Assessing Personality Disorders

The DSM-IV-TR emphasizes the medical model of psychiatric disorders. Each disorder is presented as though it were a discrete syndrome that a patient “has,” in the same way that she might “have” diabetes or asthma. Most clinicians realize that this is a simplistic view, including those clinicians who wrote the DSM-IV-TR, which is why they distinguished axis I from axis II pathology. Axis II, the PDs, forces us to recognize that each patient has a personality that interacts and often contributes to the formation of a psychiatric syndrome. Treatment focused solely on axis I disorders, therefore, can go only so far, necessitating an effort to diagnose personality traits and disorders in the initial interview.

Although the presence of a PD doesn’t make an axis I disorder any less genuine, it signals to the clinician that conventional treatment approaches, such as medication or symptom-focused psychotherapy, may not be sufficient.

PDs are notoriously difficult to diagnose. It is the rare clinician who can confidently conclude after a single interview that a patient has a PD. Thus, this chapter does not assume that you will be able to diagnose a PD quickly, but rather that you will be able to formulate some good hypotheses. Such hypotheses are usually noted on axis II as “rule out_____ personality disorder.”

TWO GENERAL APPROACHES

Two general strategies are useful for assessing PDs in the interview. They are not mutually exclusive, and clinicians commonly use both over the course of the evaluation.

Strategy 1: The Ground-Up Technique

In the ground-up technique, you gradually fashion a picture of your patient’s personality by working from the ground up—that is, by learning about her life history chronologically in the context of the social and family history. As outlined in Chapter 15, the formal social history often begins with a general question about family life.

Tell me a bit about what growing up was like for you.

As you ask chronologic questions about your patient’s life, especially those aspects of life that involve interpersonal relationships, try to identify any dysfunctional patterns of relating. Recurrent patterns are the hallmark of PDs. Memorize one or two probing questions for each PD (see the following examples) and ask them at appropriate times.

A typical example is the patient who relates a pattern of having had few close friendships throughout the early years of his life. Depending on the patient’s behavior toward you during the interview (see the section on Behavioral Clues), you may have some hypotheses about which PD is most likely. Perhaps the patient appears anxious and shy during the interview, leading you to suspect avoidant PD. You would then ask a probing question, such as

Have you tended to have few friends in your life because you didn’t want to have friends, or because you were scared of getting close to someone who might reject you?

Using the ground-up technique, you will usually be able to arrive at a good hypothesis for a PD or personality traits.

Consider the following example.

CLINICAL VIGNETTE

The interviewer is asking a patient about his work history:

Interviewer: What sorts of jobs have you had?

Patient: I’ve had a whole bunch of different jobs. I don’t stick with any one job for very long.

Interviewer: What usually happens with these jobs?

Patient: I usually quit, because the people I work with end up backstabbing me.

At this point, the interviewer suspects paranoid PD and asks the probing questions.

Interviewer: Have you found in your life that people have turned against you for no good reason?

Patient: Yeah, beginning with my parents.

Interviewer: Do you tend to think of people in general as being disloyal or dishonest?

Patient: Well, I’ve found that you just can’t trust anyone, because they’ll always try to do you in if you let down your guard.

The interviewer, having established two of the four criteria required to make the diagnosis of paranoid PD, will then go on to ask questions regarding other criteria.

Strategy 2: The Symptom-Window Technique

The symptom-window technique entails beginning with your patient’s major symptoms and using them as “windows” for exploring possible roots in PDs. This is generally done toward the end of the PPH, by which time you will have identified the major symptoms and delineated the syndromal and treatment history. The next step is to ask questions about events that may have occurred each time the symptoms arose. Were these interpersonal events? Were they related to life transitions? In your judgment, do the symptoms seem to be reasonable responses to the events, or do they seem exaggerated?

The nature of the symptoms per se does little to point to a specific PD, but using the symptoms as windows to the personality is often productive. For example, a major depression can be a product of virtually any of the PDs, but each patient will arrive at the depression by a different route. Here are some typical examples:

Narcissistic PD: The patient finds that nobody meets his high standards, thereby alienating friends and family, leading to a social isolation that can cause depression.
Avoidant PD: The patient avoids friendships for fear of rejection, leading to loneliness and depression.
Dependent PD: Patient develops a sense of worthlessness and demoralization because of an inability to make life decisions without relying on someone else.
Borderline PD: A chronic sense of inner emptiness may lead to depression, suicidality, and other problems, such as substance abuse, bulimia, and impulse control disorder.

As an example, assume you are interviewing a patient with major depression who recently considered overdosing on
some medication after being rejected by her boyfriend. You suspect borderline PD. You can broach the issue with a referred transition:

Earlier, we were talking about your depression and some of the suicidal thoughts you had after your boyfriend left you. Have you reacted in this way to rejection at other times in your life?

After you’ve gotten the ball rolling by using the referred transition, you can run through the rest of the criteria, jogging your memory with the mnemonic I DESPAIRR. You can introduce these questions with a remark such as

I’d like to ask a few more questions about your personality and the ways that you tend to react to certain situations. I’m interested in learning about what sort of person you’ve been since your teenage years, not only how you’ve been over the last few weeks.

This helps to ensure that your patient answers in terms of enduring personality traits rather than recent symptoms.

KEY POINT

This last point deserves repeating: A PD refers to a persisting pattern of dysfunctional relating styles over many years, at least since adolescence or young adulthood. Thus, when you ask about criteria for a PD, make clear to your patient that you’re interested in the long-term view. Beginners often forget this and may end up falsely diagnosing a PD when the patient actually has an acute axis I disorder. For example, depressed patients commonly appear irritable, needy, and suicidal, features that could easily lead to the diagnosis of borderline PD. Once the depression clears, such patients may magically shed their axis II pathology.

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