Posted: June 11th, 2022

discussion

ATTACHED FILE(S)
Prior to beginning work on this discussion, read Chapter 10 of the course textbook. Pay close attention to the two case illustrations in Section 10.4 as these may inform the creation of the illustration in your initial post. Also, read the articles
An Integrated Approach to Treatment of Patients With Personality Disorders(Links to an external site.)
and
Pathological Personality Traits Can CaptureDSM–IVPersonality Disorder Types(Links to an external site.)
(Clarkin et al., 2015; Miller,et al., 2015).
For this discussion, select one of the personality disorders discussed in Chapter 10 that you find interesting, then conduct web research to find a person (i.e., living or not, historical, famous, and/or even fictional) who suffers from the disorder you chose to serve as a case study. Then choose a model of personality that will serve as a framework for devising a theoretical explanation and therapeutic intervention for the case you selected.
For your initial post,
· Describe the personality disorder for the case study you selected.
· Apply the theories in your selected model to explain how the disorder may have developed for your particular case and what may have been the underlying causes. The primary focus here should be on the theoretical explanation of how your chosen disorder may have developed and should not be a detailed description of the disorder.
· Discuss possible therapeutic interventions that might be applied in your case, based on your chosen model.
Your initial post should be a minimum of 350 words and should incorporate at least one peer-reviewed article.
Guided Response:Respond substantively to at least two of your peers. Select one classmate who has chosen a different personality disorder than you did. Analyze the fictional case presented, and provide feedback on the explanation of the development and causes of your peer’s chosen disorder. Suggest other elements related to the model that might be included. If possible, also respond to a classmate who has chosen the same disorder as you have but has approached it from a different theoretical perspective. Compare and contrast your analysis to those of your classmates.
An Integrated Approach to Treatment of Patients
With Personality Disorders
John F. Clarkin
Weill Cornell Medical College
Nicole Cain
Long Island University
W. John Livesley
University of British Columbia
We describe a framework for the application of treatment modules to the major
domains of dysfunction manifested by clients with personality disorder. This integrated
approach takes the clinician beyond the existing limited treatment research by using
strategies and techniques from all the major treatment schools and orientations. This
effort is necessary and timely because the field of personality disorders is currently
struggling to further define and understand personality pathology beyond categories by
articulating major dimensions of dysfunction across the personality disorder types
marked by various degrees of severity.
Keywords: personality disorders, psychotherapy, psychotherapy integration
Personality disorders (PDs) are prevalent and
debilitating and have a powerful negative im-
pact on work functioning and intimate and in-
terpersonal relations. There are many impedi-
ments to the treatment of patients with
personality pathology, including controversies
in defining PD, the rampant comorbidity among
PDs and with symptom disorders, the range of
severity across the disorders, the difficulties in
identifying the key dimensions of personality
dysfunction, and the paucity of treatment re-
search on the numerous PD types.
In this article, we articulate an integrated
modular approach to the treatment of PDs. We
describe a framework for the application of
treatment modules to the major domains of dys-
function manifested by clients with PD. This is
called an integrated approach (Stricker, 2010;
Norcross & Wampold, 2011), because it takes
the clinician beyond the existing treatment re-
search—which is limited—and uses strategies
and techniques from all the major treatment
schools and orientations. An integrated modular
approach emphasizes: (a) the individuality of
the patient, and not the category of disorder, (b)
the domains of dysfunction in the individual
patient, (c) the therapeutic use of modules of
intervention from existing clinical approaches,
especially those that have been empirically in-
vestigated, and (d) the construction of a smooth
fabric of intervention in the context of a devel-
oping alliance between therapist and patient.
Our attempt here and elsewhere (Livesley,
Dimaggio, & Clarkin, in press) is to further the
effort at integration by articulating a treatment
framework specifically for those individuals
with PDs. This effort is necessary because the
field of PDs is currently struggling to further
define and understand personality pathology be-
yond categories by articulating major dimen-
sions of dysfunction across the PD types
marked by various degrees of severity (Clarkin,
2013).
There is an emerging consensus that the es-
sence of the PDs across the various categorical
types centers on difficulties in self-functioning
and interpersonal functioning (Sanislow et al.,
2010). The product of the Diagnostic and Sta-
tistical Manual of Mental Disorders, Fifth Edi-
tion (DSM-5) Personality Disorder Work
John F. Clarkin, Department of Psychiatry, Weill Cornell
Medical College; Nicole Cain, Department of Psychology,
Long Island University; W. John Livesley, Department of
Psychiatry, University of British Columbia.
Correspondence concerning this article should be ad-
dressed to John F. Clarkin, New York Presbyterian Hospi-
tal, Weill Cornell Medical Center—Westchester Division,
21 Bloomingdale Road, White Plains, NY 10605. E-mail:
jclarkin@med.cornell.edu
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Journal of Psychotherapy Integration © 2015 American Psychological Association
2015, Vol. 25, No. 1, 3–12 1053-0479/15/$12.00 http://dx.doi.org/10.1037/a0038766
3
mailto:jclarkin@med.cornell.edu
http://dx.doi.org/10.1037/a0038766
Group—located in Section III of DSM-5
(2013)—provides a potential correction to the
previously predominant focus on symptoms, be-
cause it brings the field back to focus on the
essence of personality pathology that is self and
interpersonal functioning.
Why Consider an Integrated
Approach to Treatment?
Evidence-based practice is defined as the
combination of best available research with
clinical expertise in the context of patient char-
acteristics, culture, and preferences. There is
every cogent reason to use information from
empirically supported treatments when avail-
able, but in reference to the PDs, the treatment
research is limited to a few disorders, and even
with those disorders, the results tend to be com-
parable across treatment packages. Evidence-
based practice for PDs must contend with a
number of limitations in the research literature,
and use clinical expertise to match the individ-
ual client with the best treatment approaches.
