Guide to SWAP-200 Interpretation

Jonathan Shedler, PhD

NOTE: THIS IS A DRAFT

DOCUMENT

UPDATED VERSIONS OF THIS DOCUMENT

WILL BE RELEASED ON AN ONGOING BASIS

Revision Date: 7-29-2009

www.SWAPassessment.org

© 2009 by Jonathan Shedler, PhD. All rights reserved.

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Table of Contents
Introduction ........................................................................................................... 3
Two Assessment Traditions .............................................................................. 3
When to Use the SWAP-200 ............................................................................. 4
Understanding Prototype Matching ................................................................... 4
Interpreting Test Results ....................................................................................... 6
DSM-IV Personality Disorders (PD T-Scores) ................................................... 6
Psychological Health Index ............................................................................... 8
SWAP Personality Syndromes (Q-Factor T-Scores) ......................................... 8
Descriptions of SWAP Personality Syndromes ................................................... 10
Dysphoric (Depressive) Personality ............................................................. 10
Antisocial-Psychopathic Personality ............................................................ 11
Schizoid-Schizotypal Personality ................................................................. 12
Paranoid Personality .................................................................................... 13
Obsessional Personality .............................................................................. 14
Histrionic Personality ................................................................................... 15
Narcissistic Personality ................................................................................ 17
Avoidant Personality .................................................................................... 18
High Functioning Depressive Personality .................................................... 19
Borderline (Emotionally Dysregulated) Personality ...................................... 20
Dependent-Victimized Personality ............................................................... 21
Hostile-Externalizing Personality ................................................................. 22
Factor T-Scores............................................................................................... 24
Summary Descriptions of SWAP-200 Factors ............................................. 26
Suggested Reading ............................................................................................ 28
Appendix 1: Psychological Health Index (highest ranked items) ........................ 30
Appendix 2: SWAP-200 Factor Structure........................................................... 31
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Introduction
The Shedler-Westen Assessment Procedure (SWAP) is based on the premise,
now well established empirically, that the psychological difficulties that bring
people to treatment are most often rooted in personality—that is, they are woven
into the fabric of the person’s life and reflected in characteristic patterns of
thinking, feeling, behaving, coping, and relating to others. Lasting treatment gains
are achieved when therapy addresses not only presenting symptoms but also the
personality patterns that fuel them. An understanding of underlying personality
patterns can clarify the meaning and function of symptoms and provide a
roadmap for conducting effective therapy.

Two Assessment Traditions

The term personality assessment is used in different ways. For clinical

practitioners, personality assessment often means clinical case formulation:
understanding the complex interplay of psychological processes that make a
person unique. Clinical case formulation is concerned with both the surface and
depth of personality—both what the person can tell about himself and what he
cannot tell. It necessarily relies on clinical observation and inference, most often
in the context of an ongoing therapy relationship (e.g., How are the person’s
wishes and fears manifested in interactions with the therapist?). The strength of
the clinical assessment tradition lies in the depth, richness, and complexity of
clinical formulations.

For empirical researchers, personality assessment often means psychometric

measurement: using structured questionnaires or inventories to measure a
predetermined set of psychological characteristics relative to population norms.
Statistical methods are used to develop scales and maximize reliability, validity,
and predictive accuracy (e.g., Does a scale designed to measure neuroticism
predict depressive episodes, peer ratings, or genetic variations linked to the
neurotransmitter serotonin?). The strength of the empirical assessment tradition
lies in its objectivity and scientific rigor.

The SWAP-200 is a unique assessment tool that bridges these assessment

traditions and combines the best features of each. It is an instrument completed
by clinicians, not patients. It relies on clinicians to do what they do best: provide
psychologically rich descriptions of the individual patients they know and treat. It
relies on psychometric and statistical methods to do what they do best: combine
information in optimal ways to maximize reliability, validity, and predictive
accuracy. The result is an assessment instrument that illuminates both the
surface and depth of personality, that is both scientifically valid and clinically
relevant.
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When to Use the SWAP-200

The SWAP-200 can be used by any trained mental health professional. Because
the instrument is completed by the clinician and not the patient, assessment with
the SWAP-200 does not require the patient’s participation. However, the clinician
must know the patient well enough to score the SWAP-200 items. If the patient is
being seen in psychotherapy, the clinician can score the SWAP-200 after a
minimum of six sessions. If the patient is being seen for assessment only (e.g.,
for forensic evaluation or for research purposes), the SWAP-200 can be
completed on the basis of an in-depth clinical interview. We have developed a
systematic Clinical Diagnostic Interview (CDI) for this purpose that can be
administered in approximately 2½ hours (clinical, forensic, and research versions
are available). If the clinician has access to additional sources of information
about the patient (e.g., patient records, collateral contacts, other psychological
tests), the clinician should draw on them freely. The SWAP-200 provides a
means of synthesizing and describing systematically everything the clinician
knows about a patient.

Clinicians using the SWAP-200 for the first time may require up to 45 minutes to
score the items. Clinicians who have used the instrument several times and are
familiar with the item set may be able to complete the scoring process in as little
as 20 minutes.

The SWAP-200 can be used to assess the personality functioning of a broad

range of patients, from psychologically healthy, high functioning individuals (who
have personalities, not personality disorders) to patients with severe character
pathology and specific personality disorder diagnoses. It is not designed for
assessing patients who have organic brain syndromes or psychotic disorders
(although it will detect subclinical thought disturbance and transient psychotic
episodes, e.g., in patients with severe borderline personality disorder).

Understanding Prototype Matching

There are many ways to select and combine test items to construct diagnostic
scales. The SWAP-200 employs several methods, but one method is unique to
the SWAP and merits special discussion. This method is diagnosis by prototype
matching.

The SWAP-200 is a set of 200 items or statements that allow a knowledgeable

clinician to describe a person’s psychological functioning in rich detail. This
detailed psychological portrait exists in quantitative form, as a configuration or
profile of scores across 200 variables.

A diagnostic prototype is a SWAP-200 description of a recognized personality

disorder or syndrome. It is not a description of an individual person, but rather a
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richly detailed description of a disorder or syndrome in its “ideal” or pure form.

Through our research, we have developed SWAP-200 diagnostic prototypes for
a wide range of personality disorders and syndromes. For example, we have
developed diagnostic prototypes for the personality disorders included in DSM-IV
(e.g., paranoid personality disorder, narcissistic personality disorder). We have
also developed diagnostic prototypes for additional personality syndromes
identified through our research (e.g., high functioning depressive personality).

Diagnosis by prototype matching involves gauging the similarity or “match”

between a patient’s SWAP-200 description and a diagnostic prototype. The
better the match, the more applicable the diagnosis. The degree of “match” is
expressed as a single numeric score. We are currently using standardized
scores (T-scores) to express the degree of match.

The SWAP-200 software computes and graphs a range of standardized scores.

The resulting graphs (score profiles) resemble MMPI profiles. A clinician can
derive a great deal of psychological information by “reading” these profiles.

Prototype matching is central to SWAP-200 personality assessment. This

approach to diagnosis has considerable advantages over other diagnostic
methods, both clinically and empirically. Among other advantages, it incorporates
a tremendous amount of diagnostic information, far more than other diagnostic
methods. Descriptions of patients and diagnostic syndromes are unusually
psychologically rich and nuanced. At the same time, it summarizes this
information and communicates it simply and efficiently, in a clear, user-friendly
form.
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Interpreting Test Results

The SWAP-200 scoring software currently generates three personality score
profiles. This document is a guide to interpreting these score profiles. Future
versions of the SWAP-200 software will automate the interpretation process and
provide computer generated interpretive reports.

All scores described in this Guide are standardized scores (T-scores) based on
norms established in a clinical sample of patients with DSM-IV Axis II diagnoses
(Westen & Shedler, 1999a).

The three personality score profiles are as follows:

1. DSM-IV Personality Disorders (PD T-Scores). This profile provides a score for
each DSM-IV personality disorder and can be used to derive a formal DSM-IV
axis II diagnosis. The profile includes a Psychological Health Index that assesses
personality strengths.

2. SWAP Personality Syndromes (Q-Factor T-Scores). This profile provides

scores for an alternative set of personality syndromes that were identified
empirically. This alternative diagnostic system addresses limitations of the DSM-
IV diagnostic system and is designed to capture more faithfully the personality
patterns and syndromes seen in clinical practice.

