Assessing personality change in psychotherapy with the SWAP-200: a case study

Many studies document the efficacy of psychotherapy for acute syndromes such as depression, but less is known about personality change in patients treated for personality pathology. The Shedler-Westen Assessment Procedure (SWAP-200; Westen & Shedler, 1999a, 1999b) is an assessment tool that measures a broad spectrum of personality constructs and is designed to bridge the gap between the clinical and empirical traditions in personality assessment. In this article, we demonstrate the use of the SWAP-200 as a measure of change in a case study of a patient diagnosed with borderline personality disorder. We collected assessment data at the start of treatment and after 2 years of psychotherapy. The findings illustrate the personality processes targeted in intensive psychotherapy for borderline personality.     

Behavioral assessment of personality disorders

This article examines the definition of personality disorders (PDs) from a functional analytical framework and discusses the potential utility of such a framework to account for behavioral tendencies associated with PD pathology. Also reviewed are specific behavioral assessment methods that can be employed in the assessment of PDs, and how information derived from these assessments may be linked to specific intervention strategies.     

Evidence-based assessment of personality disorders

The purpose of this article is to provide a foundation for the development of evidence-based guidelines for the assessment of personality disorders, focusing in particular on integrated assessment strategies. The general strategy recommended herein is to first administer a self-report inventory to alert oneself to the potential presence of particular maladaptive personality traits followed by a semistructured interview to verify their presence. This strategy is guided by the existing research that suggests particular strengths of self-report inventories and semistructured interviews relative to unstructured clinical interviews. However, the authors also consider research that suggests that further improvements to the existing instruments can be made. The authors emphasize, in particular, a consideration of age of onset, distortions in self-perception and presentation, gender bias, culture and ethnicity, and personality change.     

Relationship between patient characteristics and treatment allocation for patients with personality disorders

Within a large multi-center study in patients with personality disorders, we investigated the relationship between patient characteristics and treatment allocation. Personality pathology, symptom distress, treatment history, motivational factors, and sociodemographics were measured at intake in 923 patients, who subsequently enrolled in short-term or long-term outpatient, day hospital, or inpatient psychotherapy for personality pathology. Logistic regressions were used to examine the predictors of allocation decisions. We found a moderate relationship (R(2) = 0.36) between patient characteristics and treatment setting, and a weak relationship (R(2) = 0.18) between patient characteristics and treatment duration. The most prominent predictors for setting were: symptom distress, cluster C personality pathology, level of identity integration, treatment history, motivation, and parental responsibility. For duration the most prominent predictor was age. We conclude from this study that, in addition to pathology and motivation factors, sociodemographics and treatment history are related to treatment allocation in clinical practice.     

Domains and facets: hierarchical personality assessment using the revised NEO personality inventory

Personality traits are organized hierarchically, with narrow, specific traits combining to define broad, global factors. The Revised NEO Personality Inventory (NEO-PI-R; Costa & McCrae, 1992c) assesses personality at both levels, with six specific facet scales in each of five broad domains. This article describes conceptual issues in specifying facets of a domain and reports evidence on the validity of NEO-PI-R facet scales. Facet analysis-the interpretation of a scale in terms of the specific facets with which it correlates-is illustrated using alternative measures of the five-factor model and occupational scales. Finally, the hierarchical interpretation of personality profiles is discussed. Interpretation on the domain level yields a rapid understanding of the individual interpretation of specific facet scales gives a more detailed assessment.     

Use of the TAT in the assessment of DSM-IV cluster B personality disorders

The Social Cognition and Object Relations Scale (SCORS), developed by Western, Lohr, Silk, Kerber, and Goodrich (1985), is a diagnostic instrument used to assess an array of psychological functioning by using clinical narratives such as the Thematic Apperception Test (TAT; Murray, 1943) stories. This study investigated the utility of the SCORS to differentiate between Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994) antisocial personality disorder (ANPD), borderline personality disorder (BPD), narcissistic personality disorder (NPD), and Cluster C personality disorder (CPD). A sample of 58 patients was separated into four groups: ANPD (n = 9), BPD (n = 21; 18 with a primary BPD diagnosis and 3 with prominent borderline traits who met 4 of the 5 DSM-IV criteria necessary for a BPD diagnosis), NPD (n = 16; 8 with a primary NPD diagnosis and 8 with prominent narcissistic traits who met 4 of the 5 DSM-IV criteria necessary for a NPD diagnosis), and CPD (n = 12). These groups were then compared on the 8 SCORS variables by using 5 TAT cards (1, 2, 3BM, 4, and 13MF). Spearman-Brown correction for 2-way mixed effects model of reliability for the 8 SCORS variables ranged from .70 to .95. The results of categorical and dimensional analyses indicate that (a) SCORS variables can be used to differentiate ANPD, BPD, and NPD; (b) the BPD group scored significantly lower (greater maladjustment) than did the CPD group on certain variables; (c) the BPD group scored significantly lower (greater maladjustment) than did the NPD group on all 8 SCORS variables; (d) the ANPD group scored significantly lower than did the NPD group on certain variables; (e) certain variables were found to be empirically related to the total number of DSM-IV ANPD, BPD, and NPD criteria; and (f) certain variables were found to be empirically related to Minnesota Multiphasic Personality Inventory-2 (MMPI-2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) Personality disorder scales. The results of this study are discussed in terms of clinical utility, conceptual, and theoretical implications.     

