Anxiety Disorders and Evidence-Based Practice: The Role of Broadband Self-Report Measures of Personality in Diagnosis, Case Conceptualization, and Treatment Planning


Scale (acronym)

Description

Validity scales

Inconsistency (INC)

Inconsistency of responding throughout the inventory; scale composed of item pairs with related content

Infrequency (INF)

Inconsistency of responding throughout the inventory; scale composed of items with extremely low endorsement frequencies

Negative Impression (NIM)

Self-unfavorable responding or malingering

Positive Impression (PIM)

Self-favorable responding or disinclination to admit minor flaws

Clinical scales

Somatic Complaints (SOM)

Concern with one’s own health and physical functioning; perceived somatic impairment

Anxiety (ANX)

Cognitive, affective, and physiological symptoms of generalized anxiety, including worry, apprehension, nervousness, and physical tension and stress

Anxiety-Related Disorders (ARD)

Clinical features of specific anxiety disorders, including phobias, traumatic reactions, and obsessive–compulsive problems

Depression (DEP)

Cognitive, affective, and physiological symptoms of depression, such as pessimism, unhappiness, and sleep and appetite changes

Mania (MAN)

Symptoms characteristic of mania and hypomania; for example, grandiosity, racing thoughts, elevated mood, irritability, and impatience

Paranoia (PAR)

Clinical characteristics of paranoia and paranoid personality, including hypervigilance, distrust of others, suspicion, and hostility

Schizophrenia (SCZ)

Symptoms of psychotic disorders, such as bizarre beliefs and experiences, social poor social competence, and characteristic cognitive deficits

Borderline Features (BOR)

Features characteristic of severe personality disorder. Subscales measure affective lability and instability, problems with identity, unstable and fluctuating interpersonal relations, impulsivity, and poorly controlled anger

Antisocial Features (ANT)

Symptoms and signs relevant to of antisocial personality and psychopathy, including a history of illegal activity, difficulty with authority, lack of empathy, egocentrism, and craving for novelty and stimulation

Alcohol Problems (ALC)

Behaviors and problematic consequences indicative of alcohol abuse and alcohol dependence

Drug Problems (DRG)

Problematic consequences and behaviors characteristic of drug use and substance dependence

Treatment scales

Aggression (AGG)

Attitudes and behaviors associated with anger, aggression, and hostility; level of poorly regulated anger; potential for aggression

Suicidal Ideation (SUI)

Suicidal thoughts, ranging from hopelessness and vague thoughts of dying to active suicidal ideation associated with imminent plans for self-harm

Stress (STR)

The impact of recent stressors on a person’s life. Stressors assessed include family problems, financial hardships, employment difficulties, and major life changes

Nonsupport (NON)

Perceived social nonsupport, considering both the quantity and quality of available support

Treatment Rejection (RXR)

The degree to which a person is disinterested in and unwilling to begin, continue, and make personal change in psychotherapy

Interpersonal scales

Dominance

The extent to which a person is autonomous and forceful (versus passive and acquiescent) in personal relationships

Warmth

The degree to which a person is warm, empathic, and interested in (versus cold, rejecting, and disinterested in) personal relationships

Supplemental indexes

Malingering Index (MAL)

Malingering; More specific indicator of malingering than NIM

Rogers Discriminant Function (RDF)

Discriminant function designed to distinguish patients from malingerers

Defensiveness Index (DEF)

Defensive responding; More specific indicator of defensiveness than PIM

Cashel Discriminant Function (CDF)

Designed to distinguish between defensive and honest responding

Suicide Potential Index (SPI)

Cumulative index of risk factors for completed suicide

Violence Potential Index (VPI)

Cumulative index of risk factors for violence

Treatment Process Index (TPI)

Cumulative index of treatment amenability factors


Source: Morey (2007a, pp. 25–49)



