DiagnosingDiagnosing PersonalityPersonality DisordersDisordersDiagnosingDiagnosing PersonalityPersonality DisordersDisorders

Judy HydeJudy Hyde

Overview

• What is personality?• Why diagnose personality?• Levels of functioning• DSM-IV-TR approach • Personality pathology• Various personality types• Strengths and weaknesses of the DSM-IV

syndromal approach

What is Personality?

• Personality lies along a continuum from healthy to pathological

• It is founded on particular adaptations or arrests at various stages along the developmental path

Character structures/personality traits• Result in distinct clusters of defenses,

character structures, or personality traits

• These persist over time, become internalised and repeat as scripts

• They serve to assist us in managing anxiety and self-esteem

Character structures/Personality Traits (DSM-TR, p.686)

Enduring patterns of:• Perceiving• Relating to • Thinking about oneself and the

environment• In a wide range of social and personal

contexts

When is personality pathological?

• Where defenses become so rigid and inflexible that they are not adaptive

• Reality is distorted

• Psychological growth is prevented

• NB These were adaptive in early life

Diagnostic Criteria for a PD

• An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture.

• Is inflexible and pervasive• Leads to clinically significant distress or

impairment• Is stable and of long duration

The enduring pattern

• Not better accounted for by an Axis I disorder

• Not due to direct physiological effects of a drug, or medical condition

Not accounted for by:

• Culture• Religious beliefs• Immigration• Stressful events• Axis I disorders• Medical condition• Communication, autistic or developmental

disorder

Effects

Two or more of the following:• Cognition • Affectivity• Interpersonal functioning• Impulse control

Levels of personality functioning• Neurotic - stable, continuous, integrated

identity, with mature and flexible defenses, good reality testing

• Borderline - unstable, inconsistent, discontinuous identity, primitive defenses, adequate reality testing

• Psychotic - fragmented, confused, disorganised identity, primitive defenses, poor reality testing

Why Diagnose Personality? (McWilliams, 1994, P. 7-18.)

Treatment Planning

Where there is a specific, consensually endorsed treatment approach:

(eg. Symptom relief for anxiety - CBT; organicity - medical treatment and education etc.)

Prognostic Implications

Offers an appreciation of the depth and range of difficulties, attendant strengths and potential pitfalls in therapy (eg. An obsessive personality versus the development of a sudden intrusive obsession in response to a significant stressor)

Consumer Protection

• Gives accurate and realistic information about length and limits of therapy

• Conveys understanding of the depth of the client’s problem

• Allows both to withdraw from the illusion of a miracle cure or an unsustainable commitment to therapy

Communication of Empathy

Empathically communicates the understanding of underlying experiences (eg. The differing experiences of depression in depressive or narcissistic patients,

or the ‘manipulativeness’ of the sociopath - driven by a need for power, versus that of the borderline - driven by fear, despair and terror of abandonment)

What Is Empathy?

• Empathy is the capacity to feel what the other is feeling

• Empathy means feeling with, rather than feeling for (sympathy)

• Empathic responses essentially contribute to making a good diagnosis

Empathy Is NOT

• Warm, accepting, sympathetic reactions to the patient, no matter what they are communicating emotionally

• It is NOT a lack of empathy that allows us to feel hostility or fear in reaction to an emotional communication from a patient.

Forestalling Flight Risks

• Fears of dependency, need and vulnerability

• Attachment to the therapist stimulates dependency longings, which can be experienced as dangerous

• Counter-dependent people, whose self-esteem requires denial of their need for care from others, are humiliated by the importance of another person

Other benefits

• Provides a comforting structure of questioning

• Most clients can answer very personal questions while the professional is still a stranger

Dangers• Can detract from empathy if used

defensively• The individual can be lost in the category• Can limit understanding• Can be used pejoratively• Focus can be on the manifest problem,

without appreciation of the individual’s dynamics

• Misdiagnosis

DSM-IV-TR

• Clusters are defined by superficial similarities

• They are not based on theoretical understanding of personality structure and dynamics or research

• They are seriously limited and have not been validated

• PERSONLALITY CANNOT BE DETERMINED VIA DIRECT QUESTIONING OF SYMPTOMS AS PER AXIS I

Functional assessment:

• Motivation - What is wished for, feared, valued?

• Cognitive functioning - functioning, style, coherence, belief systems

• Affective functioning - intensity, lability, experience of affect, capacity for ambivalence

• Affect regulation - coping strategies, defenses, repertoire

functional assessment cont.

