Establishing Levels of Personality Functioning Using the Structured Interview of Personality Organization (STIPO-R): A Latent Profile Analysis.

Both the new ICD-11 and the latest Alternative DSM-5 Model for Personality Disorders focus on self and interpersonal functioning as the central feature of personality pathology, also acknowledging that personality disorders are organized along a dimensional continuum of severity. This revised understanding is in line with long-standing psychodynamic conceptualisations of personality pathology, in particular Kernberg's object relations model of personality organization. Despite existing evidence for the clinical utility of the derived Structured Interview of Personality Organization (STIPO-R), empirical support for the identification of clear cut-points between the different levels of personality functioning is missing. For this purpose, a total of 764 adult participants were recruited across two clinical (outpatient and inpatient) settings (n = 250) and two non-clinical (university students and general community) samples (n = 514). Results from the mixture modeling suggested the existence of five groups across the clinical and non-clinical samples that covered: healthy personality functioning, maladaptive personality rigidity, and mild, moderate, and severe levels of personality pathology. All five indicators of personality organization were found to be reliable predictors of personality pathology. Of the five STIPO-R indicators, Aggression and Moral Values had the most discriminative power for differentiating between the Mild, Moderate, and Severe personality disorder groups. Implications of these findings are discussed.

A case report of the treatment of narcissistic personality disorder with transference focused psychotherapy.

The following case study provides a description of the transference-focused psychotherapy (TFP) treatment of a young man diagnosed with narcissistic personality disorder (NPD). TFP is an individual, psychodynamic therapy developed to treat a range of personality disorders. TFP is evidence-based for the treatment of borderline personality disorder and has been adapted for the treatment of NPD. This case illustrates the application of the strategies and techniques of TFP to treatment of NPD as well as challenges clinicians may face in arriving at timely diagnosis of the disorder. Although no specific treatment for NPD has been empirically validated, TFP utilizes the therapeutic techniques identified across modalities for successful treatment of pathological narcissism. This report describes how treatment interventions such as goal setting, developing a therapeutic alliance, using a treatment contract and addressing treatment interfering behaviors contributed to this patient's improvement in self-reflection, formation of healthier and more flexible ideas about self and other, increased self-agency, tolerance of normative disillusionments and increase in empathy.

Identifying Splitting Through Sentiment Analysis.

In Kernerg's Object Relations Theory model of personality pathology, splitting, the mutual polarization of aspects of experience, is thought to result in a failure of identity integration. The authors sought to identify a clinician-independent, automated measure of splitting by examining 54 subjects' natural speech. Splitting in these individuals, recruited from the community, was investigated and evaluated with a shortened version of the Structured Interview of Personality Organization (STIPO-R). A type of automated sentiment textual analysis called VADER was applied to transcripts from the section of the STIPO-R that probes identity integration. Higher variability in speech valence, more negative minimum valence, and more frequent shifts in valence polarity were associated with more severe identity disturbance. The authors concluded that the degree of splitting elicited during the description of self and others is related to the degree of identity disturbance, and to the degree of negativity and instability of these descriptions of self and others.

Approximating defense mechanisms in a national study of adults: prevalence and correlates with functioning.

Despite the clinical relevance of defense mechanisms, there are no published studies in nationally representative samples of their prevalence, correlates, and association with psychosocial functioning. We sought to estimate the prevalence and correlates of 12 defense mechanisms in the general adult population by approximating from items used to assess personality traits in the National Epidemiological Survey on Alcohol and Related Conditions (NESARC), a representative sample of US adults (N = 36,653). We examined the associations between sociodemographic characteristics and prevalence of 3 types of defenses mechanisms (pathological, immature, and neurotic). For each defense mechanism, we used the Short-Form 12 to compare psychosocial functioning among 3 groups: those who (1) endorsed the mechanism with self-recognized impairment, (2) endorsed the mechanism without self-recognized impairment, and (3) did not endorse the defense mechanism. The prevalence of defense mechanisms ranged from 13.2% (splitting) to 44.5% (obsessive/controlling behavior). Pathological defenses were more strongly associated with immature defenses (OR = 5.4, 95% CI = 5.2-5.6) than with neurotic defenses (OR = 2.0, 95% CI = 1.9-2.0), whereas the association between immature and neurotic defenses had an intermediate value between the other two (OR = 2.2, 95% CI = 2.1-2.2). Pathological and immature defenses were associated with younger age, having been never married, lower educational attainment, and lower income. After adjusting the crude results for age and sex, individuals who did not endorse a given defense generally had higher scores on the mental health component of the SF-12 than those who endorsed the defense without self-recognized impairment who, in turn, had on average higher scores than those with self-recognized impairment. These results suggest that neurotic, immature, and pathological defense mechanisms are prevalent in the general population and associated with psychosocial impairment. Recognizing defense mechanisms may be important in clinical practice regardless of treatment modality.