Items for most scales are included on the basis of both rational and empirical methods. Specifically, items were selected based on a preconceived definition of each construct and later validated. This method of scale construction differs from the criterion-keying approach used by the developers of the Minnesota Multiphasic Personality Inventory (Hathaway & McKinley, 1940). Consequently, all of the items on a given scale are conceptually related to the construct they are measuring. The PAI was standardized on both normal and clinical patient groups. Clients can therefore be compared to both a normal and a clinical group. The PAI focuses predominantly on Axis I conditions, though some information relevant to Axis II conditions and personality can be gleaned from the profile of scores. For example, the computer-generated interpretive report assesses the similarity between the client’s profile and the prototypic profiles for known clinical groups, and generates hypotheses about possible Axis I and Axis II diagnoses. Treatment considerations are also provided in the report.



Millon Clinical Multiaxial Inventory-III


The Millon Clinical Multiaxial Inventory-III (MCMI-III; Millon, Millon, Davis, & Grossman, 2009) is a measure of adult personality and global psychopathology, designed to assess adults aged 18 years and older. Administration time is approximately 25–30 min. The MCMI consists of 29 primary scales: 5 Validity scales, 11 Clinical Personality Patterns scales, 3 Severe Personality Pathology scales, 7 Clinical Syndromes scales, and 3 Severe Clinical Syndromes scales. Forty-two facet scales can also be scored. Table 11.2 provides descriptions of the primary MCMI-III scales.


Table 11.2
MCMI-III validity, personality, and clinical scales











































































































Scale

Description

Modifying indices

Invalidity (V)

Inconsistency of item endorsement

Inconsistency (W)

Inconsistency of item endorsement

Disclosure (X)

Self-unfavorable responding; the extent to which the person is inclined to be self-revealing or secretive

Desirability (Y)

Self-favorable responding or reluctance to admit minor flaws

Debasement (Z)

Self-unfavorable responding; a tendency towards self-deprecation

Personality styles

Schizoid (1)

Diminished ability to experience psychic pain or pleasure; apathy, inexpressiveness and passive asociality. Corresponds to DSM-IV schizoid personality disorder

Avoidant (2A)

Reduced ability to experience pleasure, but tendency to experience psychic pain; active asociality. Corresponds to DSM-IV avoidant personality disorder

Depressive (2B)

Reduced capacity to experience psychic pleasure; pessimism, glumness, and hopelessness. Corresponds to DSM-IV research criteria for depressive personality disorder

Dependent (3)

Passive dependence on acceptance and approval of others; unassertive and sentimental. Corresponds to DSM-IV dependent personality disorder

Histrionic (4)

Active and insatiable search for approval, attention, and acceptance; fear of autonomy; fickle mood. Corresponds to DSM-IV histrionic personality disorder

Narcissistic (5)

Disinterest in the needs of others; interpersonal exploitation, self-centeredness and egocentrism. Corresponds to DSM-IV narcissistic personality disorder

Antisocial (6A)

Irresponsible interpersonal conduct; impulsive and antisocial behavior; rebellious attitude. Corresponds to DSM-IV antisocial personality disorder

Sadistic (6B)

Abrasive, unkind, and coercive interpersonal conduct; desire for dominance; irritable mood. Corresponds to DSM-III-R sadistic personality disorder

Compulsive (7)

Respectful interpersonal conduct; perfectionism and self-discipline; cognitive rigidity and indecision. Corresponds to DSM-IV obsessive–compulsive personality disorder

Negativistic (8A)

Vacillation between obedience and hostile struggle for independence; labile and irritable mood; self pity. Corresponds to DSM-IV research criteria for passive–aggressive personality disorder

Masochistic (8B)

Deferential and servile interpersonal conduct; undeserving self-image; dysphoric mood. Corresponds to DSM-III-R self-defeating personality disorder

Severe personality styles

Schizotypal (S)

Eccentric and aberrant behavior; social isolation; mistrust of others; disorganized cognition. Corresponds to DSM-IV schizotypal personality disorder

Borderline (B)

Intense moods; affective instability; erratic interpersonal relations; impulsivity; self-destructive actions. Corresponds to DSM-IV borderline personality disorder

