Drew Westen

Emory University | EU · Department of Psychology and Department of Psychiatry

We investigated the association between personality disorders (PDs) and attachment patterns, and examined the construct validity of attachment patterns against adaptive functioning. We used a multimeasure multi-informant approach, which allowed us to disentangle the effects of the methods and to examine the utility of the various methods for measur...

Emotional, physical and sexual abuse, have been consistently linked to mental health problems in adults. Previous research found that mental health providers rarely ask their patients about their childhood experiences of abuse. No study to date has examined the convergence of clinicians’ and patients’ reports of childhood abuse. The current study a...

Adaptive functioning is a key aspect of psychiatric diagnosis and assessment in research and practice. This study compared adaptive functioning validity ratings from Structured Clinical Interviews (SCIDs, symptom-focused structured diagnostic interviews), and Clinical Diagnostic Interviews (CDIs, systematic diagnostic interviews modeling naturalist...

This study describes an empirically derived approach to diagnosing adolescent personality pathology that is clinically relevant and empirically grounded. A random national sample of psychiatrists and clinical psychologists (N = 950) described a randomly selected adolescent patient (aged 13-18 years, stratified by age and gender) in their care using...

Researchers have proposed replacing the current system for diagnosing personality disorders with a dimensional trait model. Proposed trait models have been derived primarily from data provided by untrained lay informants (often via self-report questionnaires) using item sets derived from lay conceptions of personality. An alternative is to derive p...

Consistent with attachment theory and a developmental psychopathology framework, a growing body of research suggests that traumatic parental separations may lead to unique pathways of personality adaptation and maladaptation. The present study both examined personality characteristics and identified personality subtypes of adolescents with historie...

This two-part study describes the development and validation of a method for quantifying adolescent personality pathology using the latest edition of the Shedler–Westen Assessment Procedure for Adolescents (SWAP-II-A), an instrument designed to be used by clinically experienced observers. In Study 1, experienced psychologists and psychiatrists desc...

This two-part study describes the development and validation of a method for quantifying adolescent personality pathology using the latest edition of the Shedler–Westen Assessment Procedure for Adolescents (SWAP-II-A), an instrument designed to be used by clinically experienced observers. In Study 1, experienced psychologists and psychiatrists desc...

We sought to determine whether meaningful subtypes of Dysthymic patients could be identified when grouping them by similar personality profiles. A random, national sample of psychiatrists and clinical psychologists (n=1201) described a randomly selected current patient with personality pathology using the descriptors in the Shedler-Westen Assessmen...

Research has linked multiple risk and resiliency factors to developing posttraumatic stress disorder (PTSD). One potentially important construct for understanding connections between trauma and PTSD is attachment. Although relationships between attachment and risk for PTSD have been described theoretically, limited research has addressed these rela...

Central to the proposed DSM-5 general definition of personality disorder (PD) are features of self- and interpersonal functioning. The Social Cognition and Object Relations Scale-Global Rating Method (SCORS-G) is a coding system that assesses eight dimensions of self- and relational experience that can be applied to narrative data or used by clinic...

CONTEXT With growing recognition that most forms of psychopathology are best represented as dimensions or spectra, a central question becomes how to implement dimensional diagnosis in a way that is empirically sound and clinically useful. Prototype matching, which involves comparing a patient's clinical presentation with a prototypical description...

This article describes a system for diagnosing mood disorders that is empirically derived and designed for its clinical utility in everyday practice. A random national sample of psychiatrists and clinical psychologists described a randomly selected current patient with a measure designed for clinically experienced informants, the Mood Disorder Diag...

Viene presentato un sistema diagnostico della patologia di personalitŕ derivato empiricamente, clinicamente rilevante e di agevole uso quotidiano. Un campione randomizzato di 1.201 psichiatri e psicologi clinici statunitensi ha descritto un proprio paziente, selezionato in modo casuale e affetto da un disturbo della personalitŕ, utilizzando la Shed...