• Experience of self - continuity, coherence, agent, self-esteem, ideals, self presentation, identity

• Experience of others - wishes, fears, schemas

• Capacity for relatedness• Management of aggression• Emotional developmental history

Personality Disorder NOS

• Meets general criteria for a personality disorder

AND• Traits of several personality disorders are

present, but criteria for a specific personality disorder are not met

OR• The personality disorder is not included in

the classification (eg. Passive-aggressive PD)

Maladaptive personality traits

• eg. On Axis II: V71.09 No diagnosis, narcissistic personality traits

• Defenses can also be indicated, eg. Axis II: 301.50 Narcissistic personality disorder, frequent use of idealisation and denigration

Some different personality types

Psychopathic (Antisocial) PD

• Struggles with: power, aggression/ terror of weakness

• Defenses: omnipotent control, “malignant grandiosity”, projective identification, dissociation and acting out

Narcissistic structure

Psychopathic (Antisocial) PD

• Sees self as: polarised personal omnipotence/feared desperate weakness

• Presentation: Cold, hostile, remorseless, powerful, destructive

• Transference: projection of predation, sees clinician as selfish

• Countertransference: shock, resistance to identity eradication, intimidation, weak, powerless, hostility, contempt, moral outrage

The Psychopath

Psychopathic

• Childhood: insecure and chaotic; harsh discipline and overindulgence; absence of power, emotional deficit, no attachments

Aims of the psychopath

The Narcissistic Spectrum

• Malignant narcissist (Kernberg)

• Grandiose narcissist (Kohut)

• Covert narcissist

Narcissistic Personality DisordersA pervasive pattern of grandiosity (in fantasy or behaviour),

need for admiration, and lack of empathy. Five of:• Grandiose sense of self-importance• Preoccupation with fantasies of unlimited success, power,

brilliance, beauty, or ideal love• Believes he or she is ‘special’ and unique and can only be

understood by, or should associate with, other special or high status people.

• Requires excessive admiration• Has a sense of entitlement• Is interpersonally exploitative• Lacks empathy• Often envious of others, or believes others are envious of

him/her• Arrogant or haughty behaviours or attitudes

Narcissistic Personality Structure

OVERT:• Grandiose• Superior • Arrogant• Idealises the self

and ‘superior’ others

• Denigrates ‘inferior’ others

COVERT:• Depressed/empty• Inferior• Denigrates the self • Self-critical, self

persecutory• Idealises others and

fears their criticism

Types of narcissism

• Primarily Grandiose (phallic or malignant)

• Primarily Depressed/depleted

• Oscillating between Grandiose and Depressed/depleted

Shame versus guilt

• Shame – want to hide flaws

• Guilt – wants to confess

• Shame - Self-persecutory – whole person is attacked and denigrated

• Guilt – feels morally bad for specific acts

Common Features of narcissism

• Emotionally abandoned in childhood• Need mirroring from others• Values and feelings linked to external

evaluation• Lacks empathy • Feels empty• Others are not separate individuals –

shadowy figures

The Malignant Narcissist

Use guilt, splitting and fear of abandonment to achieve aims

Narcissistic aims:

Narcissistic PD

• Transference: lack of interest in the other, uses them as a mirror, idealising, devaluing

• Countertransference: boredom, irritability, sleepiness, vague sense of directionlessness; one is an audience, not an individual

Narcissistic PD (The grandiose narcissist)• Childhood: emotional abandonment &/or

narcissistic extension• Identity dependent on external validation,

difficulties with self-esteem regulation• Defenses: primitive idealisation and

devaluation

Narcissistic PD

• Sees self as: having merged with grandiose, idealised self, inadequacy, shame, weakness, inferiority is projected into others and denigrated, sense of falseness

• Presentation: self-assured, arrogant, grandiose, vain

Avoidant PD - (covert narcissist)

• Presentation: Shy, anxious, hypervigilant to criticism or failure

• Transference: Fear of criticism, being exposed as unworthy

• Countertransference: warmth, pity/ frustration, irritation, objectification

Grandiosity is hidden

Avoidant PD - (covert narcissist)

• Childhood: Critical parenting, lack of mirroring.