Paranoid (P)

Vigilant mistrust of others; interpersonal defensiveness; abrasive irritability; resistance to external influence. Corresponds to DSM-IV paranoid personality disorder

Clinical syndromes

Anxiety (A)

Phenomenology and observable signs of general anxiety

Somatoform (H)

Preoccupation with health matters and somatic complaints typically associated with somatoform disorders

Bipolar: Manic (N)

Symptoms of mania and hypomania

Dysthymia (D)

Symptoms and phenomenology of dysthymic disorder

Alcohol Dependence (B)

Problems associated with alcohol use and alcohol dependence

Drug Dependence (T)

Problems associated with drug use and drug dependence

Posttraumatic Stress Disorder (R)

Symptoms and phenomenology associated with traumatic stress reaction

Severe clinical syndromes

Thought Disorder (SS)

Symptoms relevant to the spectrum of schizophrenic disorders

Major Depression (CC)

Symptoms and phenomenology of significant depression

Delusional Disorder (PP)

Symptoms relevant to delusional disorder


Source: Millon et al. (2009, pp. 27–50)

Similar to the scale construction methodology utilized with the PAI, items for most scales were included on the basis of both rational and empirical methods. Items were selected on account of Millon’s evolutionary model of personality (see also Millon & Davis, 1996) and the DSM-IV criteria for personality disorders (American Psychiatric Association, 1994) and Axis I symptomatology. The MCMI-III was standardized on a clinical patient group and is, therefore, most appropriate for use with a clinical population. In contrast to the PAI, the MCMI focuses predominantly on Axis II conditions. In addition, raw scores are transformed into base rate (BR) scores rather than standard scores, so diagnosticians utilizing the MCMI-III should be familiar with the associated implications. Lastly, the computer-generated interpretive report provides hypotheses regarding possible Axis II and Axis I diagnoses, based on how well the client’s profile corresponds conceptually to these categories. Treatment considerations are also supplied in the report.


Millon Adolescent Clinical Inventory


The Millon Adolescent Clinical Inventory (MACI; Millon, Millon, Davis, & Grossman, 2006) is a measure of adolescent personality patterns and global psychopathology, designed to assess adolescents aged 13–19 years. Administration time is approximately 25–30 min. The MACI is comprised of 31 primary scales: 4 Validity scales, 12 Personality Patterns scales, 8 Expressed Concerns scales, and 7 Clinical Syndrome scales. Thirty-six facet scales can also be scored. In contrast to the PAI-A (which closely corresponds to the PAI), the structure of the MACI differs somewhat from that of the MCMI-III. This is largely due to the MACI’s focus on issues specifically relevant to adolescents (e.g., identity diffusion, peer insecurity, child abuse, and substance abuse proneness). Similar to the scale construction methodology utilized with the MCMI, items were selected, in part, on the basis of Millon’s evolutionary model of personality (cf., Millon & Davis, 1996). The MACI was standardized on adolescent patients and is, consequently, most suitable for use with a clinical population. Like the MCMI-III, raw scores are transformed into base rate (BR) scores rather than standard scores. The computer-generated interpretive report provides hypotheses regarding possible Axis II and Axis I diagnoses, along with ­treatment considerations (Table 11.3).


Table 11.3
MACI validity, personality, expressed concerns, and clinical scales















































































































Scale

Description

Modifying indices

Reliability (VV)

Inconsistency of item endorsement

Disclosure (X)

Self-unfavorable responding; inclination to be self-revealing

Desirability (Y)

Self-favorable responding or reluctance to admit minor flaws

Debasement (Z)

Self-unfavorable responding; a tendency toward self-deprecation

Personality patterns

Introversive (1)

Corresponds to the MCMI-III Schizoid scale

Inhibited (2A)

Corresponds to the MCMI-III Avoidant scale

Doleful (2B)

Corresponds to the MCMI-III Depressive scale

Submissive (3)

Corresponds to the MCMI-III Dependent scale

Dramatizing (4)

Corresponds to the MCMI-III Histrionic scale

Egotistic (5)