Background Limited controlled data exist to guide treatment choices for clinicians caring for patients with major depressive disorder (MDD). Although many putative predictors of treatment response have been reported, most were identified through retrospective analyses of existing datasets and very few have been replicated in a manner that can impac...

This article tells the story of the development of an outcome study of psychoanalysis and describes the debate that took place over critical methodological issues. The protocol committee included career psychotherapy researchers who have conducted rigorous outcome studies, clinical psychoanalysts, study methodologists, and a statistician with clini...

The Shedler-Westen assessment procedure (SWAP) is a personality assessment instrument designed for use by expert clinical assessors. Critics have raised questions about its psychometrics, most notably its validity across observers and situations, the impact of its fixed score distribution on research findings, and its test-retest reliability. We re...

The method of diagnosing patients used since the early 1980s in psychiatry, which involves evaluating each of several hundred symptoms for their presence or absence and then applying idiosyncratic rules for combining them for each of several hundred disorders, has led to great advances in research over the last 30 years. However, its problems have...

Individuals with diagnosed personality disorders constitute a sizable proportion of patients receiving outpatient psychodynamic therapy [1, 2]. Beyond the DSM-IV diagnosable conditions, personality is still a significant diathesis for psychopathology [3] and plays a predominant role in how patients use and respond to psychotherapy [4, 5]. How can c...

The authors describe a system for diagnosing personality pathology that is empirically derived, clinically relevant, and practical for day-to-day use. 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...

This study examined personality characteristics and identified personality subtypes of adults with childhood histories of traumatic separations from a parent. Previous work from attachment theory and developmental psychopathology suggests that distinct developmental trajectories might lead to different styles of personality adaptation after an atta...

This study examined personality subtypes of adolescents diagnosed with Panic Disorder (PD). As part of an NIMH-funded study of adolescent personality and its relation to psychopathology, randomly selected experienced licensed psychologists and psychiatrists used a Q-sort instrument to describe adolescents in their care, of whom 57 had been diagnose...

Research suggests that personality pathology is shared among a considerable portion of adolescents presenting suicidal behavior. Furthermore, heterogeneity of personality within this population suggests a need to tease apart different types of attempters. The goal of this study was to identify the personality subtypes of adolescents who attempt sui...

The authors conducted two studies to identify and to validate potential personality subtypes in the adolescent and adult children of alcoholics. As part of a broader NIMH-funded study, randomly selected psychologists and psychiatrists provided personality data on adolescent (n = 208) or adult (n = 349) children of alcoholics using a Q-sort procedur...

The ability to effectively regulate emotions and a secure attachment style are critical for maintaining mental health across the life span. The experience of childhood maltreatment interferes with normal development of emotional regulation and dramatically increases risk for a wide range of psychiatric disorders in adulthood. The central nervous sy...

A growing body of research focuses on the development and correlates of emotion dysregulation, or deficits in the ability to regulate intense and shifting emotional states. Current models of psychopathology have incorporated the construct of emotion dysregulation, suggesting its unique and interactive contributions, along with childhood disruptive...

Although establishing a coherent identity is often viewed as a normative developmental task of adolescence, an important question is whether forms of identity disturbance seen in adult personality disorders can also be distinguished in adolescents. If so, such disturbances would constitute an essential target for research and clinical interventions...

Psychiatric researchers rely heavily on patient report data for clinical research. However, patient reports are prone to defensive and self-presentation biases. Recent research using practice networks has relied on clinician reports, and both forensic and personality disorder researchers have recently turned to quantified data from clinically exper...

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...

Domestic violence is a serious problem with far-reaching consequences. This study applies a new methodology to derive subtypes of male perpetrators of intimate partner violence. As part of a larger National Institute of Mental Health (NIMH)-funded study, a national sample of randomly selected psychologists and psychiatrists describe 188 adult male...

The present study examined the application of the Antisocial Personality Disorder (APD) diagnosis to adolescents and investigated the possibility of subtypes of APD adolescents. As part of a broader study of adolescent personality in clinically-referred patients, experienced clinicians provided personality data on a randomly selected patient in the...