The difficulties with applying the empirically
supported treatment approach to the PDs are
numerous. For example, PDs are marked by
heterogeneity both within diagnosis and with
comorbidity across the PDs. The various con-
stellations that PD assumes make it difficult to
articulate a treatment that fits all individuals
even within one PD category. In addition, psy-
chotherapy research to date is limited to a few
disorders with relatively comparable effects.
Only a few of the 10 DSM PDs have attracted
psychotherapy research, with the vast majority
of treatment research focused on borderline per-
sonality disorder (BPD). There is no indication
that each disorder will be investigated with
treatment research, but the clinician must pro-
ceed despite this situation.
There is also a growing awareness that genes
and neurocognitive dysfunction are not specific
to a particular diagnostic category, but rather
are functions across diagnostic categories that
are potential foci for therapeutic intervention.
Molecular genetics will not provide a simple,
gene-based classification of psychiatric ill-
nesses, but rather genetic findings will likely
delineate specific biological pathways and do-
mains of psychopathology (Craddock, 2013). In
this regard, the National Institute of Mental
Health has declared an initiative to focus re-
search not on categories of mental illness but on
systems of neurocognitive functioning and dys-
function that extend across diagnostic catego-
ries (Hyman, 2011).
Finally, medicine in general is advancing to-
ward an individualized approach to both assess-
ment and treatment. Each individual is biolog-
ically unique, and this uniqueness suggests that
treatment should be tailored to the individual.
Although there are commonalities across people
at the psychological level of functioning, it has
become evident that each individual has a
unique psychological history of development
and engagement in the environment (Norcross
& Wampold, 2011). This uniqueness is the fo-
cus of the clinicians’ assessment of clients with
suspected PD, the results of which guide the
tailored intervention with that client.
With these issues in mind, we are recom-
mending an integrated treatment approach that
is probably already the most popular approach
to the treatment of clients with PDs. We think it
remains important to describe an integrated ap-
proach to the treatment of PDs in order to fur-
ther clarify the issues and refine the approach.
An articulation of an integrated approach to
treatment may also legitimize the wise integra-
tive approaches of many clinicians who worry
that they are violating the empirical treatment
recommendations.
What Is Integration?
We regard integration as a mental process
engaged in by the clinician. This process begins
at the first meeting between therapist and pa-
tient. The focus of the integration is the indi-
vidual patient with a PD who is seeking help.
The content of integration is the unique combi-
nation of domains of dysfunction matched with
modules of intervention that are applied in a
particular sequence over time.
In this conception of integration, one can
conceive of a number of steps in this process:
(a) arriving at a working conception of the pa-
tients’ dysfunctional domains, (b) generating a
vision of how the client could realistically
achieve a better level of adjustment, (c) imag-
ining how this client can improve over time in a
stepwise, progressive pattern, (d) using thera-
peutic interventions timed to the client’s readi-
ness to change and salient problems at the mo-
ment, and (e) therapist awareness throughout
4 CLARKIN, CAIN, AND LIVESLEY
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treatment of the client’s perception of him or
her and the impact on the process of change.
The process of integration as conceptualized
here is quite consistent with the empirically
supported treatment approach mentioned be-
fore. In the absence of empirical evidence for
specific treatments for each of the PDs, and in
the absence of empirical information on mech-
anisms of change, the clinician is forced to use
his or her clinical judgment moment-to-moment
and across a treatment episode.
Probably the most salient exception to the
dearth of empirically supported treatments for
PDs is the treatment evidence for BPD. Cogni-
tive– behavioral (Linehan, 1993), mentaliza-
tion-based (Bateman & Fonagy, 2006), and ob-
ject relations treatment (Clarkin, Yeomans, &
Kernberg, 2006) are all empirically supported.
Although we know that these treatment pack-
ages are associated with symptom change, there
is little clarity about which elements in each
approach are effective. In addition, some clients
do not respond to the particular approach. It is
possible that a more tailored approach to the
particular patient with his or her unique
strengths, weaknesses, and environment may
produce significant change.
Different Approaches to
Psychotherapy Integration
Stricker (2010) has summarized the history
and approaches to psychotherapy integration,
that is, common factors and technical, theoreti-
cal, and assimilative approaches. Each of these
approaches deserves description to clarify how
they might be used in full or in part for clients
with PD. The common factors approach refers
to the use of techniques that are used across
treatments, regardless of the theoretical orienta-
tion. Theoretical integration is an attempt to
integrate theories, such as behavioral theory and
psychoanalytic theory, to guide the treatment
interventions. Our own view is that the field of
PDs has profited from multiple theoretical ap-
proaches, but none of which to date are com-
prehensive and empirically grounded to ade-
quately guide therapeutic interventions
(Lenzenweger & Clarkin, 2005). These theories
are best described as part-theories. Theoretical
integration concerning the PDs will advance as
the empirical research progresses; however, the
clinician cannot wait for the emergence of a
comprehensive theory of personality and PDs
and instead needs a near-experience model of
personality and personality disordered function-
ing as a map to assessment and intervention.
Assimilative integration is an approach that
rests on one theoretical position, and from that
position incorporating techniques from other
therapeutic approaches.
The framework for an integrated modular
approach in this article is closest to technical
integration, which is the systematic use of tech-
niques from numerous orientations without re-
gard for theoretical orientation. Although we
refer to a prominent theory of normal personal-
ity functioning to guide thinking, there is still no
comprehensive theory of PDs (Lenzenweger &
Clarkin, 2005).
