM5-AM. After applying each diagnostic model, clinicians evaluated the clinical utility of that model with respect to communication—both with patients and with other professionals—as well as comprehensiveness, descriptiveness, ease of use, and utility for treatment planning. These perceptions were compared across DSM-IV-TR and the three components of the DSM-5-AM, and comparisons were also made between psychiatrists and non-psychiatrists. Although DSM-IV-TR was seen as easy to use and useful for professional communication, in every other respect the Alternative Model was viewed as being equally or more clinically useful than DSM-IV-TR. In particular, the DSM-5 dimensional trait
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model was seen as more useful than the DSM-IV model in 5 of 6 comparisons—a perception shared by
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psychiatrists as well as other professionals.
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Recently, a similar study by Nelson et al. [23] obtained responses from 332 individuals in doctoral training in clinical psychology (graduate students and predoctoral interns). Participants were
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asked to apply different models in conceptualizing one of their current clients; of specific interest were comparisons between the DSM-5 Alternative Model— pathological trait model--and two other potential
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models for personality description--the Shedler-Westen Assessment of Personality [24], and the
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Psychodynamic Diagnostic Manual [25]. Participants responded to a number of questions indicative of their acceptance of these approaches, including: ease of use, usefulness, reflecting a comprehensive understanding of the client, providing a better understanding of the client, capturing interpersonal
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impairment, expanding thinking about client‘s personality pathology, helpfulness for treatment planning,
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and usefulness for formulating diagnosis. For these eight utility judgments, the DSM-5-AM was rated significantly better than both the SWAP and PDM approaches in five areas, including helpfulness for
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treatment planning. The Alternative Model was seen as superior to the SWAP but not the PDM in
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―expanding thinking about client‘s personality pathology,‖ and was superior to the PDM but not the SWAP in ―usefulness for formulating diagnosis.‖ No differences between models were observed for ―capturing interpersonal impairment.‖ In no instance was either the SWAP or PDM rated as being superior to the Section III pathological trait model. To date, the data suggesting the potentially greater utility of the DSM-5-AM are limited to clinician perceptions of clinical utility. The purpose of the present investigation is to move beyond such global clinician perceptions, which may be influenced by familiarity or openness to new approaches, by studying more specific clinical judgments. In particular, the study seeks to determine whether the constructs of the Alternative Model are more closely related to clinicians‘ treatment-related decisionmaking processes than those of the extant DSM categorical model of personality disorder diagnosis.
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Thus, the current study examines treatment-related decisions made by clinicians about their own
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patients—decision related to prognosis, treatment intensity, and differential treatment planning. It is
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hypothesized that the constructs of the Alternative Model will be able to more closely model treatment decision-making than those of the DSM-IV categorical PD system—a finding that would suggest that
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these concepts may be more informative for important treatment decisions.
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2. Method
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The institutional review board of Texas A&M University approved the study protocol; all participants provided responses to indicate their informed consent to participate in the study.
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2.1 Subjects
The national sample of 337 doctoral-level psychologists (213) or psychiatrists (85) consisted of
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48% women with an average 19 years (SD = 10.9) of clinical experience. The patient sample (57% women), ranged in age from 15 to 79 (Mage = 39, SD = 13.9); 40% of the sample met criteria for BPD
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(women n=97; men n=38). A more detailed description of study participants may be found in Morey,
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Krueger, and Skodol [26].
2.2 Materials and Measures Clinicians were solicited via email from various mental-health organizations, and by means of electronic survey provided diagnostic information on a patient with whom they had spent a minimum of 5-contact hours. Section 1 of the survey obtained both clinician and target-patient demographic data. In Section 2 of the survey, clinicians were asked to indicate the suitability of particular psychotherapeutic modalities for the treatment of their target patient; specifically, individual cognitive, exploratory, and supportive therapy, as well as group therapy. The appropriateness of these modalities was assessed on a 4-point scale: 1) contraindicated, 2) unlikely to help, 3) potentially indicated, and 4) strongly indicated. Similarly, clinicians‘ determinations regarding the potential utility of the following pharmacotherapeutic
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modalities were assessed: Anti-anxiety medications, Antidepressants, Antipsychotics, Anti-seizure, and
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Mood-stabilizing medication. Next, clinicians were asked to indicate—regardless of financial
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consideration—the optimal treatment level for their target patient, ranging from 1) self-help, 2) outpatient care, 3) intensive outpatient care, 4) residential/partial hospitalization, through to 5) psychiatric
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hospitalization. Finally, clinicians provided a long-term prognosis for their target patient, the assessment of which ranged from: 1) poor, 2) guarded, 3) fair, to 4) good. Section 3 of the survey obtained
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information sufficient for DSM–IV as well as DSM–5-AM Personality Disorder diagnostic classification.
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The 79 criteria for all ten DSM-IV personality disorders were extracted verbatim and presented in random order to minimize possible halo effects. Clinicians assigned present/absent designations for each of the
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79 criteria. In contrast to the polythetic nature of the DSM-IV personality disorder constructs, the DSM5-AM defines specific diagnoses as combinations of characteristic impairments in core areas of
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personality functioning—Self and Interpersonal—with Self-functioning instantiated by Identity and Selfdirection, and Interpersonal-functioning as Empathy and Intimacy (collectively referred to as Criterion
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A). All four components are described along a single continuum that ranges from healthy functioning
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(Level = 0), to extreme impairment (Level = 4). In addition to Criterion A, a complete DSM-5-AM diagnostic profile involves the identification and selection of pathological personality trait configurations (Criterion B). For the purpose of the survey, a one- or two-sentence definition was provided for each trait, and clinicians were asked to rate patients on the applicability of the trait using a 4-point scale— ―very little or not at all descriptive,‖ ―mildly descriptive,‖ ―moderately descriptive,‖ or ―extremely descriptive.‖[27,28] To avoid any artifactual association between putatively related traits, the traits were presented in alphabetical order. 2.3 Analytic Overview The purpose of the present investigation was to examine the relationship between the DSM-IV and the DSM-5-AM Personality Disorder constructs and treatment-related decisions made by clinicians
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concerning their own patients. The initial analyses simply examined the zero-order correlations between
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both DSM-IV (i.e., 10 PD diagnoses) and DSM-5-AM (25 pathological traits and one global personality
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functioning severity dimension) constructs and clinician ratings of the 11 previously described treatment variables (the appropriateness and/or contraindications regarding four psychotherapeutic modalities, five
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pharmacotherapeutic interventions, ideal treatment intensity, and long-term prognosis). To provide an estimate of the extent of clinical decision-making that was captured by the constructs of the two
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alternative models of PD, multiple regression models were then constructed using the set of DSM-IV (10
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binary—present/absent—coded variables) and DSM-5-AM (26 variables) to predict each of the 11 treatment decision variables, deriving a multiple correlation describing the predicting capacity of the two
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different diagnostic models as a set. However, because the DSM-5-AM model includes substantially more predictor variables than the DSM-IV model, there is the potential for over-fitting, i.e., models with
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more predictors artificially elevating multiple correlations. To provide an empirical effect size estimate free from over-fitting, a Predicted Residual Sums of Squares [29], or PRESS, approach was employed, in
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which a model is built with data from every participant except the one whose score is being predicted.
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This procedure occurs for each participant (i.e., the number of regression models equals the number of participants), and a cumulative effect size is estimated based on the observed residuals from this analysis for the entire sample. The PRESS correlation provides a test of the ability of the model to generalize outside of the sample from which it is drawn, as these cross-validated values are unaffected by the number of predictors in each model. However, an omnibus F-test of the resulting PRESS correlations is not possible, and thus significance testing is described only for the full-sample models. Both regressionand PRESS-derived multiple correlations are reported for all analyses, though all substantive interpretations are based on PRESS coefficients.
