The Role of Object Relations in the Physician-Patient Relationship in a Primary Care Setting.

ABSTRACT: A good physician-patient relationship is essential for the delivery of quality health care and is associated with better health outcomes. This study explored the association between patients' object relations and the physician-patient relationship. Primary care patients (n = 72) and physicians (n = 21) participated in the study. Patients' early memories were obtained prior to their medical visit and were coded with the Social Cognition and Object Relations-Global Method (SCORS-G). Patients and physicians independently rated the quality of the physician-patient encounter. Results indicated that object relations (SCORS-G Cognitive-structural and Self factors) incrementally predicted physician-patient relationship ratings, as rated by the patient, above and beyond psychological distress, somatization, and level of physician training. Patient education, psychological distress, and level of physician training predicted physician ratings of the medical encounter. The authors discuss the discrepancy between physician and patient ratings as they relate to patients' object relations.

Enhancing Diabetes Management Through Personality Assessment: A Pilot Study.

The aims of this study were to evaluate the utility of therapeutic assessment (therapeutic assessment) as a brief intervention to target reduction in A1C levels and to assess the levels of personality functioning and broad trait domains described in the DSM-5 Alternative Model for Personality Disorders in a sample of patients with Type 2 diabetes and their relationship to A1C levels at baseline and follow-up. Participants (n = 99) were recruited from a primary care office and provided feedback on how their personality functioning and pathological personality traits might influence their diabetes management. Results indicated that 66.25% of participants receiving TA feedback decreased their A1C levels below 7. Those who improved reported less difficulty with intimacy and trends toward higher levels of personality functioning and lower levels of interpersonal detachment. Results suggest that providing TA feedback is worthy of further investigation for considering its therapeutic effects in helping patients to manage Type 2 diabetes.

Malignant Self-Regard as an Overarching Framework for the Theory and Treatment of Depressive and Masochistic (Self-Defeating) Personalities.

ABSTRACT: Kernberg and McWilliams have spawned differing conceptualizations of the relationship between depressive and masochistic (self-defeating) personalities. Kernberg describes these personality styles as largely overlapping in features, whereas McWilliams accentuates important clinical differences that make up two distinct personalities. In this article, their theoretical perspectives are discussed and framed as more complementary than competitive. The malignant self-regard (MSR) construct is introduced and reviewed as an integrative self-representation that is shared by both depressive and masochistic personalities, as well as those often referred to as vulnerably narcissistic. We investigate developmental conflicts, motivations for perfectionism, countertransference patterns, and overall level of functioning as four primary clinical features through which a therapist may differentiate a depressive from a masochistic personality. We argue that depressive personalities tend to have more dependency-related conflicts and perfectionistic strivings motivated by lost object reunification, elicit more insidiously positive countertransference reactions in session, and are generally higher-functioning individuals. Masochistic personalities have more oedipal-related conflicts and perfectionistic strivings motivated by object control, elicit more aggressive countertransference reactions, and are relatively lower functioning. MSR is positioned as a bridge between Kernberg's and McWilliam's ideas. We close with a discussion of treatment implications for both disorders as well as how to understand and treat MSR.

Assessing the Impact of Relationship Profile Test Scores, Self-Identified Ethnic Group, and Gender on Adult Attachment Style.

ABSTRACT: Research shows that the subscales of the Relationship Profile Test (RPT) are related to adult attachment. Gender differences have been implicated, but findings are inconsistent in terms of replication. A limited amount of research has been conducted on ethnic differences in the context of interpersonal dependency. This study aims to bridge the gap in the literature in terms of using the RPT to predict attachment styles and to assess gender and ethnic group differences in RPT scores. Four samples from various treatment settings were combined to yield a heterogeneous group of ethnically diverse men and women (N = 470) with a mean age of 31.96. No gender differences were observed; however, ethnic differences were noted, with the RPT scales predicting unique variance in secure and insecure attachment styles. This study evidences the incremental validity of the RPT scales when predicting adult attachment style with consideration of ethnic group differences, which can help inform the treatment and assessment process.