An empirically supported theory of person-
ality functioning can serve as a foundation for
progressing to an understanding of personal-
ity dysfunction. For example, Mischel and
Shoda (2008) have articulated a cogni-
tive�affective processing system (CAPS)
model of personality functioning that can pro-
vide an overall framework for understanding
personality functioning. The CAPS model fo-
cuses on the processes by which individuals
construe situations and themselves in adapt-
ing to the environment. This metatheory em-
phases five levels of experience: (a) an orga-
nized pattern of activation of internal
cognitive�affective units (e.g., conceptions
of self and others, expectancies and beliefs,
affects, goals and values, self-regulatory
plans), (b) behavioral expressions of this in-
ternal processing system, (c) self and other
perception of these behaviors over time, (d)
construction of one’s typical environment,
and (e) the predispositions at the biological
and genetic levels of existence. This frame-
work suggests that personality dysfunction
can occur at multiple levels, and assessment
of these crucial areas could guide targets for
intervention. Lacking a comprehensive theory
of personality pathology, we suggest that the
therapist focus on the domains of dysfunction
and how they manifest in the client’s partic-
ular environment. With the CAPS model, the
therapist would attend to both observable be-
havior and how the patient uses his or her
particular conceptualizations of self-other in-
teractions that guide behavior.
5INTEGRATED TREATMENT OF PERSONALITY DISORDERS
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An Integrated Modular Approach
Given the issues we have described above
with the assessment and treatment of PD, it
seems logical to consider the specific client in
terms of salient interpersonal difficulties and
how these difficulties are manifested in that
individual’s unique environment. Domains of
dysfunction and severity of these dysfunctions
become as important in the clinical workup as
the identification of the PD category itself. An
integrated modular approach is an invitation to
drop categorization of strategies and techniques
related to therapy school (e.g., cognitive–
behavioral, psychodynamic), and instead to fo-
cus on patient domains of dysfunction and a
variety of ways to approach them with effective
treatment modules.
Domains of Pathology in Clients With PDs
An integrated approach focuses on domains
of pathology rather than on the specific diag-
nostic categories of PD. We do this because of
the domains of dysfunction that are common
across the various PD diagnoses. The central
difficulty in those with PD is an observable
dysfunction in interpersonal relations, with a
more covert difficulty in the mental representa-
tions of self and others (Pincus, 2005; Kernberg,
1984). It is well documented that individuals
scoring high on any PD dimension have consid-
erable interpersonal difficulties characterized by
a solitary lifestyle, conflicted and distressed so-
cial relations, and lack of social support (Hen-
gartner, Müller, Rodgers, Rössler, & Ajdacic-
Gross, 2014).
With a focus on the CAPS model (Mischel &
Shoda, 2008), the domains of PD functioning
can be identified through an inspection of
DSM-5, self-report instruments, and theoretical
descriptions of the PDs.
When the DSM categories are examined at
the individual criterion level, one can recognize
the following domains of dysfunction:
• Defective or relative absence of moral
functioning (e.g., dishonesty, stealing,
physical violence, disregard for the rights
of others)
• Suicidal and self-destructive behavior;
fearful behaviors; obsessive behaviors
• Difficulties relating to others (e.g., perva-
sive distrust of others, detachment from
social relations, reduced capacity for close
relationships, instability in interpersonal re-
lations, excessive attention seeking, avoid-
ance, submissive and clinging behavior,
preoccupation with interpersonal control,
conflict, aggression)
• Difficulties in self-definition (e.g., feelings
of inadequacy, hypersensitivity to negative
evaluation, grandiosity, lack of empathy,
lack of goals).
Another approach to capture the salient areas
of function and dysfunction in personality and
PDs is to examine the factors or traits incorpo-
rated in major self-report questionnaires. For
example, major dimensional models of person-
ality and personality pathology converge on
four higher order traits: (a) neuroticism/
negative affectivity/emotional dysregulation,
(b) extraversion/positive affectivity, (c) disso-
cial/antagonism, and (d) constraint/compulsiv-
ity, conscientiousness (Trull, 2006). Newer in-
struments (e.g., the Severity Indices of
Personality Problems) focus on five factors of
personality functioning: self-control (e.g., emo-
tion regulation, effortful control), identity inte-
gration, relational capacities (e.g., intimacy, en-
during relationships), responsibility, and social
concordance (e.g., respect, cooperation; Ver-
heul et al., 2008).
In addition, measures such as the Inventory
of Interpersonal Problems have been used to
examine the specific interpersonal difficulties
associated with PDs. For example, paranoid,
narcissistic, and antisocial PDs are often asso-
ciated with domineering, vindictive interper-
sonal behavior, while histrionic PD is related to
intrusive interpersonal behavior. Avoidant PD
has been linked to avoidant and nonassertive
interpersonal behaviors and dependent PD is
characterized by exploitable interpersonal be-
havior (Wiggins & Pincus, 1989).
In summary, converging lines of evidence
have suggested four major areas of dysfunction
in individuals with PD: symptoms, emotion reg-
ulation difficulties, interpersonal functioning,
and self-functioning.
Treatment Modules
One way to tailor the treatment to the indi-
vidual is to assess for domains of dysfunction
and to match treatment modules to these do-
mains. We describe modules of treatment as an
6 CLARKIN, CAIN, AND LIVESLEY
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interconnected series of therapist interventions
(i.e., techniques) that have a specific dysfunc-
tional target. We have selected treatment mod-
ules from larger intervention packages that have
been empirically investigated (e.g., Bateman &
Fonagy, 2006; Clarkin et al., 2006; Linehan,
1993), or treatment modules devised by clinical
researchers with experience intervening with
specific target areas (e.g., Safran & Muran,
2000).
We describe two overarching modules of
treatment for those suffering from PD: (a) gen-
eral treatment modules that are used to structure
treatment, to enhance motivation for change,
and to manage the relationship between patient
and therapist (see Table 1), and (b) specific
treatment modules for specific domains of dys-
function.
General Treatment Module
Structuring treatment can be accomplished by a
careful and collaborative assessment (Hilsenroth
& Cromer, 2007), followed by negotiating a ver-
bal contract and framework for the therapeutic
work (Clarkin et al., 2006). The framework pro-
vides the client with the responsibilities of both
therapist and client necessary to achieve a success-
ful treatment. However, the structure of the treat-
ment continues beyond the early assessment and
throughout the entire treatment episode.
