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An Empirically Derived Taxonomy for Personality Diagnosis: Bridging Science and Practice in Conceptualizing Personality
Drew Westen, Ph.D.; Jonathan Shedler, Ph.D.; Bekh Bradley, Ph.D.; Jared A. DeFife, Ph.D.
Am J Psychiatry 2012;169:273-284. doi:10.1176/appi.ajp.2011.11020274
View Author and Article Information
From the Departments of Psychology and Psychiatry and Behavioral Science, Emory University, Atlanta; the Department of Psychiatry, University of Colorado School of Medicine, Denver; and the Atlanta VA Medical Center, Atlanta.

Received Feb. 17, 2011; revisions received May 3, Sept. 13, and Sept. 20, 2011; accepted Sept. 27, 2011.

The authors report no financial relationships with commercial interests.

Supported by NIMH grants R01-MH62377 and R01-MH78100.

Address correspondence to Dr. Westen (dwesten@emory.edu) or Dr. Shedler (jonathan@shedler.com).

Copyright © American Psychiatric Association

Received February 17, 2011; Revised May 3, 2011; Revised September 13, 2011; Revised September 20, 2011; Accepted September 27, 2011.

Abstract

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

Method:  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 the descriptors in the Shedler-Westen Assessment Procedure–II and completed additional research forms.

Results:  The authors applied factor analysis to identify naturally occurring diagnostic groupings within the patient sample. The analysis yielded 10 clinically coherent personality diagnoses organized into three higher-order clusters: internalizing, externalizing, and borderline-dysregulated. The authors selected the most highly rated descriptors to construct a diagnostic prototype for each personality syndrome. In a second, independent sample, research interviewers and patients' treating clinicians were able to diagnose the personality syndromes with high agreement and minimal comorbidity among diagnoses.

Conclusions:  The empirically derived personality prototypes described here provide a framework for personality diagnosis that is both empirically based and clinically relevant.

Abstract Teaser
Figures in this Article

In 1999, we described a personality disorder taxonomy (1, 2) derived empirically via Q-factor analysis (3). The research identified 11 diagnostic groupings, many of which resembled DSM-IV personality disorder diagnoses. The empirically derived taxonomy solved a number of problems associated with personality disorder diagnosis: Comorbidity among diagnoses was greatly reduced, clinicians found the diagnostic system more useful than the DSM-IV system and more useful than dimensional trait models (4, 5), and the procedure empirically identified personality syndromes absent from DSM-IV (e.g., depressive) and refined the descriptions of others.

The 1999 patient sample was, however, restricted to patients with DSM-IV personality disorder diagnoses, and patients were not selected randomly. It was therefore not a representative sample drawn from clinical practice, and it excluded an unknown number of patients with potentially significant personality pathology that did not fit existing DSM-IV diagnostic categories. The present study addresses these limitations, rederiving a personality taxonomy using an independent national sample of patients randomly selected from clinical practice.

Developing empirically sound, clinically relevant descriptions of personality syndromes requires testing prospective diagnostic criteria that cover the full spectrum of potentially relevant personality processes. We developed the Shedler-Westen Assessment Procedure (SWAP) (1, 2, 69) to provide mental health professionals with a clinically comprehensive item set for recording and quantifying their observations about a patient's personality and to provide a set of potential diagnostic criteria to test empirically. The instrument contains 200 personality-descriptive items or potential diagnostic criteria.

The SWAP-II, used in the present study, is the third-generation SWAP instrument. A guiding principle in its development was that items should be written in descriptively precise, jargon-free language useful to clinicians of any theoretical orientation. A second principle was that personality processes that have been described repeatedly in the clinical literature constitute meaningful hypotheses to test as potential diagnostic criteria and should therefore be represented in the item set.

For example, clinical writings over the better part of a century have emphasized projection (i.e., misattribution of one's own intentions to another person) as a central feature of paranoid personality, but the construct had never been tested empirically as a potential diagnostic criterion. The concept was rendered in the SWAP in jargon-free language (“Tends to see own unacceptable feelings or impulses in other people instead of in him/herself”) and did indeed emerge empirically as a central feature of paranoid personality disorder (2), irrespective of the theoretical orientation of the clinician performing the assessment.

The initial SWAP item set (10) was drawn from a wide range of sources, including the clinical literature on personality from the past 50 years (e.g., references 1114), axis II diagnostic criteria from DSM-III through DSM-IV, selected DSM axis I items that could reflect aspects of personality (e.g., depression and anxiety), empirical research on coping, defense, and affect regulation (e.g., references 1518), research on interpersonal problems in patients with personality pathology (e.g., references 19, 20), research on personality traits in nonclinical populations (e.g., references 2123), research on personality disorders conducted since the development of axis II (24), and pilot interviews in which observers watched videotaped interviews of patients with personality pathology (7).

The SWAP item set was then revised through an iterative process that incorporated the feedback of over 2,000 clinicians of all theoretical orientations. The content of 21 of the 200 items was substantially changed from the SWAP-200 to the revised SWAP-II. The revisions were based on empirical considerations and were aimed at refining the psychometric properties of the item set. In brief, we deleted items that failed to discriminate among patients (i.e., items that had minimal or no variance) and therefore contributed little or no incremental information, and we combined items that were empirically redundant (i.e., items that correlated >0.70). We also collected systematic written feedback from the users of the SWAP-200 and made text revisions to improve clarity of meaning where users indicated that they had difficulty scoring an item because its meaning seemed unclear or ambiguous. Among clinicians who have used the SWAP-II to describe a current patient, 84% “agreed” or “strongly agreed” with the statement “I was able to express the things I consider important about my patient's personality”; less than 5% disagreed (7).