Measures of Personality Pathology, Levels of Functioning, and Physical Health in an Urban Primary Care Sample.

Integrative approaches in the primary care setting have grown in favor over the past few decades, with many interesting findings about the influence of personality disorders on physical health and functioning; however, less is known about how specific pathological personality traits impact patient-provider assessments of physical and mental health. Using the DSM-5 Levels of Personality Functioning Questionnaire-Short Form (DLOPFQ-SF) and Personality Inventory for DSM-5-Brief Form, these relationships were evaluated in a sample of 50 inner-city, low-income patients in a primary care clinic. Point-biserial correlations revealed significant correlations between physical and mental health morbidities, as well as personality pathology and patient response to treatment. Our findings lend further support to describing the relationships between personality pathology, medical comorbidities, and patient response to treatment.

Examining the Interpersonal Profiles and Nomological Network Associated with Narcissistic Grandiosity and Narcissistic Vulnerability.

Theory and research have consistently shown that pathological narcissism can best be described by 2 phenotypic expressions, narcissistic grandiosity and narcissistic vulnerability. The current study sought to examine the specific types of interpersonal problems reported by those high in narcissistic grandiosity and high in narcissistic vulnerability as well as examine the nomological network associated with these 2 manifestations of narcissism. In a sample of university students who completed self-report measures of pathological narcissism, interpersonal problems, depression, self-esteem, malignant self-regard, self-defeating personality disorder symptoms, and anger, we found that narcissistic grandiosity (n = 108) was associated with one distinct interpersonal profile, for example, being overly intrusive in relationships with others, while narcissistic vulnerability (n = 88) was associated with a wider range of interpersonal problems on the interpersonal circumplex. Using cluster analysis, we found 3 interpersonal subtypes associated with narcissistic vulnerability, an intrusive subtype, a cold subtype, and a socially avoidant subtype. Further examination of group differences showed that the 3 interpersonal subtypes associated with narcissistic vulnerability could also be distinguished based on their experience and expression of anger. This suggests the importance of assessing profiles of interpersonal functioning and anger in narcissistic vulnerability. The clinical implications of our results are discussed.

Personality Disorders in the ICD-11: Opportunities and Challenges for Advancing the Diagnosis of Personality Pathology.

PURPOSE OF REVIEW: The International Classification of Diseases-11th edition (ICD-11) is poised to make a dramatic change in the diagnosis of personality disorders by introducing a fully dimensionalized framework. In this paper, the history of this process is reviewed, along with international efforts taken to address some underlying concerns with this transition. Recent studies of this framework are also reviewed. RECENT FINDINGS: Studies have concluded that the ICD-11 proposal is supported; however, there are a number of methodological limitations to these studies, including the utilization of measures that are not directly derived from the ICD-11 description of levels of personality severity and trait domains. There is a clear need for additional studies with measures that directly reflect the ICD-11 description of personality disorders. While there are some potentially positive effects of moving toward the dimensional model, there are a number of concerns remaining about the clinical utility of moving in this way.

Convergent and Discriminant Validity of Self-Report and Performance-Based Assessment of Object Relations.

This study evaluated the Social Cognition and Object Relations Global Rating Method (SCORS-G; Stein, Hilsenroth, Mulford, & Pinkser, 2011; Stein and Mulford, 2018; Westen, 1995) and the Bell Object Relation and Reality Testing Inventory (BORRTI; Bell, 1995) to determine the extent to which the measures were correlated with each other and their relationships with 2 disorders characterized by disrupted object relations: borderline personality disorder (BPD) and depressive personality disorder (DPD). One hundred sixty-nine psychiatric outpatients and 171 undergraduate students were assessed with the Personality Disorder Interview for DSM-IV (Widiger, Corbett, Ellis, Mangine, & Tomas, 1995) and the Structured Clinical Interview for DSM-IV Axis II Disorders (First et al., 1997) for BPD and DPD. Modest correlations were observed among the diagnostic interviews with the BORRTI and the SCORS-G. An exploratory factor analysis yielded 3 distinct factors, 1 of which was mainly comprised of the BORRTI scales, whereas the 2 other factors were comprised of SCORS-G dimensions. Hierarchical multiple regressions demonstrated that the BORRTI accounted for greater variance among interview scores for both groups. However, the addition of SCORS-G variables incremented the variance accounted for in the BORRTI.