Clients with PDs often encounter difficul-
ties with interpersonal functioning. Inevita-
bly, one of the first challenges of working
with PD clients is navigating the interpersonal
component of the therapy—the therapeutic
relationship. Safran and Muran (2000) have
emphasized that clients and therapists are em-
bedded in a relational matrix (Mitchell,
1988)—the therapeutic alliance—which is
shaped moment-to-moment by the implicit
needs and desires of client and therapist. Rup-
tures occur when there is tension between the
client’s and the therapist’s respective needs
and desires (Safran & Muran, 2000), and,
thus, ruptures are inevitable events in therapy
and should not be viewed as obstacles to
overcome but rather as opportunities for ther-
apeutic change. It is important for therapists
to be aware that clients often have negative or
ambivalent feelings about the therapeutic re-
lationship, which may be difficult for them to
acknowledge or to even understand. This is
especially true for PD clients. Therefore, ther-
apists should be attuned to subtle indications
of changes or ruptures in the therapeutic alli-
ance and should take the initiative to explore
these changes or ruptures moment-to-moment
in the therapy. Client change following the
exploration of an alliance rupture can be un-
derstood as involving two processes: an in-
creasing immediate awareness of self and
other, and a new interpersonal experience
with the therapist ideally resulting in social
learning that can be generalized outside of the
therapeutic relationship (Safran & Muran,
2000).
Treatment Modules for Specific Domains
and Their Sequencing
Most central to the process of treatment inte-
gration is a vision or road map concerning the
sequence of change for clients with PD. Be-
cause one of the client’s difficulties is an inabil-
ity to see a way out of current difficulties, it is
the therapist who must have an eye on the
Table 1
General Treatment Module
Treatment modules Specific procedures
Assessing personality pathology Assessment interview
Focus on domains of dysfunction
Structuring the treatment Establishing a treatment framework
Monitoring the relationship Resolving alliance ruptures
Validating the patient
Therapist alert to indications of patient positive
and negative views of therapist/therapy
Reciprocal communication strategies
Mentalizing interventions
7INTEGRATED TREATMENT OF PERSONALITY DISORDERS
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changes needed and a flexible plan of sequential
changes.
The sequence of targets of change depends on
the specific PD, but more directly, it depends on
the relative severity. Of necessity, the therapist
places a priority in the sequence of addressing
domains of dysfunction. We have described the
five phases of the treatment of patients with
PDs, including: (a) ensuring the safety of the
patient and others in the patient’s environment;
(b) containment of symptoms, emotions, and
impulses; (c) control and modulation of emo-
tions and impulses that contribute to symptoms,
including deliberate self-harm; (d) exploration
and change of the more stable cognitive�emo-
tional structures underlying maladaptive behavior
and interpersonal patterns; and (e) integration and
synthesis of a more adaptive self-structure (see
Table 2). The sequence of intervention is dictated
by concern for patient safety before moving onto
other issues, and a conception of what domains
must change in order for other domains to be
approached.
The safety issue is clear when physical integ-
rity of either the patient or a significant others is
relevant. For example, behaviors such as wrist
cutting or more serious suicidal behaviors must
be addressed immediately. This would also in-
clude potentially dangerous physical fights be-
tween patients and their intimate others. Crisis
intervention, medication, structure, and support
are all important elements in ensuring safety for
the patient. As patient safety increases, the treat-
ment can progress to a containment phase in
which structure and support are essential for the
modulation of intense emotions and impaired
cognitive functioning.
Emotion regulation, either deficient regula-
tion or constriction and inhibition, becomes the
next focus of intervention. Emotion regulation
refers to a range of cognitive�affective abilities
the individual uses to monitor, evaluate, and
modify their emotional response to interper-
sonal and other environmental demands in order
to achieve their goals (Nolen-Hoeksema, 2012).
In contrast to individuals with emotion regula-
tion skills and strategies, individuals with psy-
chopathology often exhibit emotion dysregula-
tion. Emotion dysregulation is a disrupted
domain of functioning that is central to many
disorders, including depression and anxiety dis-
Table 2
Treatment Phase and Priorities Matched to Treatment Modules
Treatment phase Treatment modules
Phase 1: Patient safety Crisis intervention
Brief hospitalization
Medication
Structure and support
Phase 2: Containment Structure and support
Establishing the treatment frame (Clarkin et al., 2006; Linehan, 1993)
Medication
Phase 3: Control and modulation Functional analysis of behavior (Linehan, 1993), with a growing awareness of
links between cognition, emotion, and behavior
Awareness and mentalization of interpersonal triggers (Bateman & Fonagy,
2006)
Mindfulness (Linehan, 1993)
Ability to identify and label emotions (Linehan, 1993)
Distress tolerance skills, such as distraction and self-soothing (Linehan, 1993)
Interpersonal effectiveness skills, such as the ability to seek out appropriate
social support and effective help-seeking behavior (Linehan, 1993)
Phase 4: Exploration and change Examination of interpersonal schemas and alliance ruptures (Safran & Muran,
2000), interpersonal signatures (Pincus, 2005; Cain & Pincus, in press), and
dominant object relations (Clarkin et al., 2006)
Phase 5: Integration and synthesis Examine sense of self and expand self-narrative (Dimaggio et al, in press) by
constructing a personal niche through engaging in hobbies, work, and
improved romantic relationships (Clarkin et al., 2006)
Expand curiosity and perception of others through mentalization (Bateman &
Fonagy, 2006) and exploration of transference (Clarkin et al., 2006)
8 CLARKIN, CAIN, AND LIVESLEY
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pu
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is
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.
T
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in
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to
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di
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em
in
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br
oa
dl
y.
orders, eating disorders, alcohol abuse, and PDs
(Nolen-Hoeksema, 2012).
