Acknowledgements. Personality Disorders in Adults and Adolescents. Why does personality matter? 2/18/13

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1 Personality Disorders in Adults and Adolescents Drew Westen, Ph.D. Departments of Psychology and Psychiatry and Behavioral Sciences, Emory University February 2013 Acknowledgements Coauthors and collaborators on the research to be described: Drs. Jared DeFife, Bekh Bradley, Jonathan Shedler, Rebecca Drill, Jack Beinashowitz, and the Laboratory of Personality and Psychopathology Supported by NIMH R01s MH62377, MH62377, and MH Disclosure: The SWAP instrument on which much of this research is based is available for beta testing at Why does personality matter? Roughly 15% of the population is afflicted The other 85% of the population is afflicted by the 15% Thanksgiving dinner: Do the math Personality pathology Constitutes a vulnerability factor for all nonpsychotic Axis I disorders in adolescents and adults Predicts development of all Axis I disorders from adolescence to early and mid adulthood Moderates response to many forms of treatment for multiple disorders, and predicts relapse in depression What s wrong with the way we diagnose personality now? Categorical diagnosis Comorbidity: patients with any diagnosis receive % of patients have subthreshold pathology Memorability: the problem of laundry lists Minimization of clinical richness of criteria and diagnoses Minimizing clinical inference has had unintended consequences Empathic psychopaths Whatever happened to passive-aggressive PD? Clinicians don t use it Imagine actually following the manual Algorithms vary by diagnosis Failure to address personality strengths Never tested empirically against alternatives 3 1

2 An alternative: Prototype diagnosis 5 very good match (patient exemplifies this disorder; prototypical case) Diagnosis 4 good match (patient has this disorder; diagnosis applies) 3 moderate match (patient has significant features of this disorder) Features 2 slight match (patient has minor features of this disorder) 1 little or no match (description does not apply) Advantages of prototype diagnosis Simple to use Dimensional/categorical Readily learned Easy to integrate ongoing clinical knowledge with learned prototypes Eliminates proliferation of diagnoses (especially NOS) Better matches the way our minds naturally categorize Allows richer clinical description Readily used online or electronically / translates to automated report-writing with about 5-10 minutes effort following a clinical assessment Personality style and level of pathology Narcissistic personality Academic male Neurotic to healthy Narcissistic neurotic Personality disorder Narcissistic personality disorder Malignant narcissist 2

3 Clinical utility (prototypes, relative to categorical DSM-IV diagnosis, N=291) (Westen, Shedler, & Bradley, 2006, Am J Psychiatry) Spitzer et al., 2008: Clinical utility (relative to DSM-IV) 70% 60% 50% 40% 30% 20% 10% 0% Prototype Counting FFM Cloninger 9 10 Rottman et al., 2009: Clinical utility ratings Can Diagnosticians Make Reliable Prototype Ratings from the SCID-I and SCID-II? Axis I Diagnoses ICC (1,3) MDD.93 Dysthymia.93 Bipolar.95 GAD.88 Panic.89 PTSD.97 Anorexia.95 Bulimia.92 Axis II Diagnoses ICC (1,3) Paranoid.88 Schizoid.85 Schizotypal.85 Antisocial.88 Borderline.92 Narcissistic.69 Histrionic.84 Avoidant.93 Dependent.91 OCPD

