Tfp : Clinical assessment borderlinedisorders.com

1. Tfp: Clinical assessmentborderlinedisorders.com Session 2: John F. Clarkin, Ph.D.

2. Taxonomy of personality disorders: Contrasting the dsm and object relations approaches

3. 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

4. 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

5. 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

6. Basic Emotional Systems (Pankseep, 2011)

7. Emotional Operating Systems Filtered Through Lens of Object Relations

8. 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

9. Level of Self and Interpersonal Functioning: DSM-5, Section 3 • Self-functioning • Identity • Self-direction • Interpersonal functioning • Empathy • Intimacy

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

11. 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.

12. Personality disorders: A taxonomy Based on the Object relations understanding of Personality

13. 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

14. 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.

15. Axis II from a Personality Organization Point of View – Levels of OrganizationA 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

16. 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

17. 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.

18. 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

19. Laying the foundation for treatment: clinical evaluation

20. BEGINNING TREATMENT Pre-Therapy Assessment Sessions Family Session Discussion of Dx and Contracting Sessions Therapy Therapy Begins (or not) N.B.: Often a Sense of Urgency Goal: To move from Acting Out to Transference

21. 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

22. 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)

23. 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

24. Review of Personality Disorders from a Personality Organization Point of View • Neurotic organization • High level borderline organization • Low level borderline organization

25. 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.

26. 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

27. 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

28. 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

29. Levels of Pathology and Major Dimensions (Identity, etc)

30. Levels of Pathology and Treatment

31. 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

33. 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

34. Constructs in the STIPO • Identity • Object relations • Primitive defenses • Coping/rigidity • Aggression • Moral values • Reality testing and perceptual distortions

35. 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)…

36. Overall Rating of Identity • Consolidated identity • Some areas of deficit, e.g., mild superficiality or instability in sense of self • Mild to moderate instability or discontinuity in sense of self and others • Marked instability and superficiality in sense of self and others • Severe: contradictory, chaotic views of self and others

37. 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?

38. Overall Rating of Object Relations • Durable, realistic, nuanced, satisfying object relations • Some degree of impairment in intimate relations • Attachments present but superficial, flawed, need fulfillment, limited empathy • Attachments few and flawed • Paucity of attachments, no capacity for empathy nor sustained interest in others

39. 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

40. Overall Rating of Primitive Defenses • No evidence of primitive defenses • Some use of primitive defenses • Shifts in perception of self and others and related limited impairment in functioning • Shifts in perception of self and others severe and pervasive • Pervasive use of primitive defenses; radical shifts of perception of self and others

41. 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

42. Overall Rating of Coping/Rigidity • Flexible, adaptive coping • Adaptive coping, but less consistency and efficacy • Inconsistent capacity for coping; vulnerable to stress and rigid coping • Rigid, maladaptive coping • Pervasive maladaptive and inflexible coping

43. 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?

44. Overall Rating of Aggression • Control, modulation, integration of anger and aggression • Aggression through self-neglect, controlling interpersonal style • Self-directed , occasional tantrums, hostile verbal aggression • Aggression against others • Serious danger to safety of others and/or self

45. 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?

46. Overall Rating of Moral Values • Appropriate concern for unethical behavior; internal moral compass • No antisocial behavior; some conflict around personal gain and ethical behavior • Some unethical/immoral behavior • Violent, aggressive antisocial behavior • Violent, aggressive antisocial behavior; no notion of moral values and guilt

47. Prototypic Neurotic, High and Low Level BPO Patients

48. 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

49. Subtypes of BPD: Assessment Implications • Assessment of extraversion/intraversion, moral values, level and management of aggression, quality of object relations

50. STIPO Profiles on SNAP Based Categories