Towards the validation of three assessment instruments derived from the PDM

Axis P:
the Psychodynamic Diagnostic Prototypes, the Core Preoccupations Questionnaire
and the Pathogenic Beliefs Questionnaire
Francesco Gazzillo*, Vittorio Lingiardi*, Franco Del Corno**
*Department of Dynamic and Clinical Psychology,
Faculty of Medicine and Psychology, Sapienza University of Rome
** University of Valle dAosta

Abstract
Objective: The aim of this paper is to explain the procedures used and show the results obtained
from an empirical study on the assessment of personality disorders using three empirical
instruments derived from the Axis P of the Psychodynamic Diagnostic Manual (PDM) (PDM Task
Force, 2006): the Psychodynamic Diagnostic Prototypes (PDP), the Core Preoccupations
Questionnaire (CPP) and the Pathogenic Beliefs Questionnaire (PBQ). Methodology: Six graduate
students in clinical psychology, who were working on their dissertation theses in Clinical
Assessment and Diagnosis and were enrolled in clinical training in the Italian National Health
System, were trained by experts to perform diagnoses using the PDM. They performed a systematic
interview for personality assessment, the Clinical Diagnostic Interview (CDI) (Westen &
Muderrisoglu, 2003), with 200 patients who were receiving psychological and/or pharmacological
treatments by clinicians who worked in the Mental Health Units of the National Health System.
These patients were assessed using the DSM-IV-TR Axis II criteria and the new instruments to be
validated. The clinicians who were treating these patients independently assessed them with the
same instruments on the basis of their knowledge of the patients. Eventually, raters and clinicians
utilized a specific clinical form for gathering information about their work and their patients.
Results: The results of this study seem to support the empirical soundness (face validity, crossinformant/cross-method reliability, convergent, discriminant and concurrent validity) and the
clinical usefulness of the PDP, CPQ, and PBQ. Conclusion: The results of this study seem to
support the reliability and validity of the new instruments derived from the PDM.
Key words: Assessment, Personality, PDM.
Introduction
The first edition of the Psychodynamic Diagnostic Manual (PDM) (PDM Task Force, 2006)
represents a turning point in clinical diagnosis. (The Italian edition was published in 2008). In fact,
the PDM is the first complete and systematic nosography generally derived from psychodynamic
clinical and empirical research and useful for mental health practitioners of different theoretical
orientations.
Different from the Diagnostic and Statistical Manual of Mental Disorders (DSM) (the fourth
edition was published in the USA in 2000 and a fifth edition is expected in 2013), the PDM is
considered to be a nosology of people rather than diseases, and its main purpose is helping
clinicians in diagnosing, writing the case formulation, and planning the best treatment for their
patients.
The PDM is divided into three sections: the first is dedicated to the assessment of adult patients; the
second discusses the diagnosis of adolescents, children, and infants; and the third contains a
selection of relevant papers on psychodynamic diagnosis and psychotherapy research.
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According to the PDM, the clinician has to assess the following in all patients except infants:
1. the level of personality organization and the prevalent personality styles or disorders (Axis P for
adults and PCA for adolescents and children);
2. the overall mental functioning, on the basis of the evaluation of 9 different but partly overlapping
capacities and according to an 8-level scale (Axis M for adults and Axis MCA for adolescents and
children);
3. patients symptoms and syndromes and their subjective experience of them (Axis S for adult and
SCA for adolescents).
PDM diagnoses are prototypic because this manual, unlike the DSM, does not intend the different
clinical and personality disorders as pools of criteria that enable one to make a categorical diagnosis
when a specific number of them is present (polythetic diagnosis). According to the PDM, it is best
to consider each disorder as a constellation of signs, symptoms, or personality traits that constitute a
unity of meaning. Therefore, the clinical presentation of each patient can be more or less similar to
the different disorders proposed by the manual.
As suggested by different authors (see Dazzi, Lingiardi, & Gazzillo, 2009; Westen & Shedler,
2004), the prototypic format of the diagnosis is more in line with the diagnostic reasoning of
clinicians and follows the same logic adopted by a well validated instrument for personality
assessment such as the Shedler-Westen Assessment Procedure (SWAP) (Westen & Shedler, 1999a,
1999b; Westen, Shedler, Bradley, & DeFife, 2012). Incidentally, the American Psychiatric
Association announced on its website that the DSM-5 will adopt this prototype matching approach
for the diagnosis of personality disorders (www.dsm5.org).
Even if one uses the PDM level of matching the clinical presentation of each patient and the
different prototypes in a dimensional assessment, it is possible to establish clinical thresholds that,
when overcome, enable a categorical diagnosis.
PDM enables both dimensional and categorical diagnoses of personality and mental functioning,