4 Inter-clinician reliability of personality disorder diagnoses Can we derive personality prototypes empirically? Goal: To see if clinicians can agree on prototype diagnoses Method: Outpatient clinicians (N = 65) made prototype diagnoses of patients personality after an initial evaluation period using the empirically derived personality prototypes External evaluators independently made prototype diagnoses after watching videotapes of the same clinical hours Results: Inter-clinician reliability was high, with a median r =.72. Cross-correlations between disorders were low, with a median r =.01. National clinical sample of 1201 patients diagnosed with personality pathology Applied a form of factor analysis (Q-factor analysis) to identifying naturally occurring groupings of patients SWAP-II: 200-item card-sorting procedure designed for personality diagnosis by experienced clinicians Tested multiple solutions, algorithms, estimation procedures, etc. Identified prototypes that were consistent across solutions and clinically and empirically coherent Westen, D., DeFife, J.A., Bradley, B., & Hilsenroth, M.J. (2010). Prototype personality diagnosis in clinical practice: A viable alternative for DSM-5 and ICD-11.Professional Psychology: Research and Practice 41(6), The SWAP-II and SWAP-II-A Q-sorts (developed in collaboration with Dr. Jonathan Shedler) Personality instrument for quantifying expert clinical judgment (adolescent and adult versions) Designed for use by experienced clinicians to apply from a systematic clinical interview or from following a patient over time Assesses the range of personality pathology Designed to assess current diagnoses, to develop new ones, or to answer specific questions (e.g., treatment response, risk for violence or suicide, relapse)

5 Empirically derived personality disorders in adults (N = 1201) Westen et al., Am J Psychiatry, January Preliminary data on reliability and validity Three samples, including two observers describing the same patient (N=1201, 117, 145) Mean coefficient alpha =.81,.78,.79 Mean within-cluster correlations, r = Mean cross-cluster correlations, = 0.0 Validity: cross-correlations between SWAP-II ratings by the Clinical Diagnostic Interview and the treating clinician (N=117) On the diagonal, r =.51 Off the diagonal, r =.01 What personality system best predicts adaptive functioning? (GAF) Diagnostic system F R 2 DSM-IV 14.59***.17 Traits (Five Factor Model) Empirically-derived diagnoses 15.31*** ***