We have proposed a prototype matching approach to personality diagnosis (9, 2528). The Appendix, below, describes the prototype matching diagnostic procedure. A premise of this approach is that a list of eight to nine criteria is often insufficient to define a multifaceted personality syndrome in a way that clearly distinguishes it from other syndromes (contributing to the problem of comorbidity). Rather, it is the configuration or pattern the personality features form that identifies unique syndromes. From this perspective, recognizing a personality syndrome is fundamentally a process of pattern recognition, much as face recognition depends on pattern recognition, not tabulation of individual features. The SWAP items that describe a diagnosis are therefore arranged to form a narratively coherent paragraph, not presented as a list of features to tabulate. Diagnosticians rate the overall similarity or “match” between a patient and the prototype, considering the prototype as a whole. This approach was designed to work with rather than against the naturally occurring cognitive decision-making processes of diagnosticians (2932).

The prototype matching method preserves a configurational or syndromal approach to personality diagnosis (3335), consistent with all editions of DSM to date, while allowing dimensional assessment on a scale from 1 (no match) through 5 (very good match). Where categorical diagnosis is desired (e.g., to facilitate clinical communication), ratings ≥4 indicate “caseness” and a rating of 3 indicates “features” or subthreshold pathology. The method parallels diagnosis in many areas of medicine, where variables such as blood pressure are measured on a continuum but physicians refer to certain ranges as “borderline” or “high.”

The reliability of SWAP prototype diagnoses made by independent observers is high, with a median interrater reliability across personality disorders of 0.72 (28), comparable to interrater reliability coefficients commonly observed for structured diagnostic interviews (mean kappa values between 0.69 and 0.84) (36, 37).

In this article, we present findings of research designed to rederive prototypes for personality disorder diagnosis using a large, clinically representative national sample and SWAP-II personality descriptors. We additionally present findings from a second, independent study examining the validity of personality diagnosis using these newly derived diagnoses.

We contacted a random national sample of 1,201 psychiatrists and psychologists with at least 5 years of posttraining practice experience, drawn from the membership registers of APA and the American Psychological Association (8, 27, 38). Because clinicians provided all data and no patient identifying information was disclosed to the investigators, clinicians rather than patients provided informed consent, as approved by the Emory University Institutional Review Board. Participating clinicians received a $200 consulting fee. We asked clinicians to describe “an adult patient you are currently treating or evaluating who has enduring patterns of thoughts, feelings, motivation, or behavior—that is, personality patterns—that cause distress or dysfunction.” To obtain a broad range of personality pathology, we emphasized that patients need not have a DSM-IV personality disorder diagnosis.

Patients met the following additional inclusion criteria: ≥18 years of age, not currently psychotic, and known reasonably well by the clinician (using the guideline of ≥6 clinical contact hours, but less than 2 years to minimize confounds due to treatment). To ensure random selection of patients, clinicians consulted their appointment calendars to select the last patient they saw during the previous week who met study criteria.

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Measures

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The Shedler-Westen Assessment Procedure–II (SWAP-II).

The SWAP-II has been described in detail elsewhere (2, 7, 8). The instrument consists of 200 personality-descriptive statements, each of which may describe a given patient well, somewhat, or not at all. Clinicians sort the statements into eight categories, from not descriptive of the patient (assigned a value of 0) to most descriptive (assigned a value of 7). Reliability and validity are high (8, 39, 40).

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Clinical data form.

The clinical data form is a clinician-report form that gathers data on demographic, diagnostic, etiological, and adaptive functioning variables. Data collected with the form concerning developmental history and life events have shown strong agreement (cross-method validity) with data collected from patients (41). Adaptive functioning variables assessed with the clinical data form (e.g., Global Assessment of Functioning Scale scores) have likewise shown high reliability and validity compared with ratings by independent observers (18, 41, 42).

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Axis II criterion checklist.

Clinicians completed a randomly ordered checklist of all criteria for all DSM-IV axis II disorders to indicate which criteria the patient met. We applied DSM-IV decision rules to generate DSM-IV diagnoses. This method provides results that mirror those of structured diagnostic interviews (4345).

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Data Analysis

We applied Q-factor analysis to identify naturally occurring diagnostic groupings empirically—that is, groupings of patients with personality features similar to one another and distinct from those of patients in other groupings. The computational algorithms are identical to those of conventional factor analysis but are applied to cases rather than variables. Factor analysis identifies groups of similar variables that assess a common underlying factor. In contrast, Q-factor analysis identifies groups of similar people who share a common syndrome. The findings reported here are based on unweighted least squares factor extraction with promax rotation. We tested other potential factor solutions, which yielded similar results.

After identifying diagnostic groupings empirically, we created psychometric scales to assess each disorder by selecting the SWAP-II items with the highest factor scores (i.e., the items that best described each diagnostic grouping). This resulted in a diagnostic scale for each diagnosis comprising 15 to 24 items, with the number of items reflecting the complexity of the personality syndrome. To create paragraph-format diagnostic prototypes useful for day-to-day diagnosis and appropriate for inclusion in a diagnostic manual, we organized the items thematically and edited the resulting descriptions for readability, redundancy, and narrative coherence. We also wrote a single-sentence summary statement (similar to the statements that begin the description of each disorder in DSM-IV but are not included in the diagnosis itself) to convey telegraphically the core features of each diagnosis (see the Appendix).

We assessed the convergent and discriminant validity of the diagnostic scales and associated prototypes using an independent sample from an ongoing study designed to compare the validity of alternative approaches to personality disorder diagnosis (including SWAP-II prototypes, dimensional trait models, and the DSM-IV diagnostic system). Patients completed self-report personality questionnaires and were evaluated by three independent research interviewers as well as their treating clinician. The research interviewers administered the Structured Clinical Interview for DSM-IV Axis II Disorders (46), the Clinical Diagnostic Interview (a systematic version of the kind of interviewing most skilled clinicians engage in during the initial hours of patient contact) (47), and the Longitudinal Interval Follow-Up Evaluation–Baseline Version (to assess adaptive functioning) (48). All assessors were blind to data provided by the others.