The personality disorders: A review and critique of contemporary assessment strategies

Despite the prevalence of personality disorders, only recently have they become the topic of extensive clinical research. Unfortunately, much of this research suffers from various assessment problems including poor interrater agreement, an overreliance on cross-sectional assessment, and inconsistencies across measures. The present review examines the strategies used to assess personality disorders. Three comprehensive tables are used to provide a quantitative review of existing studies. Although specific measures are examined, the focus remains on general strategies for assessment. Personality disorder assessment may be enhanced through the use of aggregation methods. Aggregating over raters can reduce the subjective biases inherent in any one person's perception. Aggregating data over time reduces the instability of personality assessment, while aggregating data across measures reduces the reliance on any one measure to assess personality disorders accurately. Thus, future research should be able to refine the strategies used to study personality disorders.     

On the renaissance of personality assessment and personality theory

Both personality assessment and personality theory have experienced a significant decline in the past two or three decades, giving way to alternate professional interests by some, and being attacked as both empirically unsupportable and devoid of conceptual merit by others. Several tangible signs suggest that a resurrection is underway owing to position reversals by former critics, the changing character of patient populations, refinements in personality-oriented psychometric techniques, the refurbishing of analytic, interpersonal, and learning theories of personality, and the central role assigned personality disorders in the multiaxial format of the DSM-III. Looking toward the future, the paper proposes a series of comprehensive and parallel diagnostic criteria for the personality disorders to be included in either DSM-IIIR or DSM-IV.     

Self-report methodology is insufficient for improving the assessment and classification of Axis II personality disorders

Current approaches to the assessment and classification of personality disorders (PDs) rely almost exclusively on self-report methodology. In this paper, we document the many difficulties with self-reports, including limitations in their accuracy, the confounding effect of mood state, and problems with the selection and retention of factors in factor analytic approaches to self-report questionnaires. We also discuss the role of implicit processes in self-reports, with special attention directed to the phenomenon of priming and its effect on outcome. To rectify these issues, we suggest a transtheoretical, multimethod, multimodal approach to personality pathology assessment and diagnosis, which utilizes the richness of prototypes and empirical findings on PD categories and pathologies.     

The relationship between comorbid personality disorders and treatment received in patients with anxiety disorders

Few studies have addressed the relationship between the presence of a comorbid personality disorder and the amount of psychiatric treatment received by patients with an Axis I disorder. This issue has not been studied in patients with anxiety disorders. In a prospective, naturalistic, longitudinal study of anxiety disorders, 526 subjects were assessed with the Personality Disorder Examination, and types of treatment received in 1991 and 1996 were identified. In 1991, compared to subjects without a personality disorder, subjects with a personality disorder were as likely to receive medication and they received a greater number of medications. Subjects with borderline personality disorder were more likely to receive heterocyclic antidepressants and interventions characteristic of psychodynamic psychotherapy and cognitive therapy; they also reported receiving a greater number of medications and types of psychosocial treatment than other subjects. In 1996, subjects with borderline personality disorder were more likely to receive psychodynamic interventions. These findings suggest that in patients with an anxiety disorder, the presence of a comorbid personality disorder is associated with receiving a greater number of medications but not with a greater likelihood of receiving pharmacologic or psychosocial treatment. However, the presence of borderline personality disorder is associated with a greater likelihood of receiving, and receiving a greater number of, certain types of somatic and psychosocial treatments.     

Contributions from personality- and psychodynamically oriented assessment to the development of the DSM-5 personality disorders

Advances in personality assessment over the past 20 years have notably influenced the proposed assessment and classification of personality disorders in the Diagnostic and Statistical Manual of Mental Disorders (5th ed. [DSM-5]). However, a considerable body of personality assessment and psychodynamically oriented assessment research has significant relevance to the way in which personality disorders are evaluated that appears to have gone unrecognized in the current proposals for DSM-5. In this article, I discuss the ways in which some of these 2 bodies of literature can and should inform the DSM-5 so that the diagnostic nomenclature can be more scientifically and comprehensively informed and consequently improve the clinical utility of a diagnostic system in need of considerable revision.     

A structured interview for the assessment of the Five-Factor Model of personality: facet-level relations to the axis II personality disorders

The Structured Interview for the Five-Factor Model (SIFFM; Trull & Widiger, 1997) is an 120-item semistructured interview that assesses both adaptive and maladaptive features of the personality traits included in the five-factor model of personality, or "Big Five." In this article, we evaluate the ability of SIFFM scores to predict personality disorder symptomatology in a sample of 232 adults (46 outpatients and 186 nonclinical college students). Personality disorder symptoms were assessed using the Personality Diagnostic Questionnaire-Revised (PDQ-R; Hyler & Rider, 1987). Results indicated that many of the predicted associations between lower-order personality traits and personality disorders were supported. Further, many of these associations held even after controlling for comorbid personality disorder symptoms. These findings may help inform conceptualizations of the personality disorders, as well as etiological theories and treatment.     

Endophenotypes and the diagnosis of personality disorders

It has been suggested that psychiatric diagnosis should come to depend on endophenotypes, in order to define more precisely the mechanisms behind mental disorders. This construct is associated with the assumption that mental processes can be reduced to activity at a neuronal level. The approach has had a strong influence on the conceptual basis of proposals for DSM-5, but could be consistent either with categorical or dimensional diagnosis. However, application of endophenotypes to personality disorders is unlikely for the foreseeable future, given an insufficient knowledge of etiology and pathogenesis.     

Discriminating personality disorders using the WAIS-R: a comparison of three approaches

The purpose of this article is to determine if performance on the Wechsler Adult Intelligence Scale-Revised (WAIS-R) can be used to discriminate between the different taxonomies of personality disorder classification specified by three models: the biosocial, the interpersonal, and that described by the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev. [DSM-III-R]; American Psychiatric Association, 1987). Three discriminant function analyses were performed and the results indicated the usefulness of the WAIS-R in making such differentiations for all the approaches. The WAIS-R proved most effective with the biosocial model, evidencing a robust and clinically meaningful pattern of results. Implications for further research are discussed.