Clinical utility of dimensional models for personality pathology

Clinical utility is defined as the extent to which the DSM assists clinical decision makers in fulfilling the various clinical functions of a psychiatric classification system. Distinction is made between elements of diagnostic validity that are more or less conditional to utility (i.e., coverage, and consistency with etiology and prognosis) and components of clinical utility in the narrow sense of the term (i.e., user acceptability and accuracy, communication, reliability, subtlety, and clinical decision making). Clinical utility is often considered the driving force behind the respective revisions of the DSM system, yet it has been difficult if not impossible to obtain reasonable levels of clinical utility within categorical classifications of personality disorders. This paper presents evidence that a dimensional diagnostic system will substantially improve clinical utility, especially with respect to coverage, reliability, subtlety, and clinical decision making. In addition, some evidence suggests that the purely dimensional models outperform the so-called hybrid models (i.e., dimensional profiling of categories) with respect to coverage, consistency with etiology, subtlety, and clinical decision making. Several research options that might inform future revisions, including the choice or development of a dimensional classification, are suggested.     

A dimensional model of personality disorder: incorporating DSM Cluster A characteristics

The authors articulate an expanded dimensional model of personality pathology to better account for symptoms of DSM-defined Cluster A personality disorders. Two hundred forty participants (98 first-degree relatives of probands with schizophrenia or schizoaffective disorder, 92 community control participants, and 50 first-degree relatives of probands with bipolar disorder) completed a dimensional personality pathology questionnaire, a measure of schizotypal characteristics, and Chapman measures of psychosis proneness. Scales from all questionnaires were subjected to an exploratory factor analysis with varimax rotation. A 5-factor structure of personality pathology emerged from the analyses, with Peculiarity forming an additional factor to the common 4-factor structure of personality pathology (consisting of Introversion, Emotional Dysregulation, Antagonism, and Compulsivity). These results support a 5-factor dimensional model of personality pathology that better accounts for phenomena encompassed by the Cluster A personality disorders in DSM-IV-TR (4th ed., text revised; American Psychiatric Association, 2000). This study has implications for the consideration of a dimensional model of personality disorder in DSM-V by offering a more comprehensive structural model that builds on previous work in this area.     

Dream research in schizophrenia: Methodological issues and a dimensional approach

Dreaming in patients with schizophrenia was and is of particular interest to researchers and clinicians due to the phenomenological similarities between the dreaming state and schizophrenic daytime symptomatology such as bizarre thoughts or hallucinations. Extensive literature reviews have shown that dream studies in the field of psychopathology often do not fulfill common scientific criteria. The present paper focuses on the methodological issues like sampling methods, the dream collection method, and dream content analysis that are crucial with regard to the validity of the findings. It is also suggested that the so-called dimensional approach (linking severity of daytime symptoms directly to specific dream characteristics) will be very helpful for identifying which psychopathological symptoms of schizophrenia are most closely linked to dream content.     

Individual differences in timing of discrete and continuous movements: a dimensional approach

This study investigated aspects of individual differences in timing of continuous and discontinuous movements to different pacing signals (auditory or visual), pacing intervals (500, 650, 800, 950 ms), and across effectors (dominant versus non-dominant hand). Correlation and principal component analysis demonstrated that a single statistical dimension accounted for up to 60 % of the explained variance in discontinuous tasks and 25 % of the variance in continuous tasks, when applied to performance obtained from tasks conducted with different effectors and at different pacing rates. Correlation analysis of factor scores representing effector and rate independent task performances showed that timing of discrete or continuous movements can be associated with modality independent mechanisms. Timing variability from discrete and continuous trials was not significantly correlated. This study goes beyond previous correlational work on individual differences in discrete and continuous movements, demonstrating that individual differences in discrete (event-based) or continuous (emergent) motor timing tasks can be modeled as distinctive statistical components with dissimilar capability to capture effector, rate, and modality independent variance.     

Multi-attribute utility analysis using the promes approach

Traditional utility analyses have focused on the economic value of increased job performance. While providing a great deal of information to decision makers, such approaches fail to account for other potentially critical outcomes of implementing a selection system (e.g. legal exposure). This paper proposes a new method for incorporating multiple outcomes in utility analysis. An example shows how to incorporate economic gains due to job performance, legal exposure, effect on protected groups, and organizational image in the decision to implement a new selection system. Integrating these four outcomes into utility analysis captures managerial policy that will allow examination of the process of using utility information to aid decision making. In addition, the method is amenable to use of sensitivity, breakeven, and Monte Carlo analyses advocated by utility researchers (Boudreau, 1991).     