We examined the validity of the newly derived SWAP-II diagnoses by comparing independent diagnostic assessments provided by research interviewers who administered the Clinical Diagnostic Interview with assessments provided by the patients' treating clinicians. The findings are based on data from the first 145 consecutive patients enrolled in the study. (We plan in future publications to report on the validity of the alternative diagnostic systems with respect to a range of criterion variables including adaptive functioning assessed by multiple independent observers; measures of implicit personality processes derived from indirect measures, such as reaction time to experimental stimuli; and etiological variables such as salivary DNA, family history of psychiatric disorders, and developmental history.)

The sample used to derive the SWAP-II personality prototypes consisted of 1,201 patients, 73.1% of whom were seen in independent practice and the remainder in a range of settings from outpatient clinics to forensic units; 53.2% were female, and 82.7% were Caucasian; the mean age was 42.3 years (SD=12.3). Patients spanned all social classes. GAF scores spanned a broad range, from 10 to 93 (mean=57.9, SD=10.8). One-third of the sample had had at least one psychiatric hospitalization, one-fourth had a history of suicide attempts, and one in 10 had been arrested during the previous 5 years. Clinician respondents were highly experienced (with a mean of 19.8 years of practice experience [SD=9.2]). They were diverse in theoretical orientation (e.g., biological, cognitive-behavioral, psychodynamic, integrative-eclectic, other), and no single theoretical orientation was endorsed by more than 25% of the sample.

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Deriving Diagnostic Prototypes

We first selected patients who had a level of pathology indicative of what most investigators would consider a “disorder,” operationally defined as meeting DSM-IV criteria for at least one personality disorder and having a GAF score <70. Approximately 70% of the sample met these criteria. In this stratum, we obtained a hierarchical factor structure comprising three superordinate factors or broad personality spectra (which were also obtained in the full sample): 1) internalizing pathology, 2) externalizing pathology, and 3) borderline-dysregulated pathology (Figure 1). These factors accounted for 33% of the variance in the stratum.

 
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FIGURE 1.

Hierarchical Structure of Personality Diagnoses

We then conducted second-order factor analyses, factoring patients within each broad spectrum (those with high loadings on one of the three superordinate factors) to identify specific diagnoses within each spectrum. This yielded four diagnoses within the internalizing spectrum (depressive, anxious-avoidant, dependent-victimized, and schizoid-schizotypal) and three within the externalizing spectrum (antisocial-psychopathic, narcissistic, and paranoid). The borderline-dysregulated superordinate factor was retained without further subdivision.

To identify personality syndromes that may have been missed in the analysis using the initial selection criteria, we performed a second factor analysis on patients with GAF scores ≥70. This analysis yielded two additional personality diagnoses, obsessional and hysteric-histrionic. These factors accounted for 30% of the variance in the stratum. Finally, factor analysis of the full sample yielded an additional prototype representing optimal personality health or adaptive personality strengths. The factor analyses thus empirically identified a total of 10 distinct empirically and clinically coherent personality diagnoses, plus an additional prototype representing optimal personality health. Figure 1 illustrates the hierarchical organization of the 10 personality diagnoses. (Factor analysis of the entire sample without stratification yielded similar diagnoses, although they tended to be less “clean” and sometimes mixed heterogeneous patients—for example, paranoid patients and higher-functioning individuals who were not paranoid but shared with paranoid patients prominent hostility and aggression.)

To develop scales and prototype descriptions for each diagnosis, we first listed the SWAP-II items that were most descriptive of each diagnosis in descending order of importance (by the magnitude of the factor score). Because we had obtained a hierarchical factor structure, we needed to differentiate the items that were most appropriate for describing each superordinate spectrum (items applicable to all disorders within the spectrum) from those most appropriate for describing specific diagnoses within the spectrum (items more specific to an individual diagnosis). Decisions about item inclusion and exclusion thresholds were based on psychometric considerations, taking into account item-scale correlations within and between superordinate and subordinate factors. As a guiding principle, items were retained for a given diagnostic scale or prototype if they were among the top 20–25 items with the highest factor scores for the diagnosis; if the item-scale correlation was 0.30 or higher; and if inclusion of the item did not suppress the reliability of the scale (with the goal of maintaining Cronbach's alpha values ≥0.70). Decisions that fell in gray areas were resolved conceptually—that is, items were retained if they were consistent with the broader themes of the factor.

The Appendix, below, presents the diagnostic prototypes for all personality syndromes, along with instructions on how to make diagnoses in clinical practice. Table 1 lists the number of items constituting each diagnostic scale (subsumed in the corresponding paragraph-format prototype description) and its associated reliability. All diagnoses showed high (Cronbach's alpha >0.70) to very high (Cronbach's alpha >0.85) internal consistency or reliability.

 
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TABLE 1.

Number of Items and Associated Reliability Coefficients for Diagnostic Scales (N=1,201)

Table 2 presents intercorrelations among the diagnostic scales. The results indicate excellent discriminant validity (i.e., minimal diagnostic comorbidity), with an average correlation between any two diagnostic scales of –0.04. The internalizing and externalizing clusters were highly distinct (the average correlation of internalizing disorders with disorders outside the internalizing spectrum was –0.17; the average correlation of externalizing disorders with those outside the externalizing spectrum was –0.18). Even within each spectrum, where diagnostic overlap is expected (because they are subordinate disorders within the same superordinate spectrum), the average correlations were 0.29 and 0.42 for the internalizing and externalizing spectra, respectively.