3. Results
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Tables 1 and 2 list all statistically significant (p < .05) correlations between the constructs of the
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DSM-IV and DSM-5-AM diagnostic models, respectively, and the 11 treatment decision variables. For
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the nine treatment modalities, high scores on the target variable suggest that the modality in question was indicated for the patient; thus, a negative correlation suggests that the diagnosis or trait would
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contraindicate such treatment. For long-term prognosis, high scores indicate favorable prognosis, and thus a negative correlation implies poor clinician-rated prognosis in patients with the diagnosis/trait. For
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optimal treatment level, high scores indicated high intensity treatment needs for patients with the
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disorder/trait. In general, the magnitudes of these correlations were modest to moderate, ranging up to .48 for the DSM-5-AM model, and up to .34 for the DSM-IV model. There was considerable variability in
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results across the different treatment-related decisions; for example, for these clinicians the diagnostic constructs provided relatively few correlates of decisions concerning group therapy or cognitive therapy,
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while decisions around exploratory therapy, prognosis, and most of the pharmacologic interventions yielded numerous associations with the diagnostic constructs. Of the ten DSM-IV PDs examined,
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Borderline PD demonstrated the greatest number of significant correlates with clinician‘s treatment
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recommendations, being positively associated with all pharmacotherapeutic recommendations. Of the 25 trait facets examined from the DSM-5-AM, Depressivity was associated with the greatest number of clinician‘s specific treatment modality recommendations (7 of 9 specific treatment recommendations), followed by Anxiousness (6 of 9). Table 3 presents the multiple R and PRESS-corrected multiple Rs which were used to compare DSM-IV and DSM-5-AM formulations for personality disorder in terms of their ability to explain clinicians‘ treatment-related decisions. Examination of the results for the DSM-IV model indicates that the DSM-IV personality disorder constructs captured a significant portion of the variance associated with clinicians‘ treatment-related decisions regarding one of their patients in eight of the eleven explored treatment decisions. Significant multiple Rs ranged from .28 (supportive therapy) to .47 (long-term
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prognosis). Treatment decision variables that were not significantly predicted by DSM-IV constructs
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included cognitive therapy, group therapy, and anti-seizure medication. With respect to constructs from
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the DSM-5-AM, these constructs captured a significant portion of the variance associated with clinicians‘ treatment-related decisions regarding one of their patients in nine of the eleven instances examined, with
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multiple Rs ranging from .34 (cognitive therapy, for which the PRESS R did not reach significance) to .66 (prognosis). The DSM-5-AM constructs did not significantly predict clinician judgments of suitability
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for supportive therapy and group therapy. Because the PRESS R values represent cross-validated
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regression results that are less vulnerable to over-fitting a particular data set, they provide the best basis for comparing the predictive validity of the two diagnostic models that are comprised of quite different
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numbers of predictor variables. In two instances, both of which favored the DSM-5-AM, the 95% confidence intervals for the PRESS R values for the two classifications did not overlap, these being
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decisions involving Antipsychotics and Long-Term Prognosis. However, considering the performance of the two models across all treatment variables, the DSM-5-AM PRESS correlation values exceeded the
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corresponding DSM-IV PRESS values for all treatment-related decisions except one—Supportive
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Therapy. To statistically compare the magnitude of the predictive multiple correlations across the different classification models, a paired-differences t-test was conducted upon r-to-z transformed values for the results in Table 3, revealing that the average multiple correlations for the DSM-5-AM exceeded those for the DSM-IV for both the model multiple correlations (t(10) = 8.75, p < .001, d = 1.55) and the PRESS multiple correlations (t(10) = 3.90, p < .003, d = 0.68). Furthermore, given that 10 out of 11 results indicated greater cross-validated predictive validity for the DSM-5-AM, a binomial sign test confirms that these results differ significantly from those expected if the two models did not differ (p < .0059). As such, it would appear these data suggest that across the clinical judgments examined here, the Alternative Model does consistently capture clinicians‘ treatment-related decision-making to a greater
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degree than the official DSM-IV approach, which was retained in DSM-5 Section II, to the classification
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of personality disorder. To test whether years of experience or mental health profession (psychiatrist vs. non-psychiatrist)
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was differentially related to these patterns of clinical judgments, tests of potential interactions between these variables and the 11 judgments were conducted for the DSM-IV and DSM-5-AM models described
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in Table 3. Of these 44 tests for interactions, only one achieved significance, that involving the interaction DSM-IV diagnoses with profession as related to predicting mood stabilizer indications (t=-
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2.38, p < .02), where interestingly, the DSM-IV diagnoses were more predictive of judged indication of mood stabilizers for non-psychiatrists (.41) than for psychiatrists (.16). Given the number of analyses for
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possible interactions, this finding might be spurious, and in general there was little evidence that either profession or years of experience systematically affected the relationships between personality disorder
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4. Discussion
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constructs and treatment-related clinical judgments.
Clinicians treating individuals with PDs must make complex choices in selecting and designing
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interventions, choices that should take account of numerous cognitive, behavioral, interpersonal and dynamic factors. Unfortunately, it is not clear that the extant categorical system of personality disorder diagnosis provides much guidance for assisting such choices. A primary intent for the inclusion of a ―personality‖ axis, beginning with DSM-III, was not only to facilitate awareness of personality disorders within a diagnostic system, but moreover, to encourage awareness of personality itself and its implications for treatment [30]. Unfortunately, in the interim limited data have accumulated regarding the utility of categorical PD constructs in treatment planning. The initial efforts in this area tended to demonstrate that the presence of comorbid personality disorder in combination with other mental disorders led to poorer treatment response[31], although there is typically limited specificity for such findings across different PD categories. Subsequently, an emerging literature has demonstrated the
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efficacy of various manualized treatments for certain PDs such as dialectical behavior therapy,
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mentalizing based therapy, and transference-focused therapy [5,32,33]. However, again there is a lack of
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evidence that the effects of these interventions are specific to certain PD categories, and little evidence to suggest that any one of these treatments are more effective with a particular PD than the others[34,35].
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The Alternative Model for PD (DSM-5-AM) proposed by the DSM-5 Personality and Personality Disorders Work Group was offered in the hope of providing a more valid representation of personality
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problems for both scientific and clinical application, as described by Skodol et al.[36]. These
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recommendations were rejected by the American Psychiatric Association Board of Trustees, perhaps in part because this group was heavily influenced by an outline of classification validation offered by Robins
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and Guze [37] that emphasized biobehavioral validators such as laboratory data or genetic vulnerability [38], with little reference to more clinically significant criteria such as differential treatment response.
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However, one of the primary purposes of a classification system in mental health is to provide concepts useful for treatment planning and intervention [1], and the personality disorders section of the DSM has
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often been singled out as particularly lacking in clinical utility [8]. As such, findings that the Alternative
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Model constructs are more predictive of actual clinical decision-making than extant DSM-IV/DSM-5 Section II PD concepts, despite the fact that clinicians are not yet familiar with Alternative Model concepts, provides evidence for a potentially greater clinical utility of the alternative approach. The Alternative Model predicted clinicians‘ decisions better than did the DSM-IV categories in 10 of the 11 studied clinical judgments of treatment-related decision-making. The one exception involved determinations of appropriateness for Supportive Therapy, where the DSM-IV constructs predicted clinician judgments and the DSM-5-AM constructs did not. To the extent that supportive interventions may be particularly applicable for situational crisis intervention, it is possible that the DSM-IV constructs may potentially represent more situational or contextual behaviors that are nonetheless manifestations of personality-related disorders, in contrast to traits that may present a more enduring characterization of
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personality. Indeed, prior research has indicated that traditional diagnostic features of personality
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disorder are less stable over time than are the traits they supposedly manifest [39].
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Of the 11 examined treatment-related judgments, the variable that was most consistently associated with the various personality disorder constructs was long-term prognosis, with most results
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suggesting that the presence of PD indicators were associated with poorer judged prognosis. The consistency of this finding across constructs can be considered supportive of the DSM-5-AM
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incorporation of a global severity dimension that permeates most PD variants. Indeed, the association of
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the clinician rating of this dimension (i.e., Level of Personality Functioning) with rated Long-Term Prognosis proved to be the largest single bivariate correlation observed in this study. This observation is
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consistent with findings that comorbid personality disorder typically leads to poorer treatment response[31], and highlights the importance of including such a severity dimension within a nosology for
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personality disorders.
It must be recognized that the current study examined clinical judgments, and not patient
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outcomes. Thus, although these data suggest that clinicians view certain DSM-5-AM and DSM-IV PD
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constructs as relevant in treatment planning—for example, severe impairment in personality functioning suggesting a need for high intensity treatments, or Avoidant personality indicating the potential usefulness of supportive therapy—this does not mean that these decisions are necessarily accurate. Nonetheless, the findings here represent a potentially useful source of hypotheses to be tested in subsequent outcome studies. In the years prior to the release of DSM-III, Blashfield and Draguns [1] noted that ―There is a broad consensus that the classification will have clinical utility and can override the potentially damaging effects of labelling if it provides clear indications for the type of therapy to be used and for the formulation of prognostic statements‖ [p. 577].
However, succeeding editions of the DSM
have failed to realize this goal for a classification system for personality disorder. The current study represents a preliminary step towards establishing the clinical utility of the DSM-5-AM for personality
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disorders with respect to treatment planning.
These findings must be extended through carefully
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controlled treatment and outcome studies documenting the differential validity of these constructs for
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treatment decision making. Such a program of research will be vitally important if any taxonomy for personality and personality disorder, whether the DSM-5-AM approach or any alternative, is to reach the
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important goal of established clinical utility.
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References
Blashfield RK, Draguns JG. Toward a taxonomy of psychopathology: The purpose of psychiatric classification. Br J Psychiatry 1976;129:574–83. doi:10.1192/bjp.129.6.574.
[2]
Frances A, Clarkin J. Differential therapeutics: A guide to treatment selection. Hosp Community Psychiatry 1981;32:537–46. doi:10.1007/BF01070098.
[3]
Shea MT, Pilkonis PA, Beckham E, Collins JF, Elkin I, Sotsky SM, et al. Personality disorders and treatment outcome in the NIMH treatment of depression collaborative research program. Am J Psychiatry 1990;147:711–8.
