TFP: CLINICAL ASSESSMENT

borderlinedisorders.com

Session 2: John F. Clarkin, Ph.D.

TAXONOMY OF PERSONALITY DISORDERS: CONTRASTING THE DSM AND OBJECT RELATIONS APPROACHES

1970s: Gunderson and Kernberg• Gunderson (Gunderson & Kolb, 1978): Collected clinical

descriptors manifested in the observable behavior of borderline patients; these would form the criteria for DSM-III (1980)

• Kernberg (1975): focused on the disturbed behaviors and the internal representations of self and others, suggesting these mental representations were identifiable, organized, and driving behavior

• In 1980, we began the investigation of TFP targeted to both the observable behaviors and the internal organization

Results of the Phenomenological Approach

• Search for the organization behind the 8-9 trait-like criteria in DSM

• Heterogeneity among those who met the criteria for the disorder

• Confused and unclear phenotype disrupts the search for underlying neurobiological factors

Ideas Behind the Development of DSM-5

• Notable difficulties with DSM-IV: heterogeneity within the PD diagnosis; rampant PD comorbidity; reliability but little validity

• Hyman(2011): • Too much emphasis on categories• Genes and neurobiology don’t result in clear categories• …schizophrenia and bipolar disorder might better be

conceptualized as interactions among continuous dimensions rather than well-bound categories

• Bring personality theory to bare on personality disorder diagnoses

Basic Emotional Systems (Pankseep, 2011)

PLAY/joy

PANIC/separation

CARE/nurturance

LUST/sexuality

FEAR/anxiety

RAGE/anger

SEEKING/expectancy

system

Emotional Operating Systems Filtered Through Lens of Object Relations

Confllicted, intense

Interactions with others

Distorted cognitive appraisal

Negative affect

Deficient efforfful control

Personality Disorder: DSM-5, Section 3

• Moderate or greater impairment in personality (self/interpersonal) functioning

• One or more pathological personality traits• Negative affectivity vs emotional stability• Detachment vs. extraversion• Antagonism vs. agreeableness• Disinhibition vs. conscientiousness• Psychoticism vs. lucidity

• Impairments are relatively stable across time

Level of Self and Interpersonal Functioning: DSM-5, Section 3• Self-functioning

• Identity• Self-direction

• Interpersonal functioning• Empathy• Intimacy

Levels (Least to Most Severe) of Personality Organization - Kernberg

Coping Rigidity

Identity Defenses Object Relations

Aggress-ion

Moral Values

Normal Flexibility Normal Normal Normal Modulat-ed

Present

Mild (Neurotic)

Rigidity Normal High Level Defenses

Conflicts Present

Severe (High Level BPO)

Inconsis-tent

Identity Diffusion

Primitive Defenses

Poor Varying degrees of aggress-ion

Variable

Most Severe (Low Level BPO)

Inconsis-tent

Identity Diffusion

Primitive Defenses

Poor Aggress-ion toward others

Lacking

Relationship between familiar, prototypic, personality types and structural diagnosis.Severity ranges from mildest, at the top of the page, to extremely severe at the bottom.

Arrows indicate range of severity. Kernberg & Caligor (2005). A psychoanalytic theory of personality disorders. In: Major Theories of

Personality Disorders, 2nd Ed. Eds: Clarkin & Lenzenweger. NY, Guilford, 115-156.

PERSONALITY DISORDERS: A TAXONOMY BASED ON THE OBJECT RELATIONS UNDERSTANDING OF PERSONALITY

Descriptive Features of Personality Disorder

Personality Disorders in general are distortions of normal personality characterized by:

• Rigidity or loss of flexibility of behavior patterns, resulting in poor adaptation

• Inhibition of normal behaviors• Exaggeration of certain behaviors• Chaotic alternation between inhibitory and impulsive

behavior patterns• Vicious circles develop: abnormal behaviors elicit

abnormal responses

Consequences of Personality Disorders:

- A reduction in the capacity to adapt to the psychosocial environment and to satisfy internal psychological needs (e.g., self-affirmation, sexuality, and dependency).

- In turn, personality disorders tend to be re-enforced by the pathological responses that patients elicit in their environment.

Axis II from a Personality Organization Point of View – Levels of OrganizationA mixed Categorical and Dimensional System

1-Normal flexibility and adaptation2-Neurotic level of personality organization3-Borderline level of personality organization:

• High level borderline• Low level borderline

4-Psychotic level of personality organization

Borderline Personality OrganizationThe Defining Characteristics

• Identity Diffusion vs. integrated view of self and others (internal sense of continuity)• No integrated concept of self• No integrated concept of significant others

• Primitive Defenses• Splitting• Idealization/devaluation• Projective identification• Omnipotent control• Denial

• Variable Reality Testing

Relationship between familiar, prototypic, personality types and structural diagnosis.Severity ranges from mildest, at the top of the page, to extremely severe at the bottom.

