Finding the "person" in personality disorders

I n 1874 Hughlings Jackson endorsed a two-pronged diagnostic system-one for clinicians and another for researchers (1). The report by Drew Westen in this issue of the Journal suggests that at least with regard to personality disorders, Jackson's wish may have been granted unintentionally. In a small study of his colleagues at the Cambridge Hospital and in a larger survey of a randomly selected national sample of experienced psychiatrists and psychologists, Westen found that clinicians approach the diagnosis of patients with personality disorders in ways that diverge substantially from standard research instruments geared to DSM-IV classification. Direct questions based on criteria from DSM-IV were regarded as only minimally useful in making the diagnosis of a particular personality disorder. Instead, clinicians emphasized observation of the patient's behavior during the interview and descriptions of the patient's interactions with significant others. Westen also found that clinicians tend to apply only one axis II diagnosis, while the use of currently popular research instruments based on the DSM-IV system typically results in somewhere between three and six personality disorder diagnoses if subjects are thought to have any pathology at all on axis II.