The Development of Transference-Focused Psychotherapy and Its Model of Supervision.

Transference-focused psychotherapy (TFP) is an empirically based, manualized psychodynamic psychotherapy that emerged as an adaptation of psychoanalytic techniques to meet the needs of patients with personality pathology. As it became more clearly defined through a series of treatment manuals and empirical research, TFP has also come to be considered a conceptual and technical model of therapy that can be used to introduce therapists in training to the principles of psychodynamic psychotherapy in a systematic way. Advanced levels of TFP training and practice involve an emphasis on supervision that is applied in a more structured way than traditional psychodynamic supervision, while respecting the depth and subtlety of psychoanalytic exploration. This article reviews the development of the treatment model and the supervisory process that guides the therapist to carry out TFP in accordance with its proposed mechanism of change.

Measurement Invariance of the Pathological Narcissism Inventory and Multimethod Examination of Narcissistic Presentations in Community and Clinical Samples.

The Pathological Narcissism Inventory (PNI) is extensively used in recent empirical literature on pathological narcissism. However, most studies using the PNI are community-based, and no studies have used the PNI to investigate narcissistic presentations in personality disordered patients. This study investigates measurement invariance of the PNI in community participants and patients with personality disorders, and examines differences of narcissistic presentations in these samples through a multimethod approach. Results show that the PNI can be used reliably to measure and compare traits of pathological narcissism in community participants and patients with personality disorders. Personality disordered patients show higher traits reflecting vulnerable narcissism and overt manifestations of grandiose narcissism, compared with controls. Finally, network analysis indicates that traits of grandiose fantasies and entitlement rage have a central role in defining manifestations of PNI pathological narcissism, regardless of the presence of an underlying personality disorder. Research and clinical implications are discussed.

Object Relations Theory Model of Personality Disorders.

Contemporary models of the diagnosis and classification of personality disorders have diverged from the categorical diagnostic framework of the DSM system. One response to this movement can be found in the Alternative DSM-5 Model for Personality Disorders (AMPD), which uses dimensions of personality functioning, coupled with identification of dominant pathological traits, to define and classify personality disorders. By applying psychodynamic object relations theory to the AMPD, therapists can enrich the understanding and assessment of personality functioning and pathology as described in the AMPD.

Editorial Introduction to the Special Issue: Recent Advances in Transference-Focused Psychotherapy: Extending and Refining the Treatment Model.

The authors introduce this Special Issue of Psychodynamic Psychiatry focused on developments in the practice of Transference-Focused Psychotherapy (TFP). In the context of an evolving diagnostic system that increasingly focuses on the underlying dimensions related to self and interpersonal functioning that characterize personality disorders, the authors provide an overview of the development and nature of TFP, and preview a series of contributions that describe the refinement of TFP and is broadening application across the spectrum of personality disorder, age ranges, and clinical settings.

TFP Extended: Development and Recent Advances.

Recent advances in the understanding of personality pathology have contributed to an emphasis on the core of personality pathology as deficits in self-functioning and interpersonal functioning at different levels of severity that must be assessed for clinical intervention. In concert with these conceptual and empirical advances, transference-focused psychotherapy (TFP), an empirically supported psychodynamic treatment for borderline personality disorder, has been in constant development with extensive clinical use. This article describes an object relations model for conceptualizing and assessing levels of personality organization, a transdiagnostic approach to personality pathology, and related treatment modifications, thus expanding the utilization of TFP beyond borderline personality disorder to the full range of personality dysfunction. The core of this treatment approach is a sequential interpretive process between patient and therapist. This process takes place within the context of a structured treatment frame tailored to the unique individual with problems in self-functioning and interpersonal functioning in his/her particular environment.

An Object Relations Model Perspective on the Alternative Model for Personality Disorders (DSM-5).

The Alternative Model of DSM-5 combines dimensional ratings of self-functioning, interpersonal functioning, and traits with categorical classification. The object relations model has a long tradition pre-dating the Alternative Model and, in part, has been incorporated into the Alternative Model. The object relations model provides a theoretical background (generally missing in the Alternative Model) that enhances the clinical assessment of personality pathology and its relationship to treatment planning.

Diagnosis, Classification, and Assessment of Narcissistic Personality Disorder Within the Framework of Object Relations Theory.

