36 Adolescent Psychiatry, 2012, 2, 36-45

Assessment of Adolescent Personality Disorders Through the Interview of

Personality Organization Processes in Adolescence (IPOP-A): Clinical and
Theoretical Implications#
Massimo Ammaniti*,1, Andrea Fontana1, Audrey Clarkin2, John F. Clarkin2, Giampaolo Nicolais3
and Otto F. Kernberg2

1
Department of Dynamic and Clinical Psychology, Faculty of Medicine and Psychology, “Sapienza” University of
Rome
2
Personality Disorder Institute, New York Presbyterian Hospital, Payne Whitney Westchester. Weill Medical College of
Cornell University. Address: 21 Bloomingdale Road White Plains, N.Y.10605, USA
3
Department of Developmental and Social Psychology. Faculty of Medicine and Psychology, “Sapienza” University of
Rome

Abstract: In the field of developmental research, there is a pressing need to develop clinically sounded and empirically
grounded tools for the assessment of personality development in adolescence. After a review of the relevant literature on
adolescent personality disorders we present through empirical data and clinical material the IPOP-A, a semi-structured
interview for adolescents ranging from 13 years old to 21 years old. The IPOP-A seems to be promising to gather
information about processes that constitute the building blocks of adolescent personality organization.
Keywords: Adolescent personality disorders, assessment, borderline personality organization, IPOP-A, personality
development, semi-structured interview.

Adolescence represents a period of major changes and
challenges in personality development and character
formation (Blos, 1968). During this period, adolescents have
to accomplish many different developmental tasks, including
1) the integration of sexual maturation in an adult body
image (Laufer & Laufer, 1984); 2) the second separation-
individuation process with respect to caregivers (Blos,
1967); 3) the loss of infantile object ties (A. Freud, 1958); 4)
the establishment of a coherent, stable and original identity
often after getting through a period of experimentations and
crisis (Erikson, 1956); and 5) the development of pair-bonds
and romantic experience and the establishment of mature life
goals and ambitions (Kernberg, 1998). Also cognitive
changes with more mature functioning, such as the ability to
reflect on one’s own experience, play an important role
during this period (Ammaniti, Sergi, 2003; Fonagy, Target,
1997). Given these challenges, adolescence also represents a
second chance in the development of personality: a period of
deep re-organization of self and object representations that
gathers individuals into the realm of adulthood (Blos, Shane,
1981).
*Address correspondence to this author at Via Polonia, 2 Rome – 00198,
Italy / Department of Dynamic and Clinical Psychology, Faculty of
Medicine and Psychology, “Sapienza” University of Rome, Italy; Tel: +39
06 84242173; Fax: +39 06 84242173; E-mail: maammani@tin.it
#
Presented at the Congress of the International Society for Adolescent
Psychiatry in Berlin September 16, 2011.
Clinicians and researchers also suggest that adolescence
is the onset period of major psychopathological troubles and
personality disorders (Chen, Cohen, Crawford, Kasen, Guan,
& Gordon, 2009; Kasen, Skodol, Johnson, & Brook, 1999;
Laufer & Laufer, 1984; Blos & Shane, 1981). But the
diagnosis of personality disorders during adolescence is still
a controversial issue. Despite the fact that DSM-IV-TR
(APA, 2000) stated that adolescence is the onset period of
personality disorders, the APA manual suggests avoidance of
formulating personality disorders diagnosis during
adolescence (Westen, Chang, 2000). In the past two decades,
researchers have collected empirical data to address the
major issues in the study of adolescent personality
pathology. Empirical research suggests that during
adolescence: (1) personality disorders can be diagnosed
using DSM criteria; (2) the diagnosis of personality disorders
shows moderate stability over time; (3) adolescent
personality disorders are associated with a high risk of Axis I
and Axis II diagnosis in adulthood; (4) personality disorders
are associated with substance use and conduct disorders; (5)
underlying personality pathology is crucial in understanding
the prognosis of adolescent symptomatology (Bernstein,
Cohen, Velez, Schwab-Stone, Siever, & Shinsato, 1993;
Grilo, Walker, Becker, Edell, & McGlashan, 1997;
Crawford, Cohen, Johnson, Sneed, & Brook, 2004; Cohen,
Chen, Crawford, Brook, & Gordon, 2007; Crawford, Cohen,
First, Skodol, Johnson, & Kasen, 2008; Chen et al., 2009).
The validity of the DSM approach to the assessment of
adolescent personality disorders is controversial. Since DSM
utilizes adult criteria for the assessment of personality during