The treatment of those with emotion dysregu-
lation can take many forms with the overlapping
goals of decreasing maladaptive emotion strat-
egies, such as rumination, and increasing emo-
tion regulating strategies, such as attentional
redeployment, reappraisal, and problem solv-
ing. The treatment of emotion dysregulation can
be approached by role playing of various rele-
vant scenarios (Linehan, 1993), and by increas-
ing awareness of and mentalization about dis-
ruptive interpersonal relations in which affect
regulation is problematic (Bateman & Fonagy,
2006). By focusing on the emotion arousing
events in the interaction between client and
therapist, an object relations approach fosters
reappraisal of perceptions of self and other
(Clarkin et al., 2006) in the sometimes emotion-
ally charged interaction between therapist and
client.
With more modulated emotional responses,
the treatment can focus on dysfunctional inter-
personal patterns. Patients with PD are dis-
turbed in relating to others in a cooperative,
satisfying, and productive way. These difficul-
ties are central in reducing patients’ satisfaction
in attaching to others in friendly and intimate
ways, and in interfering with work and profes-
sional success and productivity. The individual
with PD has an interpersonal style that is coun-
terproductive, that is, that gets one into conflict
with others and/or isolation. Why does this
seemingly counterproductive behavior con-
tinue, and what interaction processes are main-
taining it? In everyday interaction, the patient is
not usually given the opportunity to examine
relationship interaction. Others react to the be-
havior of the client with PD, and the perceptions
of both parties are usually not articulated or
shared. Without self-examination and self-
reflection, the patient go into a habitual, over-
learned pattern of interacting that defends his or
her self-esteem despite the interaction disrup-
tions. One possibility is that the individual is
unaware of his impact on others. He may lack
awareness when others are offended. Or he may
misinterpret the reactions of others, that is, see-
ing them as problems that the other has. This
inability of typical, daily interactions to lead to
self-correction in interpersonal conflicts and
distortions is precisely why the unique qualities
of a therapeutic interaction are needed.
Given patients’ selective attention to details
and need to present self in a positive light, the
information provided by the patient to the ther-
apist about interpersonal problems is of variable
accuracy. The patient’s narrative about current
interpersonal relations can be supplemented by
careful evaluation of how he or she relates to the
therapist, not in one moment, but in identifiable
patterns of interaction. Patients are sometimes
unaware of how they appear to others, how they
impact on others, and how their interaction
styles lead to their own difficulties. The extent
to which PD patients recognize their own con-
tributions to their interpersonal difficulties var-
ies from patient to patient, and from time to
time in the same patient. It is with those patients
who are poor at recognizing their troubling in-
teractions with others that dialogue with the
therapist are most informative.
The term interpersonal functioning covers a
wide range of activity, from intimate sexual
relations, to intimate friendships, to social rela-
tions, to work and task-oriented relations, to
instrumental relations, such as negotiating at the
counter in a food market. Relevant here are the
types of relationship deficits that patients bring
to therapy, and the ones that most interfere with
patients’ quality of life. For patients with severe
PDs, their relationships may be so isolated or
conflicted that they have not functioned in a
career or work setting. This kind of disability
seriously interferes with patients’ ability to be
independent and self-sustaining, and seriously
reduces quality of life. At the other end of the
spectrum, there are patients with less severe
PDs who are functional and quite successful in
work and profession, and who have friendships,
but who do not achieve a satisfying intimate
relationship in which love and sexuality are
combined. It is along this continuum of inter-
personal relations and the competencies re-
quired that one could think of modules of treat-
ment for these conditions.
Setting the treatment frame (Clarkin et al.,
2006) and explaining the responsibilities of both
participants is a crucial first step in constructing a
context and atmosphere in which the patient can
examine without fear or embarrassment or rejec-
tion his or her interpersonal behavior, attitudes,
and feelings. Patients’ interpersonal behavior can
be examined as it unfolds with others in their
current life context, and/or in their immediate be-
havior with the therapist. Most probably, thera-
9INTEGRATED TREATMENT OF PERSONALITY DISORDERS
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oc
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of
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T
hi
s
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of
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in
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to
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y.
pists of various persuasions use material from
both situations to deepen patients’ self-under-
standing. It seems to be a common approach to
focus on current relationships rather than on tem-
porally distant ones. Patients, of course, may com-
ment on what they see as the origins or history of
their patterns in relating, but it is the focus on
current relationships that provides the opportunity
for a wider behavioral repertoire with new ways of
relating.
Maladaptive interpersonal patterns are enacted
both inside and outside therapy, thus giving the
therapist the opportunity to understand and ex-
plore the etiology and maintenance of these dis-
turbed interpersonal patterns with the client in the
present moment. Pincus and colleagues (Cain &
Pincus, in press; Pincus, 2005; Pincus & Hop-
wood, 2012) have articulated a treatment ap-
proach that integrates contemporary interpersonal
theory with an object relations-based understand-
ing of personality structure (Clarkin et al., 2006).
The underlying premise is that interpersonal situ-
ations occur not only between self and other but
also in the mind via mental representations. Fol-
lowing Kernberg’s (1975, 1984) object relations
theory, these internalizations often consist of a
self-representation, an other-representation, and a
linking affect. Thus, treatment can proceed via an
articulation of the internalizations of self and other
using a sequence of clarifications, confrontations,
and well-timed interpretations of current interac-
tions (Clarkin et al., 2006) to identify, challenge,
and ultimately understand the etiology and main-
tenance of maladaptive interpersonal patterns,
thereby, leading to increased interpersonal aware-
ness and social learning.
Exploration of interpersonal relations very
quickly and seamlessly leads into the patient’s
perception of self. Guiding the patient to a review
of self-narrative and the gaps in it is an important
approach to the improvement of the patient’s self-
concept and self-functioning (Dimaggio et al.,
2012; Dimaggio, Popolo, Carcione, & Salvatore,
in press). Self-functioning can be parsed into at
least five different conceptualizations: self as the
total person, self as personality, self as experienc-
ing subject, self as beliefs about oneself, and,
finally, self as an executive agent. In the realm of
personality pathology, negative beliefs and feel-
ings about self, including low self-esteem, lack of
self-efficacy, and a grandiose, exaggerated sense
of self-importance, are major areas of concern and
therapeutic intervention.
