Ask the Expert: Personality Disorders

A 33-year-old woman who presented to me complaining of difficulties at her job has been in once-weekly insight-oriented psychotherapy with me for 2 months. She had no symptoms of axis I pathology and complained mostly of not being able to be assertive with her boss. Because she gave no history of suicide attempts, parasuicidal behavior, cutting, or antisocial behavior, I did not think that she had a personality disorder. She has been highly motivated to be in treatment, has been extremely cooperative, and from the beginning has expressed tremendous gratitude for the help I have been giving her, particularly since she has few friends and felt that she had no one to talk to. However, this week she became violently enraged with me when I started her session 5 minutes late. She accused me of being unprofessional and threatened to quit treatment on the spot. How should I handle this situation? How could I have predicted this behavior?

Response from Deborah Cabaniss, M.D., Associate Clinical Professor of Psychiatry, Columbia University College of Physicians and Surgeons, and Training and Supervising Analyst, Columbia University Center for Psychoanalytic Training and Research, New York City:

Accurately diagnosing personality disorders is a skill that sometimes eludes even the most experienced clinicians. No one can predict the type of behavior outlined above 100% of the time. There are, however, methods for assessing personality disorders that can help the clinician in gaining a deeper understanding of the patient’s axis II pathology from the beginning of treatment. Taking a thorough history and asking questions about the type of phenomenology outlined in DSM-IV-TR is necessary but not always enough. In the situation described above, the clinician asked about symptoms of axis I disorders and some axis II traits and concluded that no personality disorder was present. However, diagnosing personality disorders also requires a careful assessment of ego functioning, with particular attention to the characteristic ego defenses the patient uses.

The term “ego functioning” refers to a cluster of functions that help people manage anxiety, tolerate strong affect, and negotiate the relationship of the self to the environment. Ego functioning can be assessed by taking a detailed history, but the clinician can often learn more about it by paying careful attention to the patient’s behavior during the evaluation and during ensuing therapy. Ego functions are generally thought to include the following:

Weakness in any of these areas in the absence of significant axis I pathology should alert the clinician to the possibility that a personality disorder is present. Most of these functions are fairly self-explanatory and easy to assess. However, the presence or absence of a stable sense of self and the level of defensive operations may be harder for the clinician to understand and may also be harder to assess in the patient. Interestingly, Kernberg (1984) believes that reality testing, sense of identity, and level of defensive operations are the central elements in diagnosing a personality disorder.

“Level of defensive operations” refers to whether the person’s defenses are based primarily on repression or on splitting. Defenses based on repression, such as isolation of affect, reaction formation, intellectualization, rationalization, and some forms of denial, function by making or keeping ideas or affects unconscious. Defenses based on splitting, such as projection, projective identification, and pathological idealization and devaluation, function by allowing the person to experience thought or affect as if it originated from outside of the self. Patients whose level of defensive operations revolve around splitting and related defenses lack object constancy in that they have difficulty conceptualizing others as having both good and bad qualities. This cripples the person’s capacity for meaningful relationships with others, a hallmark of personality dysfunction. Defensive operations can be well assessed within the patient’s relationship with the clinician, even during the evaluation, and the clinician should be attuned to clues about level of defensive operation in order to predict the presence or absence of serious character pathology. In the example here, the clinician notes that although there is denial of axis II traits, the patient is immediately “tremendously grateful.” Although this feature is not pathognomonic for a personality disorder, very strong feelings—positive or negative—on the part of the patient early on should alert the clinician to the possibility of pathological idealization or devaluation. In this patient, early idealization quickly gave way to devaluation after an “average expectable” error on the clinician’s part. Similarly, the fact that the patient indicates that she does not have friends signals major difficulties in object relationships, another indication of poor ego functioning.

The recognition that the patient’s unpredictable behavior results from an oscillation between idealization and devaluation allows the clinician to handle this situation in a way designed to interest the patient in her unconscious defense mechanisms. For example, the clinician could say, “I’m certainly sorry that I’m starting our session late today. However, it’s interesting that my starting 5 minutes late is making you feel this bad about the whole treatment, when in the last session you were talking about how helpful this has been. Maybe this is a reaction that seems somewhat familiar to you and that you’ve had with other people in your life.” Technically, this is a confrontation—that is, a comment designed to interest the patient in the workings of her mind. It is the beginning of the larger process of interpreting a set of defenses that are operating not only in the therapeutic relationship but also in the patient’s other relationships—and that are undoubtedly at the core of the difficulties that led the patient to the consultation.