[4]
Levy KN, Wasserman RH, Scott LN, Zach SE, White C, Cain N, et al. The development of a measure to assess putative mechanisms of change in the treatment of borderline personality disorder. J Am Psychoanal Assoc 2006;54:1325–31. doi:10.1177/00030651060540040106.
[5]
Linehan MM. Cognitive-behavioral treatment of borderline personality disorder. 1993.
[6]
Dawson DF. Treatment of the borderline patient, relationship management. Can J Psychiatry/La Rev Can Psychiatr 1988;33:370–4.
[7]
Young J. Schema-focused therapy for personality disorder. Cogn Behav Ther A Guid … 2002.
[8]
Verheul R. Clinical utility of dimensional models for personality pathology. J Pers Disord 2005;19:283–302. doi:10.1521/pedi.2005.19.3.283.
[9]
Clark LA, Livesley WJ, Morey LC. Special feature: Personality disorder assessment: The challenge of construct validity. J Pers Disord 1997;11:205–31. doi:10.1521/pedi.1997.11.3.205.
[10]
Kupfer DJ, First MB, Regier DA. A research agenda for DSM-V. Washington, DC, US Am Psychiatr Assoc 2002: xxiii-307.
[11]
Rounsaville BJ, Alarcón RD, Andrews G, Jackson JS, Kendell RE, Kendler K. Basic nomenclature issues for DSM-V. A Res. agenda DSM-V, 2002: 1-29.
[12]
Bernstein DP, Iscan C, Maser J. Opinions of personality disorder experts regarding the DSM-IV personality disorders classification system. J Pers Disord 2007;21:536–51. doi:10.1521/pedi.2007.21.5.536.
[13]
Zachar P, Krueger RF, Kendler KS. Personality disorder in DSM-5: An oral history. Psychol Med 2015;in press. doi:http://dx.doi.org/10.1017/S0033291715001543.
[14]
Shedler J, Beck A, Fonagy P, Gabbard GO, Gunderson JG, Kernberg OF, et al. Personality disorders in DSM-5. Am J Psychiatry 2010;167:1026–8. doi:10.1146/annurev-clinpsy-032511143131.
[15]
Clarkin JF, Huprich SK. Do DSM-5 personality disorder proposals meet criteria for clinical utility? J Pers Disord 2011;25:192–205. doi:10.1521/pedi.2011.25.2.192.
AC
CE
PT
ED
MA
NU
SC
[1]
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Sprock J. Dimensional versus categorical classification of prototypic and nonprototypic cases of personality disorder. J Clin Psychol 2003;59:991–1014.
[17]
Rottman BM, Kim NS, Ahn WK, Sanislow CA. Can personality disorder experts recognize DSMIV personality disorders from five-factor model descriptions of patient cases? J Clin Psychiatry 2011;72:630–9. doi:10.4088/JCP.09m05534gre.
[18]
Spitzer RL, First MB, Shedler J, Westen D, Skodol AE. Clinical utility of five dimensional systems for personality diagnosis: A ―consumer preference‖ study. J Nerv Ment Dis 2008;196:356–74. doi:10.1097/NMD.0b013e3181710950.
[19]
Samuel DB, Widiger TA. Clinicians ‘ judgments of clinical utility : A comparison of the DSM-IV and five-factor models. J Abnorm Psychol 2006;115:298–308. doi:10.1037/0021-843X.115.2.298.
[20]
Lowe JR, Widiger TA. Clinicians‘ judgments of clinical utility: A comparison of the DSM-IV with dimensional models of general personality. J Pers Disord 2009;23:211–29. doi:10.1521/pedi.2009.23.3.211.
[21]
Mullins-Sweatt SN, Lengel GJ. Clinical utility of the five-factor model of personality disorder. J Pers 2012;80:1615–39. doi:10.1111/j.1467-6494.2012.00774.x.
[22]
Morey LC, Skodol AE, Oldham JM. Clinician judgments of clinical utility: A comparison of DSM-IV-TR personality disorders and the alternative model for DSM-5 personality disorders. J Abnorm Psychol 2014;123:398–405. doi:10.1037/a0036481.
[23]
Nelson S, Paggeot A, Lengu K, Huprich SK, Sohnleitner A, Shankar S. The forest and the trees: A quantitative and qualitative evaluation of student preferences for four methods of personality disorder diagnosis, Brooklyn, NY: Paper pres. Soc for Pers Assess 2015.
[24]
Shedler J, Westen D. The Shedler-Westen assessment procedure (SWAP): Making personality diagnosis clinically meaningful. J Pers Assess 2007;89:41–55. doi:10.1080/00223890701357092.
RI P
SC
NU
MA
ED
PT
CE
AC
[25]
T
[16]
PDM Task Force. Psychodynamic Diagnostic Manual. Alliance of Psychoanalytic Organizations. Silver Spring, MD 2006
[26]
Morey LC, Krueger RF, Skodol AE. The hierarchical structure of clinician ratings of proposed DSM-5 pathological personality traits. J Abnorm Psychol 2013;122:836–41. doi:10.1037/a0034003.
[27]
American Psychiatric Association . Diagnostic and Statistical Manual for Mental Disorders, 5th edition. 2013. doi:10.1176/appi.books.9780890425596.744053.
[28]
Krueger RF, Eaton NR, Derringer J, Markon KE, Watson D, Skodol AE. Helping delineate personality disorder content and framing the metastructure. J Pers Assess 2011;93:325–31. doi:10.1080/00223891.2011.577478.
[29]
Stevens JP. Applied multivariate statistics for the social sciences (4th ed.). 2002.
[30]
Frances A, Clarkin J, Perry S. Differential therapeutics in psychiatry: The art and science of treatment selection. New York: Brunner/Mazel Inc.; 1984.
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Reich JH, Green AI. Effect of personality disorders on outcome of treatment. J Nerv Ment Dis 1991;179:74–82. doi:10.1097/00005053-199102000-00003.
[32]
Bateman A, Fonagy P. 8-year follow-up of patients treated for borderline personality disorder: mentalization-based treatment versus treatment as usual. Am J Psychiatry 2008;165:631–8. doi:10.1176/appi.ajp.2007.07040636.
[33]
Clarkin JF, Levy KN, Lenzenweger MF, Kernberg OF. Evaluating three treatments for borderline personality disorder: A multiwave study. Am J Psychiatry 2007;164:922–8. doi:10.1176/ajp.2007.164.6.922.
[34]
Levy KN, Scala JW. Integrated treatment for personality disorders: A commentary. J Psychother Integr 2015;25:49–57. doi:10.1037/a0038771.
[35]
Mulder R, Chanen AM. Effectiveness of cognitive analytic therapy for personality disorders. Br J Psychiatry 2013;202:89–90. doi:10.1192/bjp.bp.112.113571.
[36]
Skodol AE, Morey LC, Bender D, Oldham JE. The Alternative DSM-5 Model for personality disorders: a clinical application. Am J Psychiatry 2015;7:606–13.
[37]
Robins E, Guze SB. Establishment of diagnostic validity in psychiatric illness: Its application to schizophrenia. Am J Psychiatry 1970;126:983–7. doi:10.1176/appi.ajp.126.7.983.
[38]
Widiger TA, Crego C, Oltmanns JR. The validation of a classification of psychopathology. Psychol Inq An Int J Adv Psychol Theory 2015;26:272–8.
[39]
Morey LC, Hopwood CJ. Stability and change in personality disorders. Annu Rev Clin Psychol 2013;9:499–528. doi:10.1146/annurev-clinpsy-050212-185637.
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Running head: DIAGNOSTIC CLASSIFICATION AND TREATMENT PLANNING
Group Therapy
AntiAnxiety
.01 -.10 .01 .00 -.02 -.10 .00 -.08 .09 -.02 .08 -.02 .09 .11 -.09 .11 .06 .05 -.05 .03 .08 -.01 -.09 -.02 -.03 -.09
-.15 .04 .14 -.07 -.17 -.16 -.18 .14 -.11 -.21 -.10 -.10 -.22 -.19 .07 -.23 -.23 -.07 -.02 .17 -.17 .10 .26 -.09 -.23 -.05
.01 .11 .19 -.01 -.12 .10 -.16 .14 .07 .05 .07 -.08 -.07 .01 .10 -.10 -.14 .01 .02 .03 -.03 .16 .11 .04 .11 .14
.00 -.02 .07 .01 -.09 -.08 .01 .07 .06 -.09 .05 -.08 -.11 .04 .03 .10 -.04 .01 -.01 -.02 .02 .09 .10 -.10 -.06 -.05
-.01 .20 .40 -.12 -.17 .11 -.18 .21 .06 .03 .11 -.14 -.07 -.06 .15 -.15 -.18 .11 .01 .08 -.15 .15 .14 .07 .11 .17
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Note. Correlations in bold are significant at p < .05.