2210-6766/12 $58.00+.00 © 2012 Bentham Science Publishers

Assessment of Personality Disorders
adolescence, this approach fails to recognize the specific
developmental characteristics of adolescent personality
disorders, impeding the identification of syndromes that
could be differently expressed in adolescents (Bradley, Zittel
Conklin, & Westen, 2005). Furthermore, the DSM is
centered on observable phenomenological behaviors that
could quickly change during adolescence while the
underlining psychological functioning could remain stable or
arrested by developmental blockages (Foelsch, Odom &
Kernberg, 2008; PDM Task Force, 2006). Another important
issue is that DSM does not address the presence of gender
differences in the phenomenological expression of
adolescent personality disorders. In their empirical research,
Bradley, Zittel, Conklin and Westen (2005) found significant
gender differences in borderline personality disorder
features, with females more emotionally dysregulated and
males more externalizing and behaviorally aggressive.
A PSYCHODYNAMIC ORIENTED FRAMEWORK
FOR THE ASSESSMENT OF PERSONALITY DEVE-
LOPMENT
Recently, a consistent effort has been made in promoting
a psychodynamic oriented assessment of personality
disorders even during adolescence (PDM Task Force, 2006).
Otto and Paulina Kernberg made a major contribution in this
realm pointing out the differences between personality
organization and personality disorder, with the former
represented by quite stable psychological functions and the
latter referable to observable constellations of behaviors
indicated by the DSM. The key features of the assessment
procedure with adolescents should take into account the
crucial importance of differentiating between normal identity
crisis and identity diffusion, the quality of object relations,
the capacity to modulate affective experience with particular
importance given to the modulation of aggression, the
development of a healthy moral values system, the reality
testing and finally, the defensive functioning (O. Kernberg,
1998; P. Kernberg, Weiner, & Bardenstein, 2000). Not all
those dimensions have the same weight in the assessment of
adolescents.
Since the consolidation of identity is one of the most
important task of adolescence, the evaluation of identity
should play a central role during the assessment of
adolescents (Westen, Betan, & Defife, 2011). Owing to the
groundbreaking work of Erik Erikson, we can look at
identity as an overall synthesis of ego functions, both
conscious and unconscious, and as something that is aligned
with group ideals and group identity (Erikson, 1956).
Kernberg’s conception of identity takes into account
Erikson’s view but also includes the importance of the
representation of significant others (Kernberg, 2006). During
their development, healthy adolescents show a progressive
integration of self-system by constructing conceptual
principles that coordinate the various and contrasting
features of the self into a coherent system (Damon & Hart,
1988). Especially in a early phase, adolescents may go
through a period of identity crisis defined as an acute but
transitory sense of confusion and puzzlement due to the
discrepancy between different experiences and perspectives
about self-image derived by a lack of confirmation and
recognition by significant others of the adolescent’s
Adolescent Psychiatry, 2012, Vol. 2, No. 1 37
changing identity (Erikson, 1956; Kernberg, 2006). Even if
confused, those adolescents show a deep and complex
representation of themselves and significant others, using
role experimentations to establish new identifications but
maintaining their efforts toward integration and a sense of
sameness through crisis. Identity pathology in adolescence is
characterized by a sense of incoherence and a lack of
integration in the representation of self and significant
others, presence of vague beliefs and inconsistencies in
behaviors, conformist over-identification with groups or
roles instead of looking for authenticity, and difficulties with
commitment to values and goals (Wilkinson-Ryan, Westen,
2000; Kernberg, 1998).
Looking at the quality of object relations during
adolescents, clinical and empirical literature highlight that
the first developmental task during adolescence is turning
away from parents (Ammaniti & Sergi, 2003; Hauser &
Schmidt, 1991). There are clear indications that in
adolescence the reliance on parents as exclusive attachment
figures decreases (Allen & Land, 1999) and that a second
separation-individuation process is promoted during
adolescence (Blos, 1967). This process involves reducing
emotional investment in parents and re-focusing and re-
directing partially this investment to relationships with peers
or nonfamily members. Even if the importance of parents as
attachment figures decreases in term of time spent with
parents and emotional closeness, parent-child relationship
remains a strong affective bond and a secure base modified
by the renegotiation of decision making, from unilateral
authority held by parents to mutuality (Ammaniti & Sergi,
2003). Another developmental task is forming pair-bonds: in
early adolescence romantic relationships are perceived in an
idealized and stereotypical way and the choice of a partner is
influenced by the expectations of the social group and by
status attainment. In contrast, during late adolescence and
early adulthood the attachment and caregiving systems
become more prominent in romantic relationships. In the
context of pair-bonds, adolescents’ experiences of their first
sexual intercourse are influenced by attachment patterns and
internal working model of relationships (Ammaniti, Nicolais,
& Speranza, 2007). Severely disturbed adolescents often
evidence impairment in the second-individuation process
from caregivers and difficulty investing in peer and romantic
relations as significant pair-bonds.
Affect regulation represents another crucial aspect in the
assessment of personality during adolescence (Hauser &
Schmidt, 1991). Affects give color to the internal experience
and represent the lexicon of the interpersonal relationship
(Cassidy, 1994; Langlois, 2004; Weinberg & Klonsky, 2009;
Shore, 2009). Affect regulation is based on interaction
between temperament and interpersonal relationships and
experiences during infancy, childhood and adolescence with
parents, family, peers and significant others. Moreover,
affect regulation is a sensitive index of the healthy
personality and its dysregulation constitutes one of the main
characteristics of borderline personality (Fonagy, Bateman,
2008). During adolescence, affective growth is
interconnected to ego developmental trajectories (Hauser &
Schmidt, 1991; Hauser & Safyer, 1994) and mentalizing
38 Adolescent Psychiatry, 2012, Vol. 2, No. 1 Ammaniti et al.