Research into personality factors related to suicidality suggests substantial variability among suicide attempters. A potentially useful approach that accounts for this complexity is personality subtyping. As part of a large sample looking at personality pathology, this study used Q-factor analysis to identify subtypes of 311 adult suicide attempte...

Research on political judgment and decision-making has converged with decades of research in clinical and social psychology suggesting the ubiquity of emotion-biased motivated reasoning. Motivated reasoning is a form of implicit emotion regulation in which the brain converges on judgments that minimize negative and maximize positive affect states a...

This study examined personality subtypes of adults diagnosed with panic disorder (PD). As part of a National Institute of Mental Health-funded study on personality in a clinical population, randomly selected psychologists and psychiatrists used a Q-sort instrument to describe 96 adults diagnosed with PD. Q-factor analysis yielded 4 personality subt...

This study examined whether personality differences might account for meaningful heterogeneity within and across DSM-IV diagnostic categories for disruptive adolescent boys. In a broader study of personality pathology in adolescence, a national sample of 293 clinicians completed the Shedler-Westen Assessment Procedure 200-A on randomly selected out...

The available research suggests that the etiology of eating disorders (EDs) is multifactorial and individually variable, with risk conferred from personality pathology, family history, developmental history, sociocultural phenomena, comorbid disorders, and genetic endowment [1–5]. The treatment of EDs is complicated by characteristic problems in in...

Mario, an accountant in his early 30s, came to therapy angry and ready to challenge the parameters of treatment (i.e., time, fees, and interventions). He displayed barely concealed disdain toward his therapist and therapy despite a desperate plea for help. He was isolated, new to the city with few attachments to tether him to the world. He was in c...

After the introduction of histrionic personality disorder (HPD), nosologists struggled to reduce its overlap with borderline personality disorder and other PDs. We studied the coherence of HPD in adults and adolescents as part of 2 larger studies. Clinicians described a random patient with personality pathology using rigorous psychometrics, includi...

Political strategists decide daily how to market their candidates. Growing recognition of the importance of implicit processes (processes occurring outside of awareness) suggests limitations to focus groups and polling, which rely on conscious self-report. Two experiments, inspired by national political campaigns, employed Internet-presented sublim...

Narcissistic personality disorder has received relatively little empirical attention. This study was designed to provide an empirically valid and clinically rich portrait of narcissistic personality disorder and to identify subtypes of the disorder. A random national sample of psychiatrists and clinical psychologists (N=1,201) described a randomly...

This study compares the clinical relevance and utility of five dimensional diagnostic systems for personality disorders that have been proposed for the forthcoming edition of DSM (DSM-V): (1) a criteria counting model based on current DSM-IV diagnostic criteria; (2) a prototype matching model based on current DSM-IV diagnostic criteria; (3) a proto...

Research has identified three personality subtypes in adults with eating disorders (EDs): a high-functioning, an undercontrolled, and an overcontrolled group. The current study investigated whether similar personality prototypes exist in adolescents with EDs, and whether these personality prototypes show relationships to external correlates indicat...

This article describes the Shedler-Westen Assessment Procedure (SWAP), a personality assessment instrument intended for use by clinically experienced interviewers, designed to maximize both psychometric precision and clinical relevance. The article focuses on the latest edition of the instrument, the SWAP-II; its use in 2 recently completed large-s...

With DSM-V and ICD-11 on the horizon, now is an excellent time to consider options for improving their utility in clinical practice. A prerequisite for determining what can be done to improve their clinical utility is to establish a baseline from which to work. Surprisingly, there is virtually no information available that illuminates how clinician...

There is a schism between science and practice in understanding and assessing personality. Approaches derived from the research laboratory often strike clinical practitioners as clinically naive and of dubious clinical relevance. Approaches derived from clinical observation and theory often strike empirical researchers as fanciful speculation. In t...

