The Unstructured Clinical Interview

In mental health, family, and community counseling settings, master's‐level counselors engage in unstructured clinical interviewing to develop diagnoses based on the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM‐IV‐TR; American Psychiatric Association, 2000). Although counselors receive education about diagnosis and the DSM classification system, the majority of them are not specifically trained in clinical interviewing. This article provides information about using the unstructured clinical interview to make a DSM‐IV‐TR diagnosis for adult clients with Axis I and Axis II disorders.     

A Comparison of Obsessive–Compulsive Personality Disorder Scales

In this study, we utilized a large undergraduate sample (N = 536), oversampled for the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision [DSM–IV–TR]; American Psychiatric Association, 2000) obsessive–compulsive personality disorder (OCPD) pathology, to compare 8 self-report measures of OCPD. No prior study has compared more than 3 measures, and the results indicate that the scales had only moderate convergent validity. We also went beyond the existing literature to compare these scales to 2 external reference points: their relationships with a well-established measure of the five-factor model of personality (FFM) and clinicians' ratings of their coverage of the DSM–IV–TR criterion set. When the FFM was used as a point of comparison, the results suggest important differences among the measures with respect to their divergent representation of conscientiousness, neuroticism, and agreeableness. Additionally, an analysis of the construct coverage indicated that the measures also varied in terms of their representation of particular diagnostic criteria. For example, whereas some scales contained items distributed across the diagnostic criteria, others were concentrated more heavily on particular features of the DSM–IV–TR disorder.     

Toward quantifying the abuse liability of ultraviolet tanning: A behavioral economic approach to tanning addiction

Many adults engage in ultraviolet indoor tanning despite evidence of its association with skin cancer. The constellation of behaviors associated with ultraviolet indoor tanning is analogous to that in other behavioral addictions. Despite a growing literature on ultraviolet indoor tanning as an addiction, there remains no consensus on how to identify ultraviolet indoor tanning addictive tendencies. The purpose of the present study was to translate a behavioral economic task more commonly used in substance abuse to quantify the "abuse liability" of ultraviolet indoor tanning, establish construct validity, and determine convergent validity with the most commonly used diagnostic tools for ultraviolet indoor tanning addiction (i.e., mCAGE and mDSM‐IV‐TR). We conducted a between‐groups study using a novel hypothetical Tanning Purchase Task to quantify intensity and elasticity of ultraviolet indoor tanning demand and permit statistical comparisons with the mCAGE and mDSM‐IV‐TR. Results suggest that behavioral economic demand is related to ultraviolet indoor tanning addiction status and adequately discriminates between potential addicted individuals from nonaddicted individuals. Moreover, we provide evidence that the Tanning Purchase Task renders behavioral economic indicators that are relevant to public health research. The present findings are limited to two ultraviolet indoor tanning addiction tools and a relatively small sample of high‐risk ultraviolet indoor tanning users; however, these pilot data demonstrate the potential for behavioral economic assessment tools as diagnostic and research aids in ultraviolet indoor tanning addiction studies.     

Beyond the DSM‐IV: Assumptions,Alternatives, and Alterations

Current diagnostic processes reflect the limitations and utility of the framework of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM‐IV; American Psychiatric Association, 1994). Clinical information in the DSM‐IV's 5‐axis system almost exclusively focuses on weaknesses and pathology and is summarized in a flawed categorical system. Hence, the authors describe 3 adjunctive, or alternative, means of conceptualizing behavior; several means of altering the current DSM‐IV system; and 2 future directions in the diagnosis of strengths.     

Ethics in Case Conceptualization and Diagnosis: Incorporating a Medical Model Into the Developmental Counseling Tradition