Corresponds to the MCMI-III Narcissistic scale

Unruly (6A)

Corresponds to the MCMI-III Antisocial scale

Forceful (6B)

Corresponds to the MCMI-III Sadistic scale

Conforming (7)

Corresponds to the MCMI-III Compulsive scale

Oppositional (8A)

Corresponds to the MCMI-III Negativistic scale

Self-Demeaning (8B)

Corresponds to the MCMI-III Masochistic scale

Borderline Tendency (9)

Corresponds roughly to the MCMI-III Borderline scale

Expressed concerns

Identity Diffusion (A)

Unclear sense of self; unfocused goals and values

Self-Devaluation (B)

Low self-esteem; dissatisfaction with self-image

Body Disapproval (C)

Dissatisfaction with physical appearance or social appeal

Sexual Discomfort (D)

Uneasiness over sexual thoughts, feelings, and impulses

Peer Insecurity (E)

Peer rejection and resultant discontent

Social Insensitivity (F)

Indifference to the welfare of others; lack of empathy; little interest in friendships

Family Discord (G)

Family tension, conflict, or rejection; feeling of estrangement

Childhood Abuse (H)

Shame and disgust associated with various forms of physical abuse

Clinical syndromes

Eating Dysfunctions (AA)

Tendencies toward anorexia nervosa and/or bulimia nervosa

Substance-Abuse Proneness (BB)

Pattern of substance use that has led to considerable impairment

Delinquent Predisposition (CC)

Tendencies toward antisocial or delinquent behavior

Impulsive Propensity (DD)

Poor control over sexual, aggressive, and other impulses

Anxious Feelings (EE)

Phenomenology and observable signs of general anxiety

Depressive Affect (FF)

Symptoms and phenomenology of depression

Suicidal Tendency (GG)

The presence of self-destructive thoughts and plans


Source: Millon et al. (2006, pp.7–24; 55–59)


NEO Personality Inventory-3


The NEO Personality Inventory-3 (NEO-PI-3; McCrae & Costa, 2010) is a measure of normal personality, which may be used with individuals aged 12 years and older. Administration time is approximately 30–40 min. The NEO-PI-3 measures the five broad domains of personality identified through years of research (cf., McCrae & Costa, 2003)—Neuroticism (N), Extraversion (E), Openness to Experience (O), Agreeableness (A), and Conscientiousness (C)—along with 30 facets of personality. Similar to the scale construction methodology utilized with the PAI and MCMI-III, items were selected on the basis of both rational and empirical methods. In contrast to the PAI and MCMI-III, the NEO-PI-3 does not directly measure psychopathology, though it does yield information directly relevant to treatment and the diagnosis of various disorders. For example, the computer-generated interpretive report compares a client’s profile to a prototypic profile for each DSM personality disorder, and generates hypotheses about possible and unlikely diagnoses. Hypotheses are also generated regarding prognosis and optimal treatment selection. The NEO-PI-3 personality domain scales and facet scales are outlined in Table 11.4.


Table 11.4
NEO-PI-3 domains and facets































































































































Scales

Description of constructs

Domains

Neuroticism (N)

General tendency to experience negative emotions (e.g., anxiety, sadness, and guilt) and to have difficulty coping with cravings and stress

Extraversion (E)

Overall propensity to be gregarious, active, assertive, and cheerful

Openness to Experience (O)

General inclination to be inquisitive about one’s inner experience and willing to entertain values, ideas, and ways of doing things that differ from one’s own

Agreeableness (A)

General proclivity to be unselfish, empathic, willing to help others, and to believe that others are trustworthy

Conscientiousness (C)

Overall tendency to be purposeful, resolute, and determined

Neuroticism facets

Anxiety (N1)

Inclination to experience worry, fear, and other anxiety-related states

Angry Hostility (N2)

Tendency to experience anger, frustration, and other anger-related states

Depression (N3)

Propensity to experience sadness, guilt, and other depression-related states

Self-Consciousness (N4)