AntiDepressant
AntiPsychotic
AntiSeizure
MoodStabilizing
Long-Term Prognosis
Optimal TX Level
-.03 .31 .33 -.04 -.24 .02 -.23 .42 .06 -.04 .07 -.20 -.15 -.11 .07 -.17 -.26 .14 -.03 .08 -.19 .21 .23 -.03 .01 .21
.25 .16 .15 -.08 -.02 .44 -.02 .15 .12 .28 .20 -.07 .14 .10 .15 .02 -.06 .14 .04 -.02 .06 .09 -.09 .23 .38 .23
.02 .06 .15 .07 -.01 .14 .01 .14 .13 .06 .15 -.04 .11 .08 -.04 -.01 .01 .02 -.05 -.05 .04 .13 -.06 .08 .05 -.01
.16 .08 .08 .15 .06 .15 .09 .16 .19 .16 .42 .10 .21 .31 -.02 .16 .07 .10 -.08 -.04 .16 .15 -.08 .13 .13 .04
-.48 -.16 .12 -.20 -.33 -.28 -.40 -.12 -.19 -.21 -.30 -.21 -.43 -.35 -.07 -.39 -.38 -.07 -.05 .11 -.32 -.08 .13 -.33 -.26 -.15
.35 .09 -.08 .08 .17 .24 .23 .05 .25 .17 .30 .09 .33 .37 .05 .31 .22 .15 .10 -.13 .31 .08 -.09 .19 .20 .14
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Support Therapy
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Exploratory Therapy
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Lev of Pers Functioning Anhedonia Anxiousness Attention Seeking Callousness Cog Per Dysregulation Deceitfulness Depressivity Distractibility Eccentricity Emotional lability Grandiosity Hostility Impulsivity Intimacy Avoidance Irresponsibility Manipulativeness Perseveration Restricted Affectivity Rigid Perfectionism Risk Taking Separation insecurity Submissiveness Suspiciousness Uns Belief/Experience Withdrawal
Cognitive Therapy
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DSM-5-AM Diagnostic Model
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Table 1 Statistically Significant Correlations between DSM-5-AM Diagnostic Constructs and 11 Clinical Treatment Decisions
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Table 2
Support Therapy
Group Therapy
AntiAnxiety
AntiDepressant
AntiPsychotic
AntiSeizure
MoodStabilizing
Long-Term Prognosis
Optimal TX Level
.01 -.04 -.07 .05 .02 -.05 .02 -.06 -.06 -.11
-.20 -.07 .02 -.14 -.09 .04 -.13 -.02 -.13 .20
-.07 .05 .04 -.06 -.04 -.04 -.01 .14 .10 .22
-.01 .05 .11 .01 -.05 -.06 -.09 .00 -.09 -.01
-.11 .14 .09 -.14 -.15 .08 -.02 .07 .10 .06
-.22 .12 .13 -.04 -.15 .06 -.12 .10 .03 .20
.03 .15 .06 -.06 -.03 .04 .09 .13 .26 .06
.05 .14 .12 .04 .04 .00 .03 .04 .05 .02
.09 .34 .10 .05 .07 -.03 .07 .00 .00 -.01
-.29 -.28 -.05 -.14 -.22 -.05 -.29 -.18 -.17 .02
.26 .23 .05 .04 .05 -.06 .14 .15 .09 -.06
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Exploratory Therapy
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Antisocial PD Borderline PD Dependent PD Histrionic PD Narcissistic PD Ob-Compuls PD Paranoid PD Schizoid PD Schizotypal PD Avoidant PD
Cognitive Therapy
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DSM-IV Categories
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Statistically Significant Correlations between DSM-IV Diagnostic Constructs and 11 Clinical Treatment Decisions
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Note. Correlations in bold are significant at p < .05.
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Running head: DIAGNOSTIC CLASSIFICATION AND TREATMENT PLANNING
(.10-.30)
.00
Anxiolytics
.31**
(.21-.40)
.21**
Antidepressants
.37**
(.27-.46)
.30**
Antipsychotics
.31**
(.21-.40)
.17
(.06-.27)
Mood-Stabilizers
.35**
(.25-.44)
Long-Term Prognosis
.47**
(.38-.55)
Optimal Treatment Level
.38**
(.28-.47)
* p ≤ .05 ** p ≤ .01
Model R .34* .50** .31
95% CI (-.02-.19) (.25 -.44) (-.08-.14)
.32
(.22-.41)
.04
(-.07-.15)
(.11 -.31)
.47**
(.38-.55)
.31**
(.21 -.40)
(.20 -.39)
.55**
(.47-.62)
.43**
(.34 -.51)
.20**
(.10 -.30)
.57**
(.49-.64)
.45**
(.36 -.53)
-.05
(-.16-.06)
.36*
(.26-.45)
.12*
(.01 -.22)
.26**
(.16 -.36)
.50**
(.42-.58)
.34**
(.24 -.43)
.41**
(.32 -.50)
.66**
(.60-.72)
.58**
(.50 -.65)
(.20 -.39)
.57**
(.49-.64)
.45**
(.36 -.53)
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Anti-seizure
95% CI (-.19-.03) (.14 -.34) (.05 -.26)
DSM-5-AM Model (Traits and Level) 95% CI PRESS R (.24-.43) .09 (.42-.58) .35** (.21-.40) .03
(-.11-.11)
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.20
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Group Therapy
Model R .15 .33** .28**
MA NU S
Treatment Cognitive Therapy Exploratory Therapy Supportive Therapy
DSM-IV Model (> Diagnostic Threshold) 95% CI PRESS R (.04-.25) -.08 (.23-.42) .24** (.18-.38) .16**
CR
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Table 3 Multiple Regression Prediction of 11 Clinical Treatment Decisions Using Variables of DSM-IV and DSM-5-III PD Diagnostic Constructs
.30**
S0010-440X(15)30338-2 doi: 10.1016/j.comppsych.2016.03.010 YCOMP 51650
To appear in:
Comprehensive Psychiatry
Please cite this article as: Morey Leslie C., Benson Kathryn T., Relating DSM-5 Section II and Section III Personality Disorder Diagnostic Classification Systems to Treatment Planning, Comprehensive Psychiatry (2016), doi: 10.1016/j.comppsych.2016.03.010
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Running head: DIAGNOSTIC CLASSIFICATION AND TREATMENT PLANNING
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Relating DSM-5 Section II and Section III Personality Disorder Diagnostic Classification Systems to
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Treatment Planning
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Leslie C. Morey
Kathryn T. Benson
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Texas A&M University
Author Note Correspondence concerning this article should be addressed to Leslie C. Morey, Department of Psychology, Texas A&M University, College Station, TX 77843-4235. E-mail: [email protected]
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Abstract
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Background: Beginning with DSM-III, the inclusion of a ―personality‖ axis was designed to encourage
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awareness of personality disorders and the treatment-related implications of individual differences, but since that time there is little accumulated evidence that the personality disorder categories provide
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substantial treatment-related guidance. The DSM-5 Personality and Personality Disorders Work Group sought to develop an Alternative Model for personality disorder, and this study examined whether this
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model is more closely related to clinicians‘ decision-making processes than the traditional categorical
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personality disorder diagnoses. Procedures: A national sample of 337 clinicians provided complete personality disorder diagnostic information and several treatment-related clinical judgments about one of Findings:
The dimensional concepts of the DSM-5 Alternative Model for personality
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their patients.
disorders demonstrated stronger relationships than categorical DSM-IV/DSM-5 Section II diagnoses to 10
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of 11 clinical judgments regarding differential treatment planning, optimal treatment intensity, and longterm prognosis. Conclusions: The constructs of the DSM-5 Alternative Model for personality disorders
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may provide more clinically useful information for treatment planning than the official categorical
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personality disorder diagnostic system retained in DSM-5 Section II.
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Treatment Planning
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1. Introduction
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Relating DSM-5 Section II and Section III Personality Disorder Diagnostic Classification Systems to
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One of the primary purposes of a classification system in mental health is to provide concepts useful for treatment planning and intervention [1]. In particular, one of the hopes for the inclusion of a
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―personality‖ axis in the diagnostic system, beginning with DSM-III, was that a consideration of important individual differences would lead to more refined treatment selection [2]. However, the
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literature on the utility of the personality disorder system for treatment assignment is quite limited; although individuals with personality disorders often have worse outcomes than those without PD in
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response to established treatment, there is often little suggestion that any particular PD construct predicts superior treatment response to any particular treatment approach [3]. In order to more precisely evaluate
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specificity of treatment effects and to assess fidelity of application, researchers have developed
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‗manualized‘ treatments for PD such as psychodynamic psychotherapy [4], Dialectical Behavior Therapy [5], and object relations/interpersonal approaches [6]. At present, the only traditional personality disorder included in the APA Division 12 ―list of empirically supported treatments‖ is Borderline Personality Disorder (BPD), and yet the treatments described for BPD are typically those elaborated for the other personality disorders as well (e.g., schema-focused therapy) [7]. It is likely that clinicians treating individuals with PDs make complex choices in selecting interventions that take account of numerous cognitive, behavioral, interpersonal, and dynamic factors, but for the most part the extant categories of personality disorder provide little guidance for such choices. As such, the personality disorders section of the DSM has often been criticized as lacking in clinical utility[8].