These common principles to approach inter-
personal difficulties can be specified as follows:
1. Setting a frame for treatment so that the
patient can anticipate examination of inter-
personal behavior without seeing it as criti-
cism or an attack.
2. Building a therapeutic alliance with the ob-
serving part of the patient. In this way, the
therapist becomes an ally to the patient in
correcting his or her interpersonal behavior.
3. Ruptures in the relationship alliance be-
tween the client and the therapist should be
expected, and should be seen as an opportu-
nity for examining the client’s understand-
ing of how the therapist is viewing and re-
lating to him or her.
4. The therapist attitude of therapeutic neutral-
ity. The patient will, at times, see the thera-
pist as entering into and contributing to a
conflicted relationship with the patient. To
examine these situations, the therapist is
aided by being neutral, that is, taking the
position of an outside observer not involved
in the conflict and taking an observing
stance.
5. Timing. It is a common assumption among
experienced clinicians that the timing of the
attempt by the therapist to reflect back to the
client a view of his or her interpersonal
behavior is crucial to the client’s receptivity
to the message, which could be experienced
as emotional arousing, critical, and destabi-
lizing.
6. There are many therapeutic approaches to
using the relationship that emerges between
client and therapist to explore the client’s
difficulties in relating to others. These ap-
proaches can be conceived along a contin-
uum from attention to overt interpersonal
behavior, both defective and new prosocial
behaviors, to internal cognitive�affective
units that represent self and other.
Research Relevant to an Integrated
Modular Approach
The modular approach assumes that different
domains of functioning will change at different
rates of time during the treatment. We (Lenzen-
weger, Clarkin, Yeomans, Kernberg, & Levy,
2008) have found that three different domains of
functioning change at different rates across three
10 CLARKIN, CAIN, AND LIVESLEY
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A
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oc
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on
or
on
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of
it
s
al
li
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pu
bl
is
he
rs
.
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al
us
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of
th
e
in
di
vi
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al
us
er
an
d
is
no
t
to
be
di
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em
in
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br
oa
dl
y.
treatment approaches (i.e., transference-focused
psychotherapy, dialectical behavior therapy, and a
supportive treatment) for clients with BPD. Em-
bedded in this finding is not only an identification
of domains relevant to borderline patients, but also
the utility of measuring domains multiple times in
a treatment in order to understand the rate of
change of a particular domain. It would be a
tremendous advance if clinical treatment research-
ers could agree on crucial domains of dysfunction
in PD patients, and use the same instruments to
measure rates of change in these domains in var-
ious treatments.
A second type of study that would further in-
tegration is the design used by Weisz et al. (2012)
in which modules from differently empirically
supported treatments were combined in different
ways tailored to the individual in the treatment of
preadolescents for symptoms and conduct prob-
lems. This tailored approach was found superior to
an empirically supported treatment alone.
Conclusion
It is paramount with PD patients, who by
definition have difficulties in interpersonal rela-
tions, that the therapist be constantly attentive to
the ongoing nature of the relationship with the
client. Treatment modules will not work with-
out the context of a productive relationship. The
careful attention to the relationship will prevent
premature dropout. The client’s belief that
change is possible is central to treatment suc-
cess. Often, clients with PD are motivated for
relief from symptoms and discomfort, but only
with some relief and a sense that treatment
might work does one begin to actually believe
that change was possible. It seems clear that the
therapist must have a vision of possible change,
and only gradually can patients begin to adopt
that vision and related motivation. In addition,
clients’ ability to go beyond their usual reactive
mode of relating to their environment must be
transformed slowly into a curiosity about and
interest in reflecting on their own experiences
and how the experiences guide their behavior.
An attempt at delivering an integrated treat-
ment to clients with PD does not come without
difficulties. Although articles like this one can
suggest a framework for considering and apply-
ing an integrated approach, its value lies in the
perceptiveness and talent of the individual cli-
nician. Integration is a somewhat unique pro-
cess in each therapist�client pair.
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Received February 19, 2014
Accepted February 24, 2014 �
12 CLARKIN, CAIN, AND LIVESLEY
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.
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is
in
te
nd
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so
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fo
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pe
rs
on
al
us
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of
th
e
in
di
vi
du
al
us
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no
t
to
be
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in
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br
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http://dx.doi.org/10.1521/pedi.2008.22.4.313
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http://dx.doi.org/10.1093/oxfordhb/9780199735013.013.0018
http://dx.doi.org/10.1093/oxfordhb/9780199735013.013.0018
http://dx.doi.org/10.1037/a0020909
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An Integrated Approach to Treatment of Patients With Personality Disorders
Why Consider an Integrated Approach to Treatment?
What Is Integration?
Different Approaches to Psychotherapy Integration
An Integrated Modular Approach
Domains of Pathology in Clients With PDs
Treatment Modules
General Treatment Module
Treatment Modules for Specific Domains and Their Sequencing
Research Relevant to an Integrated Modular Approach
Conclusion
References
Pathological Personality Traits Can Capture DSM–IV Personality
Disorder Types
Joshua D. Miller and Lauren R. Few
University of Georgia
Donald R. Lynam
Purdue University
James MacKillop
University of Georgia and Brown University
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) includes an alter-
native diagnostic approach to the assessment of personality disorders (PDs) in Section III with the aim
of stimulating further research. Diagnosis of a PD using this approach is predicated on the presence of
personality impairment and pathological personality traits. The types of traits present (e.g., callousness
vs. emotional lability) are used to derive DSM–IV PD scores. Concerns have been raised, however, that
such a trait-based approach will yield PD constructs that differ substantially from those generated using
the approaches articulated in previous iterations of the DSM. We empirically examined this issue in a
sample of 109 adults who were currently receiving mental health treatment. More specifically, we
examined the correlations between interview-based PD scores derived from DSM–IV to DSM-5 PD trait
counts, and tested them in relation to the 30 specific facets of the five-factor model, as well as
internalizing and externalizing symptoms. Overall, the DSM–IV PD scores and DSM-5 PD trait counts
correlated significantly with one another (Mr � .63), demonstrated similar patterns of interrelations
among the PDs, and manifested highly similar patterns of correlations with general personality traits and
symptoms of psychopathology. These results indicate that the DSM-5 PD trait counts specified in the
alternative DSM-5 PD diagnostic approach capture the same constructs as those measured using the more
traditional DSM–IV diagnostic system.