In this literature review, the author focuses on several ethical considerations in case conceptualization and diagnosis, including diagnostic training and competence. Meeting the American Counseling Association's (1995) ethical standard for diagnostic training has several ethical implications for counselors, counselor educators, and supervisors. For counselors who might struggle with how to meet their ethical responsibilities in diagnosis but who want to remain true to their developmental counseling emphases, the author discusses some of their concerns, the implications of and possible approaches to this aspect of their work. Conclusion Yalom (2002) asked a poignant question of counselors in his book, The Gift of Therapy: “If you were in personal psychotherapy or are considering it, what DSM‐IV diagnosis do you think your therapist could justifiably use to describe someone as complicated as you?” (p. 5). This question and continued dialogue about the ethics and implications of diagnosis are essential aspects of diagnostic training. Yalom's poignant and deeply personal question seems especially appropriate for increasing a counselor's empathy toward the client's sensitivity and vulnerability during the diagnostic process. Counselor educators might ask how one remains true to a developmental model of counseling while adhering to the ethical and accreditation standards of teaching the DSM's medical model of diagnosis. Counselors may also question how to use diagnosis ethically and empathically. Seligman (1999) recommended that clinicians view the DSM as one of many important sources of information about a person. Furthermore, counselors should seek to incorporate diagnostic information into a holistic context, recognizing that a diagnosis does not reflect the totality of the client. Some counselor educators have advised students to integrate the DSM model into their work with clients rather than abandoning their developmental roots (Waldo et al., 1993). Some counselors may not actually put their diagnoses in writing; Seligman believed, however, that thinking diagnostically may assist counselors in determining the best approaches to help clients and to help clients help themselves. This clinical and ethical debate about how, and in fact, whether, to integrate the medical model of the DSM and the developmental origins and distinctiveness of counseling continues. However, the CACREP (2001) standards, managed care systems, and other forces have pushed counseling professionals toward a medical model by mandating counselor knowledge and use of the DSM. Whatever a counselor's stance and behavior on client assessment and diagnosis may be, the literature presented in this review and discussion seems to suggest a need for heightened sensitivity to, preparation for, and accuracy in all facets of client assessment, especially diagnosis.     

Evolution of the Millon Clinical Multiaxial Inventory

Dr. Theodore Millon (1928–2014) was a primary architect for the personality disorders in the DSM–III, a structure that has endured into the DSM–5. His 1969 book, Modern Psychopathology, created an elegant framework into which the well-known personality prototypes could be fitted and understood. His theoretical work soon led into the creation of several psychological inventories, most notably the Millon Clinical Multiaxial Inventory (MCMI). The MCMI, now in preparation for its 4th major edition, has been a very popular instrument among clinicians. This article explores the history of the MCMI's development from its origins, through 2 distinct theoretical phases, and to its current status as the MCMI–IV is finalized.     

Health of entrepreneurs versus employees in a national representative sample

Prior research has found entrepreneurs to experience significantly higher job control and job demands compared with employees. This suggests that entrepreneurs have so‐called active jobs and thus may benefit from positive health consequences. The present research compared entrepreneurs' health with employees' health in a national representative sample with regard to the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD‐10) diagnoses of somatic diseases, the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM‐IV) diagnoses of mental disorders, blood pressure, well‐being (life‐satisfaction) as well as behavioural health indicators (sick days, physician visits). Entrepreneurs showed significantly lower overall somatic and mental morbidity, lower blood pressure, lower prevalence rates of hypertension, and somatoform disorders, as well as higher well‐being and more favourable behavioural health indicators. The results are discussed with regard to the active job hypothesis and recommendations for future research are provided.     

Beyond the Score: Clinical Evaluation Through Formal Psychological Assessment

Questionnaires generate numerical scores, but endorsing different sets of items could produce the same score despite reflecting qualitatively different configurations of clinical features. Formal psychological assessment (FPA) attempts to overcome this by identifying the clinical features entailed by observed response patterns. This study illustrates an application of FPA to the cleaning subscale of a questionnaire assessing obsessive–compulsive symptoms and DSM–IV–TR diagnostic criteria for obsessive–compulsive disorder. A deterministic model of the items–criteria relationships was constructed by mapping each item to each diagnostic criterion. The resulting model was tested on a large community sample (N = 4,412). Results indicate that the theoretical model has adequate fit; item error rates and probabilities for each of the criteria are examined. Clinically relevant examples of the items–criteria relationships are discussed. Possible applications of FPA to personality assessment are also discussed, including long multidimensional questionnaires and questionnaires that use subtle item content.     