combining the precision of the dimensional systems and the ease of the categorical applications.
Psychodynamic Diagnostic Prototypes, Core Preoccupations Questionnaire and Pathogenic
Beliefs Questionnaire: Three Empirical Instruments for the Axis P Assessment
PDM Axis P for adult personality assessment is clearly based on the theoretical and empirical
approaches to the diagnostic task developed by Kernberg (1984; 2004), McWilliams (1994; 1999),
Blatt (2001), and Westen and Shedler (1999a & b).
This allows the clinician to assess:
a) whether the patients personality is organized at a healthy, neurotic, or high or low borderline
level, describing each level in operational terms;
b) what is/are the names of personality style/disorder(s) that best describe(s) the clinical
presentation of the patient. The personality styles/disorders taken into account by the manual are:
schizoid; paranoid; psychopathic (subtypes: passive parasitic or aggressive); narcissistic (subtypes:
arrogant/entitled or depressed/depleted); sadistic and sadomasochistic (intermediate manifestation);
masochistic (subtypes: moral or o relational); depressive (subtypes: introjective or anaclitic) and
hypomanic; somatizing; dependent, passive-aggressive and counterdependent (converse
manifestation); phobic or counterphobic (converse manifestation); anxious; obsessive-compulsive
(subtypes: obsessive or compulsive); hysterical/histrionic (subtypes: inhibited or
demonstrative/flamboyant); and dissociative.
C) Each one of these styles is narratively described and then synthetized in little tables that
articulate its contributing constitutional-maturational patterns, central tension/preoccupation,
characteristic pathogenic beliefs about self and others, its central way of defending, and its
subtypes, if present.
Even though it is clearly influenced by the SWAP (Westen & Shedler, 2006) and the
Operationalized Psychodynamic Diagnosis (OPD) (Dahlbender, Rudolf, & OPD Task Force, 2006)
research results, the PDM Axis P is not associated with any specific empirical instrument that
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enables clinicians and researchers to reliably assess its constructs. Moreover, even though Axis P
personality styles are clearly described and connected to a number of bibliographical references, in
some cases they rely on specific psychodynamic concepts (such as projective identification,
reaction formation, and so on) whose assessment is based on adequate knowledge of
psychodynamic theory and on a certain degree of inference. For these reasons, a reliable assessment
of these constructs can be difficult for clinicians who are not psychodynamic.
In order to overcome these limitations, we have built a clinician-friendly instrument for an
empirically sound and clinically useful assessment of PDM Axis P personality styles, the
Psychodynamic Diagnostic Prototypes (PDP).
PDPs are 21 prototypical descriptions, one for each of the Axis P personality styles and their
intermediate or coverse manifestations. Each of these descriptions is composed as a pool of items
that are entirely derived from the descriptions of the disorders present in the PDM. We revised the
descriptions of the different disorders in the PDM that are too abstract or jargon-laden to make them
clearer. In doing so, we were inspired by some of the items used in empirical instruments, such as
the SWAP, the Analytic Process Scales (APS) (Lingiardi, Gazzillo & Waldron, 2010; Waldron,
Scharf, Crouse, Firestein, Burton, & Hurst, 2004a & b;), the Psychotherapy Process Q-set (PQS)
(Jones, 2000; Lingiardi, Colli, Gentile, & Tanzilli, 2011) and the Defense Mechanism Rating Scale
(DMRS) (Lingiardi, Lonati, Fossati, Vanzulli, & Maffei, 1999; Perry, 1990). Each of these
descriptions is composed of an average of 16 items (ranging from the 7 items of the
sadomasochistic prototype to the 28 items of the obsessive-compulsive prototype); the different
number of items used in the different prototypes depends on the length of the PDM descriptions of
the different personality disorders.
Table 1 shows the PDP prototype of the schizoid personality disorder.
Table 1. PDP schizoid personality disorder prototype
Schizoid people are highly sensitive and reactive to interpersonal stimulation, to which tend to respond with defensive
withdrawal. They tend easily to feel in danger of being engulfed, enmeshed, controlled, intruded upon and traumatized,
dangers that they associate with becoming involved with other people. So, they tend to seem detached and indifferent to
social acceptance or rejection.
They seem to need to establish a tolerable level of space between themselves and other people, and tend to be more
comfortable with themselves than with other people, so that they are often carachterized as loners. At the same time, they
may feel a deep yearning for closeness and have elaborate fantasies about emotional and sexual intimacy.
They seem to attend more to their inner world than to the surrounding world of human beings and seem to communicate
their concerns most intimately and comfortably via metaphors and emotionally meaningful references to literature, music
and the arts
They may show idiosyncratic worries that are rarely present in other people and may have quirky characteristics that serve,
consciously or unconsciously, to put others off.

