Diagnosing Personality Disorders

1. DiagnosingPersonalityDisorders Judy Hyde

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. The enduring pattern • Not better accounted for by an Axis I disorder • Not due to direct physiological effects of a drug, or medical condition

9. Not accounted for by: • Culture • Religious beliefs • Immigration • Stressful events • Axis I disorders • Medical condition • Communication, autistic or developmental disorder

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

11. 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

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

13. Treatment Planning Where there is a specific, consensually endorsed treatment approach: (eg. Symptom relief for anxiety - CBT; organicity - medical treatment and education etc.)

14. 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)

15. 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

16. 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)

17. 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

18. 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.

19. 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

20. Other benefits • Provides a comforting structure of questioning • Most clients can answer very personal questions while the professional is still a stranger

21. 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

22. 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

23. 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

24. 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

25. 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)

26. 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

27. Some different personality types

28. Psychopathic (Antisocial) PD • Struggles with: power, aggression/ terror of weakness • Defenses: omnipotent control, “malignant grandiosity”, projective identification, dissociation and acting out • Narcissistic structure

29. 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

30. The Psychopath

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

32. Aims of the psychopath

33. The Narcissistic Spectrum • Malignant narcissist (Kernberg) • Grandiose narcissist (Kohut) • Covert narcissist

34. 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 him/her • Arrogant or haughty behaviours or attitudes

35. 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 Narcissistic Personality Structure

36. Types of narcissism • Primarily Grandiose (phallic or malignant) • Primarily Depressed/depleted • Oscillating between Grandiose and Depressed/depleted

37. 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

38. 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

39. The Malignant Narcissist

40. Use guilt, splitting and fear of abandonment to achieve aims

41. Narcissistic aims:

42. 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

43. 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

44. 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

45. 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

46. Grandiosity is hidden

47. 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

48. Grandiosity is exposed

49. Affect • Negative and complaining • Boredom, Uncertainty • Dissatisfaction with professional and social identity • A lack of genuine commitment

50. 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