Arrows indicate range of severity. Kernberg & Caligor (2005). A psychoanalytic theory of personality disorders. In: Major Theories of

Personality Disorders, 2nd Ed. Eds: Clarkin & Lenzenweger. NY, Guilford, 115-156.

Borderline Personality Organization: Clinical Implications

• Nonspecific ego weakness• Lack of impulse control, anxiety tolerance

• Disturbed object relations• Difficulties with work and love• Sexual pathology (Two levels: inhibition of all sexual

functioning; chaotic sexuality)• Pathology of moral functioning

LAYING THE FOUNDATION FOR TREATMENT: CLINICAL EVALUATION

BEGINNING TREATMENT

AssessmentSessions

Discussion of Dx and Contracting Sessions

FamilySession Therapy

Pre-Therapy

TherapyBegins(or not)N.B.:

Often a Sense of Urgency

Goal: To move from Acting Out to Transference

• Patients with personality pathology suffer from an internal structure that results in difficulties in work, friendships, and intimate relations

• Treatment structure is essential in the treatment of personality pathology, especially in mid to severe ranges of personality pathology

CLINICAL ASSESSMENT

• The human individual is organized at multiple levels

• Personality is an organization which enables the individual to function

• Personality organization enables the individual to function in the interpersonal sphere

• Treatment choice is guided by personality organization, not simply by symptoms or conflicts (see Kernberg & Caligor, 2004)

Guiding Ideas

•Definition of terms so they are used by all in the same way

•Assessment that is reliable; done the same by everyone

•Assessment leading to the application of TFP to patients for whom it is intended

Advantages to Your Group for a Standard Assessment

• Neurotic organization• High level borderline organization• Low level borderline organization

Review of Personality Disorders from a Personality Organization Point of View

Personality Organization

 Figure 1Relationship between familiar, prototypic, personality types and structural diagnosis. Severity ranges from mildest, at the top of the page, to extremely severe at the bottom. Arrows indicate range of severity. *We include avoidant personality disorder in deference to the DSM. However, in our clinical experience, patients who have been diagnosed with avoidant personality disorder ultimately prove to have another personality disorder that accounts for avoidant pathology. As a result, we question the existence of avoidant personality as a clinical entity. This is a controversial question deserving further study.  

Structural Interview (Kernberg, 1984)

• Focus on the patient’s thinking and functioning in the present time

• Begins with standard questions:• What brings you here?• What are your current difficulties?• What do you expect from treatment?• In general, where are you now?

• Key questions assessing representations of self and others:• Describe yourself as a unique individual• Describe a significant other in detail

• Interviewer’s stance: therapeutic neutrality• Sequential use of clarification, confrontation, beginning

interpretations

• Combination of traditional psychiatric interview, with assessment of personality organization

• Standard sequence to the interview• Yield from the interview:

• Psychiatric diagnoses• Personality organization

The Structural Interview

• Patient: 43 year old male• Chief complaint: Nothing to live for; girl friend taken away• Focus of assessment: level of personality pathology;

treatment options

Symphora Tape: Structural Interview

Mild (Neurotic) Personality Pathology

Identity; advanced defenses; low aggression, moral values

Severe (High Level BPO) Personality Pathology

Identity diffusion; primitive defenses

Most Severe (Low Level BPO) Personality Pathology

Aggression; relative absence of moral values

Levels of Pathology and Major Dimensions (Identity, etc)

Mild (Neurotic) Personality Pathology

Transference InterpretationsTherapeutic Neutrality

Severe (High Level BPO) Personality Pathology

Contract SettingTransference InterpretationsIn and out of Therapeutic Neutrality

Most Severe (Low Level BPO) Personality Pathology

Questionable use of treatment

Levels of Pathology and Treatment

• Combination of traditional psychiatric interview, with assessment of personality organization

• Standard sequence to the interview• Yield from the interview:

• Psychiatric diagnoses• Personality organization

• Example: Symphora tapes

The Structural Interview

• Theory driven• Relationship of personality organization to treatment selection

• Coverage of major constructs dictated by the theory

• Semi-structured interview format to ensure reliability

Semi-Structured Interview: STIPO

• Identity• Object relations• Primitive defenses• Coping/rigidity• Aggression• Moral values• Reality testing and perceptual distortions

Constructs in the STIPO

Investment in work How important is work to you? Would you say you are

ambitious with respect to work and career? Investment in free time

On weekends, or in your free time, what interests do you pursue?