The clinician/rater who assesses his/her patient with the PDP should use a 1-5 scale to assess the
level of matching between the clinical presentation of the patient and each of the prototypes in the
PDP: 0 means that there is no resemblance between the patient and the prototypes while 5 means a
complete overlap. A score of 4 or 5 can be translated as a categorical diagnosis of personality
disorder.
This scoring procedure (see also Skodol, Oldham, Bender, Dyck, Stout, Morey, Shea, & Zanarini,
2005) is also used by the SWAP-II (Westen, Shedler, Bradley, & DeFife, 2012) and is suggested for
those using the DSM-5 personality diagnosis (see Table 2).

Table 2
The Prootypic Assessment of the Psychodynamic Diagnostic Prototype
5

Very good match

(patient exemplifies this disorder; prototypical case)

Good match

(patient has this disorder; diagnosis applies)

Moderate match

(patient has significant features of this disorder)

Slight match

(patient has minor features of this disorder)

No match

(description does not apply)

We have developed two other instruments, the Core Preoccupation Questionnaire (CPQ) and the
Pathogenic Beliefs Questionnaire (PBQ). The CPQ is composed of 18 items reflecting the 18 core
preoccupations proposed in the PDM Axis P and are associated with disorders. Some examples of
these core preoccupations are: fear of closeness/longing for closeness (schizoid); attacking/being
attacked by humiliating others (paranoid); manipulative/fear of being manipulated (psychopathic);
inflation/deflation of self-esteem (narcissistic), and so on.
The PBQ is composed of 36 items reflecting the 36 pathogenic beliefs proposed by the PDM Axis
P. Some examples of these pathogenic beliefs about self and others are: I am entitled to hurt and
humiliate others (sadistic and sadomasochistic); others exist as objects for my domination (sadistic
and sadomasochistic); by manifestly suffering, I can demonstrate my moral superiority and/or
maintain my attachment (masochistic); people pay attention only when one is in trouble
(masochistic), and so on.
Both of these instruments are used by the clinician to assess on a 1-7 Likert scale what core
preoccupations and pathogenic beliefs seem to be reflected in the behaviors, motivations,
cognitions, and emotions revealed by the patient.
The first aim of this study is to provide the first data concerning face validity and inter-rater
reliability (cross-raters/cross-methods) of these three new instruments; their concurrent and
discriminant validity; and the rate of comorbidity of the PDPs compared with DSM diagnoses.
Our second aim is to empirically verify the associations hypothesized by the PDM between specific
personality disorders and specific core preoccupations and pathogenic beliefs.
The third and last aim of this study is to provide the first data on the concurrent validity of the PDM
personality disorders assessed with the PDP and some relevant life-history data.
Methods
One of the authors of this paper (FG), after being trained to do assessments of personality using the
Clinical Diagnostic Interview (CDI) (Westen & Muderrisoglu, 2003) and the Shedler-Westen
Assessment Procedure-II (SWAP-II) (Westen, Shedler, Bradley, & DeFife, 2012) with Drew
Westen and Jonathan Shedler (at the Faculty of Psychology, Emory University, Atlanta), trained six
raters, graduate students in Psychology at the Faculty of Medicine and Psychology at Sapienza
University in Rome, to do the assessment of personality with CDI and SWAP.
These same raters were also trained by two of the authors of this paper (FG, VL) to do the
assessment of adult personality with the PDM. Incidentally, two of the authors (VL, FDC) of this
paper are the editors of the Italian edition of the PDM, and the third author (FG) translated the
manual into Italian.
After this two-week training, the raters administered the CDI to 200 patients who were being
treated by clinicians at the Mental Health Care Units of the National Health System in five Italian
cities. On the basis of the information collected with the CDI, these raters assessed the patients
involved in this study using PDP, CPQ, PBQ, and the Axis II checklist, which is composed of the
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criteria used in the DSM-IV to assess personality disorders. (See a detailed description of the
instruments below.)
These same patients were then independently assessed with PDP, CPQ, and PBQ by their treating
clinicians on the basis of their knowledge of these patients. The clinicians had received no training
in doing assessments of personality with PDM and knew nothing about the PDP.
The inclusion criteria for the selection of the patients involved in this study were: age 18; in
treatment for maladaptive pattern of cognitions, emotions, motivations, and behaviors (i.e.,
personality disorders, diagnosed or not in DSM terms and with or without DSM Axis I disorders);
no brain or psychotic syndromes or symptoms; and willingness to participate in a study on
psychological assessment in a public setting.
A subgroup of 40 of these patients was assessed by 2 independent raters (psychiatrists or
psychologists) who knew them well because they had treated them. The raters of this subgroup
were trained in the diagnosis of adult personality with PDM by one of the authors of this paper
(FDC).
For the cross-methods/cross-informants assessment of the inter-rater reliability of our new
instruments derived from PDM, we correlated the raters assessments with the clinicians
assessments of PDP, CPQ, and PBQ. For the cross-methods/cross-informants assessment of the
inter-rater reliability of our new instruments derived from PDM administered in the subgroup of 40
patients, we correlated the two clinicians assessments.
For calculating the inter-rater reliability of CPQ, PBQ, and PDP dimensional assessments, we used
the Spearman rho. To assess the inter-rater reliability of the PDP categorical diagnoses (disorder/not
disorder) we calculated the Cohens kappa.
To evaluate the concurrent and discriminant validity of PDM, we averaged the PDP, CPQ, and PBQ
evaluations of raters and clinicians, and the scores of both the clinicians who assessed the subgroup
of 40 patients, and then we calculated the correlations between PDP dimensional assessments and
DMS Axis II comparable diagnoses dimensionally assessed by the raters. Even in these cases we
used the Spearman index.
We then compared the rates of comorbidity of the PDP and DSM personality diagnoses.
After that, we attempted to understand whether the PDM hypotheses about the correlation between
specific core preoccupations and specific pathogenic beliefs with specific personality disorders
assessed with the PDP were correct. To do this, we calculated a stepwise regression using each of
the core preoccupations and pathogenic beliefs as the variables to be predicted and the PDP
disorders, dimensionally assessed, as the predicting variables. We considered an association to be
verified when the correct disorder appeared in the first model of prediction, i.e., when it was the
single best predictor of the preoccupation/belief.
Finally, in order to verify the concurrent validity of PDP diagnoses, we correlated them with
specific anamnestic or prognostic information collected by both clinicians and raters with a specific
tool, the Clinical Data Form (see its description below).
Instruments
The Clinical Diagnostic Interview (Westen & Muderrisoglu, 2003) is a systematic interview
composed of 15 broad questions and lasting approximately two-and-a-half hours. It is similar to a
normal set of clinical assessment sessions and its aim is to facilitate the collection of information
needed for a complete assessment of the personality of the patient with the SWAP and similar
instruments. The CDI standardizes the domains to be investigated while allowing the clinician the
freedom to choose the order of the questions to be asked and the language to be utilized. During the
CDI, the patient is asked to talk about his/her life and close relationships, hobbies and work, and
difficult periods of his/her life and the ways in which he/she dealt with them. The SWAP
assessments based on the CDI have a good inter-rater reliability, with a median correlation of .82.