Clinical utility of the MMPI-2 Restructured Clinical (RC) Scales in therapeutic assessment: a case study

In the following article, we provide a case study on a 25-year-old man who was released from a crisis stabilization unit following a suicide attempt. After completing a diagnostic intake, the client participated in a Therapeutic Assessment (Finn, 1996, 2003), which included the MMPI-2 (Butcher et al., 2001) and the Incomplete Sentences Blank (Rotter & Rafferty, 1950). In particular, in the article, we focus on how the Restructured Clinical (RC; Tellegen et al., 2003) scales can be used to form a personological conceptualization of the client. The RC scales measure important personality and affective trait dimensions including demoralization and both positive and negative affect, which allows for a clear explanation of the underlying etiological factors that influence a client's negative emotional experience. In this article, we highlight how explaining these underlying personality characteristics to the client within the framework of therapeutic assessment allowed for an increase in his insight.     

Toward a dimensional and psychometrically-informed approach to conceptualizing psychopathology

Most modern research on psychopathology is framed by the categorical model of mental disorders embodied in the Diagnostic and statistical manual of mental disorders, 4th edition (DSM-IV; American Psychiatric Association, 1994). Nevertheless, the categorical model of the DSM is incompatible with robust empirical observations about psychopathological variation, such as the tendency for multiple, putatively distinct mental disorders to occur in the same persons. The goal of this invited essay is to outline a potential alternative to the DSM's categorical approach: a dimensional and psychometrically-informed approach to conceptualizing and studying psychopathology. We discuss the advantages of the dimensional approach, some modern statistical technologies that can be recruited in the service of the dimensional approach, and ways of integrating the dimensional approach with a behavioral approach to psychopathology assessment and research.     

Clinical utility of the Rorschach Inkblot Method: reframing the debate

Recent published exchanges have focused on the clinical utility and diagnostic efficiency of the Rorschach Inkblot Method (RIM), but key issues remain unresolved. In this article, 5 principles for evaluating RIM research are offered to help reframe the ongoing debate in this area. These are (a) recognize what the test can and cannot do; (b) choose appropriate outcome criteria to assess RIM effectiveness; (c) use multimethod, multicriterion matrices to place results in an appropriate context; (d) consider limitations in the outcome criteria themselves; and (e) use experimental--not just correlational--data to contrast the results obtained with projective and self-report tests. Coupled with Weiner's (2000a) guidelines for RIM interpretation, the principles outlined here can improve RIM research and practice, and help resolve some longstanding controversies in this area.     

Target-directed visual attention is a prerequisite for action-specific perception

Witt et al. (2008) have recently shown that golfers who putt with more success perceive the hole to be bigger than golfers who putt with less success. In three experiments, we systematically examined whether this phenomenon, labelled action-specific perception, depends on directing visual attention towards the action target. In Experiment 1 we replicated previously reported action-specific effects on perception in golf putting. In 3 and 4 we directly assessed whether action-specific effects on perception in golf putting are dependent on focusing visual attention on the target. To this end, the participants performed the putting task while visual attention towards the target was either completely withheld (Experiment 2) or divided over the target and other task-relevant objects (Experiment 3). No action-specific effects were found when visual attention towards the action target was occluded or partially diverted from the target. Together, our results provide evidence to suggest that focusing visual attention on the target while performing the action is a prerequisite for the emergence of action-specific perception.     

Testing the representation of time in reference memory in the bisection and the generalization task: the utility of a developmental approach

This study examined the effect of the variability of representation of durations in reference memory on temporal discrimination performance in children aged 5 and 8 years as well as in adults using a bisection (Experiment 1) and a generalization task (Experiment 2). In each task, the participants were familiarized before the blocks of tested trials with either the same referent duration values (fixed condition) or a distribution of referent duration values, with a mean equal to the referent durations used in the fixed condition and a .20 coefficient of variation (variable condition). The results showed that the sensitivity to duration was lower in the variable than in the fixed condition in the children and, to a lesser extent, in the adults. The modelling of the data indicated that this effect was due to the increase in the variability of the representation of durations in reference memory, but also to changes in the decisional processes.     

