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.

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.

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.

Psychiatric assessment of aggressive patients: a violent attack on a resident.

Aggressive patients often target psychiatrists and psychiatric residents, yet most clinicians are insufficiently trained in violence risk assessment and management. Consequently, many clinicians are reluctant to diagnose and treat aggressive and assaultive features in psychiatric patients and instead focus attention on other axis I mental disorders with proven pharmacological treatment in the hope that this approach will reduce the aggressive behavior. Unclear or nonexistent reporting policies or feelings of self-blame may impede clinicians from reporting assaults, thus limiting our knowledge of the impact of, and best response to, aggression in psychiatric patients. The authors pre-sent the case of a young adult inpatient with a long history of antisocial and assaultive behavior who struck and injured a psychiatric resident. With this case in mind, the authors discuss the diagnostic complexities related to violent patients, the importance of assessing violence risk when initially evaluating a patient, and the relevance of risk assessment for treatment considerations and future management. This report illustrates common deficiencies in the prevention of violence on inpatient psychiatric units and in the reporting and response to an assault, and has implications for residency and clinician training.