Personality,life events and the course of anxiety and depression

Using data from the Netherlands Study of Depression and Anxiety, we examined among 1322 participants with a DSM‐IV diagnosis of depression or anxiety: (i) whether positive and negative life events influence 1‐year course of anxiety and depressive symptoms; (ii) whether personality traits (neuroticism and extraversion) predict symptom course and moderate the impact of life events on symptom course; and (iii) whether life events mediate relationships of neuroticism and extraversion with symptom course. Negative life events were predictive of both anxiety and depressive symptoms, while positive life events predicted the course of depressive symptoms only. Personality traits had significant predictive and moderating effects on symptom course, though these effects were rather small. Copyright © 2011 John Wiley & Sons, Ltd.     

Age Neutrality of Categorically and Dimensionally Measured DSM–5 Section II Personality Disorder Symptoms

Studies on the face validity of DSM–5 Section II categorical personality disorder (PD) symptoms indicate a bias against older adults. To extend these results, this article explores whether categorically and dimensionally scored PD symptoms of DSM–5 Section II, as measured in the Assessment of DSM–IV Personality Disorders (ADP–IV; Schotte & de Doncker, 1994), corroborate potential age bias across younger (aged 18–34), middle-aged (35–59 years), and older adults (aged 60–75). Differential item functioning (DIF) analyses, following a classical test theory approach, showed that 2 of the 79 symptoms were measured differently across 3 age groups when categorically assessed, and 4 when dimensionally measured. Nevertheless, subsequent differential test functioning analyses supported a low aggregated impact of DIF on the dimensional scales, justifying mean-level comparisons across age groups. Generalizability of the results is discussed in light of methodological issues concerning the research of age neutrality of PD symptoms, including the employed measurement instrument, PD symptom measurement approach, and sample and age range used to describe older adults.     

Ethical Challenges in a Complex World: Highlights of the 2005 ACA Code of Ethics

Being an effective counselor includes having knowledge of and the ability to integrate a code of ethics into one's professional practice. This article addresses some of the highlights of the changes in the 2005 ACA [American Counseling Association] Code of Ethics such as end‐of‐life issues, boundaries and relationships, and multicultural and diversity considerations. It is critical for counselors to demonstrate cultural sensitivity during the ethical decision‐making process throughout their counseling, supervision, teaching, and research practice.     

Development and Validation of Personality Disorder Spectra Scales for the MMPI–2–RF

The purpose of this study was to develop and validate a set of MMPI–2–RF (Ben-Porath &; Tellegen, 2008/2011) personality disorder (PD) spectra scales. These scales could serve the purpose of assisting with DSM–5 PD diagnosis and help link categorical and dimensional conceptions of personality pathology within the MMPI–2–RF. We developed and provided initial validity results for scales corresponding to the 10 PD constructs listed in the DSM–5 using data from student, community, clinical, and correctional samples. Initial validation efforts indicated good support for criterion validity with an external PD measure as well as with dimensional personality traits included in the DSM–5 alternative model for PDs. Construct validity results using psychosocial history and therapists' ratings in a large clinical sample were generally supportive as well. Overall, these brief scales provide clinicians using MMPI–2–RF data with estimates of DSM–5 PD constructs that can support cross-model connections between categorical and dimensional assessment approaches.     

Diagnoses,Relational Processes and Resourceful Dialogs: Tensions for Families and Family Therapy

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM‐5), given its psychiatric focus on mental disorders in individuals, presents families and family therapists with challenges. Despite considerable controversies over its adoption, the DSM‐5 extends a process of standardizing a language for human and relational concerns. No longer a diagnostic language of professionals alone, its use is medicalizing how mental health funders and administrators, as well as clients, respond to human concerns. For family therapists who practice systemically, particularly from poststructuralist and strengths‐based orientations, many tensions can follow when use of the DSM‐5 is expected by mental health administrators and funders, or by clients who present concerns about themselves or a diagnosed family member. In this paper, I explore how such DSM‐5 related tensions might be recognized, navigated, and negotiated in the practice of family therapy with clients, and with administrators and funders.     

