At present, descriptive psychiatric diagnosis and clinical case formulation are largely independent activities. The former is aimed at classification (a nomothetic approach) whereas the latter is aimed at understanding an individual patient (an idiographic approach). The SWAP bridges these activities. It generates dimensional diagnosis scores for each PD included in DSM-IV (as well as for the additional PDs proposed in the DSM-IV appendix) and it generates richly detailed clinical case narratives relevant to clinical case formulation and treatment planning.
Dimensional PD scores measure the "fit" or "match" between a patient and a prototype SWAP description representing each PD in its "ideal" or pure form (e.g., a prototype description of paranoid personality disorder). Thus, each PD is diagnosed on a continuum, where a low PD score indicates that the patient does not fit or match the PD syndrome and a high score indicates that the patient matches it well (with intermediate scores indicating varying degrees of "fit"). The PD scores can be graphed to create a PD profile resembling an MMPI profile, as illustrated in Figure 12.1. Dimensional PD diagnosis is consistent with clinical thinking and advocated by virtually all contemporary personality researchers (Widiger & Simonsen, 2005).
A clinical case example may best illustrate these diagnostic applications of the SWAP.3
Melania is a 30-year-old Caucasian woman. Her presenting complaints included substance abuse and inability to extricate herself from an emotionally and physically abusive relationship. The initial assessment included a psychiatric intake interview and administration of both the Structured Clinical Interview for DSM-IV (SCID) and Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II) structured interviews. She met SCID criteria for an Axis I diagnosis of substance abuse and SCID-II criteria for an Axis II diagnosis of borderline PD with histrionic traits. The intake interviewer assigned a score of 45 on the Global Assessment of Functioning (GAF) scale, indicating severe symptoms and impairment in functioning.
Melania's early family environment was marked by neglect and parental strife. A recurring family scenario is illustrative: Melania's mother would scream at her husband, telling him he was a failure and that she was going to leave him; she would then slam the door and lock herself in her room, leaving Melania frightened and in tears. Both parents would then ignore Melania, often forgetting to feed her. Melania's parents divorced when she was eight. After the divorce, Melania lived with her mother, who showed little concern for her needs or welfare.
By adolescence, Melania had developed behavioral problems. She often skipped school and spent her days sleeping or wandering the streets. At age 18, she left home and began what she described as "life on the streets." She engaged in a series of impulsive, chaotic, and rapidly changing sexual relationships which led to three abortions by age 24. She abused street drugs, eventually developing a pattern of cocaine and heroine abuse (snorting). She also engaged in petty criminal activity, including shoplifting and stealing from employers.
Melania held a series of low paying jobs that were not commensurate with her intelligence or education. She failed to hold any job for more than a few months and was fired from each when she was caught stealing. In her mid-twenties, Melania moved in with her boyfriend, a small-time drug dealer who exploited her financially and abused her physically. He spent his days sleeping or watching television while Melania worked to pay the rent. She often had sex with other men to obtain money or drugs for her boyfriend. He sometimes beat her when he was dissatisfied with what she brought home.
Melania began psychodynamic therapy at a frequency of three sessions per week. The first ten psychotherapy sessions were tape recorded and transcribed. Two clinicians (blind to all other data) reviewed the transcripts and provided SWAP-200 descriptions of Melania, based on the information contained in the session transcripts. The SWAP-200 scores were then averaged across the two clinical judges to obtain a single SWAP-200 description.4 After two years of psychotherapy, 10 consecutive psychotherapy sessions were again recorded and transcribed and the SWAP assessment procedure was repeated.