Tendency to experience shame, embarrassment, and other related states

Impulsiveness (N5)

Proclivity to have difficulty controlling cravings and urges

Vulnerability (N6)

Propensity to have difficulty coping with stress

Extraversion facets

Warmth (E1)

Tendency to be affectionate and friendly and to genuinely like people

Gregariousness (E2)

Proclivity to enjoy other the company of others

Assertiveness (E3)

Inclination to be dominant and socially ascendant

Activity (E4)

Propensity to be physically active and to experience a sense of energy

Excitement Seeking (E5)

Tendency to crave excitement and stimulation

Positive Emotions (E6)

Inclination to experience positive emotions (e.g., happiness and excitement)

Openness facets

Fantasy (O1)

Proclivity to fantasize, daydream, and to have a vivid imagination

Esthetics (O2)

Propensity to appreciate art and beauty

Feelings (O3)

Tendency to be receptive to one’s own inner feelings

Actions (O4)

Inclination to be willing to try different things

Ideas (O5)

Tendency to be open-minded and to be willing to consider new ideas

Values (O6)

Propensity to be open to reexamining one’s values

Agreeableness facets

Trust (A1)

Tendency to believe that others are sincere and have good intentions

Straightforwardness (A2)

Inclination to be truthful, genuine, and sincere

Altruism (A3)

Proclivity to be concerned about and willing to help others in need

Compliance (A4)

Propensity to cooperate and inhibit aggression during interpersonal conflict

Modesty (A5)

Inclination to be unassuming and humble

Tender-Mindedness (A6)

Tendency to be sympathetic and moved by the needs of others

Conscientiousness facets

Competence (C1)

Inclination to be capable, reasonable, and effectual

Order (C2)

Proclivity to be tidy, neat, and well organized

Dutifulness (C3)

Tendency to stick to ethical values and carry out moral obligations

Achievement Striving (C4)

Propensity to work hard to attain one’s goals

Self-Discipline (C5)

Tendency to carry tasks out to completion

Deliberation (C6)

Inclination to think through things carefully before acting


Source: McCrae and Costa (2010, pp. 19–24)



Differential Diagnosis and Comorbidity


A primary goal of personality assessment is to assist with accurately diagnosing the condition(s) that are cause for concern and to begin to disentangle factors responsible for their maintenance. Although this may appear straightforward enough in the case of anxiety disorders, it behooves diagnosticians to consider several complicating factors. First, the anxiety disorders overlap conceptually with each other and with numerous other conditions, including mood disorders, psychotic disorders, eating disorders, and various personality disorders. Second, the anxiety disorders very often co-occur with other disorders. Third, anxiety disorders are, on occasion, etiologically related to substance use and physiological conditions (e.g., in the case of substance-induced anxiety). Fourth, anxiety and fear are normal human emotions that are adaptive under certain conditions (Barlow, 2002; LeDoux, 1996).

Anxiety disorders are conceptually similar to each other and to many other DSM-IV-TR conditions (APA, 2000; cf., Barlow, Allen, & Choate, 2004). For example, panic attacks, avoidance, and worry-like cognitive phenomena are characteristics of not only panic disorder (PD) and panic disorder with agoraphobia (PDA) but also social anxiety disorder (SAD), specific phobia (SP), generalized anxiety disorder (GAD), obsessive–compulsive disorder (OCD), posttraumatic stress disorder (PTSD), separation anxiety disorder, and hypochondriasis. Similarly, avoidance is an associated feature of depressive disorders, eating disorders, and ­psychotic disorders; and the flashbacks characteristic of PTSD resemble the illusions, hallucinations, and other perceptual disturbances seen in psychotic disorders, mood disorders, and delirium. Moreover, negative affect is characteristic of both anxiety and depression (Barlow et al., 2004; Clark & Watson, 1991; Clark, Watson, & Mineka, 1994). Considering the role these phenomena are purported to play in the maintenance of anxiety ­disorders (e.g., Barlow, 2002; Kessler, 1997; Barlow et al., 2004; Borkovec, Alcaine, & Behar, 2004; Clark, 2004; Clark, 1986; Foa, Huppert, & Cahill, 2006; Rachman, 1998; Rapee & Heimberg, 1997; Riskind & Williams, 2006; Salkovskis & Freeston, 2001; Wells, 2000), diagnostic clarification has significant treatment implications.