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Given this and numerous other problems with the extant personality disorder diagnostic system,
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such as extensive co-occurrence of PDs, heterogeneity among patients receiving the same PD diagnosis,
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and limited reliability and validity of the concepts[9], the DSM-5 Personality and Personality Disorders Work Group sought to develop an approach to the Personality Disorders section of DSM-5 that might
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rectify some of these problems [10,11]. A study endorsed by two influential PD research organizations (the Association for Research on Personality Disorders and the International Society for the Study of
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Personality Disorders), found that most PD experts surveyed thought that the DSM-IV-TR categorical
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approach to PDs should be replaced, and that a ―hybrid‖ categorical-dimensional approach to PD diagnosis was the most desirable alternative to DSM-IV-TR [12]. The Work Group proposed a novel,
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hybrid model for the assessment and diagnosis of personality pathology that centers around dimensional evaluations of 1) the severity of impairment in core personality (self and interpersonal) functioning and 2)
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25 pathological personality trait "facets" organized into 5 broad trait "domains." This "Alternative Model" was approved by the DSM-5 Task Force, and was intended for inclusion in Section II of DSM-5,
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"Diagnostic Criteria and Codes." However, the Board of Trustees of the American Psychiatric
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Association voted to put the new model in Section III of the manual-- "Emerging Measures and Models," and to continue with the identical categories and criteria from DSM-IV for the personality disorders in DSM-5 Section II (to avoid confusion, this latter classification will be labeled as the ―DSM-IV‖ system in this paper even though it was retained verbatim in DSM-5 Section II). The Board‘s decision appeared to be related to the presence of considerable resistance from some PD clinicians and researchers to the substantial changes represented by the Alternative Model [13]. Among the most cited concerns was a feared loss of clinical utility resulting from a move toward a more dimensional representation of personality problems. For example, a commentary by Shedler et al. [14] stated that ―the proposed system for classifying personality disorders is too complicated, includes a traitbased approach to diagnosis without an adequate clinical rationale, and omits personality syndromes that
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have significant clinical utility,‖ [p. 1026] while Clarkin and Huprich [15] wrote that the Alternative
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Model ―does not often meet criteria for clinical relevance‖ [p. 202]. However, the concerns expressed by
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such writers were offered in the absence of relevant data. Verheul [8] observed that there have been few studies supporting the clinical utility of the extant model. Those studies that had been done typically
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compared clinical utility ratings provided by clinicians diagnosing cases, using the DSM approach to cases described by the normative Five-Factor (FFM) trait model. Such studies obtained mixed results
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that variously supported the DSM [16–18] or the FFM or other dimensional approaches [19, 20]. In
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summarizing the results of these and other studies, Mullins-Sweatt and Lengel [21] noted that it is important to compare diagnostic systems using comparable methods of assessment; when such studies are
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conducted, the FFM has been found to demonstrate equivalent or better clinical utility than the DSM categorical model, calling into question whether use of a dimensional approach would indeed result in a
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significance loss of acceptability or perceived clinical utility. One of the first studies of the perceived clinical utility of the DSM-5 Alternative Model (hereafter
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referred to as DSM-5-AM) was conducted by Morey et al. [22], who conducted a survey of 337 mental
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health clinicians (26% psychiatrists, 63% psychologists, and 11% other professional disciplines), each of whom evaluated one of their patients on all personality disorder features listed in DSM-IV-TR and DSM5-AM. After applying each diagnostic model, clinicians evaluated the clinical utility of that model with respect to communication—both with patients and with other professionals—as well as comprehensiveness, descriptiveness, ease of use, and utility for treatment planning. These perceptions were compared across DSM-IV-TR and the three components of the DSM-5-AM, and comparisons were also made between psychiatrists and non-psychiatrists. Although DSM-IV-TR was seen as easy to use and useful for professional communication, in every other respect the Alternative Model was viewed as being equally or more clinically useful than DSM-IV-TR. In particular, the DSM-5 dimensional trait
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model was seen as more useful than the DSM-IV model in 5 of 6 comparisons—a perception shared by
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psychiatrists as well as other professionals.
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Recently, a similar study by Nelson et al. [23] obtained responses from 332 individuals in doctoral training in clinical psychology (graduate students and predoctoral interns). Participants were
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asked to apply different models in conceptualizing one of their current clients; of specific interest were comparisons between the DSM-5 Alternative Model— pathological trait model--and two other potential
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models for personality description--the Shedler-Westen Assessment of Personality [24], and the
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Psychodynamic Diagnostic Manual [25]. Participants responded to a number of questions indicative of their acceptance of these approaches, including: ease of use, usefulness, reflecting a comprehensive understanding of the client, providing a better understanding of the client, capturing interpersonal
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impairment, expanding thinking about client‘s personality pathology, helpfulness for treatment planning,
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and usefulness for formulating diagnosis. For these eight utility judgments, the DSM-5-AM was rated significantly better than both the SWAP and PDM approaches in five areas, including helpfulness for
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treatment planning. The Alternative Model was seen as superior to the SWAP but not the PDM in
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―expanding thinking about client‘s personality pathology,‖ and was superior to the PDM but not the SWAP in ―usefulness for formulating diagnosis.‖ No differences between models were observed for ―capturing interpersonal impairment.‖ In no instance was either the SWAP or PDM rated as being superior to the Section III pathological trait model. To date, the data suggesting the potentially greater utility of the DSM-5-AM are limited to clinician perceptions of clinical utility. The purpose of the present investigation is to move beyond such global clinician perceptions, which may be influenced by familiarity or openness to new approaches, by studying more specific clinical judgments. In particular, the study seeks to determine whether the constructs of the Alternative Model are more closely related to clinicians‘ treatment-related decisionmaking processes than those of the extant DSM categorical model of personality disorder diagnosis.
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Thus, the current study examines treatment-related decisions made by clinicians about their own
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patients—decision related to prognosis, treatment intensity, and differential treatment planning. It is
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hypothesized that the constructs of the Alternative Model will be able to more closely model treatment decision-making than those of the DSM-IV categorical PD system—a finding that would suggest that
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these concepts may be more informative for important treatment decisions.
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2. Method
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The institutional review board of Texas A&M University approved the study protocol; all participants provided responses to indicate their informed consent to participate in the study.
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2.1 Subjects
The national sample of 337 doctoral-level psychologists (213) or psychiatrists (85) consisted of
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48% women with an average 19 years (SD = 10.9) of clinical experience. The patient sample (57% women), ranged in age from 15 to 79 (Mage = 39, SD = 13.9); 40% of the sample met criteria for BPD
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(women n=97; men n=38). A more detailed description of study participants may be found in Morey,
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Krueger, and Skodol [26].
2.2 Materials and Measures Clinicians were solicited via email from various mental-health organizations, and by means of electronic survey provided diagnostic information on a patient with whom they had spent a minimum of 5-contact hours. Section 1 of the survey obtained both clinician and target-patient demographic data. In Section 2 of the survey, clinicians were asked to indicate the suitability of particular psychotherapeutic modalities for the treatment of their target patient; specifically, individual cognitive, exploratory, and supportive therapy, as well as group therapy. The appropriateness of these modalities was assessed on a 4-point scale: 1) contraindicated, 2) unlikely to help, 3) potentially indicated, and 4) strongly indicated. Similarly, clinicians‘ determinations regarding the potential utility of the following pharmacotherapeutic
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modalities were assessed: Anti-anxiety medications, Antidepressants, Antipsychotics, Anti-seizure, and
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Mood-stabilizing medication. Next, clinicians were asked to indicate—regardless of financial
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consideration—the optimal treatment level for their target patient, ranging from 1) self-help, 2) outpatient care, 3) intensive outpatient care, 4) residential/partial hospitalization, through to 5) psychiatric
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hospitalization. Finally, clinicians provided a long-term prognosis for their target patient, the assessment of which ranged from: 1) poor, 2) guarded, 3) fair, to 4) good. Section 3 of the survey obtained
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information sufficient for DSM–IV as well as DSM–5-AM Personality Disorder diagnostic classification.