The solid line in Figure 12.1 shows Melania's PD scores at the beginning of treatment for the 10 PDs included in DSM-IV. A "healthy functioning" index is graphed as well, which reflects clinicians' consensual understanding of healthy personality
functioning (Westen & Shedler, 1999a). For ease of interpretation, the PD scores have been converted to T-scores (Mean = 50, SD = 10) based on norms established in a psychiatric sample of patients with axis II diagnoses (Westen & Shedler, 1999a). Although the SWAP assesses PDs dimensionally and treats each PD diagnosis as a continuum, we have established cutoff scores for "backward compatibility" with DSM-IV. To maintain continuity with the DSM-IV categorical diagnostic system, we have suggested T = 60 as a threshold for making a categorical PD diagnosis, and T = 55 as a threshold for diagnosing "features."5
Melania's PD profile shows a marked elevation for borderline PD (T = 65.4, approximately one and a half standard deviations above the sample mean), with secondary elevations for histrionic PD (T = 56.6) and antisocial PD (T = 55.7). Applying the recommended cutoff scores, her DSM-IV axis II diagnosis is borderline PD with histrionic and antisocial features. Also noteworthy is the T-Score of 41 for the "healthy functioning" index, nearly a standard deviation below the mean in a reference sample of patients with Axis II diagnoses. The low score indicates significant impairment in functioning and parallels the low GAF score assigned by the intake interviewer.
We can generate a narrative case description by listing the SWAP items assigned the highest scores in the patient's SWAP description (e.g., items with scores of 5, 6, and 7). Below is a narrative case description for Melania based on the top 30 most descriptive SWAP-200 items. We have grouped together conceptually related items. To aid the flow of the text, we have made some minor grammatical changes and added connecting text. However, the SWAP-200 items are reproduced essentially verbatim. The narrative description is based on the same data used to generate the PD score profile in Figure 12.1.
Melania experiences severe depression and dysphoria. She tends to feel unhappy, depressed, or despondent, appears to find little or no pleasure or satisfaction in life's activities, feels life is without meaning, and tends to feel like an outcast or outsider. She tends to feel guilty, and to feel inadequate, inferior, or a failure. Her behavior is often self-defeating and self-destructive. She appears inhibited about pursuing goals or successes, is insufficiently concerned with meeting her own needs, and seems not to feel entitled to get or ask for things she deserves. She appears to want to "punish" herself by creating situations that lead to unhappiness, or actively avoiding opportunities for pleasure and gratification. Specific self-destructive tendencies include getting drawn into and remaining in relationships in which she is emotionally or physically abused, abusing illicit drugs, and acting impulsively and without regard for consequences. She shows little concern for consequences in general.
Melania shows many personality traits associated specifically with borderline PD. Her relationships are unstable, chaotic, and rapidly changing. She has little empathy and seems unable to understand or respond to others' needs and feelings unless they coincide with her own. Moreover, she tends to confuse her own thoughts, feelings, and personality traits with those of others, and she often acts in such a way as to elicit her own feelings in other people (for example, provoking anger when she herself is angry, or inducing anxiety in others when she herself is anxious).
Melania expresses contradictory feelings without being disturbed by the inconsistency, and she seems to have little need to reconcile or resolve contradictory ideas. She is prone to see certain others as "all bad," losing the capacity to perceive any positive qualities they may have. She lacks a stable image of who she is or would like to become (e.g., her attitudes, values, goals, and feelings about self are unstable and changing) and she tends to feel empty. Affect regulation is poor: She tends to become irrational when strong emotions are stirred up and shows a noticeable decline from her customary level of functioning. She also seems unable to soothe or comfort herself when distressed and requires the involvement of another person to help her regulate affect. Both her living arrangements and her work life tend to be chaotic and unstable.
Finally, Melania's attitudes toward men and sexuality are problematic and conflictual. She tends to be hostile toward members of the opposite sex (whether consciously or unconsciously) and she associates sexual activity with danger (e.g., injury or punishment). She appears afraid of commitment to a long-term love relationship, instead choosing partners who seem inappropriate in terms of age, status (e.g., social, economic, intellectual), or other factors.
The narrative description provides a detailed portrait of a severely troubled patient with borderline personality pathology. The description helps illustrate the difference between descriptive psychiatry (aimed at establishing a diagnosis) and clinical case formulation (aimed at understanding an individual). In this instance, however, all findings are derived from the same assessment procedure and grounded in quantitative data.