To complicate things further, anxiety disorders frequently co-occur with other conditions, most often depressive disorders, alcohol and substance use disorders, and personality disorders (Barlow, 2002); Kessler, 1997. As reported by Woody and Ollendick (2006), both Axis I and Axis II comorbidity reliably predicts poorer treatment outcome in individuals being treated for anxiety. Further, personality disorder traits may well have differential effects on the treatment of some anxiety disorders (Scholing & Emmelkamp, 1999; cf., Newman, Crits-Christoph, Gibbons, & Erickson, 2006), and the moderating effects of various patient traits on treatment outcome may differ according to diagnostic category (Castonguay & Beutler, 2006a). Consequently, identifying and addressing co-occurring conditions are of utmost importance.

Anxiety disorders should also be differentiated from nonpathological anxiety. Nearly everyone experiences heightened levels of anxiety on occasion. Normal anxiety and fear are believed to have phylogenetically served the function of distancing humans and other organisms from imminent, looming threats to physical survival (Barlow, 2002; LeDoux, 1996). Anxiety and fear have thus served a universal, adaptive function over the course of evolution, protecting humans from harm. Few would argue that the momentary elicitation of high levels of fear in response to an ­individual seeing a speeding car racing toward them is pathological. In contrast to normal anxiety, anxiety disorders have primarily been conceptualized as being phenomenologically- and etiologically related emotional constructs associated with exaggerated danger perceptions (Barlow, 2002; Barlow et al., 2004; Cisler, Olatunji, & Lohr, 2009). Further, by definition, pathological ­anxiety is associated with substantial distress and/or significantly interferes with important areas of functioning (APA, 2000).

Due largely to the efforts of the American Psychological Association (APA, Division 12) Task Force on the Promotion and Dissemination of Psychological Procedures (Chambless et al., 1998), treatments and interventions that are considered to be efficacious on the basis of randomized controlled trials have been identified. These “Empirically Supported Treatments” (Chambless et al., 1998; Chambless & Hollon, 1998; cf., Nathan & Gorman, 2002) are validated for use with specific disorders, and many of these treatments were explicitly designed for specific disorders. For example, the efficacy of certain forms of cognitive–behavioral therapy designed specifically for panic disorder is strongly supported by more than 25 randomized controlled trials (White & Barlow, 2002), with treatments including interoceptive exposure yielding the largest effect sizes (Gould, Otto, & Pollack, 1995).

Impressive support has also been documented for treatments designed for other anxiety disorders (e.g., exposure plus response prevention for obsessive–compulsive disorder, exposure, and multicomponent cognitive–behavioral treatments for social anxiety disorder, exposure-based procedures for specific phobias, and cognitive–behavioral therapy for generalized anxiety disorder); depression (e.g., behavior therapy, cognitive behavior therapy, and interpersonal therapy for major depressive disorder); substance use disorders (e.g., cognitive–behavioral therapy and 12-step treatment for alcohol use disorders); and other conditions (Chambless et al., 1998; Chambless & Hollon, 1998; Nathan & Gorman, 2002). Recognizing this, an interorganizational task force was recently initiated by the Association for Behavioral and Cognitive Therapies (ABCT) to create guidelines for optimal doctoral-level education and training in cognitive and behavioral psychology (Klepac et al., 2012).

Likewise, in 2006, the Task Force on Empirically Based Principles of Therapeutic Change of Division 12 and the North American Society for Psychotherapy Research (NASPR) published a book (Beutler & Castonguay, 2006) in which it identified participant, relationship, and technique factors associated with treatment outcome in a number of disorders, including anxiety. Therefore, distinguishing between normal anxiety and dysfunctional anxiety, accurately differentiating between plausible diagnoses, and identifying comorbid conditions all have crucial implications for treatment.


