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Am J Psychiatry 1997; 154:895-903
Copyright © 1997 by American Psychiatric Association
Divergences between clinical and research methods for assessing personality disorders: implications for research and the evolution of axis II
D Westen
Department of Psychiatry, Harvard Medical School, Boston, MA, USA. dw@wjh.harvard.edu
OBJECTIVE: The purpose of this study was to examine the extent to which
instruments for assessing axis II diverge from clinical diagnostic
processes. METHOD: Subjects in the first study were 52 clinicians with
experience in assessment and treatment of patients with personality
disorders, who were surveyed about the methods they use in clinical
practice to make diagnoses and other aspects of the diagnostic process. A
second study replicated the major findings with a random national sample of
1,901 experienced psychiatrists and psychologists. RESULTS: Whereas current
instruments rely primarily on direct questions derived from DSM-IV,
clinicians of every theoretical persuasion found direct questions useful
for assessing axis I disorders but only marginally so for axis II. They
made axis II diagnoses, instead, by listening to patients describe
interpersonal interactions and observing their behavior with the
interviewer. In contrast to findings with current research instruments,
most patients with personality disorders in clinical practice receive only
one axis II diagnosis, and if they receive more than one, one is considered
primary. Clinicians reported treating a substantial number of patients for
enduring personality patterns that current axis II instruments do not
assess, many of which meet neither axis I nor axis II criteria, notably
problems with relatedness, work, self-esteem, and chronic subclinical
depressive traits. CONCLUSIONS: Measurements of axis II were constructed by
using a model derived from axis I instruments that diverges from clinical
diagnostic procedures in a way that may be problematic for the assessment
of personality disorders and the development of a more clinically and
empirically sound taxonomy.
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