Keywords: DSM-5, personality disorder, assessment, personality traits
A host of problems are associated with personality disorders
(PDs) in the Diagnostic and Statistical Manual of Mental Disor-
ders, Fourth Edition (DSM–IV), including a lack of adequate
coverage, widespread comorbidity, and difficulty distinguishing
normality from abnormality (Clark, 2007; Widiger & Trull, 2007).
In response to these problems, the DSM-5 Personality and Person-
ality Disorder Work Group (DSM-5 PPD Work Group; American
Psychiatric Association [APA], 2013) proposed a diagnostic sys-
tem that differed radically from previous iterations. The two cen-
tral components of this PD proposal are the assessment of self and
interpersonal functioning, and the use of pathological traits to
describe six DSM–IV types (i.e., schizotypal, antisocial, bor-
derline [BPD], narcissistic, avoidant, and obsessive�compul-
sive [OCPD]). For example, in this proposal, the DSM-5 narcis-
sistic PD would be diagnosed if an individual manifested self and
identity impairment and elevated scores on the traits of grandiosity
and attention seeking. The proposal also called for this system to
describe PDs that are not covered by these “types,” including four
DSM–IV PDs that were to be eliminated (i.e., paranoid, schizoid,
histrionic, and dependent), using a PD�trait specified diagnosis.
The pathological traits proposed for use in DSM-5 were derived
from a new dimensional model of personality pathology compris-
ing five higher order domains and 25 lower order traits that is
thought to be an extension of the five-factor model (FFM) of
personality (APA, 2013).
This proposal by the DSM-5 PPD Work Group was met with
substantial criticism on a host of issues, including the decision to
delete certain DSM–IV PDs (Bornstein, 2011), the mixing of
dimensional and typal systems (Livesley, 2012), and the overall
complexity of the proposal that led to concerns about its clinical
utility (Shedler et al., 2010). In the current study, we addressed
specific criticisms of the use of traits to assess PDs. For instance,
Gunderson (2010), chair of the DSM–IV PD Work Group, ex-
pressed significant concerns with the proposal for the diagnosis of
BPD, suggesting that the “trait definition proposed for BPD . . . is
not empirically based and is completely divorced from clinical
concepts and literature” (p. 699). Even trait advocates such as
Livesley (2012) argued against use of traits to capture DSM–IV PD
constructs, suggesting “these diagnoses differ from their DSM–IV
equivalents so substantially that they should be considered new
diagnostic constructs” (p. 84). Due in part to the vocal opposition
toward this diagnostic approach, the DSM-5 PPD Work Group
This article was published Online First February 10, 2014.
Joshua D. Miller and Lauren R. Few, Department of Psychology, Uni-
versity of Georgia; Donald R. Lynam, Department of Psychological Sci-
ences, Purdue University; and James MacKillop, Department of Psychol-
ogy, University of Georgia, and Department of Behavioral and Social
Sciences, Brown University.
Correspondence concerning this article should be addressed to Joshua D.
Miller, Department of Psychology, University of Georgia, 125 Baldwin
Street, Athens, GA 30602-3013. E-mail: jdmiller@uga.edu
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Personality Disorders: Theory, Research, and Treatment © 2014 American Psychological Association
2015, Vol. 6, No. 1, 32– 40 1949-2715/15/$12.00 DOI: 10.1037/per0000064
32
mailto:jdmiller@uga.edu
http://dx.doi.org/10.1037/per0000064
proposal was included in Section III of DSM-5 to encourage
further study, while the official DSM-5 PD diagnoses are made
using the diagnostic approach articulated in DSM–IV.
Use of pathological traits in the diagnosis of PDs is neither as
radical nor as exploratory as suggested by critics. A sizable
literature exists on this topic, mostly from the perspective of the
FFM, which has suggested that general traits can be used to
conceptualize and assess PDs (see Miller, 2012, for a review).
Within this approach (e.g., Miller, Bagby, Pilkonis, Reynolds,
& Lynam, 2005), an individual can be scored on a given
DSM–IV PD on the basis of a summation (or count) of scores on
a smaller number of relevant FFM traits. Research from this
perspective has demonstrated that FFM PD trait count scores
correlated significantly with DSM–IV PDs, create personality
profiles that are in line with those created by more traditional
DSM–IV PD measures, and account for unique variance in
indices of functioning, above and beyond that explained by
DSM–IV PD constructs (e.g., Miller et al., 2010). In addition,
specific to Gunderson’s concerns, FFM trait approaches to the
scoring of BPD have demonstrated substantial success in rec-
reating its nomological network (Miller, Morse, Nolf, Stepp, &
Pilkonis, 2012; Trull et al., 2003).
Few studies exist, however, addressing the success of this
count approach using the novel trait model proposed for
DSM-5. Yalch, Thomas, and Hopwood (2012) compared the
criterion validity of the DSM-5 trait count approach, a prototype
matching approach (described in the initial DSM-5 PD proposal,
but rejected early in the process), and a DSM–IV symptom-
based approach for BPD and antisocial personality disorder in
a sample of undergraduates. The trait approach manifested good
convergent validity with the other approaches and superior
criterion-related validity in relation to measures of functioning.