attitudes that help adolescents to shape and modulate their
affective experiences (Fonagy, Gergerly, Jurist, & Target,
2002). While healthy adolescents experience a wide range of
affects and reach the full capacity to modulate affective
states especially in late adolescence, most troubled
youngsters show a severe impairment in the capacity to
experience, modulate and share in others’ affective states.
EMPIRICAL AND CLINICAL DEVELOPMENT OF
THE INTERVIEW OF PERSONALITY ORGANIZA-
TION PROCESSES IN ADOLESCENCE
Valid and reliable psychoanalytically oriented tools –
those that evaluate personality functioning and not just a
collection of symptoms of personality disorders— are useful
to identify the main resources of young patients, the main
dimensions and mental functions on which clinicians should
pay peculiar attention during treatment, and the blocks that
contribute to promote psychic breakdowns (see Westen,
Dutra, & Shedler, 2005). Kernberg developed a clinical
procedure to assess the presence of personality pathology in
adults and adolescents, well known as the Structural
Interview (Kernberg, 1984). This procedure was
operationalized for empirical research through the Structured
Interview of Personality Organization (STIPO; Clarkin,
Caligor, Stern, & Kernberg, 2003; Horz et al., 2009; Stern et
al., 2010). Starting from this interview we developed an
adolescent version of the STIPO named Structured Interview
of Personality OrganizationAdolescent Version (STIPO-A)
that represents the first adaptation of the adult STIPO for
adolescence. STIPO-A assessed the same domain of the
adult STIPO: identity diffusion, quality of object relations,
primitive defenses, coping and rigidity, aggression and moral
values.
In the changing process from STIPO to STIPO-A, we
have modified the sequence of item presentation, simplified
the language in which questions were presented, and
radically adjusted the scoring system. After those
modifications, we performed an exploratory empirical study
to get the first empirical data on the psychometrical
properties of the interview—reliability, convergent validity
and capacity to differentiate between normal and clinic
adolescents (Fontana, Ammaniti, 2010). We collected a
sample of 70 adolescents (mean age = 16.2; SD = 1.4)
ranging from 14 to 18 years old, whom we interviewed using
the STIPO-A and other psycho-diagnostic tools. Thirty-five
adolescents were collected from a clinical population
recruited from therapeutic community treatment settings and
from outpatient clinical departments in the city of Rome,
while 35 adolescents were taken from a general population,
recruited in schools close to our research department. Fifty
percent of the adolescents from the clinical group evidenced
severe DSM Axis II personality disorders – the most
prominent disorders were borderline personality disorders
and narcissistic personality disorder. We assessed STIPO-A
reliability through two different methods: (1) Intra-Class
Correlation coefficients (ICC) and (2) Cronbach’s alpha. The
results were excellent since the ICC coefficients of two
independent raters blinded to the primary aims of the study
ranged from .87 to .81. Also Cronbach’s alpha index results
were excellent ranging from .96 to .81. Afterwards, we
evaluated the convergent validity between STIPO-A
dimensions and variables measured by other tools through
Spearman’s rank correlation coefficient. We assessed the
convergence between identity and object relations domains
and the severity of DSM Axis II diagnosis using the Millon
Adolescent Clinical Inventory (MACI; Millon, Davies, &
Millon, 1993). MACI is a well known and well studied self-
report for the assessment of DSM Axis II personality
disorders in adolescence. It is based on 160 items that cover
the major DSM-IIIR and DSM-IV Axis II personality