The Clinical Data Form (CDF) (Western & Shedler, 1999a) is a form that is useful for collecting
data on clinicians and patients. To gather information about the clinician, it asks about their age,
gender, theoretical orientation, work setting, and years of experience. About the patients, the rater
has to assess socio-demographic information, developmental and family history, psychopathologies
and psychiatric history of the family, and nature and effectiveness of the treatments received in the
past. Several studies have supported the validity of the data collected with this tool (ThompsonBrenner, & Westen, 2005; Westen, Shedler, Durrett, Glass, & Martens, 2003).
The Axis II Checklist (Westen, 2002) is composed of all the criteria used to assess the DSM-IV
Axis II disorders. The rater has to assess the intensity of each item/criteria on a 6-point Likert scale
where 1 = absent and 6 = strongly present. A score of 4 means that the criterion is met. It is
possible to obtain a dimensional assessment of each Axis II disorder by adding the scores used to
rate each criterion of a disorder and dividing the score obtained by the number of the criteria for
that disorder. For a DMS-IV Axis II categorical diagnosis, the rater has to judge whether the
thresholds established by the Axis II are satisfied, considering as present each criterion with a
score of 4. Therefore, the AXIS-II Checklist enables a clinician to obtain both a dimensional and
a categorical DSM-IV Axis II diagnosis.
The Psychodynamic Diagnostic Prototypes (PDP) (Gazzillo & Lingiardi, 2010), described above, is
composed of 21 profiles of the PDM Axis P disorders. The rater uses a 5-point Likert scale (1 =
very good match; 5 = no match) to measure the degree to which a patients clinical presentation
resembles each of the prototypes.
The Core Preoccupations Questionnaire (CPQ) (Gazzillo & Lingiardi, 2008) is composed of the 18
core preoccupations described in the PDM Axis P that are associated with each of its personality
disorders. The rater uses a 7-point Likert scale (1= not descriptive; 7 = completely descriptive) to
measure whether the behaviors, thoughts, emotions, and motivations revealed by a patient seem to
reflect, consciously or unconsciously, each preoccupation.
The Pathogenic Beliefs Questionnaire (QCP) (Lingiardi & Gazzillo, 2008) is composed of the 36
pathogenic beliefs described by the PDM Axis P as associated with each of its personality
disorders. The rater uses a 7-point Likert scale (1 = not descriptive; 7 = completely descriptive) to
measure whether the behaviors, thoughts, emotions, and motivations revealed by a patient seem to
reflect, consciously or unconsciously, the different pathogenic beliefs about himself/herself and
other people.
Sample
Our sample of patients was composed of 200 subjects, 197 Caucasians and 3 Africans; 119 (59.5%)
females and 81 (40.5%) males.
Their mean age was 41.2 (s.d.12.7) years, ranging from 18 to 75.
87 patients (43%) were higher-middle-class, 58 (29%) were middle class, 38 (19%) were highclass, and 17 (8%) were working-class people.
83 patients (42.7%) completed secondary school, 63 (31.2%) graduated, and 54 (26.5%) completed
only primary school.
82 (41%) patients were married, and 55 (27.5%) were single; 9 (4.5%) were separated or divorced.
52 (26%) of the patients met the criteria for a DSM-IV Axis II Cluster A diagnosis, 102 (51%) for a
Cluster B diagnosis, and 59 (29.2%) for a Cluster A diagnosis. 61 patients (30.2%) met the criteria
for having a personality disorder not otherwise specified. The most prevalent personality disorders
of patients in our sample were borderline (33 subjects) and histrionic (33), and we had only 3
patients with an obsessive-compulsive personality disorder.