 
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TABLE 2.Intercorrelations Among Personality Diagnoses (N=1,201)a
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Validity Across Independent Observers and Assessment Methods

As an initial test of validity, we report data from 145 patients from a second, independent study of comparative approaches to personality disorder diagnosis. Eligible patients were between ages 18 and 65 and were concurrently participating in psychotherapy; they were recruited from academic medical centers or through community clinicians in two metropolitan areas. Exclusion criteria were active psychosis or a previous diagnosis of schizophrenia or schizoaffective disorder, any known organic impairment, and lack of fluency in English.

To determine whether two independent observers could diagnose patients similarly despite independent and nonoverlapping sources of assessment information, we compared diagnostic scores provided by an independent assessor after administering the Clinical Diagnostic Interview (40, 49) with scores provided by the patient's treating clinician based on observations made over the course of treatment. Both assessors completed the SWAP-II and were blind to data provided by the other. The diagnoses were made in different assessment contexts based on unrelated data sources.

Table 3 presents the cross-method/cross-observer correlations of SWAP-II diagnostic scores derived from research interviewers and from treating clinicians. Validity coefficients were good to very good, with a mean cross-observer correlation of 0.51. Discriminant validity coefficients were desirably low, with a mean correlation of –0.01. Once again, even correlations within the same superordinate diagnostic spectrum were relatively low, with an average correlation among diagnoses of 0.18 and 0.22 within the internalizing and externalizing spectra, respectively. Correlations among disorders outside the same spectrum were negligible, with a mean of –0.06. The findings indicate convergence among independent observers, with minimal comorbidity among diagnoses.

 
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TABLE 3.Correlations Between Research Interviewers and Treating Clinicians (N=145)a

We derived 10 prototypes for diagnosing personality pathology. The prototypes are broadly consistent with conceptions of personality syndromes described in the clinical literature.

All 10 diagnoses replicate diagnostic groupings identified in our 1999 taxonomic research (2). This replication is noteworthy given that we used an independent sample with markedly different inclusion and exclusion criteria, a revised item set (The SWAP-II versus the SWAP-200), and a different factor-analytic procedure. A new finding is the hierarchical factor structure with superordinate internalizing, externalizing, and borderline-dysregulated factors (described in more detail below). These groupings provide an empirically based alternative to the DSM-IV approach of grouping personality disorders into “clusters” A, B, and C, which were derived post hoc and show high comorbidity within and across clusters. The factor structure is also “cleaner” than the structure we identified in 1999, which included a large internalizing factor (labeled “dysphoric”) that subsumed multiple subtypes.

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Continuities and Discontinuities With DSM-IV

Although the 10 diagnoses maintain a fair amount of continuity with DSM-IV, the prototypes differ in key respects from DSM-IV personality disorders. They are more clinically nuanced and include more items addressing internal psychological processes. They all describe multifaceted syndromes encompassing multiple domains of functioning (e.g., cognition, affectivity, interpersonal relations, impulse regulation, and affect regulation). The DSM-IV general criteria for personality disorders define them in terms of multiple domains of functioning, but most of the criterion sets for specific personality disorders do not actually encompass these multiple domains. For example, the DSM-IV criteria for paranoid personality disorder are essentially redundant indicators of a single trait, chronic suspiciousness, and do not capture the complex personality syndrome recognized by most practitioners (which includes, for example, hostility and aggression, misattribution of hostile intentions to others, externalization of blame, and distortions in thinking and reasoning).

Similarly, the DSM-IV criteria for antisocial personality disorder emphasize criminality and behaviors that can be readily inquired about in structured interviews. Our empirically derived antisocial-psychopathic prototype is closer to Cleckley's (50) conceptualization of psychopathy and the findings of subsequent empirical research on the psychopathy construct (51, 52).

Our expanded descriptions of personality syndromes solve a problem inherent in DSM-IV: it is psychometrically impossible for criterion sets of only eight or nine items to delineate distinct disorders and also retain fidelity to the clinical syndromes they are intended to describe (1). Certain personality characteristics are central to more than one personality disorder (e.g., lack of empathy is characteristic of narcissistic and antisocial personality disorder; hostility is characteristic of paranoid, antisocial, and narcissistic personality disorders). As DSM is currently configured, including the same item in more than one criterion set gives rise to unacceptably high comorbidity, but arbitrarily excluding items from criterion sets results in clinically inaccurate descriptions.

Prototype matching resolves this problem because items can be included in multiple diagnostic prototypes without giving rise to artifactual comorbidity. For example, narcissistic, antisocial-psychopathic, and borderline-dysregulated patients may all be characterized by deficits in empathy, but not in the same way. Narcissistic patients are often oblivious to others' needs, antisocial-psychopathic patients may recognize others' needs and exploit them, and borderline-dysregulated patients may have trouble recognizing others' internal states when they are overwhelmed by their own emotions or because they are prone to seeing others in black-or-white terms. Clinical practitioners generally do not confuse these configurations. The problem of “comorbidity” is not inherent in personality diagnosis but is an artifact of abbreviated criterion sets that do not capture the complexity of real-life personality syndromes.

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Hierarchical Organization of Personality Syndromes

Among patients with more severe personality pathology, we found three superordinate groupings or broad personality spectra, reflecting internalizing, externalizing, and borderline-dysregulated pathology. Patients in the internalizing spectrum are self-blaming and chronically prone to depression and anxiety. Patients in the externalizing spectrum blame others and are chronically prone to anger and aggression. Patients in the borderline-dysregulated spectrum are qualitatively distinct from stable internalizers or externalizers. Their perceptions of self and others are unstable and fluctuating, and they exhibit an impaired ability to regulate emotion (often oscillating between emotions characteristic of internalizing and externalizing pathology, for example, depression, anxiety, and rage). They may best be described as “stably unstable” (53).