Table 1. Correlations between STIPO-A Domains and MACI Personality Patterns

STIPO-A Identity Domain STIPO-A Quality of Object Relations Domain

MACI Personality Patterns
Spearman's rho p (p<.002) Spearman's rho p (p<.002)

Introversive (schizoid) 0.48 0.000 0.40 0.001

Inhibited (avoidant) 0.47 0.000 0.48 0.000

Doleful (depressive) 0.56 0.000 0.58 0.000

Submissive (dependent) -0.39 0.001 -0.36 0.002

Dramatizing (hystrionic) -0.51 0.000 -0.50 0.000

Egotistic (narcisistic) -0.51 0.000 -0.46 0.000

Unruly (antisocial) 0.37 0.002 0.30 0.011

Forceful (sadistic) 0.35 0.003 0.25 0.040

Conforming (obsessive) -0.68 0.000 -0.62 0.000

Oppositional (passive-aggressive) 0.53 0.000 0.53 0.000

Self-demeaning (masochistic) 0.51 0.000 0.52 0.000

Borderline tendency 0.60 0.000 0.61 0.000

Assessment of Personality Disorders Adolescent Psychiatry, 2012, Vol. 2, No. 1 39

Table 2. Correlations between STIPO-A Identity Domain and HCAM Scales

STIPO-A Identity Domain

HCAM Scales
Spearman's rho p

Ability to look after own body needs -0.90 0.000

Ability to learn and work -0.77 0.000

Ability to tolerate frustration and control impulses -0.80 0.000

Relationship with parents or caretakers -0.88 0.000

Relationship with siblings -0.83 0.000

Relationships with peers outside the family -0.82 0.000

Relationships with adults outside the family -0.86 0.000

Development of confidence and self-esteem -0.90 0.000

Ability to cope with very stressful events -0.88 0.000

General mood and variability of mood -0.87 0.000

Sexual development -0.85 0.000

Play. hobbies. interests -0.82 0.000

Sense of moral responsibility -0.80 0.000

Ability to adapt to changed circumstances -0.87 0.000

disorders, referring the subjects to different norms depending
from gender and age.
High levels of identity diffusion measured by the STIPO-
A were related to the presence of severe personality
disorders and poor quality of object relations were related to
the presence of severe personality disorders especially those
referable to DSM Axis II Cluster A and B.
We also assessed the convergence between the severity
of identity diffusion and the severity of emotional and social
impairment measured by the Hampstead Child Adaptation
Measure (HCAM; Target, Fonagy, Schneider, Janes, &
Hillman, 2000). The HCAM is a 100-point rating scale that
provides a systematic psychodynamically-oriented method
of assessing a child’s socio-emotional adaptation based on
Anna Freud’s concept of developmental lines (Freud, A.,
1963, 1974), covering both the adolescent’s strengths and
difficulties. This measure has shown satisfactory reliability
and validity (Fonagy & Target, 1996; 2002).
Those results were encouraging since high levels of
identity diffusion as measured by the STIPO-A were related
to severe global impairment in socio-emotional
development.
In the changing process from STIPO-A to IPOP-A, we
looked at the data previous described in order to detect items
with low item-total scale correlation (r < .70). Our main
purpose was to shorten the interview, since STIPO-A took
two hours and half to be administered running the high risk
of being boring for adolescents. Following data analysis and
clinical impressions gathered through the administration of
the interview, we dropped items from the identity and quality
relations sections, and we built a new domain about affect
regulation that was not considered in the STIPO-A. Then, we
decided to name the interview as IPOP-A, which stands for
Interview of Personality Organization Processes in
Adolescence (Ammaniti, Fontana, Kernberg, Clarkin, &
Clarkin, 2011). This change was made in order to stress the
difference between the adult version measure and the latest
one and to highlight the assessment of the developmental
processes of personality made through the IPOP-A rather
than the evaluation of the structure of personality made by
the STIPO, with the latter that is pertinent to adult’s
assessment.
The final version of IPOP-A is based on three domains
related to (1) identity formation, (2) object relations and (3)
affect regulation. The identity domain differentiates between
normal identity crisis and identity diffusion assessing several
issues linked to identity consolidation like representation of
self and significant others, sense of self-sameness across
changes, regulation of self-esteem, integration of bodily and
sexual changes in a realistic and mature body image,
capacity to invest in school activities, hobbies, and future
goals (i.e. vocational choices). The object relations domain
assesses the quality of adolescent’s interpersonal functioning