Research suggests that personality pathology lies on a continuum from relatively severe to less severe and that subthreshold variants may not be adequately captured by axis II of DSM-IV. In this study, we used a measure of personality and psychopathology designed for experienced clinical observers (the SWAP-200) to derive subthreshold personality c...

The relation between self- and peer-informant reports of personality using psychometric instruments has been the focus of considerable research. The quantified judgments of clinically experienced observers such as treating clinicians have also been studied. The focus of the present article is on the measurement of 3 personality disorders (borderlin...

The relevance of attachment theory and research for practice has become increasingly clear. The authors describe a series of studies with 3 aims: (a) to validate measures of attachment for use by clinicians with adolescents and adults, (b) to examine the relation between attachment and personality pathology, and (c) to ascertain whether factor anal...

Research on political judgment and decision-making has converged with decades of research in clinical and social psychology suggesting the ubiquity of emotion-biased motivated reasoning. Motivated reasoning is a form of implicit emotion regulation in which the brain converges on judgments that minimize negative and maximize positive affect states a...

Decisions about whether to include depressive, passive-aggressive, sadistic, and self-defeating disorders in Axis II have been made difficult by a relative dearth of data. We report the results of a study identifying potential defining features of these diagnoses and assessing their distinctiveness from other Axis II personality disorders (PDs). A...

Research has raised questions about the ability of clinicians to make reliable diagnostic judgments about personality. The aim of this study was to assess the reliability and validity of the dimensional diagnosis of pathological personality traits with the Shedler-Westen Assessment Procedure-200 (SWAP-200) Q sort. Two clinician/judges independently...

Virtually no research has tested alternatives to the diagnostic method used since DSM-III, which requires decisions about the presence/absence of individual diagnostic criteria, followed by counting symptoms and applying cutoffs (the count/cutoff method). This study tested an alternative, prototype matching procedure designed to simplify diagnosis....

The evidence-based practice movement has become an important feature of health care systems and health care policy. Within this context, the APA 2005 Presidential Task Force on Evidence-Based Practice defines and discusses evidence-based practice in psychology (EBPP). In an in- tegration of science and practice, the Task Force's report describes ps...

Although difficulty with affect regulation is generally considered a core component of borderline personality disorder (BPD), surprisingly little research has focused on the nature of affect regulation and dysregulation in BPD. A random national sample of 117 experienced clinicians provided data on a randomly selected patient with BPD (N = 90) or d...

In the first position paper of this chapter, Drew I. Westen argues, first, that patients treated in the laboratory have not been adequately representative of patients treated in the community, and second, that treatments tested in the laboratory have not been adequately representative of treatments as practiced in the community. The Evidence-Based...

Smith's article "On Construct Validity: Issues of Method and Measurement" is a fine tribute to L. J. Cronbach and P. E. Meehl (1955) that clarifies the current state and future directions in the understanding of construct validity. Construct validity is a dynamic process, and fit indices need to be used at the service of understanding, not in place...

Although childhood sexual abuse (CSA) appears to have an impact on personality, it does not affect all survivors the same way. The goal of this study was to identify common personality patterns in women with a history of CSA. A national sample of randomly selected psychologists and psychiatrists described 74 adult female patients with a history of...

Over the last 10 years, evidence-based practice in psychology has become synonymous with a particular operationalization of it aimed at developing a list of empirically supported therapies. Although much has been learned since the emergence of the empirically supported therapies movement, its restrictive definition of evidence (excluding, for examp...

Data from naturalistic samples provide an important complement to findings from randomized trials of psychotherapy. A random national sample of US clinicians provided data on 145 completed treatments of patients with bulimic symptoms. Treatment in the community was substantially longer than treatment prescribed in manuals, with a mean length of cog...

Data from naturalistic samples provide an important complement to findings from randomized trials of psychotherapy. A random national sample of US clinicians provided data on 145 completed treatments of patients with bulimic symptoms. We attempted to characterize the nature of treatments in the community and to examine the relation between treatmen...

