Prototype Personality Diagnosis in Clinical Practice: A Viable Alternative for DSM-V and ICD-11

Several studies suggest that a prototype matching approach yields diagnoses of comparable validity to the more complex diagnostic algorithms outlined in DSM-IV. Furthermore, clinicians prefer prototype diagnosis of personality disorders (PDs) to the current categorical diagnostic system or alternative dimensional methods. An important extension of this work is to investigate the degree to which clinicians are able to make prototype diagnoses reliably. The aim of this study is to assess the inter-rater reliability of a prototype matching approach to personality diagnosis in clinical practice. Using prototypes derived empirically in prior research, outpatient clinicians diagnosed patients' personality after an initial evaluation period. External evaluators independently diagnosed the same patients after watching videotapes of the same clinical hours. Inter-rater reliability for prototype diagnosis was high, with a median r = .72. Cross-correlations between disorders were low, with a median r = .01. Clinicians and clinically trained independent observers can assess complex personality constellations with high reliability using a simple prototype matching procedure, even with prototypes that are relatively unfamiliar to them. In light of its demonstrated reliability, efficiency, and versatility, prototype diagnosis appears to be a viable system for DSM-V and ICD-11 with exceptional utility for research and clinical practice.

Exploring the Psychometric Properties and Construct Validity of the MCMI-III Anxiety and Avoidant Personality Scales

The Millon Clinical Multiaxial Inventory (MCMI; Millon, 1983) is a commonly used self-report instrument designed to aid in the assessment of Axis I and Axis II disorders. Concerns have been expressed regarding the procedures used in the normative research for the current version of the MCMI (MCMI-III; Millon, 1994) leading to a call for additional validity research on the MCMI-III (Retzlaff, 1996). In this study, we investigated the psychometric properties of the MCMI-III's Anxiety and Avoidant personality scales in a sample of patients diagnosed with Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) anxiety disorders. Our results suggest that the MCMI-III Avoidant scale is reliable (r =.89) and it was found to demonstrate appropriate convergent and divergent validity with other self-report measures. The MCMI-III Anxiety scale also showed adequate reliability (r =.78); however, our findings raise some concerns about the discriminant validity of this scale. A scale composed of the MCMI-III core anxiety items was found to have better discriminant validity. These findings are consistent with those reported by other researchers regarding the relationship between self-report measures of anxiety, avoidance, and depression. We conclude that the MCMI-III measures of anxiety and avoidance are consistent with other measures of these constructs and may provide valuable clinical information in this regard.

Integrating methods to optimize circumplex description and comparison of groups

Using the interpersonal circumplex as an exemplar, this article serves as a methodological primer for integrating techniques of group description and comparison when employing circumplex-based assessment instruments. Circular statistics (Mardia & Jupp, 1999) and the structural summary method (Gurtman & Balakrishnan, 1998) each offer unique and incrementally useful information when applied to group-level data on circumplex measures. Circular statistics offer a set of parameters that are conceptually similar to their linear equivalents (i.e., mean, variance, and confidence intervals). In interpersonal circumplex models, these parameters each provide specific information regarding substantive theme and group homogeneity and allow for the statistical comparison of groups based on the geometry of the circular model. In a similar fashion, the structural summary method for circumplex data provides a set of parameters that complement circular statistics by offering measures of the interpersonal prototypicality of the group profile, levels of profile differentiation and elevation, and a weighted measure of substantive theme. Used in conjunction, these methods offer more information than is available using either in isolation. We provide 4 examples to demonstrate the complementary information the 2 methods provide for assessments employing interpersonal circumplex measures. These examples will allow investigators to generalize the methods to other personality assessment domains in which circumplex models are utilized, such as emotion and vocational preference. [Supplementary materials are available for this article. Go to the publisher's online edition of the Journal of Personality Assessment for the following free supplemental resources: an Excel file that calculates the circular statistics and structural summary information described in this article using manually entered octant scores from up to 500 participants.]