with peers, with caregivers, and with romantic mates. The
affect regulation domain assesses the capacity to be aware
of, to experience, and to modulate affects (i.e. rage, shame,
guilt, joy, sexual excitement etc..). Following Hauser’s
suggestions (Hauser & Schmidt, 1991; Hauser & Safyer,
1994), we preferred to inquire about the adolescents’
affective experiences not through direct questions but rather
40 Adolescent Psychiatry, 2012, Vol. 2, No. 1
Table 3. Domains and Items Changes from STIPO to IPOP-A
STIPO STIPO-A
Domains N of items Domains
Identity 29 Identity
Quality of object relations 22 Quality of object relations
Primitive defenses 9 Primitive defenses
Coping and rigidity 8 Coping and rigidity
Aggression 11 Aggression
Moral Values 8 Moral Values
TOTAL 87
by presenting to them typical scenes taken from everyday
life and asking them how they would feel, react to and
experience those situations. For example, in assessing the
affective experience of rage toward others we presented to
adolescents the following scenario: “When your parents
forbid you to come home later than your usual curfew
because you want to go to a special party or out with your
friends, how do you feel? Please, give me an example.”
These kinds of questions allow healthy adolescents to get
inside the emotional situation and to tell their affective
experience considering different emotional nuances, while
the most disturbed ones reply in incoherent ways, changing
topics or, for example, focusing upon how good or bad their
parents are, completely neglecting the affects prompted by
the IPOP-A question.
The IPOP-A scoring system is tailored for adolescents
ranging from 13 years old to 21 years old and it takes into
account gender differences and different phases of
adolescence (i.e. what is common and healthy for a 13 year
old boy about sexual experience should not be expected and
healthy for a 19 year old boy). The final version of the
interview is made up of 41 items and requires one hour to be
administered.
CASE PRESENTATIONS
We present two clinical cases to show how IPOP-A could
help clinicians to highlight differences between adolescent’s
personality processes and to better understand personality
functioning. The two patients presented are part of a larger
group of adolescents who participated in the ongoing IPOP-
A’s validation study. They were seen in private practice,
brought by their caregivers for a consultation. The IPOP-A
and the other tool presented were administered after the
second session. Both adolescents were white and belonged to
middle class families. For reason of length, we will report
verbatim just the first three questions of the interview in
order to make a comparison between the two adolescents.
Both interviews were audio-recorded for research purposes
after obtaining written consent from the adolescents and their
caregivers.
Flavio
Flavio was seen for evaluation when he was 14 years old.
He evidenced the presence of severe anxiety connected to a
Ammaniti et al.
IPOP-A
N of items Domains N of Items
35 Identity 16
29 Quality of object relations 11
9 Affective regulation 14
8
11
9
101 41
fear about the existence of eternal life. His concerns were
particularly focused about the consequences of his actions
and behaviors. After the first session, he decided to stop the
consultation. He came back for a second consultation when
he was 16 years old. The presence of anxiety was still
alarming; this time it was connected to the fear of being
forgotten by others, hence ceasing to exist in their minds,
and in a sense disappearing. In particular, Flavio wondered if
he would leave a mark or not. His caregivers brought him to
the consultation, connecting Flavio’s difficulties to their
traumatic separation since he did not accept it at all.
#1 IPOP-A Question: Identity – self-description,
superficiality versus depth
I.: Today, I’d like to interview you instead. Let’s start. If you
only had a few minutes, how would you describe yourself?
What kind of person do you think you are?
F.: Well, I consider myself a sportsman. And I am always
loyal to a friend; I am one of those people who believe that,
in a friendship… Friendship is the most important thing. And
I believe that what I am today, I have chosen it. I am
perfectly aware and happy of what I am, because I chose it.
I.: So, let’s see, you used certain expressions to describe
yourself, a sportsman, a friendly person…
F.: Yes, I believe friendship is the most important thing.
I.: So, what you mean is open towards your friends, that you
give great importance to friendship. And the third thing is