The Role of Personality Inventories in Diagnosis


Diagnosis is a clinician-based determination involving the integration of data from a variety of sources, often including a clinical interview, behavioral observations, information from collateral sources, narrowband self-report measures (e.g., the Beck Anxiety Inventory; Beck & Steer, 1993), performance-based measures of personality (e.g., the Rorschach Inkblot Method), and broadband instruments such as the PAI, MCMI-III, and NEO-PI-3. Although broadband measures are only one of several sources of data at the clinician’s fingertips, they provide a rich basis of empirically derived information from which to develop diagnostic hypotheses.

When a client presents for treatment reporting symptoms of anxiety, a comprehensive evaluation of his or her personality and global levels of psychopathology can shed considerable light on many variables directly relevant to diagnosis, especially when the data obtained converges with information gathered from other sources. To illustrate, a client1 of the author (Dr. Rogove) sought treatment for what he described as, “terrible anxiety.” As part of the initial evaluation, he was administered the PAI, MCMI-III, and NEO-PI-3. All of the validity scales were within normal limits. On the PAI, he obtained elevations on the Anxiety (ANX), Anxiety-Related Disorders (ARD), Depression (DEP), Stress (STR), and Nonsupport (NON) scales; on the MCMI-III, the Anxiety (A) and Major Depression (CC) scales were elevated along with a moderate elevation on the Compulsive (C) scale; and on the NEO-PI-3, he scored in the high range on the Neuroticism (N) and Con-scientiousness (C) domain scales, in the low range on the Agreeableness (A) domain scale, in the high range on the Angry Hostility (N2) and Depression (N3) facet scales, and in the very high range on the Anxiety (N1) and Vulnerability (N6) facet scales. No further scale elevations were obtained, including those that would have otherwise suggested the presence of a substance-related disorder, thought disorder, somatoform disorder, severe personality disorder, or heightened risk of suicide or violence.

In the absence of other information, the findings obtained from these instruments indicated several things about the client. First, the client’s scores on the PAI and the MCMI-III suggested that, at the time of the evaluation, he was experiencing considerable symptoms of anxiety and depression. The elevation that he obtained on the Stress (STR) scale of the PAI further indicated that recent stressors might have played a role in his condition, while the elevation on the Nonsupport (NON) scale suggested that he perceived little in the way of a social support network. Third, his profile on the NEO-PI-3 and the elevation he obtained on the Compulsiveness (C) scale of the MCMI-III further suggested that the issues that brought him in for treatment were superimposed on personality characterized by: (a) a general tendency to experience negative emotions (especially worry, fear, and other anxiety-related states), (b) a propensity for having difficulty managing stressful situations, (c) a generally disagreeable interpersonal style, and (d) obsessive–compulsive traits, including perfectionism, rigidity, and remarkable adherence to social conventions. These findings converged with data from other sources and provided empirical support for the author’s working hypothesis that the client had generalized anxiety disorder and major depressive disorder, and they resulted in empirically based hypotheses about variables maintaining his current condition and the best course of treatment. He was referred for a psychiatric consultation, a functional analysis was conducted, and cognitive–behavioral treatment was initiated to address his depression.


Transdiagnostic Factors


Despite the importance of considering diagnosis in the treatment planning process and the efficacy of selecting treatments on the basis of diagnosis, up to half of those treated with empirically supported treatments do not respond as well as might be expected (Chambless & Ollendick, 2001; Ollendick & King, 2004; Woody & Ollendick, 2006), and only 40–60% of those treated achieve high end-state functioning (Roemer, Orsillo, & Barlow, 2002). Further, meta-analyses have revealed that intervention effects, though critical, do not account for the whole picture, with some studies indicating that specific treatment methods account for no more than 8% of outcome variance across diagnoses (Wampold, 2001). Although controversial, findings like the latter clearly indicate that the effectiveness of a given intervention is likely to depend on more than the specific techniques utilized. An abundance of research has been devoted to identifying transdiagnostic variables associated with treatment outcome (cf., Castonguay & Beutler, 2006b; Norcross, 2011; Wampold, 2001). This section focuses predominantly on the patient factors most relevant to personality assessment in the context of anxiety treatment.