We additionally identified an obsessional personality syndrome and a hysteric-histrionic syndrome. We labeled them “neurotic styles” (54) because patients who match these prototypes may or may not show a level of dysfunction that warrants the term disorder (we found these syndromes in previous research as well) (55). As with all personality syndromes, patients with these syndromes fall along a continuum of severity. Some experience severe dysfunction and have frank personality disorders, but on average they tend to cluster toward the less severe end of the continuum of personality pathology.

Identification of these two syndromes resolves two conundrums that have existed since DSM-III. The first is that obsessive-compulsive personality disorder is the only DSM personality disorder that tends to correlate positively with measures of healthy adaptive functioning. The second is that the framers of DSM-III had to “ratchet up” the level of pathology of both of these personality styles (previously called obsessional and hysteric in both the clinical literature and earlier editions of DSM) to fit in a taxonomy of “disorders.” The result was an obsessive-compulsive personality diagnosis that often lacked congruence with clinical and empirical reality and a histrionic diagnosis that was empirically indistinguishable from borderline personality disorder.

The internalizing and externalizing spectra are consistent with a rich literature on childhood and adolescent disorders (56) and with recent findings on adult psychopathology obtained using very different research methods, item sets, and data-analytic approaches (57, 58). The convergence across different methodological approaches suggests that internalizing and externalizing pathology are crucial personality constructs. These spectra have the additional advantage of facilitating understanding of the relation between axis I disorders and personality substrates (e.g., individuals with internalizing personality pathology are vulnerable to mood and anxiety disorders; those with externalizing personality pathology are prone to substance abuse and impulse disorders). Identification of a borderline-dysregulated spectrum is a unique finding of this research; its emergence likely reflects the use of a clinically rich item set capable of distinguishing patients with stably high negative emotionality from those with dysregulated emotions, impulses, and perceptions of self and others.

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Personality Health Prototype

Factor analysis of the full sample yielded a prototype representing optimal personality health or adaptive personality strengths, which we also found in our 1999 study. This prototype provides a measure of personality health-sickness that cuts across all disorders. For example, a patient with narcissistic personality pathology might match the personality health prototype to varying degrees, with important implications for adaptive functioning and prognosis. Degree of match with the health prototype can help clarify where a given patient falls along the continuum of functioning from neurotic style through personality disorder (for example, in the case of obsessional and hysteric-histrionic personality). The factor has emerged repeatedly in previous research (1), and the items it comprises reflect broad consensus among clinicians of different theoretical orientations regarding the definition of healthy personality functioning. Previous research has shown that inclusion of a personality health prototype substantially increases the predictive validity of personality diagnosis (27).

The 10 empirically derived prototypes for personality diagnosis that we describe here are scientifically grounded and clinically relevant. The finding that treating clinicians and independent research interviewers can recognize the same personality configuration in a given patient is especially encouraging because it indicates that clinicians can make accurate, quantifiable assessments of complex personality syndromes in everyday practice.

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APPENDIX. Empirically Derived Prototypes for Personality Disorder Diagnosis Based on the Shedler-Westen Assessment Procedurea

For each diagnosis, please form an overall impression of the type of person described, then rate the extent to which your patient matches or resembles the prototype.
5Very good match (patient exemplifies this disorder; prototypical case)Diagnosis
4Good match (patient has this disorder; diagnosis applies)
3Moderate match (patient has significant features of this disorder)Features
2Slight match (patient has minor features of this disorder)
1No match (description does not apply)

 
Table Footer Note

a All diagnoses fall on a continuum of functioning. More severe variants may be regarded as personality disorders and less severe variants may be regarded as personality styles.

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[CrossRef] | [PubMed]
 
Westen  D;  DeFife  JA;  Bradley  B;  Hilsenroth  MJ:  Prototype personality diagnosis in clinical practice: a viable alternative for DSM-5 and ICD-11.  Prof Psychol Res Pr 2010; 41:482–487
[CrossRef] | [PubMed]
 
Kim  NS;  Ahn  WK:  Clinical psychologists' theory-based representations of mental disorders predict their diagnostic reasoning and memory.  J Exp Psychol Gen 2002; 131:451–476
[CrossRef] | [PubMed]
 
Cantor  N;  Genero  N:  Psychiatric diagnosis and natural categorization: a close analogy, in  Contemporary Directions in Psychopathology: Toward the DSM-IV . Edited by Millon  T;  Klerman  GL.  New York,  Guilford, 1986, pp 233–256
 
Rosch  E;  Mervis  CB:  Family resemblances: studies in the internal structure of categories.  Cogn Psychol 1975; 7:573–605
[CrossRef]
 
Ahn  WK:  Effect of causal structure on category construction.  Mem Cognit 1999; 27:1008–1023
[CrossRef] | [PubMed]
 
Horowitz  LM;  Post  DL;  French  RD;  Wallis  KD;  Siegelman  EY:  The prototype as a construct in abnormal psychology, 2: clarifying disagreement in psychiatric judgments.  J Abnorm Psychol 1981; 90:575–585
[CrossRef] | [PubMed]
 
Pilkonis  PA:  Personality prototypes among depressives: themes of dependency and autonomy.  J Pers Disord 1988; 2:144–152
[CrossRef]
 
Blashfield  R:  Exemplar prototypes of personality disorder diagnoses.  Compr Psychiatry 1985; 26:11–21
[CrossRef] | [PubMed]
 
Zimmerman  M:  Diagnosing personality disorders: a review of issues and research methods.  Arch Gen Psychiatry 1994; 51:225–245
[CrossRef] | [PubMed]
 