Narcissistic personality disorder (NPD) remains a controversial diagnosis, with lack of consensus on essential features of the disorder and its boundaries. Within the framework of object relations theory (ORT), core organizing, structural features define NPD and provide a coherent conceptual framework for understanding clinical features of the disorder. In the ORT model, both grandiose and vulnerable presentations of NPD are characterized by a specific form of self-pathology, reflecting the impact of a grandiose self-structure in the setting of borderline personality organization. The grandiose self-structure provides some stability of self-functioning but does not confer the self-regulatory capacities provided by normal identity formation and is reliant on maintaining a sense of the self as exceptional. We compare the ORT model of NPD to diagnostic criteria in the Alternative Model for Personality Disorders (AMPD) of the DSM-5, highlighting significant correspondence between the two models as well as conceptual differences.

Borderline personality disorder diagnosis in a new key.

BACKGROUND: Conceptualizations of personality disorders (PD) are increasingly moving towards dimensional approaches. The definition and assessment of borderline personality disorder (BPD) in regard to changes in nosology are of great importance to theory and practice as well as consumers. We studied empirical connections between the traditional DSM-5 diagnostic criteria for BPD and Criteria A and B of the Alternative Model for Personality Disorders (AMPD). METHOD: Raters of varied professional backgrounds possessing substantial knowledge of PDs (N = 20) characterized BPD criteria with the four domains of the Level of Personality Functioning Scale (LPFS) and 25 pathological personality trait facets. Mean AMPD values of each BPD criterion were used to support a nosological cross-walk of the individual BPD criteria and study various combinations of BPD criteria in their AMPD translation. The grand mean AMPD profile generated from the experts was compared to published BPD prototypes that used AMPD trait ratings and the DSM-5-III hybrid categorical-dimensional algorithm for BPD. Divergent comparisons with DSM-5-III algorithms for other PDs and other published PD prototypes were also examined. RESULTS: Inter-rater reliability analyses showed generally robust agreement. The AMPD profile for BPD criteria rated by individual BPD criteria was not isomorphic with whole-person ratings of BPD, although they were highly correlated. Various AMPD profiles for BPD were generated from theoretically relevant but differing configurations of BPD criteria. These AMPD profiles were highly correlated and showed meaningful divergence from non-BPD DSM-5-III algorithms and other PD prototypes. CONCLUSIONS: Results show that traditional DSM BPD diagnosis reflects a common core of PD severity, largely composed of LPFS and the pathological traits of anxiousness, depressively, emotional lability, and impulsivity. Results confirm the traditional DSM criterion-based BPD diagnosis can be reliably cross-walked with the full AMPD scheme, and both approaches share substantial construct overlap. This relative equivalence suggests the vast clinical and research literatures associated with BPD may be brought forward with DSM-5-III diagnosis of BPD.

An Object-Relations Based Model for the Assessment of Borderline Psychopathology.

The authors describe an object-relations based model drawing on the work of Kernberg and colleagues for the assessment of borderline pathology. The substrate of internal object relations that constitutes borderline pathology internally or structurally is described and a model for assessing such pathology in a clinical interview format focusing on identity, defensive style, and quality of object relations is presented. Two clinical examples illustrate how these data can be compiled for purposes of psychodynamic case formulation and decisions about psychodynamic treatment.

Malignant Narcissism in Relation to Clinical Change in Borderline Personality Disorder: An Exploratory Study.

BACKGROUND: Normal and pathological narcissism have been the focus of considerable theoretical discussion and empirical research in recent years in personality psychology and psychopathology. Kernberg [1-4] has argued that there is a particularly dysfunctional and impairing variant of narcissistic disturbance known as malignant narcissism. This exploratory study sought to develop, using established assessment methods, a dimensional measure of malignant narcissism that incorporates the key features of grandiose narcissism, paranoid propensities, psychopathic features, and proclivity for a sadistic and aggressive interpersonal style. Method and Sampling: This study examined 57 subjects, diagnosed with borderline personality disorder that were treated using 3 different empirically supported treatments in a previous study [5], for possible deviance on the proposed malignant narcissism index. It also evaluated 2 important clinical domains of change in relation to malignant narcissism. To wit, it was predicted, based on Kernberg's [3, 4] clinical model, that elevated levels of malignant narcissism would be significantly associated with slower rates of improvement in both general psychosocial/psychological functioning and anxiety among treated individuals. RESULTS: Higher levels of malignant narcissism were associated, as predicted, with slower rates of improvement in both global functioning and anxiety. The proposed malignant narcissism index was a more powerful predictor of slowed improvement in global functioning than simple narcissistic personality disorder features. CONCLUSIONS: The heuristic potential of the malignant narcissism construct is discussed and the utility of a dimensional approach to this construct is explored, especially in reference employing personality traits/processes to better understand pathological configurations and personality disturbance.