Symptom Severity and Distress


Treatment for anxiety is less likely to be effective when the condition(s) being treated is severe, and the client reports experiencing substantial distress (Newman et al., 2006). This is especially true in the case of social anxiety disorder (e.g., Otto, Pollack, Gould, Worthington, McArdle, & Rosenbaum, 2000; Safran, Alden, & Davidson, 1980; Scholing & Emmelkamp, 1999), PTSD (e.g., Ford, Fisher, & Larson, 1997; Johnson & Lubin, 1997; Perconte & Griger, 1991; Taylor, Fedoroff, Koch, Thordarson, Fecteau, & Nicki, 2001), PD (e.g., Emmelkamp & Kuipers, 1979), and OCD, though at least two studies have shown this to also be the case with GAD (e.g., Butler, 1993; Butler & Anastasiades, 1988). Baseline symptom severity also reliably predicts treatment outcome in child and adolescent samples undergoing anxiety treatment (e.g., Piacentini, Bergman, Jacobs, McCracken, & Kretchman, 2002; Silverman, Pina, & Viswesvaran, 2008).

As reported by Woody and Ollendick (2006), both Axis I and Axis II comorbidity also reliably predicts poorer treatment outcome in individuals being treated for anxiety. Further, personality disorder traits may well have differential effects on the treatment of some anxiety disorders (Scholing & Emmelkamp, 1999; cf., Newman et al., 2006). These findings are consistent with studies indicating that clients with more diagnoses and more severe conditions are at risk for profiting less from psychotherapy in general (for a review, see Clarkin & Levy, 2004). Low levels of symptom severity and distress may also impede therapeutic progress in certain clients, presumably because low levels of distress result in poor motivation and decreased responsibility to change (McCrae, Harwood, & Kelly, 2011; Sanderson & Clarkin, 2002).

An extensive history of research has identified moderators of the stress response that, if targeted, may buffer against the harmful psychological effects of overwhelming stress and have beneficial effects on the outcome of treatment (c.f., Feldman, Eisenberg, Gambini-Suarez, & Nassau, 2007; Lehrer, Woolfolk, & Sime, 2007; Quick, Quick, & Nelson, 1997; Smith, 2007). Moderators that may have value in the context of anxiety treatment include interpersonal conflict (Berman, Weems, Silverman, & Kurtines, 2000; Brent & Birmaher, 2006; Chambless & Steketee, 1999; Durham, Allan, & Hackett, 1997; McGrady, 2007; Tarrier, Sommerfield, Pilgrim, & Faragher, 2000), perceived social support (Newman et al., 2006), social problem solving (Chang, D’Zurilla, & Sanna, 2004; D’Zurilla & Nezu, 1999; Nezu, Wilkins, & Nezu, 2004), anger and hostility (Meichenbaum, 2007; Spielberger, 1991), cognitive appraisal (Lazarus, 1999; Meichenbaum, 2007; Pretzer & Beck, 2007), perception of control (Barlow, 2002), pessimistic attributional style (Barlow, 2002; Luten, Ralph, & Mineka, 1997), and, in children, parenting style (Barlow, 2002; Chorpita & Barlow, 1998). Thus, it behooves ­clinicians to evaluate a client’s level of distress, identify potential moderators of the stress response, and adjust interventions accordingly.

Only gold members can continue reading. Log In or Register to continue

Stay updated, free articles. Join our Telegram channel

Mar 22, 2017 | Posted by in PSYCHOLOGY | Comments Off on Anxiety Disorders and Evidence-Based Practice: The Role of Broadband Self-Report Measures of Personality in Diagnosis, Case Conceptualization, and Treatment Planning

Full access? Get Clinical Tree

Get Clinical Tree app for offline access