Theoretical-Clinical-Empirical Approach to Classifying Axis II Disorders

To the Editor: The recent articles by Drew Westen, Ph.D., and Jonathan Shedler, Ph.D. (1, 2), described an innovative and important clinical-empirical approach to classifying personality-disordered functioning. The authors suggested that their method could be used to “replace the current approach” (2, p. 284) to organizing axis II disorders. However, their results (2) lacked a theoretical discussion examining the similarities and differences between the six categories that are clinically near the axis II disorders and their appropriate DSM-IV counterparts. While a full discussion is beyond the scope of this letter, a few comments on some apparent contradictions seem necessary.

1. The statement “Has little psychological insight into own motives, behavior, etc.; is unable to consider alternative interpretations of his/her experiences” (2, p. 277) appears on the diagnostic categories for both schizoid and antisocial personality disorders (2). One explanation is that this statement is intrinsic to both categories. Another explanation is that this criterion reflects low self-directedness (3), a character dimension that has empirically/dimensionally discriminated disordered personality functioning from less disordered levels.

2. Three Shedler-Westen Assessment Procedure-200 (SWAP-200) descriptions (i.e., “Tends to feel he/she is not his/her true self with others; tends to feel false or fraudulent,” “Tends to feel life has no meaning,” and “Tends to feel empty and bored” [2, p. 279]) that appeared in the authors’ narcissistic personality disorder diagnostic category do not appear among the DSM-IV criteria for narcissistic personality disorder. While it could be that the DSM-IV Personality Disorders Work Group overlooked or intentionally excluded important features of the disorder, it seems more likely that the discrepancies reflect a pretreatment (for the DSM-IV work group) versus an in-treatment (for the reporting clinicians) focus. Drs. Westen and Shedler stated that their study’s “patients were well known to the reporting clinicians and had been seen in treatment an average of 33.95 sessions before the SWAP-200 assessment” (1, p. 266).

3. The SWAP-200 statements that describe individuals in the obsessional personality disorder diagnostic category include a preponderance of mature character traits rather than the pervasive pattern of “preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency” (DSM-IV, p. 669) found in the DSM-IV obsessive-compulsive personality disorder criteria. For example, four of the first five SWAP-200 statements seem to better reflect maturity and self-directedness (3) than the functioning of disordered personality disorder (2, p. 278).

This brief discussion underscores the importance of including relevant theory in discussions of outcome data. In my opinion, a clinical-empirical derivation such as that of Drs. Westen and Shedler (1, 2) can inform theory but not de facto replace theory.