In terms of Axis I comorbidity, 22 (11%) of our patients had a major depressive disorder while 21
(10.5%) had a generalized anxiety disorder, and 10 (5%) had an eating disorder not otherwise
specified. Each one of the other Axis I disorders was diagnosed in fewer than 10 patients.
The average score of our sample on the Global Assessment of Functioning Scale (GAF) was 59.11
(s.d. 16.5), ranging from 7 to 95.
Regarding the 41 rating clinicians involved in this study, 25 were men and 16 were women, 24 were
psychologists and 17 were psychiatrists.
In terms of their prevalent theoretical orientations, 7 clinicians were psychodynamically oriented,
and 7 were humanistically oriented, but there were also systemic-relational, cognitive-behavioral,
biological, and eclectic oriented clinicians.
Every clinician had been following the patients assessed for an average of 20.9 months (d.s. 28.4;
ranging from 1 to 151 months) and for an average of 67.9 sessions (d.s. 86.5; ranging from 2 to 576
sessions). Therefore, we can state that our clinicians knew the patients they were asked to assess
very well.
Results
Face validity
After completing their training, our 6 raters used a 5-point Likert scale (1 = no match; 5 = very
good match) to measure whether each description of the personality disorders of the PDP caught all
facets of the same disorder as described in the PDM. They gave a score of 5 to 45% of the PDP
descriptions and a score of 4 to another 45%; the remaining 10% received scores of 3 (moderate
match). Therefore, the PDP prototypes seem to be good descriptors of the PDM personality
disorders.
Inter-rater reliability
PDP
The average Cohens kappa for the PDP prototypes that were categorically assessed was .61,
ranging from .44 (hypomanic personality disorder) to .75 (counterdependent personality disorder).
The average Spearman rho of the PDP prototypes dimensionally assessed was .67, ranging from .41
(counterphobic personality disorder) to .84 (histrionic personality disorder). (See Table 3.)
We can affirm that the inter-rater reliability of the PDP is good, particularly if we take into account
the fact that clinicians and raters assessed the same patients using different kinds of data: the
clinicians on the basis of their very good experiential knowledge of the patients (on average, they
had seen them in more than 67 sessions) and the raters on the basis of the data gathered in a 2.5hour systematic interview. Moreover, while the raters were trained to do an assessment of
personality with PDM and PDP, the clinicians had not received any specific training.
The less reliable PDP disorders (with both kappa and rho <.60) were the hypomanic and the
passive-aggressive.
CPQ
The average rho of the preoccupations of the CQP was .69, ranging from .60 (counterdependent
preoccupation) to .74 (schizoid and paranoid preoccupations).
All the preoccupations seemed to be reliably assessable. (See Table 4.)
PBQ
The average rho of the pathogenic beliefs of the PBQ was .67, ranging from .53 (the pathogenic
beliefs about oneself typical of people with counterdependent personality disorder) to .78 (the
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pathogenic beliefs about oneself and other people typical of patients with dependent personality
disorders).
Only five pathogenic beliefs (masochistic and counterdependent beliefs about other people;
dependent, counterphobic, and obsessive-compulsive beliefs about oneself) showed an inter-rater
reliability < .60. (See Table 5.)
Concurrent and discriminant validity
Each one of the PDP personality disorders showed a higher correlation with the analogous DSM
Axis II personality disorder (average rho = .62) and a substantially lower correlation with the other
DSM Axis II disorders (average rho = .05) (See Table 6.) The Axis II DSM disorders taken into
accout were: schizoid, schizotypal, paranoid, antisocial, narcissistic, histrionic, avoidant, dependent,
obsessive-compulsive personality disorder.
It seems that PDP may show a good concurrent and discriminant validity, even if we have no data
about the 12 PDPs that do not have comparable disorders in the DSM-IV Axis II.
Rates of comorbidity
Using the DSM categorical diagnoses, 154 patients (79.7%) met the criteria for at least one Axis II
disorder: 92 patients satisfied the criteria for 1 disorder, 35 for two disorders, 22 for three disorders,
and 5 for four disorders. Of all the patients who met the criteria for an Axis II diagnosis, 31.3% had
more than one Axis disorder. However, if we exclude the diagnosis of personality disorder not
otherwise specified, the DSM Axis II categories could be applied only to 93 (48.5%) patients in our
sample.
If we use the PDP diagnostic system, however, 143 patients received the diagnosis of at least one
personality disorder (53 more than the patients who received a DSM Axis II specific disorder
diagnosis). Therefore, a good percentage of the patients (50 out of 60) who received a NOS
personality disorder diagnosis in DSM can be described more precisely with the PDP categories.
Regarding the PDP comorbidity rates, 78 patients met the diagnosis criteria for one disorder, 40
patients for 2 disorders, 14 for three, 5 for four, 3 for five, and 1 patient met the diagnoses for six
disorders. Regarding PDP terms, 45.5% of the patients in our sample presented at least two
diagnoses in comorbidity, a rate higher (14.2 %) than the rate of DSM diagnoses in comorbidity.
However, PDM explicitly states that comorbidity is normal in psychopathology (PDM Task Force,
2006, p. 685).
Regarding PDP terms, the most often diagnosed disorder in our sample was histrionic (38 subjects,
18.9% of the sample), followed by narcissism (24; 12%) and schizoid (23; 11.5%). No participant
received a diagnosis of sadistic or sadomasochistic personality disorder, and only one was
diagnosed with a hypomanic personality disorder.
If dimensionally assessed, no PDP disorder correlates more than .60 with another disorder; the more
correlated disorders were the somatizing and anxious (.59; p =.000) and the counterphobic and
counterdependent (.52; p =.000).
Association between core preoccupations/pathogenic beliefs and personality disorders
As already explained, we attempted to check whether the specific associations between the different
PDP disorders and the different core preoccupations and pathogenic beliefs hypothesized by the
PDM could be empirically confirmed. In order to do so, as explained, we implemented a stepwise
regression model with the preoccupations or the pathogenic beliefs as the elements to be predicted
(independent variables) and the disorders as the predictive elements (dependent variables), and we
considered the PDM predictions to be correct when the correct disorder comparison appeared in the
first model of the stepwise regression. On the basis of these analyses, we can state that 14 out of 16