3. Factor T-Scores. This profile provides scores for twelve personality factors
(trait dimensions) identified via factor analysis of the SWAP-200 item set. The
factor scores supplement the diagnostic picture by highlighting specific areas of
psychological functioning.

DSM-IV Personality Disorders (PD T-Scores)

Personality Disorder (PD) scores indicate the degree of resemblance or “match”

between your patient and diagnostic prototypes representing each DSM-IV axis II
disorder in its “ideal” or pure form (see the section, “Understanding Prototype
Matching” on page 4). The diagnostic prototypes reflect the consensual
understanding of experienced clinical practitioners and are richer and more
detailed than the diagnostic criteria included in DSM-IV. This score profile covers
the ten PDs included in DSM-IV plus depressive PD (included in the DSM-IV
appendix).

A strong match with a PD prototype (T > 60) indicates that the patient would be
given the PD diagnosis by a consensus of knowledgeable clinicians. A moderate
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match (T > 55) means that the patient has “features” of the disorder but is sub-
threshold for diagnosis. If two or more scales have scores above T=60, the
highest score provides the primary axis II diagnosis.

Figure 1

DSM-IV Personality Disorder Profile

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For the sample patient graphed in Figure 1, the formal DSM-IV axis II Diagnosis
is as follows:

—Antisocial Personality Disorder (T=65)

—Narcissistic Personality Disorder (T=61)
—Paranoid features (T=56)
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For descriptions of the DSM-IV diagnostic prototypes and their development, see
Shedler & Westen, 2004a.

Psychological Health Index

Because of the importance of assessing psychological strengths (e.g., ego

strengths) as well as limitations, the score profile includes a Psychological Health
Index (labeled “High-Fx” on the profile graph). This index measures the
resemblance or match between your patient and a prototype representing
optimal psychological health. The index serves as a global measure of
personality functioning, analogous to the Global Assessment of Functioning
(GAF) scale in DSM-IV.

A score of T=50 on the Psychological Health Index indicates an average level of

functioning relative to a sample of patients with DSM-IV Axis II diagnoses. The
low score (T=40) for the sample patient in Figure 1 indicates relatively severe
personality pathology, a standard deviation below the mean in a reference
sample of patients with personality disorders.

Scores above T=60 indicate significant psychological resources and capacities,

such as the capacity to sustain meaningful relationships, to use talents and
abilities effectively and productively, to recognize alternative perspectives, to
respond to others’ needs and feelings, to find meaning and fulfillment in life’s
activities, and so on. To facilitate interpretation of high scores, the most important
(highest ranked) items contributing to the Psychological Health Index are
reproduced in Appendix 1.

SWAP Personality Syndromes (Q-Factor T-Scores)

The DSM-IV PD score profile described above maintains “backward

compatibility” with DSM-IV for purposes of formal diagnosis, billing and coding,
and so on. However, research shows that the DSM-IV diagnostic categories are
not optimal for classifying and describing the personality syndromes seen in
clinical practice.

The SWAP Personality Syndromes (Q-Factor T-Score) profile shows the degree
of resemblance or match between your patient and an alternative set of
personality syndromes that were identified empirically (via the method of Q-factor
analysis). These personality syndromes overlap DSM-IV diagnostic categories
but differ in important ways. They are designed to more faithfully capture the
personality syndromes seen in clinical practice and to facilitate clinical case
formulation and treatment planning.
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Scores indicate the degree of resemblance or “match” between your patient and
diagnostic prototypes representing each personality syndrome in its “ideal” or
pure form (see the section, “Understanding Prototype Matching” on page 4).
Diagnosis is dimensional rather than categorical, so personality syndromes are
diagnosed on a continuum from less to more severe. Where categorical
diagnosis is desired, T-scores > 60 indicate that a diagnosis applies and T-
scores > of 55 indicate the presence of clinically significant “features.” If more
than one scale has a T-score above 60, the highest score provides the primary
personality diagnosis. The Psychological Health Index (High-Fx) is included in
the score profile as well.

Figure 2

Q-Factor T-Scores

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For the sample patient in Figure 2, the categorical diagnosis is as follows:

—Narcissistic personality (T=65)

—Obsessional features (T=56)

The high score on the Psychological Health Index (T=64) indicates that the
patient possesses significant psychological capacities and resources. His level
of functioning is considerably higher than that of the average patient who
receives an Axis II personality disorder diagnosis.

For information about the SWAP personality syndromes and the research behind
them, see Westen & Shedler, 1999b.

Descriptions of SWAP Personality Syndromes

This section provides prototype descriptions of the SWAP personality syndromes
(Q-factors) in their “ideal” or pure form. Since no patient is a perfect
representative of a diagnostic syndrome, no prototype will describe your patient
exactly. However, considering a prototype description as a whole or “gestalt,” you
should recognize similarity or fit between your patient and the prototype in
proportion to the T-Score elevation.

Where available, we have supplemented the prototype descriptions with

information about the kinds of emotional reactions the patient is likely to elicit in
the treating clinician (common countertransference responses) and brief
comments concerning treatment implications. Computer generated interpretive
reports (under development) will provide more comprehensive clinical case
formulations and treatment recommendations.

Dysphoric (Depressive) Personality

Comments: Despite its omission from DSM-IV, dysphoric or depressive

personality is the most common personality syndrome seen in clinical practice.
Dysphoric patients may present with an axis I diagnosis (e.g., major depression,
dysthymic disorder) but symptoms are rooted in enduring personality patterns.
This diagnostic grouping has several clinically distinct subtypes that are
described later in this section (avoidant, high functioning, dependent-victimized,
emotionally dysregulated, and hostile-oppositional).

Detailed description: Patients who match this prototype tend to be unhappy,

depressed, or despondent, and to find little pleasure, satisfaction, or enjoyment in
life’s activities. They tend to feel inadequate, inferior, or a failure; are insufficiently
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concerned with meeting their own needs; and seem not to feel entitled to get or
ask for things they deserve. They tend to be passive and unassertive. They
appear to want to “punish” themselves by creating situations that lead to
unhappiness or actively avoiding opportunities for pleasure and gratification.
They are also self-critical, tending to set unrealistically high standards for
themselves, showing little tolerance for their own human defects, and blaming
themselves or feeling responsible for bad things that happen. They tend to feel
guilty, ashamed, or embarrassed; to feel listless, fatigued, and lacking energy;
and to feel empty or bored. They tend to be anxious, and to feel helpless,
powerless, or at the mercy of forces outside their control. In addition to pervasive
dysphoria, individuals who fit this prototype tend to be needy or dependent,
requiring excessive reassurance or approval. They tend to fear that they will be
rejected or abandoned by those who are emotionally significant and may be
ingratiating or submissive in the hope of gaining support or approval.

Treatment Considerations: Although acute axis I symptoms may prompt the

patient to seek treatment, underlying personality patterns must be addressed to
achieve lasting treatment gains. The therapist should identify and explore self-
defeating patterns in the patient’s thinking, behavior, and relationships, including
the relationship with the therapist, and help the patient gain insight into the ways
in which he discounts or repudiates his own emotional needs or inhibits his
capacity to fulfill them. Underlying feelings of guilt, shame, anger, or
unworthiness may emerge as the patient gains greater access to inner
experience. Increased self-acceptance can develop over time as the patient
internalizes the therapist’s more benign and accepting attitudes toward his
thoughts, feelings, and impulses.

Antisocial-Psychopathic Personality

Comments: The DSM-IV diagnosis of antisocial personality disorder emphasizes

overt behavior and criminality. In contrast, this prototype places greater
emphasis on internal psychological processes and motives.

Detailed description: Patients who match this prototype tend to be deceitful, to lie
and mislead people. They take advantage of others, have minimal investment in
moral values, and appear to experience no remorse for harm or injury they cause
others. They tend to manipulate others’ emotions to get what they want; to be
unconcerned with the consequences of their actions, appearing to feel immune
or invulnerable; and to show reckless disregard for the rights, property, or safety
of others. They have little empathy and seem unable to understand or respond to
others’ needs and feelings unless they coincide with their own. Individuals who
match this prototype tend to act impulsively, without regard for consequences; to
be unreliable and irresponsible (e.g., failing to meet work obligations or honor
financial commitments); to engage in unlawful or criminal behavior; and to abuse
alcohol. They tend to be angry or hostile; to get into power struggles; and to gain
 12

pleasure or satisfaction by being sadistic or aggressive toward others. They tend

to blame others for their own failures or shortcomings and believe their problems
are caused by external factors. They have little psychological insight into their
own motives and behavior. They may repeatedly convince others of their
commitment to change but then revert to previous maladaptive behavior, often
convincing others that “this time is really different.”