Similarly, Samuel et al. (2013) examined the relations between
DSM-5 PD trait counts and DSM–IV PDs using self-report data
collected from a large undergraduate sample; they found that
DSM-5 trait counts correlated significantly with DSM–IV PDs
(Mdnr � .61) and reproduced the patterns of comorbidity found
among DSM–IV PDs.
In the current study, we tested the validity of the PD trait
count portion of the diagnostic approach for the PDs articulated
in Section III of the DSM-5 PD by examining the correlations
between DSM-5 PD trait counts and DSM–IV PDs (now the
official PD diagnostic system in DSM-5 as well) and testing
whether DSM-5 PD trait counts yield personality and psycho-
pathology profiles that are consistent with those created by
DSM–IV PDs. Ours is the first study to address these issues in
a clinical sample and using DSM–IV PD symptoms and DSM-5
PD traits that were rated by research personnel after a semi-
structured interview. We predicted that DSM-5 PD counts
would exhibit (a) substantial correlations with traditional
DSM–IV PD scores, (b) similar personality profiles as the
DSM–IV PDs using the 30 facets of the FFM as the criteria, and
(c) similar correlations with internalizing and externalizing
symptoms. We also hypothesized that DSM-5 PD trait counts
would successfully reproduce the pattern of intercorrelations
found among DSM–IV PDs, and that this pattern of overlap
would be due in large part to the use of overlapping traits.
Method
Participants and Procedure
Participants included 109 community adults (70% women; 90%
White, 6% African American; Mage � 35.8 years, SD � 12.6) who
were currently receiving psychological or psychiatric treatment.
To participate, individuals had to be currently receiving psycho-
logical care, between the ages of 18 and 65, have a minimum of a
Grade 8 education, use a computer 3� days a week (to ensure that
they could complete computerized assessments), and not be expe-
riencing psychotic symptoms. Individuals were administered a
semistructured interview for DSM–IV PD symptoms and com-
pleted a number of self-report measures across a single 3– 4 hr
protocol. Interviews were conducted by graduate students enrolled
in a doctoral program in clinical psychology. Individuals were
compensated $30 for participation. Institutional review board ap-
proval was obtained for all aspects of the study.
Measures
Structured Clinical Interview for DSM–IV Axis II Person-
ality Disorders. The Structured Clinical Interview for DSM–IV
Axis II Personality Disorders (SCID-II; First, Gibbon, Spitzer,
Williams, & Benjamin, 1997) is a semistructured interview that
assesses the 10 DSM–IV PDs. Each symptom is scored using a
1�3 rating. Symptom ratings were completed by the interviewer
(i.e., a doctoral student in clinical psychology) and a second rating
was completed (n � 103) via a review of the videotaped interview
by trained graduate students who were blind to the primary ratings.
Interrater reliability of the SCID-II ratings ranged from .79�.92
and alphas for the DSM–IV PD scores ranged from .68�.84. In
terms of diagnoses, 37.6% of the sample met criteria for at least
one PD; the most common diagnoses were avoidant (19.3%) and
BPD (11%).
DSM-5 personality disorder traits. On completion of the
SCID-II, the interviewer rated each participant on the 25 DSM-5
PD traits (e.g., callousness) using the official clinician rating guide
provided by the DSM-5 PPD Work Group, which uses single-item
ratings for each trait (0�3). Secondary ratings were generated after
a review of the SCID-II interview. Interrater reliabilities for these
25 traits ranged from .12 (perseveration) to .83 (impulsivity), with
a median of .55. DSM-5 PD traits counts were created by summing
the ratings for each PD using the traits specified by the DSM-5
PPD Work Group (e.g., DSM-5 narcissistic PD traits � attention
seeking � grandiosity). Despite not being included in Section III
of DSM-5, we included the DSM-5 PPD Work Group’s previous
specifications for scoring the four PDs specified for deletion on the
basis of the new DSM-5 trait model (paranoid � suspiciousness �
hostility � unusual beliefs and experiences � intimacy avoidance;
schizoid � withdrawal � intimacy avoidance � restricted affec-
tivity � anhedonia; histrionic � emotional lability � manipula-
tiveness � attention seeking; dependent � submissiveness �
anxiousness � separation insecurity).
Revised NEO Personality Inventory. The Revised NEO Per-
sonality Inventory (NEO PI-R; Costa & McCrae, 1992) is a 240-
item self-report measure of the FFM. Each of the five domains is
comprised of six more specific facets. Alphas for the facets ranged
from .58�.90, with a median of .81. Analyses with the NEO PI-R
were limited to 106 participants.
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33DSM-5 PERSONALITY DISORDER TRAITS
Patient-Reported Outcomes Measurement Information.
The short forms of the Emotional Distress � Anxiety and Emo-
tional Distress � Depression domains of the Patient-Reported
Outcomes Measurement Information System (Pilkonis et al., 2011)
are brief self-report questionnaires (i.e., seven and eight items for
the Anxiety and Depression scales, respectively) that assess the
experience of a particular emotion over the past 7 days. Both
variables were normally distributed (Anxiety: M � 22.15, SD �
6.50, � � .94; Depression: M � 22.20, SD � 9.17, � � .97). The
two scores correlated highly with one another (r � .81) and, thus,
were combined to create a single internalizing variable.
Brief Symptom Inventory. The Brief Symptom Inventory
(Derogatis, 1993) is a 53-item self-report inventory designed to
assess psychiatric symptoms, and it provides scores on nine symp-
tom scales (e.g., Somatization, Obsessive�Compulsive, Depres-
sion, Hostility, Phobic Anxiety, and Psychoticism), as well as a
Global Severity Index (GSI). The GSI, which we used here (� �
.97), is computed by generating an average of all 53 items.
Crime and Analogous Behavior scale. The Crime and Anal-
ogous Behavior scale (Miller & Lynam, 2003) is a self-report
inventory that assesses externalizing behaviors such as substance
use and antisocial behavior. A lifetime antisocial behavior variable
(10 items) was created by giving participant

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