of the predicted associations between disorders and preoccupations were correct. (See Table 7 for
the correlations between each preoccupation and the disorder with which it is associated.)
Concerning the predicted association between disorders and pathogenic beliefs, we can say that 27
out of 36 were correct. (See Table 8 for the correlations between each belief and a disorder.) Even
in this case, the passive-aggressive pattern, including its preoccupations and beliefs, showed some
weakness.
Preliminary data on concurrent validity using life history data as criteria
In order to obtain some data about the concurrent validity of the PDP with respect to some life
history data, we explored the correlations between patients dimensional assessments and some
relatively objective data about their life histories assessed using the CDF.
Because we lack the space to provide great detail, we will show only a few of these correlations,
taking into account only the dimensions that were easy to assess, such as 1) arrests, 2) health
problems, 3) disruptions in intimate relationships, 4) violent crimes perpetrated in adolescence, 5)
school performance in adolescence, and 6) physical abuse in childhood. Even in these cases, we
used the Spearman rho index.
The number of arrests correlated positively with the PDPs psychopathic (.31; P =.000), paranoid
(.27; p =.000), hypomanic (.26; p =.000), and sadistic (.17; p = .000) disorders and negatively with
PDPs obsessive-compulsive (-.16; p =.02) disorder.
The presence and severity of health problems correlated positively only with the somatizing PDP
(.20; P =.005) and anxious (.16; p =.02).
The number and severity of violent crimes committed in adolescence correlated with PDPs
psychopathic (.27; p =.000), sadistic (.24; p =.001), hypomanic (.19; p= .006), paranoid (.18; p
=.012) and narcissistic (.15; p =.035) disorders and negatively with PDPs depressive (-.14; p =.04)
disorder.
The school performance in adolescence correlates positively with PDPs narcissism (.19; p =.012)
and obsessive compulsive disorder (.19; p =.011) and negatively with PDPs paranoid (-.34; p
=.000), psychopathic (-.23; p =.002), dissociative (.21; p = .003), masochistic (.19; p =.010),
sadistic (.15; P 0 .036) and sadomasochistic (.14; p .050) disorders.
Eventually, the presence of physical abuses in childhood correlates with PDPs masochistic (.24; p
=.001), dissociative (. 20; p =.007), somatizing (.18; p =.016), dependent (.16; p =.029) and
histrionic (.16; p =.033) disorders.
From these preliminary data, it seems that at least some of the PDP disorders (psychopathic,
sadistic, somatizing, anxious, obsessive-compulsive and dissociative) show a good concurrent
validity.
Discussion
To sum up the data collected for this study, we can consider PDP, CPQ, and PBQ to be
substantially reliable and valid instruments. CPQ and PBQ (composed of the core preoccupations
and the pathogenic beliefs included in the PDM Axis P) as well as the PDP (derived from the
description of the personality types of the PDM Axis P) showed a good level of face validity. Only
2 of the 21 PDPs presented unsatisfying reliability indexes (the hypomanic PDP and the passiveaggressive PDP).
All the core preoccupations seem reliably assessable with the exception of the sadistic and the
obsessive-compulsive preoccupations Similarly, of the 36 pathogenic beliefs included in the PDM,
only 5 were not reliable enough, and 9 seemed not specifically connected with the expected
disorder (the two beliefs connected to the dissociative personality disorder; the two beliefs
connected to the counterphobic personality disorder; one belief connected to the obsessivecompulsive personality disorder; one belief connected to the narcissistic PDP, one belief connected