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The 79 criteria for all ten DSM-IV personality disorders were extracted verbatim and presented in random order to minimize possible halo effects. Clinicians assigned present/absent designations for each of the
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79 criteria. In contrast to the polythetic nature of the DSM-IV personality disorder constructs, the DSM5-AM defines specific diagnoses as combinations of characteristic impairments in core areas of
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personality functioning—Self and Interpersonal—with Self-functioning instantiated by Identity and Selfdirection, and Interpersonal-functioning as Empathy and Intimacy (collectively referred to as Criterion
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A). All four components are described along a single continuum that ranges from healthy functioning
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(Level = 0), to extreme impairment (Level = 4). In addition to Criterion A, a complete DSM-5-AM diagnostic profile involves the identification and selection of pathological personality trait configurations (Criterion B). For the purpose of the survey, a one- or two-sentence definition was provided for each trait, and clinicians were asked to rate patients on the applicability of the trait using a 4-point scale— ―very little or not at all descriptive,‖ ―mildly descriptive,‖ ―moderately descriptive,‖ or ―extremely descriptive.‖[27,28] To avoid any artifactual association between putatively related traits, the traits were presented in alphabetical order. 2.3 Analytic Overview The purpose of the present investigation was to examine the relationship between the DSM-IV and the DSM-5-AM Personality Disorder constructs and treatment-related decisions made by clinicians
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concerning their own patients. The initial analyses simply examined the zero-order correlations between
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both DSM-IV (i.e., 10 PD diagnoses) and DSM-5-AM (25 pathological traits and one global personality
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functioning severity dimension) constructs and clinician ratings of the 11 previously described treatment variables (the appropriateness and/or contraindications regarding four psychotherapeutic modalities, five
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pharmacotherapeutic interventions, ideal treatment intensity, and long-term prognosis). To provide an estimate of the extent of clinical decision-making that was captured by the constructs of the two
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alternative models of PD, multiple regression models were then constructed using the set of DSM-IV (10
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binary—present/absent—coded variables) and DSM-5-AM (26 variables) to predict each of the 11 treatment decision variables, deriving a multiple correlation describing the predicting capacity of the two
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different diagnostic models as a set. However, because the DSM-5-AM model includes substantially more predictor variables than the DSM-IV model, there is the potential for over-fitting, i.e., models with
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more predictors artificially elevating multiple correlations. To provide an empirical effect size estimate free from over-fitting, a Predicted Residual Sums of Squares [29], or PRESS, approach was employed, in
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which a model is built with data from every participant except the one whose score is being predicted.
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This procedure occurs for each participant (i.e., the number of regression models equals the number of participants), and a cumulative effect size is estimated based on the observed residuals from this analysis for the entire sample. The PRESS correlation provides a test of the ability of the model to generalize outside of the sample from which it is drawn, as these cross-validated values are unaffected by the number of predictors in each model. However, an omnibus F-test of the resulting PRESS correlations is not possible, and thus significance testing is described only for the full-sample models. Both regressionand PRESS-derived multiple correlations are reported for all analyses, though all substantive interpretations are based on PRESS coefficients.
3. Results
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Tables 1 and 2 list all statistically significant (p < .05) correlations between the constructs of the
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DSM-IV and DSM-5-AM diagnostic models, respectively, and the 11 treatment decision variables. For
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the nine treatment modalities, high scores on the target variable suggest that the modality in question was indicated for the patient; thus, a negative correlation suggests that the diagnosis or trait would
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contraindicate such treatment. For long-term prognosis, high scores indicate favorable prognosis, and thus a negative correlation implies poor clinician-rated prognosis in patients with the diagnosis/trait. For
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optimal treatment level, high scores indicated high intensity treatment needs for patients with the
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disorder/trait. In general, the magnitudes of these correlations were modest to moderate, ranging up to .48 for the DSM-5-AM model, and up to .34 for the DSM-IV model. There was considerable variability in
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results across the different treatment-related decisions; for example, for these clinicians the diagnostic constructs provided relatively few correlates of decisions concerning group therapy or cognitive therapy,
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while decisions around exploratory therapy, prognosis, and most of the pharmacologic interventions yielded numerous associations with the diagnostic constructs. Of the ten DSM-IV PDs examined,
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Borderline PD demonstrated the greatest number of significant correlates with clinician‘s treatment
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recommendations, being positively associated with all pharmacotherapeutic recommendations. Of the 25 trait facets examined from the DSM-5-AM, Depressivity was associated with the greatest number of clinician‘s specific treatment modality recommendations (7 of 9 specific treatment recommendations), followed by Anxiousness (6 of 9). Table 3 presents the multiple R and PRESS-corrected multiple Rs which were used to compare DSM-IV and DSM-5-AM formulations for personality disorder in terms of their ability to explain clinicians‘ treatment-related decisions. Examination of the results for the DSM-IV model indicates that the DSM-IV personality disorder constructs captured a significant portion of the variance associated with clinicians‘ treatment-related decisions regarding one of their patients in eight of the eleven explored treatment decisions. Significant multiple Rs ranged from .28 (supportive therapy) to .47 (long-term
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prognosis). Treatment decision variables that were not significantly predicted by DSM-IV constructs
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included cognitive therapy, group therapy, and anti-seizure medication. With respect to constructs from
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the DSM-5-AM, these constructs captured a significant portion of the variance associated with clinicians‘ treatment-related decisions regarding one of their patients in nine of the eleven instances examined, with
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multiple Rs ranging from .34 (cognitive therapy, for which the PRESS R did not reach significance) to .66 (prognosis). The DSM-5-AM constructs did not significantly predict clinician judgments of suitability
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for supportive therapy and group therapy. Because the PRESS R values represent cross-validated
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regression results that are less vulnerable to over-fitting a particular data set, they provide the best basis for comparing the predictive validity of the two diagnostic models that are comprised of quite different
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numbers of predictor variables. In two instances, both of which favored the DSM-5-AM, the 95% confidence intervals for the PRESS R values for the two classifications did not overlap, these being
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decisions involving Antipsychotics and Long-Term Prognosis. However, considering the performance of the two models across all treatment variables, the DSM-5-AM PRESS correlation values exceeded the
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corresponding DSM-IV PRESS values for all treatment-related decisions except one—Supportive
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Therapy. To statistically compare the magnitude of the predictive multiple correlations across the different classification models, a paired-differences t-test was conducted upon r-to-z transformed values for the results in Table 3, revealing that the average multiple correlations for the DSM-5-AM exceeded those for the DSM-IV for both the model multiple correlations (t(10) = 8.75, p < .001, d = 1.55) and the PRESS multiple correlations (t(10) = 3.90, p < .003, d = 0.68). Furthermore, given that 10 out of 11 results indicated greater cross-validated predictive validity for the DSM-5-AM, a binomial sign test confirms that these results differ significantly from those expected if the two models did not differ (p < .0059). As such, it would appear these data suggest that across the clinical judgments examined here, the Alternative Model does consistently capture clinicians‘ treatment-related decision-making to a greater
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degree than the official DSM-IV approach, which was retained in DSM-5 Section II, to the classification
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of personality disorder. To test whether years of experience or mental health profession (psychiatrist vs. non-psychiatrist)
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was differentially related to these patterns of clinical judgments, tests of potential interactions between these variables and the 11 judgments were conducted for the DSM-IV and DSM-5-AM models described
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in Table 3. Of these 44 tests for interactions, only one achieved significance, that involving the interaction DSM-IV diagnoses with profession as related to predicting mood stabilizer indications (t=-
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2.38, p < .02), where interestingly, the DSM-IV diagnoses were more predictive of judged indication of mood stabilizers for non-psychiatrists (.41) than for psychiatrists (.16). Given the number of analyses for
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possible interactions, this finding might be spurious, and in general there was little evidence that either profession or years of experience systematically affected the relationships between personality disorder
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4. Discussion
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constructs and treatment-related clinical judgments.
Clinicians treating individuals with PDs must make complex choices in selecting and designing
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interventions, choices that should take account of numerous cognitive, behavioral, interpersonal and dynamic factors. Unfortunately, it is not clear that the extant categorical system of personality disorder diagnosis provides much guidance for assisting such choices. A primary intent for the inclusion of a ―personality‖ axis, beginning with DSM-III, was not only to facilitate awareness of personality disorders within a diagnostic system, but moreover, to encourage awareness of personality itself and its implications for treatment [30]. Unfortunately, in the interim limited data have accumulated regarding the utility of categorical PD constructs in treatment planning. The initial efforts in this area tended to demonstrate that the presence of comorbid personality disorder in combination with other mental disorders led to poorer treatment response[31], although there is typically limited specificity for such findings across different PD categories. Subsequently, an emerging literature has demonstrated the
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efficacy of various manualized treatments for certain PDs such as dialectical behavior therapy,
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mentalizing based therapy, and transference-focused therapy [5,32,33]. However, again there is a lack of
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evidence that the effects of these interventions are specific to certain PD categories, and little evidence to suggest that any one of these treatments are more effective with a particular PD than the others[34,35].
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The Alternative Model for PD (DSM-5-AM) proposed by the DSM-5 Personality and Personality Disorders Work Group was offered in the hope of providing a more valid representation of personality
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problems for both scientific and clinical application, as described by Skodol et al.[36]. These
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recommendations were rejected by the American Psychiatric Association Board of Trustees, perhaps in part because this group was heavily influenced by an outline of classification validation offered by Robins
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and Guze [37] that emphasized biobehavioral validators such as laboratory data or genetic vulnerability [38], with little reference to more clinically significant criteria such as differential treatment response.