This study aimed to identify personality features characterizing adolescent girls and boys with borderline personality disorder (BPD) and to see whether meaningful patterns of heterogeneity exist among adolescents diagnosed with the disorder. Two hundred and ninety-four randomly selected doctoral-level clinicians described adolescent patients using...

Although Paul E. Meehl demonstrated the limits of informal aggregation of data and prognostication by presumed experts, he remained convinced that clinical experience confers expertise of some kind. The authors explore this forgotten side of Meehl's legacy by reconsidering the validity of clinical judgment in its natural context, everyday clinical...

We appreciate the three comments on our original article (Westen & Weinberger, 2004) and our opportunity to reply to them. Schulz and Waldinger (2005) make the im-portant point that just as researchers can capitalize on the knowledge of experienced clinical observers through aggregation, they can aggregate the judgment of lay observers in assessing...

This study examined the relation between attachment constructs assessed by self-report and object relations constructs assessed from narratives. Young adult participants (N = 65; median age 28) completed the Reciprocal Attachment Questionnaire (West, Sheldon, &Reiffer, 1987), provided a set of interpersonal narratives rated using the Social Cogniti...

The aim of this study was to ascertain whether the structure of personality disorder (PD) symptoms in adolescents assessed using DSM-IV diagnoses and diagnostic criteria resembles the structure intended for the diagnosis of PDs in adults. A national sample of clinicians rated DSM-IV Axis II criteria on 294 adolescent patients in treatment for endur...

Research has identified three personality subtypes in patients with eating disorders: emotionally dysregulated, constricted and high-functioning/perfectionistic. To see whether the subtypes are distinguished in ways indicative of valid classification, notably in patterns of adaptive functioning, comorbidity, treatment response and therapeutic inter...

Most studies of borderline personality disorder have drawn patients from among hospital inpatients or outpatients. The aims of this study were to examine the nature of borderline personality disorder patients in everyday clinical practice and to use data from a sample of borderline personality disorder patients seen in the community to refine the b...

This study provides initial data on the reliability and factor structure of a measure of countertransference processes in clinical practice and examines the relation between these processes and patients' personality pathology. A national random sample of 181 psychiatrists and clinical psychologists in North America each completed a battery of instr...

Replies to Crits-Christoph et al. (see record 2005-04167-007) and Weisz et al (see record 2005-04167-008). Evidence-based practice (EBP) is not a synonym of empirically supported therapies (ESTs). ESTs reflect 1 kind of evidence that should guide EBP. The authors focus in this response on 4 issues: the distinction between 2 functions of randomize...

The concept of transference has broadened to a recognition that patients often express enduring relational patterns in the therapeutic relationship. To examine the structure of patient relational patterns in psychotherapy and their relation with DSM-IV personality disorder symptoms. A random sample of psychologists and psychiatrists (n=181) complet...

Personality pathology constitutes a major form of psychopathology in adolescents. To examine the reliability and validity of a Q-sort instrument for assessing adolescent personality pathology designed for clinically experienced informants. A sample of 294 randomly selected psychiatrists and psychologists each provided data on a current patient, age...

The authors present a multidimensional meta-analysis of studies published between 1980 and 2003 on psychotherapy for PTSD. Data on variables not previously meta-analyzed such as inclusion and exclusion criteria and rates, recovery and improvement rates, and follow-up data were examined. Results suggest that psychotherapy for PTSD leads to a large i...

This article provides a contemporary view of the psychodynamics of borderline personality disorder (BPD) from a developmental psychopathology perspective. We first briefly describe the evolution of the borderline construct in psychoanalysis and psychiatry. Then we provide clinically and empirically informed model of domains of personality function...

A substantial body of research points to several variables relevant to the etiology of borderline personality disorder (BPD), notably childhood physical and sexual abuse, childhood family environment, and familial aggregation of both internalizing and externalizing disorders. However, these variables tend to be correlated, and few studies have exam...