to the paranoid PDP, one belief connected to the passive-aggressive PDP, and one belief connected
to the hypomanic PDP).
All the PDPs with analogous DSM disorders showed a good concurrent and divergent validity, but
we do not have data on the validity of PDPs without analogous disorders in the Axis II of the DSM.
Finally, there seem to be no excessive correlations among the PDPs dimensionally assessed, i.e., all
the PDPs seem to depict traits different enough to assess and at least some of the PDPs seemed to
show a good predictive validity.
Therefore, these first data mean that we can say that PDP, PBQ, and CPQ could be considered to be
good empirical instruments for the assessment of some of the Axis P constructs of the PDM.
However, this study had some limitations. First of all, it is based on a limited number of subjects (N
= 200), and in this sample we had only three patients with a DSM diagnosis of obsessivecompulsive personality disorder; in PDM terms, then, few patients (5) received the diagnosis of
masochistic, hypomanic, counterdependent, counterphobic and dissociative personality disorders.
Therefore, our data about these disorders is probably not informative enough; however, all the
disorders were dimensionally assessed in each one of our 200 patients; that means that the data,
based on their dimensional assessments derive from the 200 subjects.
The second possible weakness of our study is that the assessing clinicians had a very good
knowledge of the patients assessed but evaluated them only with the three new instruments, while
the raters talked for only 2-3 hours with each patient but scored them with most of the instruments
examined in this study. Therefore, those who knew the patients better were less involved in the
research. However, the good reliability of most of the variables investigated supports the soundness
of the instruments, even with the design limitations and the cross-method/cross-informant nature of
our procedure (see also Westen, Shedler, Bradley, & DeFife, 2012).
In future research, we will try to overcome these limitations and the problems that emerged with our
instruments derived from the PDM. In particular, we will need to check the concurrent and
discriminant validity of the 12 personality disorders without analogous disorders in DSM and to
modify the PDP hypomanic and passive-aggressive disorders in an attempt to increase their interrater reliability.
We also need to modify the phrasing of the 5 less reliable beliefs and to propose different
preoccupations and beliefs for the dissociative, counterphobic, obsessive, narcissistic, paranoid,
passive-aggressive, and hypomanic PDPs. The data collected in this study can help us complete this
task.
We will also explore whether adding an emotionally disregulated personality disorder, following a
suggestion made by some of the clinicians involved in this study (see also Westen, Shelder,
Bradley, &DeFife, 2012), which can help us in diagnosing at least some of the patients in the
sample who, even though they showed severe personality patterns, did not receive a specific
personality diagnosis with the PDP.
Eventually, we have integrated the PDP with the CPQ and PBQ for clinical purposes. (See Table 9
for an example.)