that you are well aware and confident of who you are, right?
F.: Of course.
I.: Is that so…?
F.: Yes. There’s an expression I like very much, “What I am,
I chose to be.” 1,
I.: I would like you to give an example for each one of these
qualities, to explain what you mean.
F.: Ok.
I.: Let’s start with sportsman.
1
The Italian expression is "Quello che sono l'ho voluto io"
Assessment of Personality Disorders
F.: An example… It means I spend most of my time, well, a
good portion of my time doing sports. I play rugby, three
practices a week plus a game on Sunday. And when I get the
chance, I might play a football or tennis match with my
friends.
I.: Perfect. And what about being open and helpful towards
friends?
F.: Right, I used the adjective loyal. Having had… I mean,
friendship is the most important thing. Having had a family
that… Let’s say, my parents’ separation was hard. The lack
of loyalty between friends has become a serious issue for
me. I obviously want to avoid all that happened to me, or to
my mother …. Loyalty is one of the fundamental elements to
maintain a balance. Then the ‘What I am, I chose it’, in the
sense that I don’t let others influence me. I don’t know… For
example, I like to dress smartly. It’s not that if I’m going out
with friends who dress casually… You know, on Sunday,
one might go out with jeans, I might wear a jacket instead,
not a suit jacket, but I just dress a bit more elegantly than the
others, I don’t feel embarrassed because of this, I don’t ask
myself “Oh God, what will they think”. I know what I want
and who I am. If this is what I am, if I am this kind of
person, it’s because I wanted it. It’s not a consequence of
other factors, I don’t depend on anything.
I.: So with your friends, you use your clothes…
F.: Exactly, my way of being is that I am like this,
independently from other things. It’s the other things that
depend on me, on what I want.
#2 IPOP-A Question: Identity – self-description,
coherence versus incoherence
I.: I was wondering… How do you put together the fact of
being open to friendship and loyal and the fact of being so
determined about what you want?
F.: Why? What do you mean with ‘how do I put the two
things together’?
I.: In the sense that, being loyal to friends means referring to
others and so on…
F.: But, I mean that according to me friendship must be
based upon loyalty, so I will never betray a friend…
I..: Yes, I understand that. What I meant is that on one side
there is openness towards others and loyalty towards others,
but on the other side is a certain concentration on yourself;
it’s a bit as if there were a centre of attraction in others and
another centre in yourself, do you see what I mean?
F.: Oh, OK. So how do I make these two things coincide?
I.: Coincide is a bit too strong, but how do you make them
meet?
F.: Maybe by being well disposed towards others without
letting them influence me, without living in function of
others but maintaining my own identity. Wanting to be
helpful towards friends does not necessarily mean being
dominated or submissive, I mean, or doing whatever they
want. Yes, I always try to be loyal, helpful, open, outgoing,
while maintaining my identity.
Adolescent Psychiatry, 2012, Vol. 2, No. 1 41
#3 IPOP-A Question: Identity – self-esteem
I.: Are you satisfied with yourself?
F.: Yes, well enough. Anyway, there are some things you
want you can obtain yourself, but other things obviously
don’t depend on you, they don’t depend on me.
I.: And do you happen to compare yourself to other, to your
friends for example?
F.: Yes, of course.
I..: And comparing yourself to others, does your self-esteem
change or not?
F.: Ehm… no. It might sometimes happen, when doing
sports, that I see someone playing my same role, a guy with
more muscles, and I might think “I wish I were like him”. He
might just be more inclined to working out in the gym. Of a
friend or someone else, I might think ‘Look how good he is
at doing that thing, I wish I were like that’. But I always
maintain my self-esteem because I think we all have our
limits. No one is perfect, and if someone thinks he is perfect,
I believe he is just a perfect idiot ... That’s the thing; but
wanting to be perfect is different, I think. If you want to be
perfect it means you are asking more of yourself, but
believing you are perfect is like being nothing, according to
me…
I.: If I understand correctly, you are making a distinction…
F.: About wanting to be the best. Because many people
criticize me, well, not many, but some people I have
disagreed with have criticized me for always wanting to be
