At the Personality Disorders Institute at Cornell we have developed a particular mental status examination designated "structural interviewing," geared to the differential diagnosis of personality disorders. In essence, this interview, that ordinarily takes up to one and one half-hours of exploration, consists of various steps of inquiry into the patient's functioning. The first step evaluates all the patient's symptoms, including physical, emotional, interpersonal and generally psychosocial aspects of malfunctioning, inappropriate affect experience and display, inappropriate behavior, inordinate difficulties in assessing self and others in interactions and in negotiating ordinary psychosocial situations. This inquiry into symptoms is pursued until a full differential diagnosis of prominent symptoms and characterological difficulties has been achieved.
The second step of this interview explores the patient's present life situation, including his or her adaptation to work or a profession, the patient's love life and sexual experiences, the family of origin, the patient's friendships, interests, creative pursuits, leisure activities, and social life in general. It also explores the patient's relation to society and culture, particularly ideological and religious interests, and his or her relationship to sports, arts, and hobbies. In short, we attempt to obtain as full a picture as possible of the patient's present life situation and interactions, raising questions whenever any aspect of the patient's present life situation seems obscure, contradictory, or problematic. This inquiry complements the earlier step of exploration of symptoms and, at the same time, makes it possible to compare the patient's assessment of his or her life situation and potential challenges and problems with the patient's interaction with the diagnostician as this exploration proceeds. At this point, we obtain an early assessment of pathological character traits, be they predominantly inhibitory, reaction formations, or contradictory and conflictual behavior patterns.
A third step of this structural interview consists in raising the question of the personality assessment by the patient of the two or three most important persons in his or her present life, followed by the assessment of his or her description of himself or herself as a unique, differentiated individual. The leading questions here are: "Could you now describe to me the personality of the most important persons in your present life that you have mentioned, so that I can acquire a live picture of them?" "And now, could you also describe yourself, your own personality, as it is unique or different from anybody else, so that I can acquire a live picture of it?"
As the fourth step of this interview, and only in cases with significant disturbances in the manifestations of their behavior, affects, thought content, or formal aspects of verbal communication during the interview, the diagnostician raises, tactfully, questions about that aspect of the patient's behavior, affect, thought content, or verbal communication that has appeared as particularly curious, strange, inappropriate, or out of the ordinary, warranting such attention. The diagnostician communicates to the patient that a certain aspect of his or her communication has appeared puzzling or strange to the diagnostician, and raises the question, whether the patient can see that, and what his or her explanation would be for the behavior that puzzles the diagnostician.
Such a tactful confrontation will permit the patient with good reality testing to be aware of what it is in himself or herself that has created a particular reaction of the interviewer, and provide him or her with an explanation that reduces the strangeness or puzzling aspect of that behavior. This response, in other words, indicates good reality testing. If, to the contrary, such inquiry leads to an increased confusion, disorganization, or abnormal behavior in the interaction with the diagnostician, reality testing is presumably lost. The maintenance of reality testing is an essential aspect of the personality disorders, who may have lost the subtle aspects of tactfulness in social interactions, but maintained good reality testing under ordinary social circumstances. Loss of reality testing presumably indicates an atypical psychotic disorder or an organic mental disorder: that finding would lead to further exploration of such behavior, affect, or thought in terms of a standard mental status examination. In any case, a clear loss of reality testing indicates that an active psychotic or organic mental disorder is present, and that the primary diagnosis of a personality disorder cannot be established at this time.
Otherwise, with reality testing maintained, the interview would permit the diagnosis of a personality disorder, the predominant constellation of pathological character traits, and its severity in terms of the presence or absence of the syndrome of identity diffusion. The capacity to provide an integrated view of significant others and of self indicates normal identity. Good interpersonal functioning, that does not even raise the question of any strange or puzzling aspect of the present interaction would not warrant the exploration of reality testing. Patients with borderline personality organization, who present identity diffusion, also typically evince behaviors reflecting primitive defensive operations in the interaction with the diagnostician. These findings are less crucial than the diagnosis of the identity diffusion, but they certainly reinforce that diagnostic conclusion.
While this method of clinical interviewing has proven enormously useful in the clinical setting, it does not lend itself, unmodified, for empirical research. A group of researchers at our Institute is presently transforming this structural interview into a semi-structured interview, geared to permit the assessment of personality disorders by way of an instrument (Structured Interview for Personality Organization [STIPO]; Clarkin, Caligor, Stern, & Kernberg, 2003) geared to empirical research. The clinical usefulness of the structural interview, however, may be illustrated by typical findings in various characterological constellations.