6 Depressive personality Antisocial-psychopathic personality Summary statement: Individuals with Depressive personality are prone to feelings of depression and inadequacy, tend to be self-critical or self-punitive, and may be preoccupied with concerns about abandonment or loss. Individuals who match this prototype tend to feel depressed or despondent and to feel inadequate, inferior, or a failure. They tend to find little pleasure or satisfaction in life s activities and to feel life has no meaning. They are insufficiently concerned with meeting their own needs, disavowing or squelching their hopes and desires to protect against disappointment. They appear conflicted about experiencing pleasure, inhibiting feelings of excitement, joy, or pride. They may likewise be conflicted or inhibited about achievement or success (for example, failing to reach their potential or sabotaging themselves when success is at hand). Individuals who match this prototype are generally self-critical, holding themselves to unrealistic standards and feeling guilty and blaming themselves for bad things that happen. They appear to want to punish themselves by creating situations that lead to unhappiness or avoiding opportunities for pleasure and gratification. They have trouble acknowledging or expressing anger and instead become depressed, self-critical, or self-punitive. They often fear that they will be rejected or abandoned, are prone to painful feeling of emptiness, and may feel bereft or abjectly alone even in the presence of others. They may have a pervasive sense that someone or something necessary for happiness has been lost forever (for example, a relationship, youth, beauty, success). Summary statement: Individuals with Psychopathic-Antisocial Personality exploit others, experience little remorse for harm or injury caused to others, and have poor impulse control. Individuals who match this prototype take advantage of others, tend to lie or deceive, and to be manipulative. They show a reckless disregard for the rights, property, or safety of others. Their interpersonal relationships are fundamentally exploitive. They often appear to gain pleasure by being sadistic or aggressive toward others, and they may attempt to dominate significant others through intimidation or violence. They experience little remorse for harm or injury caused to others, and they lack empathy for others needs and feelings. They appear impervious to consequences and seem unable or unwilling to modify their behavior in response to threats or consequences. They generally lack psychological insight and blame their difficulties on other people or circumstances. Individuals who match this prototype tend to be impulsive, to seek thrills, novelty, and excitement, and require high levels of stimulation. They tend to be unreliable and irresponsible and fail to meet work obligations or honor financial commitments. They may engage in antisocial behavior, including unlawful behavior, substance abuse, or violence. They may repeatedly convince others of their commitment to change, leading others to think "this time is really different," only to revert to their previous maladaptive behavior. Narcissistic personality Summary statement: Individuals with Narcissistic personality are grandiose and entitled, dismissive and critical of others, and often show underlying signs of vulnerability beneath a grandiose façade. Individuals who match this prototype have an exaggerated sense of self-importance. They feel privileged and entitled, expect preferential treatment, and seek to be the center of attention. They have fantasies of unlimited success, power, beauty, or talent, and tend to treat others primarily as an audience to witness their importance or brilliance. They tend to believe they can only be appreciated by, or should only associate with, people who are high-status, superior, or "special." They have little empathy and seem unable to understand or respond to others' needs and feelings unless they coincide with their own. Individuals who match this prototype tend to be dismissive, haughty, and arrogant. They tend to be critical, envious, competitive with others, and prone to get into power struggles. They attempt to avoid feeling helpless or depressed by becoming angry instead, and tend to react to perceived slights or criticism with rage and humiliation. Their overt grandiosity may mask underlying vulnerability: Individuals who match this prototype are invested in seeing and portraying themselves as emotionally strong, untroubled, and emotionally in control, often despite clear evidence of underlying insecurity or distress. A substantial subset of narcissistic individuals tend to feel inadequate or inferior, to feel that life has no meaning, and to be self-critical and intolerant of their own human defects, holding themselves to unrealistic standards of perfection. Borderline (dysregulated) spectrum Summary Statement: Individuals with Borderline personality have impaired ability to regulate their emotions, have unstable perceptions of self and others that lead to intense and chaotic relationships, and are prone to act on impulses, including self-destructive impulses. Individuals who match this prototype have emotions that can change rapidly and spiral out of control, leading to extremes of sadness, anxiety, and rage. They tend to catastrophize, seeing problems as disastrous or unsolvable, and are often unable to sooth or comfort themselves without the help of another person. They tend become irrational when strong emotions are stirred up, showing a significant decline from their usual level of functioning. Individuals who match this prototype lack a stable sense of who they are: Their attitudes, values, goals, and feelings about themselves may seem unstable or ever-changing, and they are prone to painful feelings of emptiness. They likewise have difficulty maintaining stable, balanced views of others: When upset, they have trouble perceiving positive and negative qualities in the same person at the same time, seeing others in extreme, black-or-white terms. Consequently, their relationships tend to be unstable, chaotic, and rapidly changing. They are needy and dependent, fear rejection and abandonment, and fear being alone. They tend to become attached quickly and intensely, developing feelings or expectations that are not warranted by the relationship history or context. They are prone to feeling misunderstood, mistreated, or victimized. Interpersonally, they tend to elicit intense feelings in others or stir up conflict or animosity between other people. Individuals who match this prototype tend to be impulsive. Their work life or living arrangements may be chaotic and unstable. They may act on self-destructive impulses, including self-mutilating behavior, suicidal threats or gestures, and genuine suicidality, especially when an attachment relationship is disrupted or threatened. 6

