Barry L. Stern

Structured Interview of Personality Organization (STIPO): preliminary psychometrics in a clinical sample.

In this article, we describe the development and preliminary psychometric properties of the Structured Interview of Personality Organization (STIPO), a semistructured interview designed for the dimensional assessment of identity, primitive defenses, and reality testing, the three primary content domains in the model of personality health and disorder elaborated by Kernberg (1984; Kernberg & Caligor, 2005). Results of this investigation, conducted in a clinical sample representing a broad range of personality pathology, indicate that identity and primitive defenses as operationalized in the STIPO are internally consistent and that interrater reliability for all 3 content domains is adequate. Validity findings suggest that the assessment of ones sense of self and significant others (Identity) is predictive of measures of positive and negative affect, whereas the maladaptive ways in which the subject uses his or her objects for purposes of regulating ones self experience (Primitive Defenses) is predictive of measures of aggression and personality disorder traits associated with cluster B personality disorders. We discuss implications of these findings in terms of the theory-driven and trait-based assessment of personality pathology.

Why We Recommend Analytic Treatment for Some Patients and Not for Others

One hundred consecutive patients applying for analysis completed a comprehensive battery of structured interviews and self-report questionnaires assessing dimensions of psychopathology and psychological functions that analysts consider important when evaluating patients for analysis. Patients were evaluated for analysis by a candidate supervised by a training analyst. Fifty patients were accepted for analysis and fifty rejected. In both groups, psychiatric morbidity and psychosocial impairment were high, with a 50% current and 74% lifetime diagnosis of mood disorder, 56% current and 61% lifetime history of anxiety disorder. The mean Beck Depression Inventory score fell in the moderate range, 19.1 (SD = 11.0), mean Hamilton Depression score in the mild range, 14.1 (SD = 7.8), and the mean Hamilton Anxiety score in the moderate range, 14.6 ( SD = 8.1), with 57% meeting criteria for an Axis II diagnosis, and mean social adjustment in the moderate to high pathology range. Patients accepted and rejected for analysis did not differ with regard to any of these dimensions. Accepted patients scored lower on measures of impulsivity, aggression, and sociopathy, and on scores of personality rigidity, primitive defenses, and outward aggression. The major finding was the striking similarity between patients accepted and rejected for psychoanalytic treatment.

Transference Focused Psychotherapy for Patients with Comorbid Narcissistic and Borderline Personality Disorder

Clinical experience involving the treatment of patients with comorbid borderline and narcissistic personality disorders suggests that this patient population is among the more difficult to treat within the personality disorder spectrum. In this article, we present refinements of Transference Focused Psychotherapy (TFP) based on our clinical experience with and research data on patients with comorbid narcissistic personality disorder/borderline personality disorder (NPD/BPD). We briefly review object relations formulations of severe narcissistic pathology, as well as recent research in attachment and the allied concept of mentalization, which have provided a new lens through which to view narcissistic disorders. The research findings from two randomized clinical trials demonstrating the efficacy and effectiveness of TFP are presented. The data from the two Randomized Clinical Trials (RCT) allowed for the study of the characteristics of the subgroup of borderline personality disorder patients who have comorbid NPD/BPD. Findings on comorbidity, attachment status, capacity for mentalization, and level of personality organization of borderline patients with comorbid NPD/BPD, compared with borderline patients without comorbid narcissistic pathology (BPD), are presented. Clinical implications of the observed group differences are discussed, with a focus on refinements in the technique of TFP. Clinical case material is presented to illustrate the specific challenges posed by narcissistic patients to carrying out TFP in each phase of treatment.

A Prototypical Profile of Borderline Personality Organization Using the Structured Interview of Personality Organization (STIPO)

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Refining personality disorder subtypes and classification using finite mixture modeling.

The current Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic system for Axis II disorders continues to be characterized by considerable heterogeneity and poor discriminant validity. Such problems impede accurate personality disorder (PD) diagnosis. As a result, alternative assessment tools are often used in conjunction with the DSM. One popular framework is the object relational model developed by Kernberg and his colleagues (J. F. Clarkin, M. F. Lenzenweger, F. Yeomans, K. N. Levy, & O. F. Kernberg, 2007, An object relations model of borderline pathology, Journal of Personality Disorders, Vol. 21, pp. 474-499; O. F. Kernberg, 1984, Severe Personality Disorders, New Haven, CT: Yale University Press; O. F. Kernberg & E. Caligor, 2005, A psychoanalytic theory of personality disorders, in M. F. Lenzenweger & J. F. Clarkin, Eds., Major Theories of Personality Disorder, New York, NY: Guilford Press). Drawing on this model and empirical studies thereof, the current study attempted to clarify Kernbergs (1984) PD taxonomy and identify subtypes within a sample with varying levels of personality pathology using finite mixture modeling. Subjects (N = 141) were recruited to represent a wide range of pathology. The finite mixture modeling results indicated that 3 components were harbored within the variables analyzed. Group 1 was characterized by low levels of antisocial, paranoid, and aggressive features, and Group 2 was characterized by elevated paranoid features. Group 3 revealed the highest levels across the 3 variables. The validity of the obtained solution was then evaluated by reference to a variety of external measures that supported the validity of the identified grouping structure. Findings generally appear congruent with previous research, which argued that a PD taxonomy based on paranoid, aggressive, and antisocial features is a viable supplement to current diagnostic systems. Our study suggests that Kernbergs object relational model offers a plausible substantive aid in refining PD classification.