the best. And I sincerely have never considered this a bad
thing, because wanting to be the best means aiming high,
asking more of yourself, not settling for less; while thinking
you are the best is different. Because if I think I am the best,
it means I have a lot more to learn, a lot more to…
Those three IPOP-A questions evidence Flavio’s
preoccupations with orderliness, perfectionism and mental
and interpersonal control at the expense of flexibility,
openness and efficiency. This is particularly evident in his
clichéed reply about self-description and when Flavio
interpreted the second question about coherence as
“coincidence”. It seems that Flavio could not think about
different aspects of himself as psychological features that
could be linked together forming a core self, but as disparate
aspects that could coexist but not integrate. Flavio also
shows difficulties in taking into account possible negative
aspects of his self-image. Furthermore, he evidences troubles
in entering into adolescence as a period of experimentation
about the self, as it could easily be noted by his sharp and
defined replies (i.e. “I know what I want and who I am”) that
give no space for confusion and uncertainty. His refrain,
“What I am, I chose to be,” seems to highlight his
narcissistic concerns about fear of being influenced by others
and fear of relying too much on them. Flavio’s difficulties
are also outlined in IPOP-A’s affect regulation domain
where he tried to handle affective experiences with isolation,
compartmentalization and intellectualization. He has never
had any romantic relation. In order to avoid impulsivity
Flavio tends to over-focus on intellectual and idealistic
42 Adolescent Psychiatry, 2012, Vol. 2, No. 1
Fig. (1). Flavio: MACI personality pattern.
pursuits as also indicated by the MACI Personality Pattern.
From a clinical point of view Flavio’s diagnosis is obsessive-
compulsive personality disorder in the context of a neurotic
personality organization.
Adriano
Adriano, a 17 year old son of a cultivated middle class
family, was brought for consultation by his parents because
they were worried about his academic performance and
because he spent most of his time using his laptop computer,
chatting and smoking. Furthermore, Adriano showed few
investments in hobbies and other interests and, when he did
get involved in them, he frequently forgot his duties and
appointments. During the first session with his parents, he
clearly seemed to minimize the importance of his problems.
Even if he had a lot of friends around, he gave the
impression of having no intimacy with them. Moreover, he
was not involved in any romantic relationships. He seemed
to be concerned with the powers of others, especially those
of the opposite gender.
#1 IPOP-A Question: Identity – self-description,
superficiality versus depth
I: So, let’s start … I would ask you to tell me something
about you … what kind of person do you think you are?
A: It’s a difficult question
I: Yes, it is a quite broad question, but if you would like to
describe me how you are, in a short time, how would you
describe yourself?
A: I am easy going … I'm one who takes things very lightly,
although I think a lot … I mean … I take decisions lightly
although I think about them so much, although I think about
them a lot … I like having fun, I don’t like making any kind
of effort and things that I don’t want to do. I am a very
outgoing person, even if I can be nagging, I can be ...
Ammaniti et al.
I: When you say nagging, what do you mean?
A: I mean annoying, annoying, very immature in some
things, very mature in others , and ... stop, that’s all!
I: Well I think you have given me many adjectives that
describe you, is there any example or episode that could help
me to understand better what you said?
A.: Well, for example my parents know that I am very
immature about schoolwork, about … I don’t know … even
living alone, I would not be able to live alone because I don’t
know how to set limits on myself… but they know they can
trust me when I go out in the evening … I know what to do
in crisis situations, this also because I've been several times
in such situations with my friends ...
#2 IPOP-A Question: Identity – self-description,
coherence versus incoherence
I: You described yourself as a person who takes things
lightly, and at the same time thinks a lot. I wonder how you
can combine those so different aspects of yourself?
A: I mean, I take things very lightly, but there are some
things, some aspects with which I do not… I get fixated on
I: And what are those aspects with which you go deeper?