Lobbestael  J;  Leurgans  M;  Arntz  A:  Inter-rater reliability of the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID I) and Axis II Disorders (SCID II).  Clin Psychol Psychother 2011; 18:75–79
[CrossRef] | [PubMed]
 
Russ  E;  Shedler  J;  Bradley  R;  Westen  D:  Refining the construct of narcissistic personality disorder: diagnostic criteria and subtypes.  Am J Psychiatry 2008; 165:1473–1481
[CrossRef] | [PubMed]
 
Westen  D;  Weinberger  J:  When clinical description becomes statistical prediction.  Am Psychol 2004; 59:595–613
[CrossRef] | [PubMed]
 
Westen  D;  Muderrisoglu  S:  Reliability and validity of personality disorder assessment using a systematic clinical interview: evaluating an alternative to structured interviews.  J Pers Disord 2003; 17:350–368
[CrossRef]
 
DeFife  JA;  Drill  R;  Nakash  O;  Westen  D:  Agreement between clinician and patient ratings of adaptive functioning and developmental history.  Am J Psychiatry 2010; 167:1472–1478
[CrossRef] | [PubMed]
 
Dutra  L;  Campbell  L;  Westen  D:  Quantifying clinical judgment in the assessment of adolescent psychopathology: reliability, validity, and factor structure of the Child Behavior Checklist for clinician report.  J Clin Psychol 2004; 60:65–85
[CrossRef] | [PubMed]
 
Westen  D;  Shedler  J;  Durrett  C;  Glass  S;  Martens  A:  Personality diagnoses in adolescence: DSM-IV axis II diagnoses and an empirically derived alternative.  Am J Psychiatry 2003; 160:952–966
[CrossRef] | [PubMed]
 
Morey  LC:  Personality disorders in DSM-III and DSM-III-R: convergence, coverage, and internal consistency.  Am J Psychiatry 1988; 145:573–577
[PubMed]
 
Blais  M;  Norman  D:  A psychometric evaluation of the DSM-IV personality disorder criteria.  J Pers Disord 1997; 11:168–176
[CrossRef] | [PubMed]
 
First  MB;  Gibbon  M;  Spitzer  RL;  Williams  JBW;  Benjamin  L:  Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II): User's Guide .  Washington, DC,  American Psychiatric Press, 1997
 
Westen  D;  Muderrisoglu  S:  Clinical assessment of pathological personality traits.  Am J Psychiatry 2006; 163:1285–1287
[CrossRef] | [PubMed]
 
Keller  MB;  Lavori  PW;  Friedman  B:  The Longitudinal Interval Follow-Up Evaluation: a comprehensive method for assessing outcome in prospective longitudinal studies.  Arch Gen Psychiatry 1987; 44:540–548
[CrossRef] | [PubMed]
 
DeFife  JA;  Westen  D:  Empirically informed clinical interviewing for personality disorders, in  Psychodynamic Psychotherapy Research: Evidence-Based Practice and Practice-Based Evidence . Edited by Levy  RA;  Ablon  JS;  Kächele  H.  Totowa, NJ,  Humana Press (in press)
 
Cleckley  H:  The Mask of Sanity .  St Louis,  Mosby, 1941
 
Hare  RD:  The Hare Psychopathy Checklist–Revised .  Toronto,  Multi-Health Systems, 1991
 
Hare  R;  Neumann  C:  The role of antisociality in the psychopathy construct: comment on Skeem and Cooke (2010).  Psychol Assess 2010; 22:446–454
[CrossRef] | [PubMed]
 
Schmideberg  M:  The borderline patient, in  American Handbook of Psychiatry . Edited by Arieti  S.  New York,  Basic Books, 1959, pp 398–416
 
Shapiro  D:  Neurotic Styles .  New York,  Basic Books, 1965
 
Blagov  P;  Westen  D:  Questioning the coherence of histrionic personality disorder: borderline and hysterical personality subtypes in adults and adolescents.  J Nerv Ment Dis 2008; 196:785
[CrossRef] | [PubMed]
 
Achenbach  T;  Edelbrock  C:  The classification of child psychopathology: a review and analysis of empirical efforts.  Psychol Bull 1978; 85:1275–1301
[CrossRef] | [PubMed]
 
Krueger  RF:  The structure of common mental disorders.  Arch Gen Psychiatry 1999; 56:921–926
[CrossRef] | [PubMed]
 
Kendler  KS;  Prescott  CA;  Myers  J;  Neale  MC:  The structure of genetic and environmental risk factors for common psychiatric and substance use disorders in men and women.  Arch Gen Psychiatry 2003; 60:929–937
[CrossRef] | [PubMed]
 
References Container

FIGURE 1. 

Hierarchical Structure of Personality Diagnoses

Anchor for Jump
TABLE 1.

Number of Items and Associated Reliability Coefficients for Diagnostic Scales (N=1,201)

Anchor for Jump
TABLE 2.Intercorrelations Among Personality Diagnoses (N=1,201)a
Anchor for Jump
TABLE 3.Correlations Between Research Interviewers and Treating Clinicians (N=145)a
Table Footer Note

a All diagnoses fall on a continuum of functioning. More severe variants may be regarded as personality disorders and less severe variants may be regarded as personality styles.