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However, one of the primary purposes of a classification system in mental health is to provide concepts useful for treatment planning and intervention [1], and the personality disorders section of the DSM has
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often been singled out as particularly lacking in clinical utility [8]. As such, findings that the Alternative
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Model constructs are more predictive of actual clinical decision-making than extant DSM-IV/DSM-5 Section II PD concepts, despite the fact that clinicians are not yet familiar with Alternative Model concepts, provides evidence for a potentially greater clinical utility of the alternative approach. The Alternative Model predicted clinicians‘ decisions better than did the DSM-IV categories in 10 of the 11 studied clinical judgments of treatment-related decision-making. The one exception involved determinations of appropriateness for Supportive Therapy, where the DSM-IV constructs predicted clinician judgments and the DSM-5-AM constructs did not. To the extent that supportive interventions may be particularly applicable for situational crisis intervention, it is possible that the DSM-IV constructs may potentially represent more situational or contextual behaviors that are nonetheless manifestations of personality-related disorders, in contrast to traits that may present a more enduring characterization of
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personality. Indeed, prior research has indicated that traditional diagnostic features of personality
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disorder are less stable over time than are the traits they supposedly manifest [39].
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Of the 11 examined treatment-related judgments, the variable that was most consistently associated with the various personality disorder constructs was long-term prognosis, with most results
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suggesting that the presence of PD indicators were associated with poorer judged prognosis. The consistency of this finding across constructs can be considered supportive of the DSM-5-AM
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incorporation of a global severity dimension that permeates most PD variants. Indeed, the association of
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the clinician rating of this dimension (i.e., Level of Personality Functioning) with rated Long-Term Prognosis proved to be the largest single bivariate correlation observed in this study. This observation is
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consistent with findings that comorbid personality disorder typically leads to poorer treatment response[31], and highlights the importance of including such a severity dimension within a nosology for
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personality disorders.
It must be recognized that the current study examined clinical judgments, and not patient
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outcomes. Thus, although these data suggest that clinicians view certain DSM-5-AM and DSM-IV PD
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constructs as relevant in treatment planning—for example, severe impairment in personality functioning suggesting a need for high intensity treatments, or Avoidant personality indicating the potential usefulness of supportive therapy—this does not mean that these decisions are necessarily accurate. Nonetheless, the findings here represent a potentially useful source of hypotheses to be tested in subsequent outcome studies. In the years prior to the release of DSM-III, Blashfield and Draguns [1] noted that ―There is a broad consensus that the classification will have clinical utility and can override the potentially damaging effects of labelling if it provides clear indications for the type of therapy to be used and for the formulation of prognostic statements‖ [p. 577].
However, succeeding editions of the DSM
have failed to realize this goal for a classification system for personality disorder. The current study represents a preliminary step towards establishing the clinical utility of the DSM-5-AM for personality
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disorders with respect to treatment planning.
These findings must be extended through carefully
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controlled treatment and outcome studies documenting the differential validity of these constructs for
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treatment decision making. Such a program of research will be vitally important if any taxonomy for personality and personality disorder, whether the DSM-5-AM approach or any alternative, is to reach the
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important goal of established clinical utility.
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References
Blashfield RK, Draguns JG. Toward a taxonomy of psychopathology: The purpose of psychiatric classification. Br J Psychiatry 1976;129:574–83. doi:10.1192/bjp.129.6.574.
[2]
Frances A, Clarkin J. Differential therapeutics: A guide to treatment selection. Hosp Community Psychiatry 1981;32:537–46. doi:10.1007/BF01070098.
[3]
Shea MT, Pilkonis PA, Beckham E, Collins JF, Elkin I, Sotsky SM, et al. Personality disorders and treatment outcome in the NIMH treatment of depression collaborative research program. Am J Psychiatry 1990;147:711–8.
[4]
Levy KN, Wasserman RH, Scott LN, Zach SE, White C, Cain N, et al. The development of a measure to assess putative mechanisms of change in the treatment of borderline personality disorder. J Am Psychoanal Assoc 2006;54:1325–31. doi:10.1177/00030651060540040106.
[5]
Linehan MM. Cognitive-behavioral treatment of borderline personality disorder. 1993.
[6]
Dawson DF. Treatment of the borderline patient, relationship management. Can J Psychiatry/La Rev Can Psychiatr 1988;33:370–4.
[7]
Young J. Schema-focused therapy for personality disorder. Cogn Behav Ther A Guid … 2002.
[8]
Verheul R. Clinical utility of dimensional models for personality pathology. J Pers Disord 2005;19:283–302. doi:10.1521/pedi.2005.19.3.283.
[9]
Clark LA, Livesley WJ, Morey LC. Special feature: Personality disorder assessment: The challenge of construct validity. J Pers Disord 1997;11:205–31. doi:10.1521/pedi.1997.11.3.205.
[10]
Kupfer DJ, First MB, Regier DA. A research agenda for DSM-V. Washington, DC, US Am Psychiatr Assoc 2002: xxiii-307.
[11]
Rounsaville BJ, Alarcón RD, Andrews G, Jackson JS, Kendell RE, Kendler K. Basic nomenclature issues for DSM-V. A Res. agenda DSM-V, 2002: 1-29.
[12]
Bernstein DP, Iscan C, Maser J. Opinions of personality disorder experts regarding the DSM-IV personality disorders classification system. J Pers Disord 2007;21:536–51. doi:10.1521/pedi.2007.21.5.536.
[13]
Zachar P, Krueger RF, Kendler KS. Personality disorder in DSM-5: An oral history. Psychol Med 2015;in press. doi:http://dx.doi.org/10.1017/S0033291715001543.
[14]
Shedler J, Beck A, Fonagy P, Gabbard GO, Gunderson JG, Kernberg OF, et al. Personality disorders in DSM-5. Am J Psychiatry 2010;167:1026–8. doi:10.1146/annurev-clinpsy-032511143131.
[15]
Clarkin JF, Huprich SK. Do DSM-5 personality disorder proposals meet criteria for clinical utility? J Pers Disord 2011;25:192–205. doi:10.1521/pedi.2011.25.2.192.
AC
CE
PT
ED
MA
NU
SC
[1]
ACCEPTED MANUSCRIPT 17
DIAGNOSTIC CLASSIFICATION AND TREATMENT PLANNING
Sprock J. Dimensional versus categorical classification of prototypic and nonprototypic cases of personality disorder. J Clin Psychol 2003;59:991–1014.
[17]
Rottman BM, Kim NS, Ahn WK, Sanislow CA. Can personality disorder experts recognize DSMIV personality disorders from five-factor model descriptions of patient cases? J Clin Psychiatry 2011;72:630–9. doi:10.4088/JCP.09m05534gre.
[18]
Spitzer RL, First MB, Shedler J, Westen D, Skodol AE. Clinical utility of five dimensional systems for personality diagnosis: A ―consumer preference‖ study. J Nerv Ment Dis 2008;196:356–74. doi:10.1097/NMD.0b013e3181710950.
[19]
Samuel DB, Widiger TA. Clinicians ‘ judgments of clinical utility : A comparison of the DSM-IV and five-factor models. J Abnorm Psychol 2006;115:298–308. doi:10.1037/0021-843X.115.2.298.
[20]
Lowe JR, Widiger TA. Clinicians‘ judgments of clinical utility: A comparison of the DSM-IV with dimensional models of general personality. J Pers Disord 2009;23:211–29. doi:10.1521/pedi.2009.23.3.211.
[21]
Mullins-Sweatt SN, Lengel GJ. Clinical utility of the five-factor model of personality disorder. J Pers 2012;80:1615–39. doi:10.1111/j.1467-6494.2012.00774.x.
[22]
Morey LC, Skodol AE, Oldham JM. Clinician judgments of clinical utility: A comparison of DSM-IV-TR personality disorders and the alternative model for DSM-5 personality disorders. J Abnorm Psychol 2014;123:398–405. doi:10.1037/a0036481.
[23]
Nelson S, Paggeot A, Lengu K, Huprich SK, Sohnleitner A, Shankar S. The forest and the trees: A quantitative and qualitative evaluation of student preferences for four methods of personality disorder diagnosis, Brooklyn, NY: Paper pres. Soc for Pers Assess 2015.
[24]
Shedler J, Westen D. The Shedler-Westen assessment procedure (SWAP): Making personality diagnosis clinically meaningful. J Pers Assess 2007;89:41–55. doi:10.1080/00223890701357092.
RI P
SC
NU
MA
ED
PT
CE
AC
[25]
T
[16]
PDM Task Force. Psychodynamic Diagnostic Manual. Alliance of Psychoanalytic Organizations. Silver Spring, MD 2006
[26]
Morey LC, Krueger RF, Skodol AE. The hierarchical structure of clinician ratings of proposed DSM-5 pathological personality traits. J Abnorm Psychol 2013;122:836–41. doi:10.1037/a0034003.
[27]
American Psychiatric Association . Diagnostic and Statistical Manual for Mental Disorders, 5th edition. 2013. doi:10.1176/appi.books.9780890425596.744053.
[28]
Krueger RF, Eaton NR, Derringer J, Markon KE, Watson D, Skodol AE. Helping delineate personality disorder content and framing the metastructure. J Pers Assess 2011;93:325–31. doi:10.1080/00223891.2011.577478.
[29]
Stevens JP. Applied multivariate statistics for the social sciences (4th ed.). 2002.
[30]
Frances A, Clarkin J, Perry S. Differential therapeutics in psychiatry: The art and science of treatment selection. New York: Brunner/Mazel Inc.; 1984.