Treatment Considerations: Antisocial-psychopathic patients are motivated by a

desire for power and by pleasure in “getting one over” on others, including the
therapist. They may give the impression of working in therapy if they perceive
some immediate personal advantage to doing so (e.g., inducing the therapist to
intercede on their behalf, or to get out of legal trouble) but have little genuine
interest in self-examination. They are likely to perceive the therapist’s
sympathetic attention or compassion as weakness. Therapeutic leverage, to the
extent there is any, comes from a position of power and dominance that most
therapists are reluctant to assume (and that would be counterproductive with
other patients). Prognosis is poor.

Schizoid-Schizotypal Personality

Comments: SWAP research does not support the DSM-IV distinction between
schizoid and schizotypal personality disorders. The empirical data indicate a
single personality syndrome.

Detailed description: Patients who match this prototype lack close friendships
and relationships. They appear to have little need for human company or contact
and to be indifferent to the presence of others. They lack social skills and often
appear socially awkward or inappropriate. They tend to be shy or reserved in
social situations; to avoid social situations because of fear of embarrassment or
humiliation; and to feel like an outcast or outsider. Their appearance or manner
may seem odd or peculiar (e.g., grooming, hygiene, posture, eye contact, speech
rhythms, etc. seem somehow strange or “off”). They appear to have a limited or
constricted range of emotions. They tend to be inhibited or constricted; to be
passive and unassertive; to have difficulty acknowledging or expressing anger; to
have difficulty experiencing strong pleasurable emotions (e.g., excitement, joy,
pride); and they tend to elicit boredom in others. They have difficulty making
sense of other people’s behavior and often misunderstand, misinterpret, or are
confused by others’ actions and reactions. They appear unable to describe
important others in a way that conveys a sense of who they are as people, and
their descriptions of others come across as two-dimensional and lacking in
richness. They have little psychological insight into their own motives and
behavior. They tend to think in concrete terms and interpret things in overly literal
ways, and have limited ability to appreciate metaphor, analogy, or nuance. Their
reasoning processes or perceptual experiences seem may seem odd and
idiosyncratic (e.g., they may make seemingly arbitrary inferences, or see hidden
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messages or special meanings in ordinary events), and their perception of reality

can become grossly impaired under stress.

Treatment Considerations: Although DSM-IV describes schizoid patients as

indifferent to social relationships and emotionally detached, some individuals who
match this prototype crave social contact but avoid it because they are
exquisitely sensitive to the pain of interpersonal engagement. They easily
feel in danger of being engulfed, enmeshed, controlled, intruded upon, or
traumatized, dangers they associate with becoming involved with others. The
therapist should respect the patient’s interpersonal vulnerabilities and proceed
slowly and patiently. Over time, the patient may gradually allow the therapist
greater access to his or her inner world and reveal a capacity for attachment that
was not initially evident.

Where disturbance in thinking and reasoning is prominent, the patient may be

suffering from a subclinical schizophrenic spectrum disorder rather that a
personality disorder. The Thought Disorder factor score (see section on “Factor
T-Scores,” below) can help clarify the extent of thought disturbance, as can
additional psychological testing. A thorough history may reveal a biological
relative with a psychotic disorder.

Paranoid Personality

Comment: This diagnostic prototype overlaps the DSM-IV construct of Paranoid

Personality Disorder but emphasizes traits and personality dynamics that are not
recognized by DSM-IV.

Detailed description: Patients who match this prototype tend to hold grudges and
may dwell on insults or slights for long periods. They are quick to assume that
others wish to harm them or take advantage, and tend to perceive malevolent
intentions in others’ words and actions. They tend to feel misunderstood,
mistreated, or victimized. People who match this prototype also tend to express
intense and inappropriate anger, out of proportion to the situation at hand; to be
critical of others; to be angry or hostile; to get into power struggles; to be
oppositional, contrary, or quick to disagree; and to react to criticism with feelings
of rage or humiliation. They tend to see certain others as “all bad” and lose the
capacity to perceive any positive qualities the person may have. They tend to
blame others for their own failures or shortcomings and to believe their problems
are caused by external factors. They are likely to see their own unacceptable
feelings or impulses in other people instead of in themselves. Individuals who
match this prototype may become irrational when strong emotions are stirred up.
They may “catastrophize,” seeing problems as disastrous, unsolvable, etc. They
tend to be self-righteous or moralistic, and often elicit dislike or animosity in
others.
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Common therapist reactions to paranoid patients: Therapists treating paranoid

patients report that the patients stir up very strong feelings in them. They report
feeling criticized by the patient; feeling unappreciated; feeling dismissed or
devalued; feeling mistreated or abused; feeling like they are “walking on
eggshells,” afraid the patient will explode, fall apart, or walk out if they say the
wrong thing; feeling overwhelmed by the patient’s strong emotions; feeling
frightened; feeling annoyed, angry, or even enraged; feeling anxious or
depressed; feeling used or manipulated; having trouble relating to the patient’s
feelings; disliking the patient; wishing they had never taken on the patient;
dreading sessions; feeling resentful working with the patient; feeling repulsed by
the patient; feeling frustrated in sessions; and feeling that they have to work to
stop themselves from responding to the patient in aggressive or critical ways.

Treatment considerations: The therapist’s own strong reactions give some hint of
the fear and anger the patient chronically experiences and seeks to manage
through externalization and projection. The therapist can help the patient reality
test by encouraging him to explore his assumptions and conclusions about
interactions with the therapist and with others, and by sharing his own alternative
perspectives and reasoning processes. The therapist may also invite the patient
to participate in finding solutions to the ongoing dilemma inherent in the therapy
relationship: that the patient has come to therapy for help, yet often responds to
the therapist in ways that make it difficult to provide help. An overly friendly or
sympathetic stance may arouse the patient’s suspicions and intensify paranoia. A
neutral, matter-of-fact stance is generally more helpful. Effective treatment must
ultimately address the patient’s underlying aggression and help him develop
more effective ways of expressing and regulating it. Patients who have the
capacity to maintain meaningful attachments are likely to benefit from
psychotherapy. In the absence of a genuine capacity for empathy and
attachment, prognosis is poor.

Obsessional Personality

Comments: Obsessional patients generally fall toward the healthier end of the
personality spectrum, and the psychological characteristics described in the
diagnostic prototype are often accompanied by significant ego strengths. Except
in extreme cases, obsessional personality does not reach the severity of
pathology typically associated with an Axis II personality “disorder” and may be
better conceptualized as a personality pattern or style. Contrary to common
assumptions, obsessional personality is largely unrelated to axis I obsessive-
compulsive disorder, which appears to be a distinct syndrome with a separate
etiology.

Detailed description: Patients who match this prototype are excessively devoted
to work and productivity, to the detriment of leisure and relationships. They tend
to see themselves as logical and rational, uninfluenced by emotion; prefer to
 15

operate as if emotions were irrelevant or inconsequential; tend to think in abstract

and intellectualized terms, even in matters of personal import; and appear to
have a limited or constricted range of emotions. They tend to be inhibited or
constricted; to have difficulty allowing themselves to acknowledge or express
wishes and impulses; to have difficulty allowing themselves to experience strong
pleasurable emotions (e.g., excitement, joy, pride); and to have difficulty
acknowledging or expressing anger. They tend to deny or disavow their own
need for caring, comfort, closeness, etc., or to consider such needs
unacceptable. Additionally, they tend to be controlling; competitive with others
(whether consciously or unconsciously); critical of others; conflicted about
authority (e.g., they may feel they must submit, rebel against, win over, defeat,
etc.); prone to get into power struggles; and self-righteous or moralistic. They are
also self-critical, tending to set unrealistically high standards for themselves,
showing little tolerance for their own human defects, and expecting themselves to
be "perfect." They may adhere rigidly to daily routines and become anxious or
uncomfortable when they are altered.