The adoption of approach versus avoidance goals: The role of goal-relevant resources

The present research investigated whether the adoption of approach versus avoidance goals is affected by goal-relevant resources. When individuals have few goal-relevant resources, they should prefer avoidance goals, whereas when individuals have many goal-relevant resources, they should adopt approach goals. The individual’s outcome expectancy is assumed to mediate this relationship. This hypothesis is supported by the findings of four multi-method studies with student samples. A cross-sectional field study showed a positive relationship between the extent of goal-relevant resources and approach goal adoption. In a longitudinal field study, a high number of resources predicted the increase in personal approach goal adoption over a period of 4 months, controlling for neuroticism. Two experiments showed that the manipulation of resources affected approach versus avoidance task goal adoption, with outcome expectancy mediating the relationship. These findings complement existing findings on dispositional determinants of approach versus avoidance goal adoption.     

A dimensional approach to the circular ordering of the emotions

A circular ordering of eight primary emotional categories was derived from the postulated underlying dimensions of hedonic and autonomic arousal. The model was contrasted with other approaches in the literature and then compared with a similar model proposed by Plutchik (1980) in postdicting the pattern of results in several studies in the literature. The results of two empirical studies based upon the present model were then presented. It was concluded that sufficient empirical support and advantage, compared with other models, was found to warrant further research.     

The practice of empathy as a prerequisite for informed consent

The patient-physician relationship, as formulated in the traditional biomedical model of medicine, is inherently flawed. In entering this relationship, most patients seek simply to be delivered from illness back to normal psychosocial functioning. The physician, however, almost invariably responds with a purely biologic approach to diagnosis and treatment that often does not effectively address the patient's needs. This precludes the opportunity for a consensus between them, and may in fact lead to the physician manipulating the patient's decisions about the course of therapy. The relationship should be reshaped within a new scientific model of patient care that combines the biomedical analysis of disease with an empathic understanding of the patient's illness experience. Truly informed consent is viewed as a natural outcome of the application of this more comprehensive framework.     

Testing the representation of time in reference memory in the bisection and the generalization task: The utility of a developmental approach

This study examined the effect of the variability of representation of durations in reference memory on temporal discrimination performance in children aged 5 and 8 years as well as in adults using a bisection (Experiment 1) and a generalization task (Experiment 2). In each task, the participants were familiarized before the blocks of tested trials with either the same referent duration values (fixed condition) or a distribution of referent duration values, with a mean equal to the referent durations used in the fixed condition and a .20 coefficient of variation (variable condition). The results showed that the sensitivity to duration was lower in the variable than in the fixed condition in the children and, to a lesser extent, in the adults. The modelling of the data indicated that this effect was due to the increase in the variability of the representation of durations in reference memory, but also to changes in the decisional processes.     

Genetics and adoption: Forming a partnership

Genetic issues are demanding more attention in the area of public health. Adoption agencies and policymakers are beginning to address these issues where they relate to the adoption process and to the many families involved in adoption in this country. Genetic counselors need to play an active role as both educators of and consultants for adoption professionals and the families with whom they work. To facilitate a partnership between genetics and adoption we have developed a workshop intended to educate adoption professionals about the lifelong implications of genetic conditions on the adoption triad.     

Clinical utility of the Rorschach with African Americans.

In this study we sought to identify Rorschach differences between African Americans and White Americans and to understand these differences within a social and cultural framework. Data from the Exner (1993) Comprehensive System normative sample (N = 700) was used to form a group of 44 African Americans and 44 White Americans matched for age, sex, education, and socioeconomic status. Twenty-three Rorschach variables were chosen a priori and group differences were analyzed. The only clinically significant difference found was that African Americans offered significantly less cooperative movement. This lower frequency of cooperative movement may suggest African Americans do not anticipate cooperative interactions with others as a routine event. This may reflect a shared feeling among African Americans that most members of our society are less likely to be sensitive to or responsive to their needs relative to others. However, the study demonstrates a striking similarity between the groups, supporting the clinical use of the Rorschach with African Americans.     

Clinical utility of the TEMAS with nonminority children.

The Tell Me a Story (TEMAS) Test is a thematic apperception technique composed of 23 chromatic pictures, depicting either minority or nonminority characters interacting in primarily urban and familial settings, and is scored for perceptual and cognitive style, affective state, and personality functioning. Previous research has supported the reliability and validity of the ethnic minority version of the TEMAS test for Hispanic and Black children and adolescents. In this study, we investigated the validity of the nonminority version by discriminating public school (n = 49) and outpatient (n = 36) samples of White examinees from inner city, low to lower middle socioeconomic status, largely female-headed households. Results indicate that TEMAS profiles significantly discriminated between the normal functioning and clinical groups (p < .001), with 86% classification accuracy. The results, which provide some support for the general clinical utility of the TEMAS technique, are discussed in terms of the need to develop and validate unbiased projective techniques for both ethnic minority and nonminority children.