+

References

Westen  D;  Shedler  J:  Revising and assessing axis II, part I: developing a clinically and empirically valid assessment method.  Am J Psychiatry 1999; 156:258–272
[PubMed]
 
Westen  D;  Shedler  J:  Revising and assessing axis II, part II: toward an empirically based and clinically useful classification of personality disorders.  Am J Psychiatry 1999; 156:273–285
[PubMed]
 
Block  J:  The Q-Sort Method in Personality Assessment and Psychiatric Research .  Palo Alto, Calif,  Consulting Psychologists Press, 1978
 
Spitzer  RL;  First  MB;  Shedler  J;  Westen  D;  Skodol  AE:  Clinical utility of five dimensional systems for personality diagnosis: a “consumer preference” study.  J Nerv Ment Dis 2008; 196:356–374
[CrossRef] | [PubMed]
 
Rottman  BM;  Ahn  WK;  Sanislow  CA;  Kim  NS:  Can clinicians recognize DSM-IV personality disorders from five-factor model descriptions of patient cases? Am J Psychiatry 2009; 166:427–433
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Shedler  J;  Westen  D:  Dimensions of personality pathology: an alternative to the five-factor model.  Am J Psychiatry 2004; 161:1743–1754
[CrossRef] | [PubMed]
 
Shedler  J;  Westen  D:  The Shedler-Westen Assessment Procedure (SWAP): making personality diagnosis clinically meaningful.  J Pers Assess 2007; 89:41–55
[CrossRef] | [PubMed]
 
Westen  D;  Shedler  J:  Personality diagnosis with the Shedler-Westen Assessment Procedure (SWAP): integrating clinical and statistical measurement and prediction.  J Abnorm Psychol 2007; 116:810–822
[CrossRef] | [PubMed]
 
Shedler  J;  Westen  D:  Refining personality disorder diagnosis: integrating science and practice.  Am J Psychiatry 2004; 161:1350–1365
[CrossRef] | [PubMed]
 
Shedler  J;  Westen  D:  Refining the measurement of axis II: a Q-sort procedure for assessing personality pathology.  Assessment 1998; 5:333–353
[CrossRef] | [PubMed]
 
Kernberg  O:  Borderline Conditions and Pathological Narcissism .  Northvale, NJ,  Jason Aronson, 1975
 
Kernberg  O:  Severe Personality Disorders .  New Haven, Conn,  Yale University Press, 1989
 
Kohut  H:  The Analysis of the Self: A Systematic Approach to the Treatment of Narcissistic Personality Disorders .  New York,  International Universities Press, 1971
 
Linehan  MM:  Cognitive-Behavioral Treatment of Borderline Personality Disorder .  New York,  Guilford, 1993
 
Perry  JC;  Cooper  SH:  Empirical studies of psychological defense mechanisms, in  Psychiatry . Edited by Michels  R;  Cavenar  JO  Jr.  Philadelphia,  JB Lippincott, 1987
 
Shedler  J;  Mayman  M;  Manis  M:  The illusion of mental health.  Am Psychol 1993; 48:1117–1131
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Vaillant  GE(ed):  Ego Mechanisms of Defense: A Guide for Clinicians and Researchers .  Washington, DC,  American Psychiatric Press, 1992
 
Westen  D;  Muderrisoglu  S;  Fowler  C;  Shedler  J;  Koren  D:  Affect regulation and affective experience: individual differences, group differences, and measurement using a Q-sort procedure.  J Consult Clin Psychol 1997; 65:429–439
[CrossRef] | [PubMed]
 
Westen  D:  Cognitive-behavioral interventions in the psychoanalytic psychotherapy of borderline personality disorders.  Clin Psychol Rev 1991; 11:211–230
[CrossRef]
 
Westen  D;  Lohr  N;  Silk  KR;  Gold  L;  Kerber  K:  Object relations and social cognition in borderlines, major depressives, and normals: a Thematic Apperception Test analysis.  Psychol Assess 1990; 2:355–364
[CrossRef]
 
Block  J:  Lives Through Time .  Berkeley, Calif,  Bancroft, 1971
 
John  O:  The big five factor taxonomy: dimensions of personality in the natural language and in questionnaires, in  Handbook of Personality: Theory and Research . Edited by Pervin  L.  New York,  Guilford, 1990, pp 66–100
 
McCrae  R;  Costa  P:  Personality in Adulthood .  New York,  Guilford, 1990
 
Livesley  WJ:  The DSM-IV Personality Disorders .  New York,  Guilford, 1995
 
Westen  D;  Shedler  J:  A prototype matching approach to diagnosing personality disorders toward DSM-V.  J Pers Disord 2000; 14:109–126
[CrossRef] | [PubMed]
 
Ortigo  KM;  Bradley  B;  Westen  D:  An empirically based prototype diagnostic system for DSM-V and ICD-11, in  Contemporary Directions in Psychopathology: Scientific Foundations of the DSM-V and ICD-11 . Edited by Millon  T;  Krueger  R;  Simonsen  E.  New York,  Guilford, 2010, pp 374–390
 
Westen  D;  Shedler  J;  Bradley  R:  A prototype approach to personality disorder diagnosis.  Am J Psychiatry 2006; 163:846–856
[CrossRef] | [PubMed]
 
Westen  D;  DeFife  JA;  Bradley  B;  Hilsenroth  MJ:  Prototype personality diagnosis in clinical practice: a viable alternative for DSM-5 and ICD-11.  Prof Psychol Res Pr 2010; 41:482–487
[CrossRef] | [PubMed]
 
Kim  NS;  Ahn  WK:  Clinical psychologists' theory-based representations of mental disorders predict their diagnostic reasoning and memory.  J Exp Psychol Gen 2002; 131:451–476
[CrossRef] | [PubMed]
 
Cantor  N;  Genero  N:  Psychiatric diagnosis and natural categorization: a close analogy, in  Contemporary Directions in Psychopathology: Toward the DSM-IV . Edited by Millon  T;  Klerman  GL.  New York,  Guilford, 1986, pp 233–256
 
