An Empirically Derived Taxonomy for Personality Diagnosis: Bridging Science and Practice in Conceptualizing Personality

Abstract

Objective The authors describe a system for diagnosing personality pathology that is empirically derived, clinically relevant, and practical for day-to-day use. Method A random national sample of psychiatrists and clinical psychologists (N=1,201) described a randomly selected current patient with any degree of personality dysfunction (from minimal to severe) using the descriptors in the Shedler-Westen Assessment Procedure–II and completed additional research forms. Results The authors applied factor analysis to identify naturally occurring diagnostic groupings within the patient sample. The analysis yielded 10 clinically coherent personality diagnoses organized into three higher-order clusters: internalizing, externalizing, and borderline-dysregulated. The authors selected the most highly rated descriptors to construct a diagnostic prototype for each personality syndrome. In a second, independent sample, research interviewers and patients’ treating clinicians were able to diagnose the personality syndromes with high agreement and minimal comorbidity among diagnoses. Conclusions The empirically derived personality prototypes described here provide a framework for personality diagnosis that is both empirically based and clinically relevant.

The contribution of Sidney Blatt's two-polarities model to the Psychodynamic Diagnostic Manual

“…It should be noted that some authors share Blatt's original conceptualization of depressive personalities as primarily characterized by anaclitic and introjective variants (Blatt, 1974;Zuroff, 1994;Zuroff & Fitzpatrick, 1995), while others empathize with a more unified perspective, through which an individual with a depressive personality structure is seen as both self-critical and dependent. For example, Westen, Shedler, Bradley, and DeFife (2012) empirically identified a depressive personality syndrome in which both introjective and anaclitic features were salient. Similarly, several authors from different clinical perspectives have suggested a broad variation in the phenotypic expression of narcissism and the existence of two distinct subtypes of narcissistic personalities (Cain, Pincus, & Ansell, 2008;Gabbard & Crisp-Han, 2016;Levy, 2012).…”

Dimensions of Personality and Personality Pathology: Factor Structure of the Shedler–Westen Assessment Procedure-II (SWAP-II)

“…By contrast, both traits and dimensional personality disorder diagnoses derived from data provided by experienced clinicians using a systematic clinical research interview correlate in the range of r = .50 to .70 with the same variables as assessed by treating clinicians Westen et al, 2012). Similarly, research on "illusory mental health" (Shedler, Mayman, & Manis, 1993) demonstrates that self-report measures of neuroticism (or negative affectivity) cannot distinguish psychologically healthy individuals from psychologically distressed individuals who lack self-awareness.…”

“…It can also be accomplished via a prototype matching procedure, whereby diagnosticians gauge the similarity or "fit" between a patient's clinical presentation and a paragraph-length narrative description of each disorder (Rottman, Ahn, Sanislow, & Kim, 2009;Spitzer, First, Shedler, Westen, & Skodol, 2008;Westen & Shedler, 2000;Westen, Shedler, & Bradley, 2006). Elsewhere, we have proposed a dimensional approach to personality diagnosis based on empirically derived personality prototypes (Westen & Shedler, 1999a, 1999bWesten, Shedler, Bradley, & DeFife, 2012). This diagnostic system preserves a syndromal approach to personality, consistent with all editions of DSM to date; however, both the diagnostic groupings and the descriptions of the diagnoses are derived empirically and reflect naturally occurring groupings in the clinical population.…”

“…They can also be analyzed via Q-factor analysis (a person-centered approach) to identify groupings of patients who share a common personality syndrome (i.e., who are psychologically similar to one another and distinct from patients in other groupings). Thus, the SWAP instruments can be used to derive both (a) trait dimensions and (b) naturally occurring diagnostic grouping in the clinical population (i.e., diagnostic prototypes; Westen & Shedler, 1999b;Westen et al, 2012). Because the item sets for both adult and adolescent versions of the SWAP cover the domains included in DSM-III-R and DSM-IV, the instruments can additionally be used to derive (dimensional) DSM Axis II diagnoses.…”

Co-Occurring Disorders and Treatment Complexity Within Personality Disorders

“…Empirical efforts to ascertain hierarchies have failed (7), thus making it difficult for clinicians to determine which personality disorder to diagnose and treat. Although there are a number of explanations for the high rate of PD co-occurrence, it appears that this is an artifact of a criterion count system that does not reflect daily clinical practice, which is closer to a prototype matching system (8,9).…”