To begin, in the case of adolescents, structural interviewing makes it possible to differentiate adolescent identity crises from identity diffusion. In the case of identity crises, the adolescent may present with a sense of confusion about the attitude of significant others toward himself, and puzzlement about their attitude that does not correspond to his self-assessment. Asked to describe the personality of significant others, however, particularly from his immediate family, their description is precise and in depth. By the same token, while describing a state of confusion about his relationships with others, the description of his own personality also conveys an appropriate, integrated view, even including such confusion about his relationships that corresponds to the impression that the adolescent gives to the interviewer. In addition, adolescents with identity crisis but without identity diffusion usually show a normal set of internalized ethical values, interests, and ideals, commensurate with their social and cultural background. It is remarkable that, even if such adolescents are involved in intense struggles around dependence and independence, autonomy and rebelliousness with their environment, they have a clear sense of these issues and their conflictual nature, and their description of significant others with whom they enter in conflict continues to be realistic and cognizant of the complexity of the interactions.
To the contrary, in the case of identity diffusion, the descriptions of the most important persons in his or her life on the part of an adolescent with borderline personality organization are vague and chaotic, and so is his or her description of the self, in addition to the emergence of significant discrepancies in the description of the adolescent's present psychosocial interactions, on the one hand, and the interaction with the interviewer, on the other. It is also typical for severe identity diffusion in adolescence that there exists a breakdown in the normal development of ideals and aspirations. The adolescent with identity diffusion may display a severe lack of internalized value systems, or a chaotic and contradictory attitude toward such value systems.
In contrast to the diagnostic value of exploring identity and internalized value systems, other aspects of the mental status examination are less important in the case of adolescents. Thus, particularly, the dominance of primitive defensive operations is less important than it would be in adult patients. The reason is that, with a reactivation of oedipal conflicts, and conflicts about sexuality in general, primitive defensive operations may emerge, particularly in the area of conflicts with the parents. Severe conflicts with intimate members of the family are diagnostically much less important than they would be later on. Chaotic experiences in the sexual realm, manifestations of polymorphous perverse infantile sexuality, rather extreme oscillations between inhibited, puritanical attitudes and impulsive sexual behavior also are not necessarily indicative of identity diffusion at this time.
The nature of adolescent school failure also includes a broad spectrum of diagnostic possibilities and does not reflect directly the syndrome of identity diffusion: depressive reactions, attention-deficit-hyperactivity disorder, physical, sexual or emotional abuse, significant inhibitions of many origins, the characteristic pattern of narcissistic personalities of being the best student in some courses and the worst in others, and generalized breakdown in the functioning at school as a reflection of identity diffusion have to be differentiated from each other. The capacity to fall in love and to maintain a stable love relation, in general, is related to normal identity, but some adolescents may be delayed in their capacity to establish sexual intimacy out of inhibition, and the absence of that capacity is not necessarily diagnostic. Sexual promiscuity, on the other hand, may or may not reflect identity diffusion in adolescence. Significant changes in mood and emotional lability are also less important in the diagnosis of identity diffusion in adolescence than in adults. Finally, the relationship of an adolescent with his or her particular psychosocial group may provide important clues to both identity and superego developments. The capacity for a harmonious participation in group structures needs to be differentiated from the blind adherence to an isolated social subgroup, and from the incapacity to function outside the protective structure of such a group. Chronic social isolation, in contrast to the capacity to adjust to group situations also may point to significant character pathology. The relationship to groups permits us to clarify the potential presence of a negative identity.
The most typical manifestations of the syndrome of identity diffusion, that is, a clear lack of integration of the concept of self and of the concept of significant others can be found in patients with borderline personality disorder, and, to a somewhat lesser degree, in patients with histrionic or infantile personality disorder. In contrast, in the case of the narcissistic personality disorder, what is most characteristic is the presence of an apparently integrated, but pathological, grandiose self, contrasting sharply with a severe incapacity to develop an integrated view of significant others: the lack of the capacity for grasping the personality of significant others is most dramatically illustrated in the narcissistic personality disorder. An opposite situation may emerge in patients with schizoid personality disorders, where a lack of integration of the concept of the self may be matched by very subtle observations of significant others. In the case of schizotypal personality, in contrast, both the concept of self and the concept of significant others are severely fragmented, similar to the case of the borderline personality disorders. It is interesting to observe that in the rare cases of multiple personalities, a careful evaluation of the personality structure of the alters reflects the mutually split off fragmentation of the patient's self concept, while a similar lack of integration of the concept of significant others permeates all the alters of the patient's personality.
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