Treatment considerations: Obsessional personality is organized around a need to

defend against unacceptable affect, especially fear and rage. For this reason,
obsessional patients prefer to think rather than feel. Reliance on
intellectualization, adherence to routine, and preoccupation with work and
productivity serve to ward off threatening affect, but underlying fear and
aggression tend to “leak out” in the form of critical attitudes, controlling behavior,
power struggles, and so on. Obsessional patients will benefit from an interpretive
approach aimed at helping them recognize and understand their efforts, often
unconscious, to ward off painful affect, and the cost of these defenses vis-à-vis
relationships and capacity for enjoyment. The therapist should be alert to the
patient’s tendency to intellectualize, especially the tendency to treat the
therapist’s comments as abstract theories to ponder. For example, if the patient
says the therapist’s comments “make sense,” the therapist might ask whether the
comments just “make sense,” or whether the patient actually recognizes
something in himself and feels it to be personally true. In this way, the therapist
may gently draw the patient’s attention to affective experience.

Histrionic Personality

Comments: Patients who match this prototype rely on sexuality to gain attention
and notice. They tend to be attention seeking, flamboyant, and seductive, and to
express emotion in dramatic, even theatrical ways. Sexualization and attention
seeking serve to ward off underlying fears of abandonment and powerlessness.

Detailed description: Patients who match this prototype tend to be overly needy
or dependent, requiring excessive reassurance or approval. They tend to be
overly sexually seductive or provocative, whether consciously or unconsciously
(e.g., they may be inappropriately flirtatious, preoccupied with sexual conquest,
 16

or prone to “lead people on”); to use their physical attractiveness to an excessive

degree to gain attention or notice; and to choose sexual or romantic partners who
seem inappropriate in terms of age, status (e.g., social, economic, intellectual),
etc. They seek to be the center of attention; fantasize about finding ideal, perfect
love; and are suggestible or easily influenced. Their perceptions seem glib,
global, and impressionistic; they have difficulty focusing on specific details.
Individuals who match this prototype tend to become attached quickly or
intensely, and to develop feelings, expectations, etc. that are not warranted by
the history or context of the relationship. They tend to fear they will be rejected or
abandoned by those who are emotionally significant; yet they become attached
to, or romantically interested in, people who are emotionally unavailable.
Patients who match this prototype express emotion in exaggerated and theatrical
ways, and tend to become irrational when strong emotions are stirred up. They
may have difficulty soothing or comforting themselves when distressed, and
require involvement of another person to help regulate affect. Their emotions
tend to spiral out of control, and to change rapidly and unpredictably. They tend
to be anxious, and to develop somatic symptoms in response to stress or conflict
(e.g., headache, backache, abdominal pain, asthma, etc.).

Common therapist reactions to histrionic patients: Therapists treating histrionic

patients report thinking or fantasizing about ending the treatment (especially
therapists treating male histrionic patients); feeling resentful working with the
patient; feeling angry with the patient; feeling pushed to set very firm limits;
having trouble relating to the patient’s feelings; feeling frightened by the patient;
losing their temper with the patient; feeling that they have to stop themselves
from saying or doing something aggressive or critical; more than with most
patients, feeling that they’ve been pulled into things that they didn't realize until
after the session was over; feeling dismissed or devalued; at times disliking the
patient; not trusting what the patient is telling them; feeling annoyed in sessions;
feeling repulsed by the patient; feeling used or manipulated; and feeling that they
are being mean or cruel to the patient.

Treatment considerations: Clinical experience suggests that heterosexual

histrionic patients perceive the opposite gender as powerful, exciting, and
potentially dangerous, and their own gender as relatively weak, needy, and
powerless. Sexual attention seeking can be understood as an effort, generally
unconscious, to avoid feared rejection and abandonment, and to gain power over
the opposite gender through sexuality and seductiveness. Healthier patients with
histrionic styles may be charming and engaging, but sicker patients (such as
those described by the prototype) tend to paradoxically elicit the very
dismissiveness they fear, as therapists (and others) become exasperated with
continuing drama, the feeling of being manipulated, and the patient’s seemingly
willful naïveté and apparent lack of interest in self examination. Histrionic patients
benefit from an insight oriented approach emphasizing patient, self-paced
exploration of underlying needs, feelings, wishes, fears, and defenses. A didactic
or authoritarian stance may inadvertently reinforce feelings of deficiency and
 17

powerlessness. Sicker histrionic patients (e.g., those prone to impulsive acting

out and frank manipulation, or those with borderline features) may require more
explicit limit setting, attention to boundary issues, and confrontation of destructive
acting out that may occur inside or outside of therapy sessions.

Narcissistic Personality

Comments: This diagnostic prototype overlaps the DSM-IV construct of

Narcissistic Personality Disorder but emphasizes traits and personality dynamics
that are not currently recognized by DSM-IV.

Detailed description: Patients who match this prototype have fantasies of

unlimited success, power, beauty, talent, brilliance, etc. They appear to feel
privileged and entitled, and expect preferential treatment. They have an
exaggerated sense of self-importance, and believe they can only be appreciated
by, or should only associate with, people who are high-status, superior, or
otherwise “special.” Individuals who match this prototype seek to be the center of
attention, and seem to treat others primarily as an audience to witness their own
importance, brilliance, beauty, etc. They tend to be arrogant, haughty, or
dismissive; to be competitive with others (whether consciously or unconsciously);
to feel envious; and to think others are envious of them. They expect themselves
to be “perfect” (e.g., in appearance, achievements, performance, etc.). They are
likely to fantasize about finding ideal, perfect love. They tend to lack close
friendships and relationships; to feel life has no meaning; and to feel like they are
not their true selves with others, so that they may feel false or fraudulent.

Common therapist reactions to narcissistic patients: Narcissistic patients stir up

strong feelings in therapists, which can fluctuate between anger and boredom.
Therapists treating narcissistic patients report feeling unappreciated; criticized;
dismissed or devalued, used or manipulated; and mistreated or abused by the
patient. They report feeling like they are “walking on eggshells,” afraid the patient
will explode, fall apart, or walk out if they say the wrong thing. They report
disliking the patient at times; feeling resentful working with the patient; feeling
annoyed; feeling angry; feeling enraged; losing their temper; having to stop
themselves from saying or doing something aggressive or critical; feeling like
they are being mean or cruel to the patient; and with opposite sex patients,
feeling sexual tension in the room. Additionally, therapists treating narcissistic
patients report feeling bored in sessions; watching the clock more than with other
patients; and struggling to keep their minds from wandering. They report talking
more about the patient with their spouse or significant other than about other
patients; feeling hopeless working with the patient; dreading sessions; dreading
phone messages; fantasizing about ending the treatment; and wishing they had
never taken him on as a patient.
 18

Treatment considerations: For most narcissistic patients, grandiosity and self-

importance serve a defensive function, serving to ward off painful feelings of
inadequacy, smallness, anxiety, and loneliness. The narcissistic patient wants to
feel important and privileged, and when defenses are operating effectively, he
does. When defenses fail, there is a powerful undercurrent of negative affect and
feelings of inadequacy, often accompanied by rage. Narcissistic patients may
alternately idealize and devalue others, including the therapist. When they
idealize someone with whom they are connected, they feel special or important
by virtue of association. When they devalue someone, they feel superior.

Effective treatment may require a careful balancing act, with a judicious blend of
empathy and confrontation. Narcissistic patients benefit from empathic
understanding of their underlying pain, insecurity, and vulnerability (including
open and honest acknowledgement of the therapist’s own inevitable empathic
failures in the therapy relationship), and with the therapist’s help, may develop
greater capacity to tolerate these feelings without resorting to grandiosity and
devaluation. On the other hand, the patient may benefit from confrontation of
narcissistic defenses (e.g., against shame, envy, and normal dependency) and
exploration of the considerable cost of these defenses. Narcissistic patients may
be most receptive to psychotherapy in mid-life or later, when fantasies of limitless
beauty, fame, wealth, or power have been disappointed and they are forced to
confront life’s realistic limits. Where narcissism is accompanied by sadistic
aggression and psychopathy (the syndrome of “malignant narcissism”),
prognosis is poor.

Avoidant Personality

Comments: Patients who match this prototype attempt to manage chronic

dysphoric affect through avoidance and withdrawal. This syndrome is a clinically
important subtype of the dysphoric or depressive personality syndrome.