The case of Melania has a happy ending. After two years of psychotherapy, the SWAP assessment revealed significant personality changes. The changes parallel concrete behavior changes as well as changes in Melania's life circumstances (e.g., ending her drug abuse, getting and keeping a good job, ending her involvement with her abusive boyfriend, and no longer engaging in theft, promiscuous sex, or prostitution).
The dotted line in Figure 12.1 shows Melania's PD scores after two years of treatment. Her scores on the borderline, histrionic, and antisocial dimensions have dropped below T = 50 and she no longer warrants a PD diagnosis. Her score on the healthy functioning index has increased by two standard deviations, from 41.0 to 61.2.
To assess change in an ideographic, more fine-grained manner, we created a change score for each individual SWAP item by subtracting the item score at Time 1 from the score at Time 2. The narrative description of change, below, is comprised of the SWAP items with change scores > 4. Again, we have made some minor grammatical changes and added connecting text to aid the flow of the text, but the SWAP-200 items are reproduced essentially verbatim.
Melania has developed strengths and inner resources that were not evident at the Time 1 assessment. She has come to terms with painful experiences from the past, finding meaning in, and growing from, these experiences; she has become more articulate and better able to express herself in words; she has a newfound ability to appreciate and respond to humor; she is more capable of recognizing alternative viewpoints, even in matters that stir up strong feelings; she is more empathic and sensitive to other's needs and feelings; and she is more likeable.
There is marked improvement in many areas associated specifically with borderline psychopathology. With respect to affect regulation, Melania is less prone to become irrational when strong emotions are stirred up, is more likely to express affect appropriate in quality and intensity to the situation at hand, and is better able to soothe or comfort herself when distressed. She is less prone to confuse her own thoughts and feelings with those of others, less manipulative, and less likely to devalue others and see them as "all bad." She has come to terms with negative feelings toward her parents.
Melania is also less impulsive, more conscientious and responsible, and more aware of the consequences of her actions. Her living arrangements are more stable, as is her work life. Melania's use of illicit drugs has decreased significantly, and she is no longer drawn to abusive relationships.
As the more severe aspects of borderline personality pathology have receded, other conflicts and symptoms have moved to the fore. For example,
Melania appears to have developed somewhat obsessional defenses against painful affect. She adheres more rigidly to daily routines and becomes anxious or uncomfortable when they are altered. She is more prone to think in an abstract and intellectualized manner, and tries to see herself as more logical and rational, less influenced by emotion.
Despite her wish to act more logically and rationally, Melania seems engaged in an active struggle to control her affect and impulses. She tends to oscillate between undercontrol and overcontrol of needs and wishes, either expressing them impulsively or disavowing them entirely. She has more difficulty allowing herself to experience strong pleasurable emotions (e.g., excitement, joy). She is more prone to repress, "forget," or otherwise distort distressing events.
Finally, there are changes in Melania's relationships and orientation toward sexuality. Whereas before she presented in a histrionic manner (i.e., with exaggerated feminine traits), she is now more disparaging of traditionally feminine traits, instead emphasizing independence and achievement. Whereas previously she engaged in multiple chaotic sexual relationships, she now seems conflicted about her intimacy needs. She craves intimacy but tends to reject it when offered. She has more difficulty directing both sexual and tender feelings toward the same person, seeing men as either respectable and virtuous, or sexy and exciting, but not both. She is more likely to hold grudges.
We leave it to readers to judge the clinical relevance of the SWAP as an assessment tool and the value of the diagnostic profiles and narrative case descriptions it provides. Note, however, that the standard vocabulary of the SWAP ensures that different clinicians will describe the same patient in much the same way, once they learn to use the SWAP reliably. Had other clinicians described Melania using the SWAP, the narrative descriptions would have been much the same, since the descriptive statements comprising the narrative were taken directly from the SWAP-200 item set.
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