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, including the SWAP-II (a Q-sort that captures personality and its pathology in adults) in study 1 and the SWAP-II-A (the adolescent version) in study 2. Using DSM-IV-based measures, we identified patients who met HPD criteria with varying degrees of diagnostic confidence. Central tendencies in the SWAP-II and SWAP-II-A profiles revealed that both the most descriptive and most distinctive features of the patients included some features of HPD but also many features of borderline personality disorder. Q-factor analyses of the SWAP data yielded 3 types of patients in each of the 2 samples. The HPD diagnosis may not be sufficiently coherent or valid.
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"The SWAP instruments (the original SWAP-200 and revised SWAP-II for adults, and the SWAP-200-A and revised SWAP-II-A for adolescents) have been used to develop an empirically based classification of personality disorders (PDs; Shedler & Westen, 2007; Westen & Shedler, 1999a, 1999b; Westen, Shedler, Bradley, & DeFife, in press; Westen, Waller, Shedler, & Blagov, in press), to refine current diagnostic constructs by identifying richer diagnostic criterion sets more faithful to the clinical syndromes observed in practice as well as in the lab (Blagov & Westen, 2008; Russ, Bradley, Shedler, & Westen, 2008; Shedler & Westen, 2004a; Zittel & Westen, 2005), to identify clinically important personality dimensions via factor analysis that are absent from other dimensional models of personality (Shedler & Westen, 2004b; Westen, Shedler, Bradley, & DeFife, in press), to link SWAP-assessed dimensions to etiological and outcome variables (including, e.g., genetic history , psychosocial history variables, and treatment response to both psychotherapy and pharmacological interventions; Westen & Shedler, 2007), to develop dimensional prototype models for personality diagnosis as an alternative to the categorical approach of Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV; Shedler & Westen, 2004a; Spitzer, First, Shedler, Westen, & Skodol, 2008; Westen, Shedler, & Bradley, 2006; Westen, Shedler, et al., in press), to explore subthreshold forms of personality pathology currently absent from the diagnostic manuals (Blagov, Bradley, & Westen, 2007), to assess subtypes of Axis I and Axis II disorders (e.g., DiLallo, Jones, & Westen, 2009; Russ et al., 2008), and to assess change in psychotherapy (Lingiardi, Shedler, & Gazillo, 2006). "
[Show abstract][Hide abstract] ABSTRACT: 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 review empirical data addressing its validity, emphasizing the multitrait-multimethod approach to evaluating test validity. To evaluate the hypothesis that the fixed, asymmetric score distribution artifactually inflates correlations between SWAP profiles, we conducted Monte Carlo simulations and also presented empirical data from a large patient sample. We observed a mean correlation of zero between simulated SWAP profiles, indicating that the score distribution does not impact the correlation coefficients. Empirical correlations between SWAP profiles of actual patients were small and similar to those obtained using Diagnostic and statistical manual of mental disorders, fourth edition (DSM-IV) personality disorder scales that had no fixed score distributions, suggesting that the correlations were not a methodological artifact of the SWAP. We report new test-retest reliability data (median coefficient > .85) for the SWAP's trait and personality disorder dimensions. The SWAP appears to be reliable and valid. The data do not support its primary psychometric critiques.
[Show abstract][Hide abstract] ABSTRACT: Psychoanalysts have long relied on the case study method to support the validity of their theoretical hypotheses and clinical techniques and the efficacy of their treatments. However, limitations of the case study method have become in-creasingly salient as the medical-scientific community and policymakers have increasingly emphasized the need for empirical data. This article describes the progression of an analysis from the perspective of both the treating analyst and an independent research team using empirical methods to study verbatim session transcripts. Empirical measures include the Shedler-Westen Assessment Procedure-200 (Westen & Shedler, 1999a, b; Shedler & Westen, 2006), the Defense Mechanism Rating Scale (Perry, 1990a) and the Analytic Process Scales (Waldron, Scharf, Crouse, Firestein, & Burton, 2004, and Waldron, Scharf, Hurst, et al., 2004). The article illustrates one way in which clinical and empirical methods can complement each other synergistically and lead to a deeper and more precise understanding of analytic process and psychological change. As the history of science attests (and, as recently emphasized by the American Psychological Association in their guidelines defining "evidence"), scientific evidence includes and often for their comments and feedback. The research presented in this paper derives in part from the Ph.D. dissertation of one of the authors (F. G.).
[Show abstract][Hide abstract] ABSTRACT: The Personality and Personality Disorders Work Group has proposed five specific personality disorder (PD) types for DSM-5, to be rated on a dimension of fit: antisocial/psychopathic, avoidant, borderline, obsessive-compulsive, and schizotypal. Each type is identified by core impairments in personality functioning, pathological personality traits, and common symptomatic behaviors. The other DSM-IV-TR PDs and the large residual category of personality disorder not otherwise specified (PDNOS) will be represented solely by the core impairments combined with specification by individuals' unique sets of personality traits. This proposal has three main features: (1) a reduction in the number of specified types from 10 to 5; (2) description of the types in a narrative format that combines typical deficits in self and interpersonal functioning and particular configurations of traits and behaviors; and (3) a dimensional rating of the degree to which a patient matches each type. An explanation of these modifications in approach to diagnosing PD types and their justifications--including excessive co-morbidity among DSM-IV-TR PDs, limited validity for some existing types, lack of specificity in the definition of PD, instability of current PD criteria sets, and arbitrary diagnostic thresholds--are the subjects of this review.