Detailed description: Patients who match this prototype tend to be shy or

reserved in social situations, and tend to avoid social situations because of fear
of embarrassment or humiliation. They lack social skills, and lack close
friendships and relationships. They tend to feel like an outcast or outsider, and to
feel as if they do not truly belong. More generally, they tend to feel inadequate,
inferior, or a failure; to feel ashamed or embarrassed; to be anxious; and to be
self-critical, setting unrealistically high standards for themselves. They tend to
blame themselves or feel responsible for bad things that happen, and to find little
or no pleasure, satisfaction, or enjoyment in life’s activities. Individuals who
match this prototype tend to be inhibited or constricted, having difficulty allowing
themselves to acknowledge or express their wishes and impulses. They display a
limited or constricted range of emotions. They tend to have difficulty allowing
themselves to experience strong pleasurable emotions (e.g., excitement, joy,
pride); to be passive and unassertive; to have difficulty acknowledging or
 19

expressing anger; and to be inhibited about pursuing goals or successes,

sometimes leading to aspirations or achievements below their potential. They
may seem to know less about the ways of the world than might be expected,
given their intelligence, background, etc.

Treatment Considerations: Avoidant personality is a subtype of Dysphoric

(Depressive) personality and similar treatment considerations apply. However,
the therapy should specifically address the patient’s avoidance. Patients with
avoidant personality may be verbally as well as behaviorally avoidant, and may
steer clear of difficult topics or change the subject when disturbing thoughts or
feelings arise. The patient may require extra help and encouragement from the
therapist to experience, name, and express emotions. When the patient
responds to situations (both inside and outside of therapy sessions) with fearful
avoidance, the therapist should challenge the patient’s expectations and beliefs
(“And what would happen then?”). When a secure working alliance has been
established, the patient should be urged to face feared situations and
experiences, ideally in progressive and manageable steps.

High Functioning Depressive Personality

Comments: This is a distinct personality syndrome observable in a large

percentage of patients treated in the community. It does not reach the severity of
pathology typically associated with an Axis II personality “disorder” and may be
better regarded as a personality pattern or style. Patients who match this
prototype possess many personality strengths and capacities in combination with
dysphoric, self-denigrating personality dynamics. This syndrome is a clinically
important subtype of the dysphoric or depressive personality syndrome.

Detailed description: Patients who match this prototype have many

psychological strengths. They tend to be articulate; empathic; capable of
sustaining a meaningful love relationship characterized by genuine intimacy and
caring; able to form close and lasting friendships; and able to find meaning and
fulfillment in guiding, mentoring, or nurturing others. Further, they tend to be
psychologically insightful, able to understand themselves and others in subtle
and sophisticated ways; to be creative; to appreciate and respond to humor; and
to be able to hear information that is emotionally threatening (i.e., that challenges
cherished beliefs, perceptions, and self-perceptions) and use and benefit from it.
Their strengths and weaknesses, however, tend to spring from the same wells:
They may be conscientious and responsible to a fault; they have moral and
ethical standards and strive to live up to them, often at the cost of their happiness
or self-esteem; they enjoy challenges and are able to use their talents, abilities,
and energy effectively and productively, but often put tremendous pressure on
themselves; and they tend to seek out or create interpersonal relationships in
which they are in the role of caring for, rescuing, or protecting the other. They
tend to blame themselves or feel responsible for bad things that happen; to feel
 20

guilty; to feel unhappy, depressed, or despondent; and to feel listless, fatigued, or

lacking in energy. They tend to be self-critical, setting unrealistically high
standards for themselves and being intolerant of their own human defects. They
tend to fear that they will be rejected or abandoned by those who are emotionally
significant.

Common therapist reactions to high-functioning depressive patients:

Therapists treating patients who match this prototype tend to feel hopeful about
the gains the patient is making or will likely make in treatment; tend to like the
patient a good deal; regard the patient as one of their favorites; feel that if s/he
were not a patient, they could imagine being friends; look forward to sessions;
feel pleased or satisfied after sessions; find it exciting to work with the patient;
and feel that they understand the patient. They also tend to report that the
patient makes them feel good about themselves and the therapy work.

Treatment considerations: Generally, high functioning depressive patients derive

benefit from treatment and are seen as “good” patients. The flip side is that the
therapist may feel good because the patient is recreating a pattern of
subordinating his needs to those of others (in this case, those of the therapist),
squelching negative feelings toward the therapist, or in other ways attending to
the therapist’s perceived needs rather than his own, as the patient tends to do in
relationships more generally. The therapist would do well to point out these
patterns as they arise and to help the patient understand their relation to
depression. More specifically, it is vital when treating such patients to elicit their
negative feelings, especially their hostility and criticism, because they typically
idealize the therapist, try to be good patients, and tend to interpret the therapist’s
noncritical acceptance as evidence that the therapist has not yet noticed how bad
they really are. It is also important to help depressive patients see how they
persist in believing that their badness is the cause of the difficulties and losses
they experience.

Borderline (Emotionally Dysregulated) Personality

Comments: This diagnostic prototype overlaps the DSM-IV construct of

Borderline Personality Disorder. Patients who match this prototype suffer from
deficits in the capacity for affect regulation. They experience intense and volatile
affect, profound states of desperation and despair, and are prone to self-harm.

Detailed description: Patients who match this prototype struggle with emotions
that spiral out of control, leading to extremes of anxiety, sadness, rage, etc. They
are unable to soothe or comfort themselves when distressed and may require
involvement of another person to help regulate their emotions. They struggle
with genuine wishes to kill themselves; tend to make repeated suicidal threats or
gestures, either as a “cry for help” or as an effort to manipulate others; and tend
to engage in self-mutilating behavior (e.g., self-cutting, self-burning, etc.).
 21

Individuals who match this prototype tend to feel unhappy, depressed, or

despondent; to feel life has no meaning; to be preoccupied with death and dying;
to feel empty; and to find little or no pleasure, satisfaction, or enjoyment in life’s
activities. They are likely to “catastrophize,” seeing problems as disastrous or
unsolvable. They tend to become irrational when strong emotions are stirred up
and may show a noticeable decline from their customary level of functioning.
Their emotions tend to change rapidly and unpredictably. They tend to be angry
or hostile (whether consciously or unconsciously), and to feel misunderstood,
mistreated, or victimized. Patients who match this prototype tend to feel like an
outcast or outsider; to feel inadequate, inferior, or a failure; and to be overly
needy or dependent. They may repeatedly re-experience or re-live a past
traumatic event (e.g., having intrusive memories or recurring dreams of the
event, or becoming startled or terrified by present events that resemble or
symbolize the past event).

Treatment Considerations: Borderline patients benefit from psychotherapy but

are among the most challenging patients to treat, predictably testing the limits of
therapists’ capacities. They require intensive, long-term treatments, active
management of a range of acute axis I symptoms, and management of
destructive and self-destructive behaviors. All effective treatments for borderline
personality emphasize active limit setting, attention to boundary issues, and
management of behavior that is potentially destructive to the therapy and the
therapy relationship. A number of therapies have shown empirical efficacy for
borderline personality, including variants of psychodynamic psychotherapy
(Transference-Focused Psychotherapy and Mentalization-Based Therapy) and
variants of cognitive behavioral therapy (Dialectical Behavior Therapy and
Schema-Focused Therapy).

Dependent-Victimized Personality

Comments: Patients who match this prototype are characterized by extreme

dependency which leads them to subordinate their own needs to those of others,
and leaves them vulnerable to relationships in which they are exploited or ill-
used. This syndrome is a clinically important subtype of the dysphoric or
depressive personality syndrome.

Detailed description: Patients who match this prototype tend to get drawn into or
remain in relationships in which they are emotionally or physically abused. They
tend to be ingratiating or submissive; to be overly needy or dependent; to be
suggestible or easily influenced; to have trouble making decisions, often
vacillating when faced with choices; and to be unable to soothe or comfort
themselves when distressed, requiring involvement of another person to help
regulate their emotions. They tend to become attached quickly or intensely;
developing feelings, expectations, etc. that are not warranted by the history or
context of the relationship. They fear being alone, and fear that they will be
 22

rejected or abandoned by those who are emotionally significant. They are likely
to become attached to, or romantically interested in, people who are emotionally
unavailable; to choose sexual or romantic partners who seem inappropriate in
terms of age, status (e.g., social, economic, intellectual), etc.; to idealize certain
others in unrealistic ways, seeing them as “all good,” to the exclusion of
commonplace human defects; and to fantasize about finding ideal, perfect love.
Patients who match this prototype tend to be passive and unassertive; to have
difficulty acknowledging or expressing anger; and to express aggression in
passive and indirect ways (e.g., they may make mistakes, procrastinate, forget,
become sulky, etc.). They lack a stable image of who they are or would like to
become (e.g., their attitudes, values, goals, and feelings about themselves may
be unstable and changing). They may repeatedly convince others of their
commitment to change, but then revert to previous maladaptive behavior.