ACCEPTED MANUSCRIPT 18
DIAGNOSTIC CLASSIFICATION AND TREATMENT PLANNING
Reich JH, Green AI. Effect of personality disorders on outcome of treatment. J Nerv Ment Dis 1991;179:74–82. doi:10.1097/00005053-199102000-00003.
[32]
Bateman A, Fonagy P. 8-year follow-up of patients treated for borderline personality disorder: mentalization-based treatment versus treatment as usual. Am J Psychiatry 2008;165:631–8. doi:10.1176/appi.ajp.2007.07040636.
[33]
Clarkin JF, Levy KN, Lenzenweger MF, Kernberg OF. Evaluating three treatments for borderline personality disorder: A multiwave study. Am J Psychiatry 2007;164:922–8. doi:10.1176/ajp.2007.164.6.922.
[34]
Levy KN, Scala JW. Integrated treatment for personality disorders: A commentary. J Psychother Integr 2015;25:49–57. doi:10.1037/a0038771.
[35]
Mulder R, Chanen AM. Effectiveness of cognitive analytic therapy for personality disorders. Br J Psychiatry 2013;202:89–90. doi:10.1192/bjp.bp.112.113571.
[36]
Skodol AE, Morey LC, Bender D, Oldham JE. The Alternative DSM-5 Model for personality disorders: a clinical application. Am J Psychiatry 2015;7:606–13.
[37]
Robins E, Guze SB. Establishment of diagnostic validity in psychiatric illness: Its application to schizophrenia. Am J Psychiatry 1970;126:983–7. doi:10.1176/appi.ajp.126.7.983.
[38]
Widiger TA, Crego C, Oltmanns JR. The validation of a classification of psychopathology. Psychol Inq An Int J Adv Psychol Theory 2015;26:272–8.
[39]
Morey LC, Hopwood CJ. Stability and change in personality disorders. Annu Rev Clin Psychol 2013;9:499–528. doi:10.1146/annurev-clinpsy-050212-185637.
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[31]
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Running head: DIAGNOSTIC CLASSIFICATION AND TREATMENT PLANNING
Group Therapy
AntiAnxiety
.01 -.10 .01 .00 -.02 -.10 .00 -.08 .09 -.02 .08 -.02 .09 .11 -.09 .11 .06 .05 -.05 .03 .08 -.01 -.09 -.02 -.03 -.09
-.15 .04 .14 -.07 -.17 -.16 -.18 .14 -.11 -.21 -.10 -.10 -.22 -.19 .07 -.23 -.23 -.07 -.02 .17 -.17 .10 .26 -.09 -.23 -.05
.01 .11 .19 -.01 -.12 .10 -.16 .14 .07 .05 .07 -.08 -.07 .01 .10 -.10 -.14 .01 .02 .03 -.03 .16 .11 .04 .11 .14
.00 -.02 .07 .01 -.09 -.08 .01 .07 .06 -.09 .05 -.08 -.11 .04 .03 .10 -.04 .01 -.01 -.02 .02 .09 .10 -.10 -.06 -.05
-.01 .20 .40 -.12 -.17 .11 -.18 .21 .06 .03 .11 -.14 -.07 -.06 .15 -.15 -.18 .11 .01 .08 -.15 .15 .14 .07 .11 .17
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Note. Correlations in bold are significant at p < .05.
AntiDepressant
AntiPsychotic
AntiSeizure
MoodStabilizing
Long-Term Prognosis
Optimal TX Level
-.03 .31 .33 -.04 -.24 .02 -.23 .42 .06 -.04 .07 -.20 -.15 -.11 .07 -.17 -.26 .14 -.03 .08 -.19 .21 .23 -.03 .01 .21
.25 .16 .15 -.08 -.02 .44 -.02 .15 .12 .28 .20 -.07 .14 .10 .15 .02 -.06 .14 .04 -.02 .06 .09 -.09 .23 .38 .23
.02 .06 .15 .07 -.01 .14 .01 .14 .13 .06 .15 -.04 .11 .08 -.04 -.01 .01 .02 -.05 -.05 .04 .13 -.06 .08 .05 -.01
.16 .08 .08 .15 .06 .15 .09 .16 .19 .16 .42 .10 .21 .31 -.02 .16 .07 .10 -.08 -.04 .16 .15 -.08 .13 .13 .04
-.48 -.16 .12 -.20 -.33 -.28 -.40 -.12 -.19 -.21 -.30 -.21 -.43 -.35 -.07 -.39 -.38 -.07 -.05 .11 -.32 -.08 .13 -.33 -.26 -.15
.35 .09 -.08 .08 .17 .24 .23 .05 .25 .17 .30 .09 .33 .37 .05 .31 .22 .15 .10 -.13 .31 .08 -.09 .19 .20 .14
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Support Therapy
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Exploratory Therapy
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Lev of Pers Functioning Anhedonia Anxiousness Attention Seeking Callousness Cog Per Dysregulation Deceitfulness Depressivity Distractibility Eccentricity Emotional lability Grandiosity Hostility Impulsivity Intimacy Avoidance Irresponsibility Manipulativeness Perseveration Restricted Affectivity Rigid Perfectionism Risk Taking Separation insecurity Submissiveness Suspiciousness Uns Belief/Experience Withdrawal
Cognitive Therapy
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DSM-5-AM Diagnostic Model
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Table 1 Statistically Significant Correlations between DSM-5-AM Diagnostic Constructs and 11 Clinical Treatment Decisions
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Table 2
Support Therapy
Group Therapy
AntiAnxiety
AntiDepressant
AntiPsychotic
AntiSeizure
MoodStabilizing
Long-Term Prognosis
Optimal TX Level
.01 -.04 -.07 .05 .02 -.05 .02 -.06 -.06 -.11
-.20 -.07 .02 -.14 -.09 .04 -.13 -.02 -.13 .20
-.07 .05 .04 -.06 -.04 -.04 -.01 .14 .10 .22
-.01 .05 .11 .01 -.05 -.06 -.09 .00 -.09 -.01
-.11 .14 .09 -.14 -.15 .08 -.02 .07 .10 .06
-.22 .12 .13 -.04 -.15 .06 -.12 .10 .03 .20
.03 .15 .06 -.06 -.03 .04 .09 .13 .26 .06
.05 .14 .12 .04 .04 .00 .03 .04 .05 .02
.09 .34 .10 .05 .07 -.03 .07 .00 .00 -.01
-.29 -.28 -.05 -.14 -.22 -.05 -.29 -.18 -.17 .02
.26 .23 .05 .04 .05 -.06 .14 .15 .09 -.06
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Exploratory Therapy
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Antisocial PD Borderline PD Dependent PD Histrionic PD Narcissistic PD Ob-Compuls PD Paranoid PD Schizoid PD Schizotypal PD Avoidant PD
Cognitive Therapy
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DSM-IV Categories
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Statistically Significant Correlations between DSM-IV Diagnostic Constructs and 11 Clinical Treatment Decisions
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Note. Correlations in bold are significant at p < .05.
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Running head: DIAGNOSTIC CLASSIFICATION AND TREATMENT PLANNING
(.10-.30)
.00
Anxiolytics
.31**
(.21-.40)
.21**
Antidepressants
.37**
(.27-.46)
.30**
Antipsychotics
.31**
(.21-.40)
.17
(.06-.27)
Mood-Stabilizers
.35**
(.25-.44)
Long-Term Prognosis
.47**
(.38-.55)
Optimal Treatment Level
.38**
(.28-.47)
* p ≤ .05 ** p ≤ .01
Model R .34* .50** .31
95% CI (-.02-.19) (.25 -.44) (-.08-.14)
.32
(.22-.41)
.04
(-.07-.15)
(.11 -.31)
.47**
(.38-.55)
.31**
(.21 -.40)
(.20 -.39)
.55**
(.47-.62)
.43**
(.34 -.51)
.20**
(.10 -.30)
.57**
(.49-.64)
.45**
(.36 -.53)
-.05
(-.16-.06)
.36*
(.26-.45)
.12*
(.01 -.22)
.26**
(.16 -.36)
.50**
(.42-.58)
.34**
(.24 -.43)
.41**
(.32 -.50)
.66**
(.60-.72)
.58**
(.50 -.65)
(.20 -.39)
.57**
(.49-.64)
.45**
(.36 -.53)
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Anti-seizure
95% CI (-.19-.03) (.14 -.34) (.05 -.26)
DSM-5-AM Model (Traits and Level) 95% CI PRESS R (.24-.43) .09 (.42-.58) .35** (.21-.40) .03
(-.11-.11)
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.20
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Group Therapy
Model R .15 .33** .28**
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Treatment Cognitive Therapy Exploratory Therapy Supportive Therapy
DSM-IV Model (> Diagnostic Threshold) 95% CI PRESS R (.04-.25) -.08 (.23-.42) .24** (.18-.38) .16**
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Table 3 Multiple Regression Prediction of 11 Clinical Treatment Decisions Using Variables of DSM-IV and DSM-5-III PD Diagnostic Constructs
.30**