Expanding the Role of Levels of Personality Functioning in Personality Disorder Taxonomy: Commentary on "Criterion A of the AMPD in HiTOP".

The Alternative Model for Personality Disorders (AMPD) construes personality disorder diagnosis in terms of levels of personality functioning (LPF) as well as dimensions of pathological personality traits. The Hierarchical Taxonomy of Psychopathology (HiTOP), which offers a comprehensive framework for conceptualizing psychopathology, integrates pathological personality traits into a model for understanding different disorders, deficits, and personality problems. Widiger et al. ( 2018 ) placed LPF within the HiTOP model, suggesting that LPF might already be subsumed by trait dimensions and other spectra representing severity of psychopathology. This commentary raises a number of questions about their underlying assumptions, and advocates for an expanded role for LPF to more fully capture the complexity and instability inherent in personality disorder pathology.

Personality-driven depression: The case for malignant self-regard (and depressive personalities).

Many patients with chronic depression are not well-treated. In part, this is due to the underlying personality dynamics that maintain the depressive experience are ignored. In this paper, I describe the concept of malignant self-regard, a derivative of the depressive personality. I describe briefly its origins in the clinical and empirical literature and focus upon the presentation of a case of a patient who displays a prototypic manifestation of malignant self-regard. I offer some ideas for how to manage such patients, with a focus on countertransference experiences that can be used to inform treatment.

Moving beyond categories and dimensions in personality pathology assessment and diagnosis.

It has been suggested that a dimensional model of personality pathology should be adopted for the development and refinement of personality disorder classification. In this article, the advantages and challenges of moving toward a dimensional model are briefly reviewed. However, it is suggested that although categories and dimensions are valuable frameworks for personality pathology diagnosis, an expansion beyond categories and dimensions is needed to improve the shortcoming seen in current diagnostic systems. Ideas and examples are offered for how this might occur.Declaration of interestNone.

Introduction to the Special Series on the Personality Functioning Component of the Alternative DSM-5 Model for Personality Disorders.

The Alternative DSM-5 Model for Personality Disorders (AMPD; American Psychiatric Association, 2013 ) was created to remedy the previously well-explicated limitations of the categorical DSM-IV personality disorders. The AMPD combines dimensional assessments of personality functioning (Criterion A) and traits (Criterion B), which can be used independently or together, and serve as the basis for defining six categorical disorder options. The Criterion A Level of Personality Functioning Scale (LPFS) defines a continuum characterized by the four elements of identity, self-direction, empathy, and intimacy. Empirical work related to the LPFS has been growing, and this Journal of Personality Assessment special series features reports from a variety of research groups around the world. These studies provide contributions for better understanding the reliability, validity, and utility of the LPFS, as well as describing new measures that have been created to investigate personality functioning.

Convergent and Discriminant Validity and Utility of the DSM-5 Levels of Personality Functioning Questionnaire (DLOPFQ): Associations with Medical Health Care Provider Ratings and Measures of Physical Health.