Common therapist reactions to Dependent Patients: Therapists treating

Dependent patients report feeling pushed to set very firm limits with the patient;
not trusting what the patient tells them; when checking phone messages, feeling
anxiety or dread about receiving a message from the patient; thinking or
fantasizing about ending treatment; worrying about the patient after sessions
more than other patients; having their mind wander to things other than what the
patient is talking about; feeling confused in sessions with the patient; thinking the
patient might do better with another therapist or in a different kind of therapy;
returning the patient’s phone calls less promptly than usual; wishing they had
never taken him on as a patient; feeling sad in sessions with the patient; feeling
annoyed in sessions; feeling like their hands have been tied or that they have
been put in an impossible bind; and feeling used or manipulated by the patient.

Treatment considerations: Dependent-victimized patients seem to repetitively

place themselves in harm’s way. They appear to operate on the belief that
attachment requires suffering and may cling to relationships that, in the eyes of
virtually everyone else, are destructive. In severe cases, existence outside of the
relationship, however abusive, may seem unimaginable. While Dependent-
victimized patients may present as helpless, an underlying (passive) aggression
is often evident in the tenacity with which they defeat the therapist’s interventions
and resist efforts to help. The therapist’s frustration and annoyance may provide
a window into the kind of reactions the patient elicits from others (who are
generally less inclined than the therapist to inhibit sadistic and punitive impulses).
When a secure working alliance is established, the patient should be confronted
with his own contributions to recurring difficulties, and the therapist should be
prepared for the patient’s resulting anxiety or anger. It can be helpful to make
explicit the ways in which the patient places the therapist (and himself) in
untenable binds and invite the patient to explore solutions for getting out of them,
instead of the therapist undertaking the generally futile task of trying to find
solution on the patient’s behalf.
 23

Hostile-Externalizing Personality

Comments: Hostile/Externalizing patients represent a subtype of depressive or

dysphoric personality characterized by anger, hostility, and externalization of
blame. Because hostile/externalizing patients blame their difficulties on external
factors, they tend to be angry, critical, oppositional, and conflicted about
authority. When these traits emerge in therapy, they present considerable
treatment challenges.

Detailed description: Patients who match this diagnostic prototype tend to get
into power struggles. They tend to be angry or hostile (whether consciously or
unconsciously); to blame others for their own failures or shortcomings; and to
believe their problems are caused by external factors. They tend to be
oppositional, contrary, or quick to disagree. They tend to be critical of others;
controlling; and hostile toward members of the opposite sex (whether consciously
or unconsciously). They tend to express aggression in passive and indirect ways
(e.g., by making mistakes, procrastinating, forgetting things, become sulky, etc.),
and they tend to see their own unacceptable feelings or impulses in other people
instead of in themselves. Individuals who match this prototype tend to be
conflicted about authority (e.g., feel they must submit, rebel against, win over,
defeat, etc.), and to react to criticism with feelings of rage or humiliation. They
tend to feel misunderstood, mistreated, or victimized; to feel helpless, powerless,
or at the mercy of forces outside their control; and to assume that others wish to
harm or take advantage of them. They are likely to hold grudges, dwelling on
insults or slights for long periods. They often appear inhibited about pursuing
goals or successes, so that their aspirations or achievements may be below their
potential

Common therapist reactions to hostile-externalizing patients: Therapists treating

hostile/externalizing patients report having trouble relating to the feelings the
patient expresses; not feeling engaged in sessions with the patient; feeling
annoyed with the patient; feeling dismissed or devalued; feeling unappreciated;
feeling criticized; feeling used or manipulated; at times disliking the patient; and
at times dreading sessions. The therapist may feel a “pull” toward becoming
controlling in turn.

Treatment implications: Hostile-externalizing patients present treatment

challenges because they blame others for their difficulties and see their problems
as externally caused. They may misuse therapy appointments as complaint
sessions, recounting dissatisfactions and grievances with others instead of
examining their own contributions to repetitive dissatisfying interactions. The
patient should be helped to recognize how his interpersonal style drives others
away or leads them to respond in hostile or controlling ways, and how this
creates a vicious cycle that leaves the patient feeling still more angry, depressed,
or alienated. The therapist can empathize with the patient’s unhappiness while
 24

also confronting the externalization (“If you are certain that your difficulties are
caused by other people, I’m sympathetic to your situation, but there is little I can
do as a therapist to help. On the other hand, if you think there is something you
are contributing to these unhappy interactions, we can work to understand that
so you don’t have to keep reliving the same kind of painful experience.”).
Underlying feelings of pain, loneliness, and inadequacy will emerge as the
patient relinquishes externalizing defenses and increasingly attends to inner
experience.

Factor T-Scores

The diagnostic approach described in the previous sections is person-centered.

Diagnostic constructs are types of people (e.g., people with narcissistic
personality disorder, people with high functioning depressive personality) and
scale scores measure the extent to which a patient resembles or matches the
personality type.

An alternative assessment approach is variable-centered. Diagnostic constructs

are personality traits, often identified via the statistical method of factor analysis.
Scale scores measure the patient on each trait relative to population norms.
Person-centered (type) and variable centered (trait) approaches serve different
purposes and provide different kinds of information.

Factor analysis of the SWAP-200 item set yields twelve conceptually

interpretable trait dimensions or factors. Some of the factors converge on
recognized personality disorders (e.g., Psychopathy, Narcissism). Other factors
highlight important psychological characteristics that are not synonymous with a
specific personality disorder (e.g., Hostility, Thought Disorder, Sexual Conflict).
The factor scores supplement the diagnostic picture provided by the other score
profiles and provide additional information relevant to case formulation and
treatment planning. All scores are T-Scores based on norms established in a
reference sample of patients with DSM-IV personality disorder diagnoses.
 25

Figure 3

Factor T-Scores

80
75
70
65
60
T-score

55
50
45
40
35
30
i sm

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The sample patient graphed in Figure 3 shows profile elevations on Dissociation

(T=72), Sexual Conflict (T=68), and Dysphoria (T=64). High scores on the
Dissociation factor indicate pronounced discontinuities in mental life, generally
due to an inability to integrate painful or traumatic experience. Some patients
with high scores on this factor experience dissociative episodes (e.g., altered
states of consciousness, depersonalization, derealization). High scores on the
Sexual Conflict factor indicate disturbed attitudes toward sexuality, for example,
associating sex with danger and experiencing sexuality as shameful or
disgusting. The sample patient’s combined high scores on Dissociation and
Sexual Conflict are consistent with a history of sexual abuse and trauma. The
high score on Dysphoria indicates that the patient experiences considerable
emotional distress and is chronically susceptible to painful affect.

To facilitate interpretation of the Factor T-Scores, a brief summary description of

each factor is provided below. The summary descriptions do not necessarily
 26

capture the complexities and nuances of the factors. For more comprehensive
descriptions, please consult the complete listing of items and factor loading in
Appendix 1.

For additional information about the SWAP-200 factors and their derivation, see
Shedler & Westen, 2004b.

Summary Descriptions of SWAP-200 Factors

Psychological Health measures the positive presence of psychological

resources and capacities (e.g., ego strengths). It encompasses the capacity to
love, to use one’s talents and abilities effectively and creatively, to pursue long-
term goals, to respond to others’ needs and feelings, and to hear and make
constructive use of challenging information.

Psychopathy assesses attitudes and behaviors associated with antisocial

personality disorder and psychopathy. High scores are associated with increased
likelihood of unlawful behavior, disregard for the rights of others, lack of remorse,
deceitfulness, irresponsibility, exploitation of others, impulsivity, thrill seeking
behavior, and a tendency to abuse substances.

Hostility measures chronic anger, hostility, suspiciousness, and mistrust.

Narcissism assesses self-importance, grandiosity, arrogance, entitlement,

fantasies of unlimited success, and a tendency to treat others as an audience.

Emotional Dysregulation refers to a deficiency in the capacity to modulate and

regulate affect, so that affect tends to spiral out of control, change rapidly and
unpredictably, get expressed in extreme form, and overwhelm rational thought.

Dysphoria measures chronic feelings of depression, inadequacy, meaningless,

emptiness, and shame.