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Table 9
PDP Psychopathic Personality Disorder Prototype
Psychopathic patients tend to manipulate and are afraid of being manipulated by other people. Tend to feel rage and
envy and to think that they can make anything happen and that everyone is selfish, manipulative and dishonorable. So,
they tend to control other people in persistent and pervasive way and to use their power only for their own sake.
Psychopathic people are much more preoccupied with self-definition than with relationships and tend to feel anxiety
less frequently or intensely than other people. They seek stimulation addictively.
Psychopathic people seem to lack a moral center of gravity but may be charming and charismatic, read others
emotional state with great accuracy and be hyperacute to their surroundings. However, their emotional life tends to be
impoverished, they to be insincere and manipulative when express their affects and lack the capacity to describe their
own emotional reactions with any depth or nuance and tend to somatize.
Their emotional connection with other people is minimal, they typically lose their interest in people they see as no
longer useful to them and tend to be self-centered and manipulative. They lack of remorse and to devalue love and
kindness as illusory.
Some of them tend to be overly aggressive, explosive and actively predatory while other seem to be passive, more
dependent, less aggressive, relatively not violent but in any case manipulative and exploiting with other people.

The authors wish to thank all the institutions and the clinicians who took part in this research. In
particular, we want to mention:
Dr. Guido Taidelli (Associazione per la Ricerca in Psicologia Clinica (ARP), Milan.
The Clinical Psychology Unit, A.O. Salvini, Garbagnate Milanese (Milan) and Dr. Mariarosaria
Monaco
The Mental Health Center of Colleferro (ASL RM G) and Giuseppe Nicol, psychiatrist
and psychotherapist (Direttore U.O.C. DSM Palestrina-Colleferro); Enrico Pompili, psychiatrist and
psychotherapist (U.O.S. CSM Colleferro); Anna Legrottaglie, psychologist and psychotherapist;
Assuntina De Castris, psychologist and psychotherapist; Alda Santalucia, psychologist and
psychotherapist; Cristiana Silvestrini, psychitrist, clinical psychologist and psychotherapist; Isabella
Castiglia, psychiatrist and psychotherapist; Nella Feliziani, psychiatrist; Franca Ripari, psychiatrist;
Linda Intreccialagli, psychologist and psychotherapist; Fabrizio Baiocchi, psychologist; Annalisa
Spelta, psychologist and psychotherapist; Serena Cacciotti, psychologist and psychotherapist;
Teresa Fera, psychologist; Simona Priori, psychologist
The Mental Health Center of Piazza Cinecitt 11 (ASL RM B) and Dr. Alberto Sonnino,
psychiatrist and psychoanalyst and Dr. Vincenzo Tallarico, psychiatrist.
Il Mental Health Center of via Plinio 33 (ASL RM E) and Dr. Fulvia Arfuso, psychologist and
psychotherapist
Il Mental Health Center of the ASL of Pescara and Dr. Rossella Sasso, psychiatrist and
psychoanalyst, Dr. Donato Garibaldi, psychiatrist, and Dr. Vittorio di Michele, psychiatrist
The Service for Addiction Care (SERT) of the ASL of Pescara and Dr. Alessandra Cicconetti,
psychiatrist, and Nicoletta DAloisio, psychologist and psychotherapist
The Service for Diagnosis and Care (SPDC) of the ASL of Pescara and Dr. Annamaria Pace,
psychiatrist
The Service for Alcoholic Patients of the ASL of Pescara and Dr. Susanna
Fratamico, psychiatrist
Il Mental Health Unit of Ceccano (ASL of Frosinone)
The Mental Health Unit of Civitavecchia
Finally, we offer great thanks to our raters: Dr. Nadia Aioub, Serena Brilli, Evita Gobbo Carrer,
Margherita Mattacolla, Selena Tomei, and Alessia Viselli

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