Cognition and Affect in Psychoanalytic TheoryPropositions toward An Integrated Cognitive-psychodynamic Model of Cognition and AffectEmpirical SupportA Case ExampleConclusion References

A number of qualitative and meta-analytic reviews point to the efficacy of psychotherapeutic and pharmacological interventions for obsessive-compulsive disorder (OCD). In this article, we report a multidimensional meta-analysis of psychological and pharmacological treatment studies for OCD published between 1980 and 2001, examining a range of varia...

Researchers have advocated replacing the DSM-IV classification of personality disorders with an alternative diagnostic system based on the five-factor model. This study evaluates the clinical comprehensiveness of the five-factor model and addresses the broader question of how many factors, and which factors, are necessary to understand personality...

This article reconsiders the issue of clinical versus statistical prediction. The term clinical is widely used to denote 1 pole of 2 independent axes: the observer whose data are being aggregated (clinician/expert vs. lay) and the method of aggregating those data (impressionistic vs. statistical). Fifty years of research suggests that when formulas...

Personality disorder researchers are currently evaluating a range of potential solutions to problems with the DSM-IV diagnostic categories. This article proposes changes to the diagnostic categories and criteria based on empirical findings from a national sample of patients with personality disorder diagnoses. The Shedler-Westen Assessment Procedur...

The commentaries on D. Westen, C. M. Novotny, and H. Thompson-Brenner's (2004; see records 2004-15935-005; 2004-15935-006; and 2004-15935-007) review suggest a number of questions, such as how an empirically informed clinician can integrate both applied and basic science into practice. The authors suggest recommendations for design and funding o...

This article provides a critical review of the assumptions and findings of studies used to establish psychotherapies as empirically supported. The attempt to identify empirically supported therapies (ESTs) imposes particular assumptions on the use of randomized controlled trial (RCT) methodology that appear to be valid for some disorders and treatm...

To assess sexuality, personality, and eating pathology in women with eating disorders (EDs), we asked a random sample of 234 clinicians to describe an ED patient (age 16-65). Restricting AN patients tended to be childlike and prim/proper, while BN patients tended to be flirtatious and promiscuous. A constricted/overcontrolled personality predicted...

Borderline personality disorder (BPD) is one of the most prevalent, most widely studied, and yet most controversial of the personality disorders (PDs) described in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association [APA], 1994). Its public health significance arguably rivals tha...

The aim of this study was to assess the reliability and validity of the Child Behavior Checklist (CBCL) as completed by doctoral-level clinicians in the treatment of adolescents. We asked 294 randomly selected, experienced psychiatrists and psychologists to describe a patient aged 14 to 18 in treatment for personality pathology. Clinicians complete...

The present study focused on the link between parental bonding and personality pathology. We developed a clinician-report version of the Parental Bonding Instrument (PBI; Parker, Tupling, and Brown, 1979), which 203 clinicians applied to a randomly selected patient in their care. The goal of the study was to examine the reliability and validity of...

We report a multidimensional meta-analysis of psychotherapy trials for bulimia nervosa published between 1980 and 2000, including multiple variables in addition to effect size such as inclusion and exclusion, recovery, and sustained recovery rates. The data point to four conclusions. First, psychotherapy leads to large improvements from baseline. A...

We report a multidimensional meta-analysis of psycho- therapy trials for bulimia nervosa published between 1980 and 2000, including multiple variables in addition to effect size such as inclusion and exclusion, recovery, and sustained recovery rates. The data point to four conclu- sions. First, psychotherapy leads to large improvements from baselin...

Like other core psychoanalytic constructs, the theory of therapeutic action is currently in flux, as theorists of differing persuasions propose different mechanisms. In this article, the authors attempt to integrate developments within and without psychoanalysis to provide a working model of the multifaceted processes involved in producing change i...

Da mesma forma que outros aspectos medulares da psicanálise, a teoria da ação terapêutica está atualmente em processo de mudança, com os teóricos de diferentes correntes propondo diferentes mecanismos. Neste artigo, os autores tentam integrar os desenvolvimentos dentro e fora da psicanálise, para dar um modelo de trabalho aos processos multifacétic...