Schizoid Orientation assesses a pervasive impoverishment in both

relationships and mental life. Individuals who score high on this factor lack close
relationships, appear indifferent to human company or contact, think in concrete,
overly literal ways, and have a limited or constricted range of affect.

Obsessionality assesses excessive concern with rules and procedures,

preoccupation with detail, rigid adherence to routine, concerns about dirt and
cleanliness, a cognitive style characterized by intellectualization, and a tendency
to experience intrusive obsessional thoughts.

Thought Disorder (or schizotypy) assesses peculiarities in thinking and

reasoning and deficits in reality testing. Higher scores on this factor are
 27

associated with increased likelihood of having a biological relative with a

psychotic disorder.

Oedipal Conflict indicates a tendency to choose sexual or romantic partners

who are emotionally unavailable or inappropriate, to be overly sexually seductive
or provocative, and to become embroiled in romantic or sexual “triangles” that
involve a third party competitor.

Dissociation refers to disconnected thoughts, feelings, and memories, gaps in

memory, and a tendency to enter altered, dissociated states. Such discontinuities
in mental life are generally related to a history of trauma or abuse.

Sexual Conflict indicates disturbed attitudes toward sexuality. Sexual activity is

consciously or unconsciously associated with danger (e.g., injury, punishment),
sexuality is associated with guilt, shame, or disgust, and there may be a specific
sexual dysfunction.
 28

Annotated Bibliography
Shedler, J. & Westen, D., (2007). The Shedler-Westen Assessment Procedure
(SWAP): Making personality diagnosis clinically meaningful. Journal of
Personality Assessment, 89, 41-55.

An overview of the SWAP-200 instrument and research program. The best starting point
for practitioners and researchers new to the SWAP.

Lingiardi, V., Shedler, J., Gazillo, F. (2006). Assessing personality change in

psychotherapy with the SWAP-200: a case study. Journal of Personality
Assessment, 86, 23-32.

A case study of a patient with borderline personality disorder assessed with the SWAP-
200 at the start of treatment and after two years of psychotherapy. This is the most
therapy-relevant SWAP article, demonstrating the use of the SWAP for initial assessment
and for tracking personality change in intensive psychotherapy.

Westen, D., & Shedler, J. (1999a). Revising and assessing Axis II, Part 1:
Developing a clinically and empirically valid assessment method.
American Journal of Psychiatry, 156, 258-272.

Westen, D., & Shedler, J. (1999b). Revising and assessing Axis II, Part 2:
Toward an empirically based and clinically useful classification of
personality disorders. American Journal of Psychiatry, 156, 273-285.
These papers, published as a two-part series, are the seminal articles on the SWAP-200.
They describe the rationale, development, and validity of the instrument. Part 1
describes the normative sample and the development and validation of SWAP
personality disorder (PD) scores. Part 2 describes the research behind the SWAP
diagnostic syndromes (Q factors).

Shedler, J., & Westen, D. (2004a). Refining personality disorder diagnoses:

Integrating science and practice. American Journal of Psychiatry, 161, 1-
16.

This paper provides detailed SWAP-200 descriptions of DSM-IV personality disorders as

conceptualized by clinical practitioners and observed in clinical practice. It discusses the
limitations of the Axis II diagnostic system and offers recommendations for the next
revision of the DSM.

Shedler, J., & Westen, D. (2004b). Dimensions of personality pathology: An

alternative to the Five Factor Model. American Journal of Psychiatry,
161,1743-1754.

This paper describes the SWAP-200 factors and the methods used to derive them.
 29

Westen, D. & Shedler, J. (2007). Personality diagnosis with the Shedler-Westen

Assessment Procedure (SWAP): Integrating clinical and statistical
measurement and prediction. Journal of Abnormal Psychology, 116, 810-
822.
This paper addresses technical psychometric and methodological issues and presents
preliminary findings for the SWAP-II (the successor to the SWAP-200). Primarily for
technically oriented readers.

Spitzer, R.L., First, M.B., Shedler, J., Westen, D., & Skodal, M.D. (2008). Clinical
Utility of Five Dimensional Systems for Personality Diagnosis: A
“Consumer Preference” Study. Journal of Nervous and Mental Disease,
196, 356-374.

This article examines the clinical utility of the SWAP diagnostic system (SWAP
personality syndromes) relative to the DSM-IV diagnostic system and other dimensional
models of personality.

Zittel Conklin, C., & Westen, D. (2005). Borderline personality disorder as seen
in clinical practice: Implications for DSM-V. American Journal of
Psychiatry, 162: 867-875.

Russ, E., Bradley, R., Shedler, J., & Westen, D. (2008). Refining the construct of
narcissistic personality disorder: Diagnostic criteria and subtypes.
American Journal of Psychiatry, 165, 1473-1481.

Westen, D., & Harnden-Fischer, J. (2001). Classifying eating disorders by

personality profiles: Bridging the chasm between Axis I and Axis II.
American Journal of Psychiatry, 158, 547-562.
A selection of SWAP articles focusing on specific syndromes and disorders.
 30

Appendix 1: Psychological Health Index (highest ranked

items)

Item Score

Appreciates and responds to humor. 6.41

Is empathic; is sensitive and responsive to other peoples’ needs and feelings. 6.24
Tends to be conscientious and responsible. 6.24
Is able to use his/her talents, abilities, and energy effectively and productively. 6.18
Is able to form close and lasting friendships characterized by mutual support and 6.12
sharing of experiences.
Tends to express affect appropriate in quality and intensity to the situation at hand. 6.06
Generally finds contentment and happiness in life’s activities. 6.00
Is creative; is able to see things or approach problems in novel ways. 6.00
Has moral and ethical standards and strives to live up to them. 5.94
Is capable of sustaining a meaningful love relationship characterized by genuine 5.88
intimacy and caring.
Is able to assert him/herself effectively and appropriately when necessary. 5.82
Finds meaning in belonging and contributing to a larger community (e.g., organization, 5.76
church, neighborhood, etc.).
Is able to find meaning and satisfaction in the pursuit of long-term goals and ambitions. 5.76
Is articulate; can express self well in words. 5.71
Enjoys challenges; takes pleasure in accomplishing things. 5.65
Is capable of hearing information that is emotionally threatening (i.e., that challenges 5.65
cherished beliefs, perceptions, and self-perceptions) and can use and benefit from it.
Is able to find meaning and fulfillment in guiding, mentoring, or nurturing others. 5.59
Has the capacity to recognize alternative viewpoints, even in matters that stir up strong 5.41
feelings.
Appears to have come to terms with painful experiences from the past; has found 5.35
meaning in, and grown from such experiences.
Tends to elicit liking in others. 5.29
Appears comfortable and at ease in social situations. 5.24
Tends to be energetic and outgoing. 5.18
Has an active and satisfying sex life. 4.76
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Appendix 2: SWAP-200 Factor Structure

