Training - Psychology - Macquarie University

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Transcript Training - Psychology - Macquarie University

Diagnosing Personality Disorders
Judy Hyde
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
adaptations or arrests at various
stages along the developmental path
Character structures/personality
• 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
• In a wide range of social and personal
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
• Is inflexible and pervasive
• Leads to clinically significant distress or
• Is stable and of long duration
The enduring pattern
• Not better accounted for by an Axis I
• Not due to direct physiological effects of a
drug, or medical condition
Not accounted for by:
Religious beliefs
Stressful events
Axis I disorders
Medical condition
Communication, autistic or developmental
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
development of a sudden intrusive
obsession in response to a significant
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
understanding of underlying experiences
(eg. The differing experiences of
depression in depressive or narcissistic
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
• Attachment to the therapist stimulates
dependency longings, which can be
experienced as dangerous
• Counter-dependent people, whose selfesteem requires denial of their need for
care from others, are humiliated by the
importance of another person
Other benefits
• Provides a comforting structure of
• Most clients can answer very personal
questions while the professional is still a
• Can detract from empathy if used
• 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
• Misdiagnosis
• Clusters are defined by superficial similarities
• They are not based on theoretical understanding
of personality structure and dynamics or
• They are seriously limited and have not been
Functional assessment:
• Motivation - What is wished for, feared,
• Cognitive functioning - functioning, style,
coherence, belief systems
• Affective functioning - intensity, lability,
experience of affect, capacity for
• 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,
• Capacity for relatedness
• Management of aggression
• Emotional developmental history
Personality Disorder NOS
• Meets general criteria for a personality
• Traits of several personality disorders are
present, but criteria for a specific
personality disorder are not met
• The personality disorder is not included in
the classification (eg. Passive-aggressive
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
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
The Psychopath
• 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 Disorders
A 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
• Arrogant or haughty behaviours or attitudes
Narcissistic Personality Structure
• Grandiose
• Superior
• Arrogant
• Idealises the self
and ‘superior’
• Denigrates
‘inferior’ others
• Depressed/empty
• Inferior
• Denigrates the self
• Self-critical, self
• Idealises others and
fears their criticism
Types of narcissism
• Primarily Grandiose (phallic or
• Primarily Depressed/depleted
• Oscillating between Grandiose and
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
Common Features of narcissism
• Emotionally abandoned in childhood
• Need mirroring from others
• Values and feelings linked to external
• 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,
• Countertransference: boredom, irritability,
sleepiness, vague sense of
directionlessness; one is an audience, not
an individual
Narcissistic PD (The grandiose
• Childhood: emotional abandonment &/or
narcissistic extension
• Identity dependent on external validation,
difficulties with self-esteem regulation
• Defenses: primitive idealisation and
Narcissistic PD
• Sees self as: having merged with
grandiose, idealised self, inadequacy,
shame, weakness, inferiority is projected
into others and denigrated, sense of
• 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
• 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
• 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
• 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,
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, hardworking, dependable, self-critical,
conscientious, honest
Obsessive-compulsive PD
• Transference: experiences therapist as
devoted, but judgemental and demanding,
undertone of resentment, criticism,
• Countertransference: Annoyed
impatience, irritation, discouraged,
undermined, distanced
• 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
• 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
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, 273285.
Westen, D. & Shedler, J. (2000). A prototype matching approach to
personality disorders: Toward DSM-V. Journal of Personality
Disorders, 14, 2, 109-126.