The ability to evaluate patients' level of personality functioning in assessing personality disorders has become increasingly important since the DSM-5 Section III hybrid system of personality disorder assessment was released. One measure developed to assess this criterion is the DSM-5 Levels of Personality Functioning Questionnaire (DLOPFQ; Huprich et al., 2017 ), which assesses individuals' self and other representations in four domains-self-direction, identity, empathy, and intimacy-across two contexts-work or school and relationships. A sample of 140 psychiatric and internal medicine outpatients were administered several questionnaires, including the DLOPFQ. Provider ratings also were obtained for level of functioning and DSM-5 pathological personality traits. Several of the DLOPFQ scales were significantly correlated with self-reported and provider-reported measures of DSM-5 trait domains and levels of functioning, along with self-reported measures of effortful control, overall physical and mental health, and well-being. Certain DLOPFQ scales and subscales were associated with provider ratings of likeability and patient contact with the providers. However, relatively modest validity coefficients, as well as poor discriminant validity of domain scales, indicate further research and measure refinement might be needed. It is concluded that, although further research is necessary, the DLOPFQ could be useful for understanding patients' personality pathology in clinical settings.

Are malignant self-regard and vulnerable narcissism different constructs?

In the clinical and empirical literature, vulnerable narcissism and malignant self-regard (MSR) have been found to be highly interrelated and associated with theoretically related personality constructs, suggesting that the two constructs may be much more similar than different. The present study set out to test this hypothesis by examining the relationship of vulnerable narcissism and MSR to experiences and expressions of anger, the factor structure of grandiose and vulnerable narcissism with MSR, the associations of MSR and vulnerable narcissism to the five factor model of personality, and to global self-esteem in self-report measures within 1168 undergraduate students. A separate study of 158 undergraduates also assessed how MSR and vulnerable narcissism predicted state and trait anxiety and anger after receiving positive or negative feedback, and the extent to which negative feedback interacted with MSR and vulnerable narcissism. Overall, compared with grandiose narcissism, both MSR and vulnerable narcissism were more associated with experiencing anger internally, self-reports of state and trait anger, high levels of neuroticism and openness, and lower levels of extraversion and global self-esteem. Both vulnerable narcissism and MSR uniquely predicted trait levels of anger and anxiety and state levels of anger after receiving negative feedback. It is concluded that MSR and vulnerable narcissism are likely identical constructs.

Personality Pathology in Primary Care: Ongoing Needs for Detection and Intervention.

Recent studies demonstrate that personality disorders are prevalent within outpatient psychiatry clinics, though they also are quite common in primary care settings. Studies across multiple health care settings demonstrate that those with a known PD have higher incidences of health problems, higher utilization of the health care system, and have a life expectancy 17.7 years less than that of the population in general. Despite these data, little attention has been directed toward detecting, managing, and treating patients with personality pathology in primary care settings. Consequently, it is argued that more attention be devoted to detecting PDs in this population, training physicians and primary care professionals in the rapid screening of personality pathology, the management of patients with personality pathology, and utilizing behavioral health specialists and reliable referral sources to address these problems as part of their overall health care management. Suggestions for how to implement these ideas are offered.

Sidney Blatt's Object Relations Inventory: Contributions and Future Directions.

In this article, we provide a historical overview of the Object Relations Inventory (ORI) and related methods for the assessment of object relations constructed by Sidney Blatt and colleagues (e.g., Blatt, Bers, & Schaffer, 1992 ; Blatt, Wein, Chevron, & Quinlan, 1979 ; Diamond, Kaslow, Coonerty, & Blatt, 1990 ). We clarify terminology that has been used inconsistently in the literature, especially by way of differentiating the methods used to collect descriptions of significant figures, such as the ORI and its predecessor, the Parental Description (PD) task, and the rating scales that Blatt and colleagues constructed to rate those descriptions. We provide a tabular summary of empirical studies of the measure and offer a critical review of those aspects of the instrument that require further empirical investigation and methodological rigor.

Advancing the Assessment of Personality Pathology With the Cognitive-Affective Processing System.