Comparison of the Structured DSM-5 Clinical Interview for the Level of Personality Functioning Scale With the Structured Interview of Personality Organization.

In Section III of DSM-5, the Level of Personality Functioning Scale (LPFS), a component of the DSM-5 Alternative Model for Personality Disorders (AMPD), offers a dimensional approach to the assessment of personality pathology. Similar to the psychoanalytic concept of personality organization developed by Kernberg ( 1984 ), personality disorders are assessed not only by categorical diagnoses, but also by measuring impairment of personality functioning. In this study we empirically investigate the convergence between two instruments examining personality functioning, the Structured Clinical Interview for the DSM-5 Alternative Model for Personality Disorders Module I (SCID-AMPD) and the Structured Interview of Personality Organization (STIPO). For this goal, correlations between both the overall scores of the two instruments as well as between the corresponding domain scale scores were examined. In addition, the relationship between interview ratings and clinical criteria quantifying the severity of the disorder (suicide attempts, frequency of psychiatric hospitalization, ICD-10 diagnoses) were analyzed. Based on videotaped assessments of 30 psychotherapeutic in- and outpatients with both instruments, significant correlations between overall scores and domain scales of the two interviews were found. Moreover, the ratings from both interviews showed high correlations with criteria of clinical severity.

Clinician-Guided Assessment of Personality Using the Structural Interview and the Structured Interview of Personality Organization (STIPO).

This article demonstrates the utility of a theory-guided psychodynamic approach to the assessment of personality and personality pathology based on the object relations model developed by Kernberg (1984). We describe a clinical interview, the Structural Interview (SI; Kernberg, 1984), and also a semistructured approach, the Structured Interview of Personality Organization (STIPO; Clarkin, Caligor, Stern, & Kernberg, 2004) based on this theoretical model. Both interviews focus on the assessment of consolidated identity versus identity disturbance, the use of adaptive versus lower level defensive operations, and intact versus loss of reality testing. In the context of a more clinically oriented assessment, the SI makes use of tactful confrontation of discrepancies and contradictions in the patient's narrative, and also takes into account transference and countertransference phenomena, whereas the more structured approach of the STIPO incorporates clinical judgment informed by clinical theory into a well-guided interaction with the patient. Both interviews have good interrater reliability and are coherent with the alternative model for personality disorder diagnosis proposed by the Diagnostic and Statistical Manual of Mental Disorders (5th ed.), Section III. Finally, they provide the clinician with specific implications for prognosis and treatment planning and can rationally guide clinical decision making.

The efficacy of psychotherapy: focus on psychodynamic psychotherapy as an example.

The growing number of individuals seeking treatment for mental disorders calls for intelligent and responsible decisions in health care politics. However, the current relative decrease in reimbursement of effective psychotherapy approaches occurring in the context of an increase in prescription of psychotropic medication lacks a scientific base. Using psychodynamic psychotherapy as an example, we review the literature on meta-analyses and recent outcome studies of effective treatment approaches. Psychodynamic psychotherapy is an effective treatment for a wide variety of mental disorders. Adding to the known effectiveness of other shorter treatments, the results indicate lasting change in many cases, especially for complex and difficult to treat patients, ultimately reducing health-care utilization. Research-informed health care decisions that take into account the solid evidence for the effectiveness of psychotherapy, including psychodynamic psychotherapy, have the potential to promote choice, increase mental health, and reduce society's burden of disease in the long run.

Supervision and responses of psychiatry residents to adverse patient events.

OBJECTIVE: Throughout training, psychiatry residents may experience adverse patient outcomes. The purpose of this study was to explore whether residents' perceptions of the quality of their supervision impacts their emotional reactions to adverse events. METHODS: All psychiatry residents from a training program at an academic medical center who were in their PGY2-4 years, as well as those in their first year out of training, were recruited to participate. Those who self-identified as having experienced an adverse event participated in a semi-structured interview. For the purpose of the study, "adverse event" was defined as follows: patient suicide, patient homicide or homicide attempt outside the hospital, patient violence inside the hospital, life-threatening reaction to psychotropic medication, and physical assault of a resident by a patient. RESULTS: In this sample, 22 of the 64 residents (34 %) reported experiencing an adverse event. Of these, 21/22 (95 %) participated in the interview. Two residents reported experiencing two adverse events; the total number of adverse events analyzed was 23. For 21/23 (91 %) of these events, respondents felt that the quality of the supervision they received impacted their emotional reactions to the event. CONCLUSION: The supervisory relationship appears to play a significant role in how residents experience, and potentially learn from, adverse events; this has practical implications for educators and leaders.