Rorschach assessment of reality testing, affect and object representation of borderline pathology: a comparison of clinical samples

This study examines the personality functioning of outpatients diagnosed with borderline pathology (BP) compared to a nonborderline pathology Axis I clinical control group (NonBP). Interrater reliability for all variables was in the good or excellent range. Significant differences were found examining Rorschach variables assessing dysphoric affect and affect regulation/experiencing with BP when compared to the Axis I group. Additionally, individuals with BP had more malevolent object representations than individuals with only Axis I disorders. The clinical implications of these findings with regard to borderline pathology are discussed.

Rorschach correlates of adolescent self-mutilation

The present study examined various Rorschach variables of aggression, dysphoric affect, and disordered thinking in relation to self-mutilation in samples of self-mutilating (SM; n=16) and nonself-mutilating (N-SM; n=26) adolescent inpatients. Categorical comparisons indicated that SM patients had significantly higher mean scores for Aggressive Past (AgPast), but not for Aggressive Content (AgC), Aggressive Movement (AG), Morbid Content (MOR), Inanimate Movement (m), Sum Shading (SumY), and the Perceptual-Thinking Index (PTI), than N-SM patients. Additionally, logistic regression results suggested that PTI and AgPast were the most robust predictors of group membership. The authors propose that self-mutilating adolescents may struggle with internally directed aggression and victimized sense of self that, when coupled with disordered thinking, significantly predicts self-mutilation.

Therapist affect focus and patient outcomes in psychodynamic psychotherapy: a meta-analysis

OBJECTIVE

The authors systematically examined the relationship between therapist facilitation of patient emotional experience/expression and outcome in psychodynamic psychotherapy.

METHOD

Computer and manual searches were conducted for relevant publications, and 10 independent samples of short-term dynamic psychotherapy were included in a meta-analysis. Data analysis included calculation of an overall effect size of the relationship between therapist affect focus and outcome, statistical significance, and test for homogeneity. In addition, moderator analyses were conducted to examine the potential impact of type of outcome construct used and the methodological quality of individual studies.

RESULTS

The overall average weighted effect size across all outcome types was statistically significant (r=0.30), and the homogeneity statistic was nonsignificant. Moderator analyses indicated a statistically significant relationship between therapist facilitation of patient emotional experience/expression and outcome when more than one outcome construct was included but not when either a single or an unclear outcome construct was used. There were no significant relationships between methodological quality and the size of the effects, although use of audio- or videotaping for supervision demonstrated a moderate effect.

CONCLUSIONS

These data indicate that therapist facilitation of patient affective experience/expression is associated with patient improvement over the course of psychodynamic psychotherapy. Although the size of this relationship was not significantly related to methodological quality, results suggest the importance of close supervision of actual techniques through the use of audio- or videotapes. Additionally, results highlight the importance of defining outcome in a multidimensional way to properly assess theoretically relevant effects.

Borderline pathology and the Personality Assessment Inventory (PAI): an evaluation of criterion and concurrent validity

In this study, we examined how patients diagnosed with borderline pathology (BP) would respond on the Personality Assessment Inventory (PAI; Morey, 1991) Borderline (BOR) scales in relation to patients without BP pathology. In addition, we examined whether the PAI BOR scales would be related to variables on the Social Cognition and Object Relations Scale (SCORS; Hilsenroth, Stein, & Pinsker, 2004; Westen, 1995) derived from early memory narratives. Results indicate that outpatients with a Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994) diagnosis of BP scored significantly higher on the PAI BOR Total (BOR-Total) score, Identity Problems, and Self- Harm scales in comparison to a Non-BP clinical sample. The overall correct classification rate for the presence or absence of BP using the BOR Total scale (T >or= 70) was 73%. In addition, there were several significant relationships between dimensional PAI BOR scales and the presence versus absence of DSM-IV BP. Moreover, both the BOR-Total and Affect Instability scales were significantly related to the SCORS variable Complexity of Representations. We provide clinical examples to illustrate these research findings in an applied manner.