Rosch  E;  Mervis  CB:  Family resemblances: studies in the internal structure of categories.  Cogn Psychol 1975; 7:573–605
[CrossRef]
 
Ahn  WK:  Effect of causal structure on category construction.  Mem Cognit 1999; 27:1008–1023
[CrossRef] | [PubMed]
 
Horowitz  LM;  Post  DL;  French  RD;  Wallis  KD;  Siegelman  EY:  The prototype as a construct in abnormal psychology, 2: clarifying disagreement in psychiatric judgments.  J Abnorm Psychol 1981; 90:575–585
[CrossRef] | [PubMed]
 
Pilkonis  PA:  Personality prototypes among depressives: themes of dependency and autonomy.  J Pers Disord 1988; 2:144–152
[CrossRef]
 
Blashfield  R:  Exemplar prototypes of personality disorder diagnoses.  Compr Psychiatry 1985; 26:11–21
[CrossRef] | [PubMed]
 
Zimmerman  M:  Diagnosing personality disorders: a review of issues and research methods.  Arch Gen Psychiatry 1994; 51:225–245
[CrossRef] | [PubMed]
 
Lobbestael  J;  Leurgans  M;  Arntz  A:  Inter-rater reliability of the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID I) and Axis II Disorders (SCID II).  Clin Psychol Psychother 2011; 18:75–79
[CrossRef] | [PubMed]
 
Russ  E;  Shedler  J;  Bradley  R;  Westen  D:  Refining the construct of narcissistic personality disorder: diagnostic criteria and subtypes.  Am J Psychiatry 2008; 165:1473–1481
[CrossRef] | [PubMed]
 
Westen  D;  Weinberger  J:  When clinical description becomes statistical prediction.  Am Psychol 2004; 59:595–613
[CrossRef] | [PubMed]
 
Westen  D;  Muderrisoglu  S:  Reliability and validity of personality disorder assessment using a systematic clinical interview: evaluating an alternative to structured interviews.  J Pers Disord 2003; 17:350–368
[CrossRef]
 
DeFife  JA;  Drill  R;  Nakash  O;  Westen  D:  Agreement between clinician and patient ratings of adaptive functioning and developmental history.  Am J Psychiatry 2010; 167:1472–1478
[CrossRef] | [PubMed]
 
Dutra  L;  Campbell  L;  Westen  D:  Quantifying clinical judgment in the assessment of adolescent psychopathology: reliability, validity, and factor structure of the Child Behavior Checklist for clinician report.  J Clin Psychol 2004; 60:65–85
[CrossRef] | [PubMed]
 
Westen  D;  Shedler  J;  Durrett  C;  Glass  S;  Martens  A:  Personality diagnoses in adolescence: DSM-IV axis II diagnoses and an empirically derived alternative.  Am J Psychiatry 2003; 160:952–966
[CrossRef] | [PubMed]
 
Morey  LC:  Personality disorders in DSM-III and DSM-III-R: convergence, coverage, and internal consistency.  Am J Psychiatry 1988; 145:573–577
[PubMed]
 
Blais  M;  Norman  D:  A psychometric evaluation of the DSM-IV personality disorder criteria.  J Pers Disord 1997; 11:168–176
[CrossRef] | [PubMed]
 
First  MB;  Gibbon  M;  Spitzer  RL;  Williams  JBW;  Benjamin  L:  Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II): User's Guide .  Washington, DC,  American Psychiatric Press, 1997
 
Westen  D;  Muderrisoglu  S:  Clinical assessment of pathological personality traits.  Am J Psychiatry 2006; 163:1285–1287
[CrossRef] | [PubMed]
 
Keller  MB;  Lavori  PW;  Friedman  B:  The Longitudinal Interval Follow-Up Evaluation: a comprehensive method for assessing outcome in prospective longitudinal studies.  Arch Gen Psychiatry 1987; 44:540–548
[CrossRef] | [PubMed]
 
DeFife  JA;  Westen  D:  Empirically informed clinical interviewing for personality disorders, in  Psychodynamic Psychotherapy Research: Evidence-Based Practice and Practice-Based Evidence . Edited by Levy  RA;  Ablon  JS;  Kächele  H.  Totowa, NJ,  Humana Press (in press)
 
Cleckley  H:  The Mask of Sanity .  St Louis,  Mosby, 1941
 
Hare  RD:  The Hare Psychopathy Checklist–Revised .  Toronto,  Multi-Health Systems, 1991
 
Hare  R;  Neumann  C:  The role of antisociality in the psychopathy construct: comment on Skeem and Cooke (2010).  Psychol Assess 2010; 22:446–454
[CrossRef] | [PubMed]
 
Schmideberg  M:  The borderline patient, in  American Handbook of Psychiatry . Edited by Arieti  S.  New York,  Basic Books, 1959, pp 398–416
 
Shapiro  D:  Neurotic Styles .  New York,  Basic Books, 1965
 
Blagov  P;  Westen  D:  Questioning the coherence of histrionic personality disorder: borderline and hysterical personality subtypes in adults and adolescents.  J Nerv Ment Dis 2008; 196:785
[CrossRef] | [PubMed]
 
Achenbach  T;  Edelbrock  C:  The classification of child psychopathology: a review and analysis of empirical efforts.  Psychol Bull 1978; 85:1275–1301
[CrossRef] | [PubMed]
 
Krueger  RF:  The structure of common mental disorders.  Arch Gen Psychiatry 1999; 56:921–926
[CrossRef] | [PubMed]
 
Kendler  KS;  Prescott  CA;  Myers  J;  Neale  MC:  The structure of genetic and environmental risk factors for common psychiatric and substance use disorders in men and women.  Arch Gen Psychiatry 2003; 60:929–937
[CrossRef] | [PubMed]
 
References Container
+
+

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