• Struggles with: inadequacy, failure BUT also: secret grandiosity, entitlement, & omnipotence, of which they are ashamed

• Defenses: primitive idealisation, envy, and denigration of others (splitting)/entitled and omnipotent in intimate relationships

• Sees self as: empty, depleted, a failure, unworthy, anxious BUT covert: grandiose, entitled and omnipotent

Grandiosity is exposed

Affect

• Negative and complaining

• Boredom, Uncertainty

• Dissatisfaction with professional and social identity

• A lack of genuine commitment

Histrionic (Hysterical) PD

• Struggles with: Safety and acceptance/seductiveness/ fear and guilt

• Defenses: Repression, sexualisation and regression

• Childhood: Gender-based power differential, attention to external or infantile attributes

Histrionic (Hysterical) PD

• Sees self as: a small, fearful and defective child coping in a world of powerful and alien others

• Presentation: Anxious, warm, energetic, intuitive, reactive, intense, superficial, labile, dramatic

Histrionic (Hysterical) PD

• Transference: differ according to gender. With male therapists females excited, intimidated and defensively seductive. Male clients vary according to whether greater power is assigned to maternal or paternal figures

• Countertransference: Defensive distancing, infantalisation, patronising, omnipotence

Obsessive-compulsive PD

• Struggles with: control and moral rectitude vs. feeling (right/wrong)

• Defenses: isolation, rationalisation, moralisation, compartmentalisation, intellectualisation, undoing, reaction formation and displacement of anger

• Childhood: High parental standards, expectation of conformity, strict, consistent, unreasonably exacting, condemning of feelings, thoughts and fantasies - controlling

Obsessive-compulsive PD

• Sees self as: guilty, anxious, responsible, self-doubting, loving

• Presentation: serious, righteous, hard-working, dependable, self-critical, conscientious, honest

Obsessive-compulsive PD

• Transference: experiences therapist as devoted, but judgemental and demanding, undertone of resentment, criticism, control

• Countertransference: Annoyed impatience, irritation, discouraged, undermined, distanced

Impact

• Sense of self• Relationships• Occupation

Strengths of syndromal diagnosis:

• Descriptive & atheoretical - non-etiological• Clinically useful, reliable and valid for Axis I• Contains proliferation of terminology• Provides consensual usage of terms• Useful for research• Simplifies complexity - parsimonious

Weaknesses of Axis II classification

• Promotes a disease or medical, rather than a biopsychosocial, model

• Ignores strengths which may rule out a PD - eg. loving, empathic narcissist

• Does not rate severity• Can pathologise normal behaviour• Ignores reality - Personality is dimensional not

categorical• Unlike Axis I disorders, PD cannot be assessed

using direct questions

Effect of research

• Limited number of narrow criteria (7-10 criteria)/disorder - evolved into multiple behavioural indicators of a single trait, eg, Paranoid PD - 6 redundant criteria for chronic mistrust, ignores thinking, motives, emotions and how they are dealt with

• To maximise internal consistency assign criteria without reason - eg. lack of empathy in Narcissism, not Paranoid or Antisocial PD

Effect of research

• If you can’t measure it, it doesn’t exist - loss of passive-aggressive PD

Difficulties for research

• Validity sacrificed for heightened reliability - test-retest, interrater

• Test-retest reliability >2 weeks remains unacceptably low

• No evidence these instruments validly assess constructs

• Cluster approach shows no validity and often disagrees with empirical findings from factor and cluster analyses

• Very poor relationship between instruments - self-report, clinical ratings and interview measures

Difficulties for research

• Particular lack of discriminant validity• Comorbidity - extensive overlap av no =

2.8 - 4.6 or more of a possibility of 10• Arbitrary thresholds with no theoretical or

empirical justification• Dichotomises continuous variables• Proliferation of PDs from 6 -> 13

Difficulties for clinicians.

• Clinicians deal with complexity, not simplicity - much gets lost or constrained by a focus on symptoms

• A large spectrum of personality patterns that do not meet criteria for a PD, but bring clients to treatment are not included (eg. intimacy, self-esteem, work)

• Clinicians prioritise PDs, rather than give multiple diagnoses

• Provides no real guide to treatment or the type of therapeutic relationship needed

• Lack of theory empties it of meaning

References

McWilliams, N. (1994). Psychoanalytic diagnosis: Understanding personality structure in the clinical process. Guilford Press, NY.

Shedler, J. & Westen, D. (1998). Refining the measurement of Axis !!: A Q-sort procedure for assessing personality pathology. Assessment, 5, 4, 333-353.

Westen, D. (1997). Divergences between clinical and research methods for assessing personality disorders: Implications for research and the evolution of Axis II. American Journal of Psychiatry, 154, 7, 895-903.

Westen, D. & Shedler, J. (1999a). Revising and assessing Axis I, Part I: Developing a clinically and empirically valid assessment method. American Journal of Psychiatry, 156, 2, 258-272.

Westen, D. & Shedler, J. (1999b). Revising and assessing Axis II, Part II: Toward an empirically based and clinically useful classification of personality disorders. American Journal of Psychiatry, 156, 273-285.

Westen, D. & Shedler, J. (2000). A prototype matching approach to personality disorders: Toward DSM-V. Journal of Personality Disorders, 14, 2, 109-126.