The MMPI–2 Restructured Form Personality Psychopathology Five Scales: Bridging DSM–5 Section 2 Personality Disorders and DSM–5 Section 3 Personality Trait Dimensions

This study examined in a college sample and a sample of non-treatment-seeking, trauma-exposed veterans the association between the MMPI–2 Restructured Form (MMPI–2–RF) Personality Psychopathology Five (PSY–5) Scales and DSM–5 Section 2 personality disorder (PD) criteria, the same system used in DSM–IV–TR, and the proposed broad personality trait dimensions contained in Section 3 of DSM–5. DSM–5 Section 2 PD symptoms were assessed using the SCID–II–PQ, and applying a replicated rational selection procedure to the SCID–II–PQ item pool, proxies for the DSM–5 Section 3 dimensions and select facets were constructed. The MMPI–2–RF PSY–5 scales demonstrated appropriate convergent and discriminant associations with both Section 2 PDs and Section 3 dimensions in both samples. These findings suggest the MMPI–2–RF PSY–5 scales can serve both conceptually and practically as a bridge between the DSM–5 Section 2 PD criteria and the DSM–5 Section 3 personality features.     

Dimensions of Normal and Abnormal Personality: Elucidating DSM‐IV Personality Disorder Symptoms in Adolescents

ABSTRACT The present study aimed to elucidate dimensions of normal and abnormal personality underlying DSM‐IV personality disorder (PD) symptoms in 168 adolescents referred to mental health services. Dimensions derived from the Big Five of normal personality and from Livesley's (2006) conceptualization of personality pathology were regressed on interview‐based DSM‐IV PD symptom counts. When examined independently, both models demonstrated significant levels of predictive power at the higher order level. However, when added to the higher order Big Five dimensions, Livesley's higher and lower order dimensions afforded a supplementary contribution to the understanding of dysfunctional characteristics of adolescent PDs. In addition, they contributed to a better differentiation between adolescent PDs. The present findings suggest that adolescent PDs are more than extreme, maladaptive variants of higher order normal personality traits. Adolescent PDs seem to encompass characteristics that may be more completely covered by dimensions of abnormal personality. Developmental issues and implications of the findings are discussed.     

Exploring the processes involved in long‐term recovery from chronic alcohol addiction within an abstinence‐based model: Implications for practice

Background: There is little consensus at policy or treatment level as to what defines ‘recovery’ in the alcohol addiction field. Aim: From interviewing a cohort of eight severely alcohol‐dependent people who fulfilled all categories of DSM‐IV and ICD 10 diagnostic criteria and had achieved long‐term recovery (LTR) of between 8 and 48 years, and who are long‐term AA members, a definition of recovery that is inclusive, and achievable, was sought from their lived experiences. Methodology: Interpretative Phenomenological Analysis was used. Findings: This research uncovers the processes involved in long‐term recovery, and identifies them as: sober; maintaining sobriety; and recovery. It suggests a move away from the acute model of cure by brief, time‐limited therapy, towards a model of sustained, on‐going and life‐long recovery management, combined with pro‐social aid resources. Individuals need to observe, and hear, the success narratives of others, and the therapeutic conditions of empathy, unconditional positive regard and congruence need to be strongly experienced by the individual.     

Counseling Clients Who Self‐Injure: Ethical Considerations

This article provides an overview of ethical considerations related to counseling clients who engage in self‐injurious behaviors. Ethical issues concerning client welfare, counselor competence, countertransference, referral and consultation, informed consent, and duty to protect are discussed in relation to the American Counseling Association's (1995) Code of Ethics and Standards of Practice. Implications and recommendations for counselors who work with clients who self‐injure are provided.     

The six most essential questions in psychiatric diagnosis: A pluralogue part 2: Issues of conservatism and pragmatism in psychiatric diagnosis

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM ?C whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article took up the first two questions. Part II will take up the second two questions. Question 3 deals with the question as to whether DSM-V should assume a conservative or assertive posture in making changes from DSM-IV. That question in turn breaks down into discussion of diagnoses that depend on, and aim toward, empirical, scientific validation, and diagnoses that are more value-laden and less amenable to scientific validation. Question 4 takes up the role of pragmatic consideration in a psychiatric nosology, whether the purely empirical considerations need to be tempered by considerations of practical consequence. As in Part 1 of this article, the general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances.