Emory University, Atlanta, Georgia
Center for Anxiety and Related Disorders and Department of Psychology, Boston University, Boston, Massachusetts
University of Denver, Denver, Colorado, USA
Correspondence: Dr Drew Westen, Department of Psychology and Department of Psychiatry and Behavioral Sciences, Emory University, 532 N. Kilgo Cir., Atlanta, Georgia 30322, USA. E-mail: dwesten{at}emory.edu
Funding detailed in Acknowledgements.
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ABSTRACT |
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Aims To examine the reliability and validity of a Q-sort instrument for assessing adolescent personality pathology designed for clinically experienced informants.
Method A sample of 294 randomly selected psychiatrists and psychologists each provided data on a current patient, aged 14-18 years. Clinicians completed several measures, including the Shedler-Westen Assessment Procedure for Adolescents (SWAP-200-A).
Results Factor analysis identified II dimensions of adolescent personality: psychopathology/malignant narcissism, dysphoria/inhibition, psychological health, histrionic sexualisation, schizotypy, sexual conflict, emotional dysregulation, anxious obsessionality, peer rejection, delinquent behaviour and attentional dysregulation. These correlated in predicted ways with a range of criterion variables, including measures of adaptive functioning, Axis II pathology, the Five Factor Model and the Child Behavior Checklist.
Conclusions The SWAP-200-A shows promise as an instrument for assessing personality pathology in adolescents. Trait dimensions such as delinquent behaviour and emotional dysregulation may prove useful additions to a classification of personality.
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INTRODUCTION |
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METHOD |
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Measures
SWAP-200-A
The 200-item Shedler-Westen Assessment Procedure for Adolescents
(SWAP-200-A) is a Q-sort instrument for assessing adolescent personality
pathology designed for use by skilled clinical observers based on either
longitudinal knowledge of the patient over the course of treatment or a
systematic clinical interview of the patient and parents. A Q-sort is a set of
statements that provides a standard vocabulary for clinicians to
use to describe their clinical observations. To describe a patient, the
clinician sorts statements into categories based on their applicability to the
patient, from those that are irrelevant or not descriptive to those that are
highly descriptive. In this study clinicians used a semi-constrained rating
scale version of the instrument (see
Westen et al,
2003).
The SWAP-200-A was adapted from the SWAP-200 for adults; both measures have shown initial evidence of reliability and validity (Westen & Shedler, 1999a, b, 2000; Westen & Muderrisoglu, 2003). Preliminary research has shown high correlations between SWAP-200 descriptions made by treating clinicians and independent interviewers and between independent observers reviewing recorded interviews (Westen & Muderrisoglu, 2003). The SWAP-200-A correlates with a range of variables such as attachment status, and history of suicide attempts, psychiatric hospitalisations, arrests, and family and developmental history variables (Nakash-Eisikovits et al, 2003; Westen et al, 2003).
The items reflect constructs from a mixture of sources: Axis II criteria for DSM-III through DSM-IV; selected Axis I criteria associated with personality disturbance (e.g. depression and anxiety); clinical literature and research on personality disorders, normal personality traits and psychological health; a model of functional diagnosis (Westen, 1998); research on child and adolescent personality and psychopathology; videotaped clinical interviews; and feedback from over a thousand experienced clinicians. To develop the adolescent version of the instrument, we deleted, revised and added items as appropriate based on the adolescent literature, the authors' prior research and experience with adolescent personality pathology, and consultation with senior clinicians in adolescent psychiatry who used the instrument to describe patients and then provided feedback on items that were ambiguous, necessary for describing their patient but missing from the item set, and so on.
Two features of the SWAP-200-A are of particular relevance to assessment of adolescent personality pathology. First, the instrument is intended for use by clinically experienced observers, based on either all available data over the course of their work with a patient or a systematic clinical interview with the patient and parents, the Clinical Diagnostic Interview for Adolescents (CDI-A; further details available from the author upon request). The SWAP-200-A does not presume that patients, particularly adolescents, can self-report their maladaptive personality traits. Rather, it presumes that a skilled clinical interviewer can listen to patients' narratives, observe their interactions with their parents and the interviewer, and integrate information across informants to make judgements about adolescents' characteristic ways of thinking, feeling, regulating affect and so forth. Second, the instrument can be used to assess Axis II diagnoses in adolescents, by correlating patients' 200-item profiles with diagnostic prototypes of each personality disorder derived from a normative adult sample (Westen & Shedler, 1999a). Alternatively, it can be used in taxonomic work, as in this study, to develop non-redundant (i.e. relatively non-comorbid) diagnostic categories or dimensions.
Clinical Data Form
Following basic demographic and diagnostic questions, the Clinical Data
Form (CDF) (see Westen & Shedler,
1999a) asks clinicians to rate the patients
adaptive functioning, including school functioning (1 severe conduct
problems/suspensions, 7 working to potential); peer functioning (1 very poor,
7 very good); history of suicide attempts, arrests and hospitalisations; and
social support (number of people in whom the patient feels comfortable
confiding). Research has demonstrated that clinician ratings of adaptive
functioning variables, including the variables assessed by the CDF, show
strong correlations with the same variables obtained by interview (see
Westen & Weinberger,
2004). The CDF also measures family and developmental history
variables; however, because we do not analyse those data here, we shall not
describe them further.
Axis II pathology
To maximise reliability of measurement, we assessed Axis II pathology as
defined by DSM-IV (American Psychiatric
Association, 1994) in more than one way. First, we listed the Axis
II disorders and asked clinicians to rate the extent to which the patient met
criteria for each disorder on a sevenpoint rating scale. Second, we provided
clinicians with a checklist of all Axis II criteria, randomly ordered, and
asked them to rate each criterion as present or absent, as in DSM-IV, and then
to rate the extent to which each item applied using a seven-point scale. These
checklist data generated two additional dimensional measures of Axis II
pathology (number of diagnostic criteria met for each personality disorder and
the mean of the ratings 1-7 for each criterion for each diagnosis), as well as
categorical diagnoses derived by summing the number of criteria present and
applying DSM-IV thresholds. To maximise reliability, we created a composite
measure of personality pathology by transforming the three sets of dimensional
scores (global ratings, number of Axis II criteria met and summed seven-point
ratings across criteria for each disorder) into Z scores, which we then
averaged to form composite personality disorder ratings.
Five Factor Model adjective checklist
The Five Factor Model (FFM; McCrae
& Costa, 1997) is a model of personality derived by factor
analysis. It isolates five general personality traits: neuroticism,
extroversion, openness to experience, agreeableness and conscientiousness.
According to the most widespread version of the model, embodied in the NEO
Personality Inventory Revised (NEO-PI-R;
McCrae & Costa, 1997), each factor includes six sub-factors or facets. For this study
we developed a brief clinician-report FFM adjective checklist, consisting of
35 items rated on a seven-point scale, one for each of the NEO-PI-R factors
and one for each of the six facets. Coefficient alphas for the five NEO-PI-R
factors were largely acceptable, ranging from 0.64 to 0.92, with both mean and
median greater than 0.80.
Child Behavior Checklist
The Child Behavior Checklist (CBCL;
Achenbach, 1991) is a widely
used questionnaire designed to assess the behavioural problems and social
competencies of children aged 4-18 years; it includes 11 problem scales. The
CBCL also yields two broadband, higher-order psychopathology scales,
internalising and externalising. We asked
clinicians to complete the parent-report version of the CBCL, which they were
able to do without difficulty. Clinician-reported data on the CBCL show
similar psychometric properties to parent-reported data, including high
internal consistency for the problem scale scores (median coefficient
> 0.80), virtually identical factor structure and predictable
correlates suggesting convergent and discriminant validity
(Dutra et al,
2004).
Statistical analyses
We analysed the data as follows. First, we subjected the SWAP-200-A items
to exploratory factor analysis (because of the absence of prior research on
the factor structure of the instrument). As a preliminary test of the validity
of the factors, we then performed a series of analyses. (For simplicity of
presentation, in the tables that follow, we indicate criterion variables
predicted a priori to be most strongly associated with each factor in
bold. To minimise overinterpretation of findings, we focus only on findings
that are relevant to our hypotheses, form a coherent pattern, or were not
predicted but were significant at P<0.01.) In a first set of
analyses, we correlated patients' factor-based scores with dimensional
measures of personality pathology, to locate them within a nomological net
(Cronbach & Meehl, 1955) provided by the more familiar DSM-IV Axis II diagnoses. We then examined their
relation to personality as measured by the FFM adjective checklist and the
problem scales of the CBCL. Finally, we assessed the relation between
SWAP-200-A factors and adaptive functioning variables selected a
priori as likely to be associated with different forms of personality
pathology, including ratings of school performance and quality of peer
relationships; number of close friends or confidantes; and history of
psychiatric hospitalisations, suicide attempts and arrests.
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RESULTS |
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Factor structure of the SWAP-200-A
As a first step, we subjected the SWAP-200-A items to a principal
components analysis, examining the resulting eigenvalues, percentage of
variance accounted for by each factor, and scree plot. The scree plot showed a
gradual break between 12 and 15 factors. We obtained similar factor structures
using 12-15 factors with both varimax (orthogonal) and promax (oblique)
solutions and multiple extraction methods. We retained and report here the
first 11 of the 12-factor promax (oblique) solution using principal axis
factoring. These factors were readily interpretable, reproducible across
several estimation procedures and algorithms, and well marked by multiple
items. Communalities were all greater than 0.70, with most between 0.80 and
0.90, suggesting that the items did in fact include substantial common
components. The 11 factors cumulatively accounted for 52% of the variance.
Reliability (coefficient ) was above 0.80 for all factors except factor
10 (
=0.72), with a median of 0.86.
Table 1 lists the items that
loaded most highly on each of the 11 factors.
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The first factor, psychopathy/malignant narcissism, includes items associated with narcissism, disruptive behaviour disorders, hostility, antisocial personality disorder and psychopathy. The second factor, dysphoria/inhibition, includes depression, anhedonia, shame, guilt and a number of related cognitive and emotional processes. It also includes a tendency to be inhibited in a number of domains, including social, motivational and affective inhibition. The third factor, psychological health, reflects the presence of psychological strengths and inner resources, including the capacity to love, find meaning in life experiences and gain insight into the self. Factor 4, histrionic sexualisation, reflects sexuality typically seen in histrionic personality disorder. Patients scoring high in this dimension tend to be sexually provocative and promiscuous; they also have a tendency to fantasise about ideal love but become involved in emotionally charged, unhealthy romantic relationships. The fifth factor, schizotypy, describes patients with sub-clinical positive and negative symptoms. Patients scoring high on this dimension tend to have barren representations of themselves and others, impoverished thought more generally and emotional flatness or constriction. They also tend to have odd appearances, mannerisms, reasoning processes and/or perceptual experiences. Factor 6, emotional dysregulation, includes a deficiency in the capacity to modulate and regulate affect, so that in such individuals affect tends to spiral out of control, change rapidly, be expressed in intense and unmodified form, and overwhelm reasoning. This emotional dysregulation may lead to self-destructive attempts to regulate affects, such as suicidality and parasuicidality, self-injury and/or bingeing and purging. The construct of emotional dysregulation is central to contemporary clinical thought, especially with respect to borderline personality disorder (see Westen, 1991; Linehan, 1993; Westen et al, 1997). Of note is its statistical independence from our two negative affect factors tapping dysphoria and anxiety. Factor 7, anxious obsessionality, reflects highly anxious individuals who may experience obsessions, compulsions, phobias and/or panic attacks; these patients tend to develop somatic problems in response to stress. Factor 8, delinquent behaviour, reflects a tendency to engage in criminal behaviour, misuse drugs and alcohol, run away from home, seek out thrills and adventure and surround oneself with delinquent peers. Factor 9, sexual conflict, is descriptive of patients who are confused about their sexual orientation and appear to be struggling with counter-normative sexual desires and mannerisms. Factor 10, attentional dysregulation, describes a constellation of personality processes associated with attentional deficits, including low tolerance of frustration and irresponsibility. Factor 11, peer rejection, describes adolescents who have poor social skills and tend to be neglected, avoided or bullied by their peers. Adolescents with high scores on this factor tend to lack close friendships and relationships.
Assessing validity
The factors that emerged are clinically and theoretically coherent, and
most resemble factors that emerged from factor analysis of the SWAP-200 Q-sort
for adults (Shedler & Westen,
2004). To assess the validity of these factors (their association
with external criteria), we first examined their relation to dimensional
personality disorder diagnoses. As can be seen from
Table 2, the SWAP-200-A factors
tended to be associated with theoretically relevant variables in predictable
ways (predicted correlations are in bold). For example, schizotypy and peer
rejection were both strongly associated with personality disorders involving
social isolation and peculiarity. The emotionally dysregulated and histrionic
sexualisation factors were both associated with borderline, histrionic and
dependent personality disorders - three disorders that tend to demonstrate
significant diagnostic overlap in adult samples. Also of note is that the
psychological health factor was negatively associated with most of the
personality disorders.
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Our next set of analyses examined the association between the SWAP-200-A factors and the FFM checklist (Table 3) and the CBCL (Table 4). As predicted, SWAP-200-A factors involving negative emotions (notably dysphoria/inhibition, anxious obsessionality and emotional dysregulation) were strongly associated with neuroticism, whereas factors involving externalising pathology (particularly malignant narcissism) tended to correlate negatively with agreeableness and conscientiousness. Of note was the negative correlation between schizotypy and openness to experience, which makes theoretical sense in light of the concreteness and affective detachment of patients rated high on this factor, but does not accord with predictions of FFM researchers who have tried to account for schizotypal thinking as extreme openness to experience (e.g. Widiger et al, 2002). With respect to CBCL variables, SWAP-200-A factors with item content suggesting negative emotionality were most highly associated with the internalising score and related sub-scales, whereas factors suggesting externalising pathology correlated most highly with the externalising scale and its component scales.
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Finally, we examined the relationship between the SWAP-200-A factors and adaptive functioning variables (Table 5). The data provided additional preliminary support for validity. For example, psychopathy/malignant narcissism correlated with all six variables in the expected directions and also predicted history of trouble with the law. Although most of the SWAP-200-A factors predicted poor peer relationships, the correlations were particularly large for schizotypy and peer rejection. The psychological health factor also performed as expected. Of particular interest is the strong pattern of associations between SWAP-200-A factors and variables such as history of suicide attempts, arrests and psychiatric hospitalisation, which are relatively objective and require minimal clinical inference (and hence are not readily attributable to clinician biases).
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DISCUSSION |
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Several aspects of the factor solution are interesting from a conceptual and clinical point of view. The factor structure of the adolescent instrument strongly resembles the factor structure obtained using the adult version of the instrument (Shedler & Westen, 2004), with a few important exceptions. Whereas the adult instrument yields separate factors for narcissism, psychopathy and hostility, the SWAP-200-A yields a large first factor that blends these constructs, and includes a separate factor that assesses delinquent behaviour. These differences may reflect developmental differences in the expression of the underlying traits, or they may reflect instability of the factor solution reflecting sample size. A distinction between a core psychopathy factor and a delinquent behaviour factor, however, mirrors results of factor analysis of the Psychopathy Checklist - Revised, which similarly distinguishes a callous, hostile, externalising personality style from a tendency to become involved in criminal activity (Hare, 1998). Other differences between the adult and adolescent factor structures seem to reflect developmental differences. For example, where the adult instrument yields a schizoid factor and a thought disorder (schizotypy) factor, the adolescent version yields a single schizotypy factor and a separate peer rejection factor. Further, although both versions of the instrument produced a sexual conflict factor, in adolescents the items focus primarily on conflicts regarding sexual orientation, probably reflecting the salience of this issue in adolescents struggling with homosexual feelings, and the lack of knowledge both teenagers and their clinicians are likely to have about other kinds of sexual conflict that might not become expressed until adulthood.
Also notable is the distinction between dysphoria/inhibition (the factor most closely related to negative affectivity or neuroticism), anxious obsessionality and emotional dysregulation, three variables that were only moderately intercorrelated. The distinction between negative affectivity on the one hand and emotional dysregulation on the other has emerged recently in other samples using both factor and Q-factor analysis with a variety of instruments (e.g. Livesley et al, 1998; Westen & Shedler, 1999b; Westen et al, 2003). Whereas most factor-analytically derived models of personality and mood distinguish positive and negative affectivity - or (in the FFM) their close cousins, extroversion and neuroticism - the emergence of an independent emotional dysregulation factor in clinical samples with instruments intended for clinical use may be significant, drawing attention to the distinction between stably anxious or dysphoric personality traits and a distinct form of affectivity in which emotions spiral out of control. Emotional dysregulation appears to be associated with history of traumatic experiences such as sexual abuse and early parental separations (e.g. Nakash-Eisikovits et al, 2003) and may be related to dysregulation of corticotrophin releasing factor, which has been linked both to childhood trauma and to later vulnerability to syndromes such as major depression and panic disorder (Heim & Nemeroff, 2001).