Sense of self Tell me about yourself…describe yourself so that I get

a live and full picture of you Representation of others

Tell me about (most important person)…

Identity

1. Consolidated identity2. Some areas of deficit, e.g., mild superficiality or

instability in sense of self3. Mild to moderate instability or discontinuity in sense of

self and others4. Marked instability and superficiality in sense of self and

others5. Severe: contradictory, chaotic views of self and others

Overall Rating of Identity

Interpersonal relations Do you have close friends? Tell me about your

friendship…what do you share with one another? Intimate relations and sexuality

Have you been involved in any romantic relationships in the past 5 years?

Do you find it difficult to experience tender feelings while still enjoying sex?

Internal working model of relationships What is it like for you when people close to you are in

need of comfort, or are in emotional distress?

Object Relations

1. Durable, realistic, nuanced, satisfying object relations2. Some degree of impairment in intimate relations3. Attachments present but superficial, flawed, need

fulfillment, limited empathy4. Attachments few and flawed5. Paucity of attachments, no capacity for empathy nor

sustained interest in others

Overall Rating of Object Relations

Paranoia Would you consider yourself someone who is

cautious about what other people know about you? Erratic behavior Idealization/devaluation

Do your feelings for people run “hot and cold”, change quickly?

Black and white thinking Primitive denial Externalization Projective identification

Primitive Defenses

1. No evidence of primitive defenses2. Some use of primitive defenses3. Shifts in perception of self and others and related

limited impairment in functioning4. Shifts in perception of self and others severe and

pervasive5. Pervasive use of primitive defenses; radical shifts of

perception of self and others

Overall Rating of Primitive Defenses

Anticipation When you are anticipating stressful events, do

you spend time planning ahead?SuppressionFlexibilitySelf-blameProactive copingPerfectionismShifting setsControlWorryingChallenges

Coping/Rigidity

1. Flexible, adaptive coping2. Adaptive coping, but less consistency and efficacy3. Inconsistent capacity for coping; vulnerable to stress

and rigid coping4. Rigid, maladaptive coping5. Pervasive maladaptive and inflexible coping

Overall Rating of Coping/Rigidity

• Self-directed aggression• Do you sometimes neglect your physical

health?• Do you at times do things that seem unwise

and potentially dangerous, e.g. unprotected sex, heavy drinking or drug use?

• Other-directed aggression• Do you lose your temper with others?• Have you at any time ever intentionally

seriously harmed someone physically?

Aggression

1. Control, modulation, integration of anger and aggression

2. Aggression through self-neglect, controlling interpersonal style

3. Self-directed , occasional tantrums, hostile verbal aggression

4. Aggression against others5. Serious danger to safety of others and/or self

Overall Rating of Aggression

• Behavior• Are there times when you deliberately deceive

others?• Have you ever done anything that is illegal?

• Guilt• Can you think of an example when you failed

to live up to your personal code? How did you feel? Would you say that you felt guilty?

Moral Values

1. Appropriate concern for unethical behavior; internal moral compass

2. No antisocial behavior; some conflict around personal gain and ethical behavior

3. Some unethical/immoral behavior4. Violent, aggressive antisocial behavior5. Violent, aggressive antisocial behavior; no notion of

moral values and guilt

Overall Rating of Moral Values

Prototypic Neurotic, High and Low Level BPO Patients

• Provides reliable assessment of level of personality organization

• Defines in concrete terms and questions psychoanalytic concepts such as identity

• Provides a method of empirically subgrouping patients (e.g., borderline, low level borderline)

• First step to measurement of change in personality organization

Uses of the STIPO

• Assessment of extraversion/intraversion, moral values, level and management of aggression, quality of object relations

Subtypes of BPD: Assessment Implications

0246810121416

NPOBPO-HighBPO-Low

STIPO Profiles on SNAP Based Categories

Antisocial Paranoia Aggression

Group I Low Low Low

Group II Moderate High Low

Group III High Moderate High

Finite Mixture Modeling: Groups of BPD Patients

• Group I: high Constraint, high Social Closeness, low Physical Abuse, low Depression and Somatization

• Group II: low Social Closeness, high Sexual Abuse

• Group III: high Negative Affect, low Constraint, high Depression and Somatization, high Identity Diffusion

Associated Features of the Three Groups