Transference-focused psychotherapy for narcissistic personality.

The authors outline the application of Transference-Focused Psychotherapy (TFP), a structured, twiceweekly psychoanalytic psychotherapy, to patients with narcissistic pathology. The operation of splittingbased defenses in the maintenance of the pathological grandiose self that is characteristic of individuals with narcissistic personality disorders is described, as are the obstacles posed by this structure to therapists attempting to establish a viable treatment frame and engage patients in the early treatment process. The narcissistic patient’s difficulty tolerating the interpretive process in psychoanalytic psychotherapy is formulated based on the ideas of several writers in the modern Kleinian tradition as well as contemporary object relations theory. An extended case discussion illuminates the foregoing, and several modifications related to tact and timing, drawn from various analytic sources, are outlined to enhance the interpretive process in TFP.

The Structured Interview of Personality Organization (STIPO): An Instrument to Assess Severity and Change of Personality Pathology

The assessment and diagnosis of personality disorders for clinical intervention and research purposes is at crossroads. The diagnostic criteria for the personality disorders in DSM-IV TR Axis II are a listing of symptoms in search of a unifying assessment of personality dysfunction. The utilization of the diagnosis of these criteria has resulted in an advance in the reliability of personality disorders, but it has become evident that there are numerous difficulties in the personality disorder diagnoses made by the criterion-based, atheoretical approach of Axis II. The major problem involves the heterogeneity of the patient groups selected by the categorical system without any rating of severity of dysfunction. While a categorical approach to diagnosis focuses on the presence or absence of the disorder, based on a number of fulfilled criteria or symptoms, a dimensional approach also assesses the severity of symptoms or dimensions of personality pathology. As patients seen in clinical practice tend to present with different levels of severity of pathology, a dimensional approach provides the clinician with a diagnosis more reflective of the clinical picture, which also includes an assessment of strengths and deficits on each of the dimensions. The clinical usefulness of the categorical system has been seriously questioned [1]. The proposed changes in DSM-V define personality disorders as a failure to develop self-identity and capacity for adaptive interpersonal functioning, focus on the assessment on personality disorder prototypes, and provide a severity rating of personality disorder functioning. These proposed changes are congruent with the object relations view of personality pathology and call attention to the need for reliable diagnostic instruments based on psychodynamic object relations theory. In this chapter, we describe such an instrument, which provides evaluation of core dimensions of personality functioning emphasized by the DSM V Personality Disorders Task Force (www.dsm5.org)

The Psychodynamic Treatment of Borderline Personality Disorder: An Introduction to Transference-Focused Psychotherapy

The authors describe the application of a twice-weekly exploratory psychotherapy, transference-focused psychotherapy (TFP), to patients with borderline personality disorder. The article describes the pathology of internal object relations that provides a framework for understanding borderline personality and how TFP establishes a treatment framework to address such pathology and set the stage for working at the level of internal psychological structure. An outline of the assessment and treatment protocol is described along with a case example to illustrate the same.

Position Paper—Transference-Focused Psychotherapy (TFP) for Narcissistic Personality

Purpose of reviewThe authors describe the application of a twice-weekly, exploratory psychotherapy, Transference-Focused Psychotherapy (TFP), to patients with Narcissistic Personality Disorder (NPD). The paper describes the pathology of object relations within which narcissistic pathology can be understood, and how TFP establishes a treatment framework to address narcissistic pathology. An outline of the assessment and treatment protocol is described along with a case example to illustrate the same.Current findingsThe application of TFP to patients with NPD follows from recent research demonstrating the effectiveness of TFP for patients with BPD including some patients with comborbid NPD.SummaryAlthough empirical studies of the efficacy of TFP for NPD are lacking and warranted the authors suggest that, in the absence of any other empirically supported treatment for NPD, TFP may be applied to this challenging patient population.

Transference-focused psychotherapy (TFP) for narcissistic personality: Engaging patients in the early treatment process.

The authors outline the application of Transference-Focused Psychotherapy (TFP), a structured, twice-weekly psychoanalytic psychotherapy, to patients with narcissistic pathology. The operation of splitting-based defenses in the maintenance of the pathological grandiose self that is characteristic of individuals with narcissistic personality disorders is described, as are the obstacles posed by this structure to therapists attempting to establish a viable treatment frame and engage patients in the early treatment process. The narcissistic patient’s difficulty tolerating the interpretive process in psychoanalytic psychotherapy is formulated based on the ideas of several writers in the modern Kleinian tradition as well as contemporary object relations theory. An extended case discussion illuminates the foregoing, and several modifications related to tact and timing, drawn from various analytic sources, are outlined to enhance the interpretive process in TFP.