A.: I don’t know … girls, surely, social life ...
I: Girls, you mean that you think about them more than other
issues?
A.: Yes, I think about them more than other issues, about the
kind of behavior I have towards them, even the guys, about
the kind of behavior that I have with my friends … and about
the kind of behavior that they have toward me, I think about
it a lot ...
I: And what do you take lightly?
Assessment of Personality Disorders
Fig. (2). Adriano: MACI personality pattern.
A.: Each problem that I have, each problem at school, family
situations … no family situations no, I think a lot about
them, but I don’t know, also all the things that I don’t want
to think about ...
#3 IPOP-A Question: Identity – self-esteem
I: Listen, are you satisfied with yourself and how you are?
A.: On certain aspects yes, on others less
I: In which sense?
A.: For example, I believe that taking things lightly is both a
quality and a fault, taking things lightly makes your life
more peaceful ...
I: Right, but does this make you satisfied or not?
A.: Yes and no, because it also penalize me … and that’s all!
The three IPOP-A questions give evidence of Adriano’s
elusiveness: Adriano gives the impression of being
undefined with a lot of difficulty in talking about himself in
a vivid and in-depth way. Considering that Adriano is a 17
year old boy, his lack of subtlety and his confusing way of
addressing the first three questions about self-description and
self-esteem are quite surprising. His “yes and no” replies
communicate his confusing and confounding sense of self.
He seems not to be able to talk about himself, evidencing
some defensiveness in his approach to the interview. The
entire IPOP-A interview also evidences his self-dramatizing,
attention-seeking, provocative behaviors and the presence of
alcohol abuse during weekends. Adriano seems to act in a
chameleon-like manner, adapting his self-representations and
behaviors to other’s expectations. It is interesting to also take
into account his non-verbal communication during the
interview: like some adolescents, Adriano shows an
effeminate aspect that could represent a version of self-
dramatization. MACI Personality Patterns scales remain
under the clinical threshold, with high-point for histrionic
Adolescent Psychiatry, 2012, Vol. 2, No. 1 43
scale. From a clinical point of view, Adriano’s diagnosis is
histrionic personality disorder in the context of a high-level
borderline personality organization.
DISCUSSION
The IPOP-A seems to be a clinically and empirically
promising way to gather information about processes that
constitute the building blocks of adolescent personality
organization. The interview highlights the differences
between Flavio’s and Adriano’s self-representation: while
Flavio is rigid, controlled, over-defined and tends to talk
about himself in an intellectualized way, Adriano is elusive,
impressionistic, self-centered and emotionally detached in
talking about himself. Moreover, Flavio describes himself in
a stereotyped way, while Adriano is very superficial and
undefined. Looking at self-esteem, Flavio tends to regulate
his self-esteem by aspiring to be the best, “aiming high,
asking more of yourself, not settling for less,” and thus
running the risk to hold himself to unreasonably high
standards. On the contrary, Adriano clearly uses avoidance
to respond to the questions, using his superficial way of
replying and closing any possibility of confrontation with “
... and that’s all!”. Through his self-dramatizing and
attention-seeking style, Adriano also avoids confronting
himself with his difficulties.
The IPOP-A domains, especially identity and quality of
object relations, are also in line with DSM-5 revised criteria
for the assessment of personality functioning. The DSM-5
approach underlines that the assessment of the self (i.e.
identity and self-direction) and of interpersonal functioning
(i.e. empathy and intimacy) are crucial in the evaluation of
personality functioning (APA, 2010). It seems to us that
DSM-5’s identity and self-direction moderately overlaps
with the IPOP-A’s identity domain while DSM-5’s
interpersonal dimension is close to IPOP-A’s quality of
object relations domain.
44 Adolescent Psychiatry, 2012, Vol. 2, No. 1
ACKNOWLEDGEMENTS
We are grateful to Eve Caligor and Barry Stern for their
work on the STIPO, Pamela Foelsch for her comments and
suggestions, Claudio Bencivenga, Romana Panieri and
Chiara Cafaro for the help given gathering data, and to
Emanuele Preti for his cooperation in the inter-rater
reliability process.
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