TFP: CLINICAL ASSESSMENT

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

borderlinedisorders.com
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)

PANIC/
separation

SEEKING/
CARE/
expectancy
nurturance
system

PLAY/joy

LUST/sexuali
RAGE/anger
ty

FEAR/
anxiety
Emotional Operating Systems Filtered
Through Lens of Object Relations
Negative
affect
Distorted Deficient
cognitive efforfful
appraisal control
Confllicted,
intense
Interactions
with others
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 Identity Defense Object Aggress Moral
Rigidity s Relation -ion Values
s
Normal Flexibility Normal Normal Normal Modulat- Present
ed
Mild Rigidity Normal High Level Conflicts Present
(Neurotic) Defenses
Severe Inconsis- Identity Primitive Poor Varying Variable
(High tent Diffusion Defenses degrees of
Level aggress-
BPO) ion
Most Inconsis- Identity Primitive Poor Aggress- Lacking
Severe tent Diffusion Defenses ion toward
(Low Level others
BPO)
 FIGURE 1

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 Organization
A mixed Categorical and Dimensional System

1-Normal flexibility and adaptation

2-Neurotic level of personality organization
3-Borderline level of personality organization:
• High level borderline
• Low level borderline
4-Psychotic level of personality organization
Borderline Personality Organization
The 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
 FIGURE 1

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
Pre-Therapy

Assessment Discussion of Dx and Family

Sessions Contracting Sessions Session Therapy

Therapy
Begins
N.B.: (or not)
Often a Sense of Urgency

Goal: To move from Acting Out to Transference

CLINICAL ASSESSMENT
• 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
Guiding Ideas
• 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)
Advantages to Your Group for a Standard
Assessment
• 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
Review of Personality Disorders from a Personality
Organization Point of View

• Neurotic organization
• High level borderline organization
• Low level borderline organization
 Personality Organization

Figure 1
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.

*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
The Structural Interview
• Combination of traditional psychiatric interview,
with assessment of personality organization
• Standard sequence to the interview
• Yield from the interview:
• Psychiatric diagnoses
• Personality organization
Symphora Tape: 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
Levels of Pathology and Major
Dimensions (Identity, etc)
Mild (Neurotic) Identity; advanced
Personality Pathology defenses; low
aggression, moral
values
Severe (High Level Identity diffusion;
BPO) Personality primitive defenses
Pathology
Most Severe (Low Level Aggression; relative
BPO) Personality absence of moral values
Pathology
Levels of Pathology and Treatment
Mild (Neurotic) Transference
Personality Pathology Interpretations
Therapeutic Neutrality
Severe (High Level Contract Setting
BPO) Personality Transference
Pathology Interpretations
In and out of
Therapeutic Neutrality
Most Severe (Low Level Questionable use of
BPO) Personality treatment
Pathology
The Structural Interview
• 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
Semi-Structured Interview: STIPO
• Theory driven
• Relationship of personality organization to
treatment selection
• Coverage of major constructs dictated by the
theory
• Semi-structured interview format to ensure
reliability
Constructs in the STIPO
• Identity
• Object relations
• Primitive defenses
• Coping/rigidity
• Aggression
• Moral values
• Reality testing and perceptual distortions
Identity
 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)…
Overall Rating of Identity
1. Consolidated identity
2. Some areas of deficit, e.g., mild superficiality or
instability in sense of self
3. Mild to moderate instability or discontinuity in sense of
self and others
4. Marked instability and superficiality in sense of self and
others
5. Severe: contradictory, chaotic views of self and others
Object Relations
 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?
Overall Rating of Object Relations
1. Durable, realistic, nuanced, satisfying object relations
2. Some degree of impairment in intimate relations
3. Attachments present but superficial, flawed, need
fulfillment, limited empathy
4. Attachments few and flawed
5. Paucity of attachments, no capacity for empathy nor
sustained interest in others
Primitive Defenses
 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
Overall Rating of Primitive Defenses
1. No evidence of primitive defenses
2. Some use of primitive defenses
3. Shifts in perception of self and others and related
limited impairment in functioning
4. Shifts in perception of self and others severe and
pervasive
5. Pervasive use of primitive defenses; radical shifts of
perception of self and others
Coping/Rigidity
 Anticipation
 When you are anticipating stressful events, do
you spend time planning ahead?
 Suppression
 Flexibility
 Self-blame
 Proactive coping
 Perfectionism
 Shifting sets
 Control
 Worrying
 Challenges
Overall Rating of Coping/Rigidity
1. Flexible, adaptive coping
2. Adaptive coping, but less consistency and efficacy
3. Inconsistent capacity for coping; vulnerable to stress
and rigid coping
4. Rigid, maladaptive coping
5. Pervasive maladaptive and inflexible coping
Aggression
• 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?
Overall Rating of 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 others
5. Serious danger to safety of others and/or self
Moral Values
• 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?
Overall Rating of 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 behavior
4. Violent, aggressive antisocial behavior
5. Violent, aggressive antisocial behavior; no notion of
moral values and guilt
Prototypic Neurotic, High and Low Level
BPO Patients
Uses of the STIPO
• 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
Subtypes of BPD: Assessment
Implications
• Assessment of extraversion/intraversion, moral values,
level and management of aggression, quality of object
relations
STIPO Profiles on SNAP Based
Categories
16
14
12
10
8
6
4
2 NPO
0 BPO-High
BPO-Low
 Antisocial Paranoia Aggression

Group I Low Low Low

Group II Moderate High Low

Group III High Moderate High

Associated Features of the
Three Groups
• 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