Factor Loading
Factor 1: Psychological health
Is capable of sustaining a meaningful love relationship characterized by genuine intimacy and caring 0.75
Is able to find meaning and satisfaction in the pursuit of long-term goals and ambitions 0.75
Is capable of hearing information that is emotionally threatening (i.e., that challenges cherished beliefs, 0.73
perceptions, and self-perceptions) and can use and benefit from it
Is creative, is able to see things or approach problems in novel ways 0.73
Is able to use his or her talents, abilities, and energy effectively and productively 0.72
Enjoys challenges, takes pleasure in accomplishing things 0.72
Is empathic, is sensitive and responsive to other peoples’ needs and feelings 0.71
Is able to assert himself or herself effectively and appropriately when necessary 0.71
Appreciates and responds to humor 0.71
Tends to elicit liking in others 0.67
Is articulate, can express self well in words 0.67
Is able to find meaning and fulfillment in guiding, mentoring, or nurturing others 0.66
Finds meaning in belonging and contributing to a larger community (e.g., organization, church, 0.65
neighborhood, etc.)
Appears comfortable and at ease in social situations 0.64
Tends to be energetic and outgoing 0.64
Has an active and satisfying sex life 0.62
Has moral and ethical standards and strives to live up to them 0.58
Tends to be conscientious and responsible 0.56
Factor 2: Psychopathy
Tends to engage in unlawful or criminal behavior 0.80
Tends to show reckless disregard for the rights, property, or safety of others 0.79
Tends to be deceitful, tends to lie or mislead 0.74
Appears to experience no remorse for harm or injury caused to others 0.69
Tends to be unreliable and irresponsible (e.g., may fail to meet work obligations or honor financial 0.68
commitments)
Takes advantage of others, is out for number one, has minimal investment in moral values 0.67
Tends to be unconcerned with the consequences of his or her actions, appears to feel immune or 0.67
invulnerable
Tends to act impulsively, without regard for consequences 0.67
Tends to abuse illicit drugs 0.67
Tends to abuse alcohol 0.61
Tends to seek thrills, novelty, adventure, etc. 0.58
Seeks to dominate an important other (e.g., spouse, lover, family member) through violence or intimidation 0.54
Repeatedly convinces others of his or her commitment to change but then reverts to previous maladaptive 0.53
behavior; tends to convince others that “this time is really different”
Tends to break things or become physically assaultive when angry 0.52
Factor 3: Hostility
Tends to be critical of others 0.64
Tends to be angry or hostile (whether consciously or unconsciously) 0.62
Is quick to assume that others wish to harm or take advantage of him or her, tends to perceive malevolent
intentions in others’
words and actions 0.61
Tends to hold grudges, may dwell on insults or slights for long periods 0.61
Tends to express intense and inappropriate anger that is out of proportion to the situation at hand 0.60
Tends to be oppositional, contrary, or quick to disagree 0.59
Tends to get into power struggles 0.56
Tends to elicit dislike or animosity in others 0.52
Tends to feel misunderstood, mistreated, or victimized 0.50
Factor 4: Narcissism
Seems to treat others primarily as an audience to witness own importance, brilliance, beauty, etc. 0.75
Appears to feel privileged and entitled, expects preferential treatment 0.69
Has fantasies of unlimited success, power, beauty, talent, brilliance, etc. 0.68
Seeks to be the center of attention 0.65
Has an exaggerated sense of self-importance 0.63
Tends to be arrogant, haughty, or dismissive 0.57
Tends to believe he or she can only be appreciated by, or should only associate with, people who are high- 0.55
status, superior, or otherwise “special.”
Tends to think others are envious of himself or herself 0.50
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Factor 5: Emotional dysregulation

Emotions tend to spiral out of control, leading to extremes of anxiety, sadness, rage, excitement, etc. 0.68
Emotions tend to change rapidly and unpredictably 0.68
Expresses emotion in exaggerated and theatrical ways 0.66
Is unable to soothe or comfort self when distressed, requires involvement of another person to help regulate 0.56
affect
Tends to become irrational when strong emotions are stirred up, may show a noticeable decline from 0.51
customary level of functioning
Tends to be overly needy or dependent, requires excessive reassurance or approval 0.48
Tends to “catastrophize”; is prone to see problems as disastrous, unsolvable, etc. 0.45
Factor 6: Dysphoria
Tends to feel he or she is inadequate, inferior, or a failure 0.60
Tends to feel life has no meaning 0.58
Tends to feel empty or bored 0.55
Tends to feel unhappy, depressed, or despondent 0.54
Appears to find little or no pleasure, satisfaction, or enjoyment in life’s activities 0.52
Tends to avoid social situations because of fear of embarrassment or humiliation 0.51
Tends to feel ashamed or embarrassed 0.50
Tends to feel like an outcast or outsider, feels as if he or she does not truly belong 0.49
Tends to feel listless, fatigued, or lacking in energy 0.48
Factor 7: schizoid orientation
Appears to have little need for human company or contact, is genuinely indifferent to the presence of others 0.58
Tends to think in concrete terms and interpret things in overly literal ways; has limited ability to appreciate 0.57
metaphor, analogy, or nuance
Appears unable to describe important others in a way that conveys a sense of who they are as people; 0.52
descriptions of others come across as two-dimensional and lacking in richness
Has little or no interest in having sexual experiences with another person 0.46
Tends to elicit boredom in others (e.g., may talk incessantly, without feeling, or about inconsequential 0.46
matters)
Lacks close friendships and relationships 0.45
Appears to have a limited or constricted range of emotions 0.43
Has little empathy, seems unable to understand or respond to others’ needs and feelings unless they 0.40
coincide with his or her own
Factor 8: Obsessionality
Tends to be overly concerned with rules, procedures, order, organization, schedules, etc. 0.72
Tends to become absorbed in details, often to the point that he or she misses what is significant in the 0.70
situation
Tends to adhere rigidly to daily routines and become anxious or uncomfortable when they are altered 0.62
Tends to be preoccupied with concerns about dirt, cleanliness, contamination, etc. (e.g., drinking from
another person’s glass,
sitting on public toilet seats, etc.) 0.54
Is troubled by recurrent obsessional thoughts that he or she experiences as senseless and intrusive 0.52
Tends to be stingy and withholding (whether of money, ideas, emotions, etc.) 0.44
Tends to think in abstract and intellectualized terms, even in matters of personal import 0.44
Has difficulty discarding things even when they are worn out or worthless; tends to hoard, collect, or hold on 0.43
to things
Is excessively devoted to work and productivity to the detriment of leisure and relationships 0.42
Factor 9: Thought disorder (schizotypy)
Reasoning processes or perceptual experiences seem odd and idiosyncratic (e.g., may make seemingly 0.70
arbitrary inferences; may see hidden messages or special meanings in ordinary events)
Tends to be superstitious or believe in magical or supernatural phenomena (e.g., astrology, tarot cards, 0.60
crystals, estrasensory perception, “auras,” etc.)
Perception of reality can become grossly impaired under stress (e.g., may become delusional) 0.49
Appearance or manner seems odd or peculiar (e.g., grooming, hygiene, posture, eye contact, speech 0.49
rhythms, etc., seem somehow strange or “off”)
Speech tends to be circumstantial, vague, rambling, digressive, etc. 0.45
Is extremely identified with a social or political “cause” to a degree that seems excessive or fanatical 0.41
Feels some important other has a special, almost magical ability to understand his or her innermost 0.40
thoughts and feelings (e.g., may imagine rapport is so perfect that ordinary efforts at communication are
superfluous)
Tends to confuse own thoughts, feelings, or personality traits with those of others (e.g., may use the same 0.37
words to describe the self and another person, believe the two share identical thoughts and feelings, or treat
the person as an “extension” of himself or herself, etc.)
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Factor 10: Oedipal conflict (histrionic sexualization)

Tends to choose sexual or romantic partners who seem inappropriate in terms of age, status (e.g., social, 0.63
economic, intellectual), etc.
Tends to become attached to, or romantically interested in, people who are emotionally unavailable 0.60
Tends to become involved in romantic or sexual “triangles” (e.g., is most interested in partners who are 0.59
already attached, sought by someone else, etc.)
Tends to be overly sexually seductive or provocative, whether consciously or unconsciously (e.g., may be 0.54
inappropriately flirtatious, preoccupied with sexual conquest, prone to “lead people on,” etc.)
Fantasizes about finding ideal, perfect love 0.44
Tends to be sexually possessive or jealous, tends to be preoccupied with concerns about real or imagined 0.38
infidelity
Factor 11: Dissociation
Tends to describe experiences in generalities, is unwilling or unable to offer specific details 0.59
Verbal statements seem incongruous with accompanying affect or incongruous with accompanying 0.57
nonverbal messages
Appears to experience the past as a series of disjointed or disconnected events; has difficulty giving a 0.53
coherent account of his or her life story
Tends to repress or “forget” distressing events or distort memories of distressing events beyond recognition 0.52
Tends to enter altered, dissociated state of consciousness when distressed (e.g., the self or the world feels 0.38
strange, unfamiliar, or unreal)
Expresses contradictory feelings or beliefs without being disturbed by the inconsistency, has little need to 0.37
reconcile or resolve contradictory ideas
Factor 12: Sexual conflict
Appears to associate sexual activity with danger (e.g., injury, punishment, contamination, etc.), whether 0.70
consciously or unconsciously
Tends to feel guilty or ashamed about his or her sexual interests or activities (whether consciously or 0.58
unconsciously)
Tends to see sexual experiences as somehow revolting or disgusting 0.54
Experiences a specific sexual dysfunction during sexual intercourse or attempts at intercourse (e.g., 0.48
inhibited orgasm or vaginismus in women, impotence or premature ejaculation in men)
When romantically or sexually attracted, tends to lose interest if other person reciprocates 0.36
Has difficulty directing both tender feelings and sexual feelings toward the same person (e.g., sees people 0.35
as respectable and virtuous or sexy and exciting but not both)