The Cognitive-Affective Processing System (CAPS) is a dynamic and expansive model of personality proposed by Mischel and Shoda (1995) that incorporates dispositional and processing frameworks by considering the interaction of the individual and the situation, and the patterns of variation that result. These patterns of cognition, affect, and behavior are generally defined through the use of if … then statements, and provide a rich understanding of the individual across varying levels of assessment. In this article, we describe the CAPS model and articulate ways in which it can be applied to conceptualizing and assessing personality pathology. We suggest that the CAPS model is an ideal framework that integrates a number of current theories of personality pathology, and simultaneously overcomes a number of limits that have been empirically identified in the past.

Comparing the Personality Disorder Interview for DSM-IV (PDI-IV) and SCID-II borderline personality disorder scales: an item-response theory analysis.

One-hundred sixty-nine psychiatric outpatients and 171 undergraduate students were assessed with the Personality Disorder Interview-IV (PDI-IV; Widiger, Mangine, Corbitt, Ellis, & Thomas, 1995) and the Structured Clinical Interview for DSM-IV Axis II disorders (SCID-II; First, Gibbon, Spitzer, Williams, & Benjamin, 1997) for borderline personality disorder (BPD). Eighty individuals met PDI-IV BPD criteria, whereas 34 met SCID-II BPD criteria. Dimensional ratings of both measures were highly intercorrelated (rs = .78, .75), and item-level interrater reliability fell in the good to excellent range. An item-response theory analysis was performed to investigate whether properties of the items from each interview could help understand these differences. The limited agreement seemed to be explained by differences in the response options across the two interviews. We found that suicidal behavior was among the most discriminating criteria on both instruments, whereas dissociation and difficulty controlling anger had the 2 lowest alpha parameter values. Finally, those meeting BPD criteria on both interviews had higher levels of anxiety, depression, and more impairments in object relations than those meeting criteria on just the PDI-IV. These findings suggest that the choice of measure has a notable effect on the obtained diagnostic prevalence and the level of BPD severity that is detected.

Factor Structure of the Assessment of Qualitative and Structural Dimensions of Object Representations (AOR) Scale.

The Assessment of Qualitative and Structural Dimensions of Object Representations assessment instrument (AOR; Blatt, Chevron, Quinlan, Schaffer, & Wein, 1992 ) is one measure of parental representations used in the literature that assesses nonconscious processes while minimizing self-presentation biases. However, only 2 studies have considered the latent factor structure, with mixed findings reported that raise questions about the constructs being assessed. This study used archival data from 4 previous studies containing clinical and nonclinical samples, totaling 722 participants. Individuals were divided into 2 groups in which an exploratory factor analysis (EFA) was followed by a confirmatory factor analysis (CFA). Results of both the EFA and CFA suggested that a 3-factor solution was best, with factors that were labeled Agency, Communion, and Punitive based on previous research. The implications of these findings are explored, particularly with regard to the punitive aspect of maternal representations, as well as a possible revision to the scoring rubric.

Malignant self-regard: accounting for commonalities in vulnerably narcissistic, depressive, self-defeating, and masochistic personality disorders.

Several personality disorders (PDs) have been of interest in the clinical literature, yet failed to have been adequately represented in the diagnostic manuals. Some of these are masochistic, self-defeating, depressive, and narcissistic PDs. The theoretical and empirical relationships among these disorders are reviewed. It is proposed that a particular type of self-structure, malignant self-regard (MSR), may account for similarities among all of them and provide a better framework upon which to understand the nature of these personality types and their discrimination from related constructs. Subsequently, a questionnaire to assess MSR was created and evaluated for its psychometric properties. The measure was found to be reliable (Cronbach's alpha=.93) and valid, given its correlations with measures of self-defeating, depressive, and vulnerably narcissistic personalities (rs range from .66 to .76). MSR also can be meaningfully differentiated from a nomological network of related constructs, including neuroticism, extraversion, depression, and grandiose narcissism. The utility of assessing self-structures, such as MSR, in the diagnostic manuals is discussed.