Differences between the factor solution obtained here and the personality prototypes obtained from the same sample using Q-factor analysis are also instructive. It is noteworthy that the first six factors resemble six of the seven obtained Q factors, which means that two very different ways of analysing the data - one identifying types (prototypes) and the other traits - yielded similar dimensions. However, the remaining scales identify traits or psychological functions that represent important aspects of personality pathology in adolescents but do not define a broader personality style: anxious obsessionality, delinquent behaviour, sexual conflict, attentional dysregulation and peer rejection.
Potential objections and limitations
This study has three primary limitations. The first is its exclusive
reliance on a single informant (the treating clinician), which creates the
possibility (like most studies of psychopathology, which rely exclusively on
patient reports) of observer bias. Future research should attempt to replicate
these findings using interview, informant and laboratory data as external
criteria. Nevertheless, several factors limit this concern. First, SWAP-200
personality descriptions and ratings of adaptive functioning show high
interrater reliability and validity and strongly predict relevant criterion
variables as assessed by independent informants
(Westen & Muderrisoglu,
2003; Westen & Weinberger,
2004). Second, clinicians varied in their training (psychiatrists
and psychologists) and theoretical orientations, and were unfamiliar with the
factor structure of the instrument, minimising the likelihood of systematic
sources of error stemming from rater biases. Finally, whereas factor analysis
of the DSM-IV Axis II checklist in this sample produced a factor structure
that strongly resembled the DSM-IV classification
(Durrett & Westen, 2005), factor analysis of the items of the SWAP-200-A, which include items assessing
all of the Axis II criteria, did not. Thus, it is difficult to see how
clinician biases could both lead to convergence with and divergence from the
DSM-IV description of personality pathology in an adolescent sample.
A second potential objection is sample size. Clearly, the next step in this research requires a substantially larger sample, and such a study is now nearing completion (projected n=1000). Nevertheless, recent thinking about factor analysis, based on data from Monte Carlo simulations and other studies, suggests that factor solutions stabilise with far fewer cases than previously believed (often by 100 cases) as long as the factors are well marked by a sufficient number of items with loadings above 0.40 or 0.50, as they were here (see Fabregar et al, 1999; Russell, 2002).
A final potential objection regards the question of the durability of personality pathology in adolescents and the appropriateness of diagnosing personality pathology at all in teenagers, an issue we have addressed elsewhere in detail (Westen & Chang, 2000). The data presented here are cross-sectional, and future research should employ longitudinal designs. Nevertheless, recent research using different designs and measures suggests not only that personality can be assessed reliably in adolescents but that recognisable forms of personality pathology can be measured in adolescents and predict substantial variance in a range of outcomes, including outcomes measured longitudinally, above and beyond Axis I diagnosis (Ludolph et al, 1990; Johnson et al, 1999; Westen et al, 2003).
Implications
We note here two implications. First, research on adolescent
psychopathology has often ignored personality variables because of the lack of
appropriate constructs and measures. Availability of reliable and valid
measures of adolescent personality pathology may prove useful in
distinguishing clinical phenomena that may be quite distinct, such as
different types of adolescents who share an Axis I mood disorder
diagnosis.
Second, the data raise questions about whether we do better to characterise adolescent personality pathology in terms of the kinds of broad constellations connoted by the term personality disorder or whether we might do better to focus on more specific traits that combine in various ways to form some of those constellations. Although we are far from a definitive answer to foundational questions such as these (with respect to either child and adolescent or adult psychopathology), one potential solution might be to combine both forms of classification. For example, an adolescent personality axis could include both a set of personality prototypes describing personality constellations as well as a small set of non-redundant traits such as attentional dysregulation or sexual conflict. From a clinical standpoint, aside from these descriptive (typological and trait approaches), another approach to diagnosis - explicit in the construction of the SWAP-200-A item set (which describes not only behaviours but also internal processes) - is functional assessment. A functional assessment focuses on understanding what is going right, what is going wrong and under what conditions certain pathological processes manifest for a given patient (i.e. the conditions under which certain functions go awry or break down). One way to reduce the gulf between clinicians and researchers is to decrease the gap between descriptive nosological constructs, which tend to be the focus of research, and functional constructs, which are essential to everyday clinical practice.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Received for publication January 5, 2004. Revision received September 9, 2004. Accepted for publication September 10, 2004.