Is dimensional scoring of borderline personality disorder important only for subthreshold levels of severity?
ABSTRACT Studies comparing dimensional and categorical representations of personality disorders (PDs) have consistently found that PD dimensions are more reliable and valid. While comparisons of dimensional and categorical scoring approaches have consistently favored the dimension model, two reports from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project have raised questions as to when dimensional scoring is important. In the first study, Asnaani, Chelminski, Young, and Zimmerman (2007) found that once the diagnostic threshold for borderline PD was reached the number of criteria met was not significantly associated with indices of psychosocial morbidity. In the second study, Zimmerman, Chelminski, Young, Dalrymple, and Martinez (2012) found that patients with 1 criterion of borderline PD had significantly more psychosocial morbidity than patients with 0 criteria. The findings of these two studies suggest that dimensional ratings of borderline PD may be more strongly associated with indicators of illness severity for patients who do not versus do meet the DSM-IV criteria for borderline PD. In this third report from the MIDAS project, we tested this hypothesis in a study of 3,069 psychiatric outpatients evaluated with semi-structured diagnostic interviews. In the patients without borderline PD the number of borderline features was significantly associated with each of 6 indicators of illness severity, whereas in the patients with borderline PD 3 of the 6 correlations were significant. The mean correlation between the number of borderline PD criteria and the indicators of illness severity was nearly three times higher in the patients without borderline PD than the patients with borderline PD (0.23 versus 0.08), and 4 of the 6 correlation coefficients were significantly higher in the patients without borderline PD. These findings suggest that dimensional scoring of borderline PD is more important for subthreshold levels of pathology and are less critical once a patient meets the diagnostic threshold. The implications of these findings for DSM-5 are discussed.
Canadian Psychology 01/2015; 56(2):168-190. DOI:10.1037/cap0000024 · 1.54 Impact Factor
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ABSTRACT: Although early editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM; Alliance of Psychoanalytic Organizations, 2006) incorporated a broad array of psychodynamic concepts, the influence of psychoanalysis in the DSM series has waned with each successive revision. The depsychoanalyzing of the DSM had a number of negative effects (e.g., increased syndrome comorbidity, diminished clinical utility). This article discusses how psychoanalytic concepts—once central but now marginalized—have much to contribute to DSM-6. I examine several ways in which a psychodynamic perspective can enhance the diagnostic manual, and challenges that may arise when psychodynamic concepts are reintroduced. I then present a psychodynamically informed framework for diagnosis in DSM-6 and beyond, which incorporates information in 4 domains: (a) overall level of functioning, (b) symptoms and syndromes, (c) underlying dynamics (i.e., ego strength, defense style, object relations), and (d) contextualizing factors (i.e., culture, stress, resilience and adaptation). I note how key constructs can be operationalized by clinicians and clinical researchers, and how dynamic assessment data can be integrated with descriptive, symptom focused information to enhance diagnosis and facilitate treatment planning.Psychoanalytic Inquiry 01/2015; 35(sup1):45-59. DOI:10.1080/07351690.2015.987592 · 0.47 Impact Factor
Canadian Psychology 01/2015; 56(2):208-226. DOI:10.1037/cap0000026 · 1.54 Impact Factor