7 Obsessional character style Personality strengths Summary statement: Individuals with Obsessional character are emotionally constricted and rigid, intellectualized and overly rational in their thinking, and are conflicted about anger, aggression, and compliance with authority. Individuals who match this prototype tend to see themselves as logical and rational, uninfluenced by emotion, and prefer to operate as if emotions were irrelevant or inconsequential. They tend to be inhibited and constricted, and have difficulty acknowledging or expressing wishes, impulses, or anger. They tend to deny or disavow their need for nurturance or comfort, often regarding such needs as weakness. They tend to adhere rigidly to daily routines, becoming anxious or uncomfortable when they are altered, and to be overly concerned with rules, procedures, order, organization, schedules, and so on. They may be preoccupied with concerns about dirt, cleanliness, or contamination. They tend to be excessively devoted to work and productivity to the detriment of leisure and relationships. They tend to be self-critical, expecting themselves to be perfect. They tend to think in abstract and intellectualized terms and to become absorbed in details, often to the point of missing what is important. Rationality and regimentation generally mask underlying feelings of anxiety or anger. They tend to be critical of others, controlling, oppositional, self righteous or moralistic, and stingy and withholding (for example, of time, money, or affection). They are often conflicted about authority, struggling with contradictory impulses to submit versus defy. They are invested in seeing and portraying themselves as emotionally strong, untroubled, and in control, despite evidence of underlying insecurity, anxiety, or distress. Degree of match to this prototype provides a measure of adaptive psychological strengths. The more individuals match this prototype, the more they are able to engage in meaningful and mature relationships, find meaning and satisfaction in life s pursuits, and make effective use of their talents and abilities. Individuals who match this prototype are capable of sustaining meaningful relationships characterized by genuine intimacy and caring. They are empathic and responsive to others needs and feelings, and have the capacity to recognize alternative viewpoints, even when emotions are strong. They have moral and ethical standards, strive to live up to them, and tend to be conscientious and responsible. They appear comfortable in social situations, are able to assert themselves effectively and appropriately when necessary, tend to be energetic and outgoing, and tend to be liked by others. They tend to have satisfying sex lives. They are psychologically insightful and able to understand themselves and others in nuanced ways. They are capable of hearing and making effective use of information that is emotionally threatening, and have generally come to terms with painful experiences from the past, finding meaning in the experiences and growing from them. They tend to express emotion appropriate in quality and intensity to the situation at hand. They generally find contentment and happiness in life s activities and find meaning and fulfillment in guiding or nurturing others, in belonging and contributing to a larger community, and in the pursuit of long-term goals and ambitions. They are able to use their talents, abilities, and energy effectively and productively, enjoying challenges and taking pleasure in accomplishing things. They are able to express themselves verbally, have a sense of humor, and tend to see things and approach problems in creative ways. Do adolescents have personalities? Ask any parent Are they set in stone? No, but they are also not set in Playdough Widespread (mis)conceptions: DSM-IV Central questions Do stable forms of personality disturbance exist in adolescence, and if so, what forms? At what point are adult forms of personality pathology recognizable in adolescents? How can we diagnose patients in a way that is reliable and useful in clinical practice?

8 Can we derive adolescent personality prototypes empirically? Empirically derived personality disorders in adolescents (N = 946) National clinical sample of 946 adolescent patients diagnosed with personality pathology (aged 13-18) Applied Q-factor analysis to identify naturally occurring groupings of adolescent patients SWAP-II-A for adolescents Tested multiple solutions, algorithms, estimation procedures, etc. Identified prototypes that were consistent across solutions and clinically and empirically coherent Antisocial-psychopathic personality Summary statement: Adolescents with Psychopathic-Antisocial Personality exploit others, experience little remorse for harm or injury caused to others, and have poor impulse control. Adolescents who match this prototype take advantage of others, tend to lie or deceive, and to be manipulative. They show a reckless disregard for the rights, property, or safety of others. Their interpersonal relationships are fundamentally exploitive. They often appear to gain pleasure by being sadistic or aggressive toward others, and they may attempt to dominate significant others through intimidation or violence. They experience little remorse for harm or injury caused to others, and they lack empathy for others needs and feelings. They appear impervious to consequences and seem unable or unwilling to modify their behavior in response to threats or consequences. Adolescents who match this prototype tend to be impulsive, to seek thrills, novelty, and excitement, and require high levels of stimulation. They tend to be unreliable and irresponsible and to surround themselves with peers who are delinquent or deeply alienated. They tend to be rebellious or defiant toward authority figures, and may derive satisfaction or self-esteem from being, or being seen as, bad or tough. They tend to engage in antisocial behavior, including criminal or delinquent behavior, substance abuse, or violence. Conclusions For better or worse, our patients have personalities Before treating a patient s symptoms, it s good to know the person who is hosting those symptoms If you disagree with me, no doubt you re passiveaggressive, but lucky for you, you re undiagnosable 31 8