Psychologists work with complex diagnostic and treatment issues on a daily basis. Current standards of care (and reimbursement) have guided diagnosis and treatment to seem focused on DSM-5 categories and ICD-10 codes. Clinicians I have interacted with seem to appreciate the aspects of continuum versus strictly categorical diagnoses added to DSM-5. This may open avenues into helping psychologists better describe, understand and treat their patients with compassion.
A continuum model of personality organization is outlined in chapter 3 of Nancy McWillam’s book, Psychoanalytic Diagnosis. This model has important implications in the work clinicians do with patients regardless of their chosen theoretical orientation. The psychodynamic concepts in this particular chapter apply to any overriding theoretical orientation just as the concept of transference does. In the middle of the 20th century and beyond, many analysts followed in the tradition of Freud in differentiating psychopathological conditions as either neurotic or psychotic. Neurotics were described as having some insight into their difficulties of which, a source of reality based stress was likely being managed poorly. Conversely, psychotics who were having psychological difficulties experienced distress based on misinterpretations of reality. At the same time other clinicians began to question these discrete categories because they noticed patients who seemed to fall on a borderline between neurosis and psychosis. It is a crucial point to understand that this concept is NOT describing Borderline Personality Disorder. We all have a unique personality that has developed for a variety of biological and psychological reasons. The model described in McWilliams’s book and by many other modern psychodynamic theorists, organizes personality in a thermometer like fashion with three overall categories: Neurotic, Borderline and Psychotic. Levels of personality organization tend to lend themselves to the idea of fixation in a particular developmental stage.
Neurotic Personality Organization
When a patient with Neurotic Personality Organization (NPO) presents to psychotherapy, it is more likely that they see their distress as ego dystonic or ego alien. NPO typically relies on repression as a defense mechanism as opposed to more primitive defenses such as splitting, or projective identification. If you ask a neurotically organized patient to tell you about themselves, they can describe a person who has an integrated sense of identity on some level. They can tell you enduring traits about themselves and have some insight into what parts of themselves have been more constant over time. It requires a severe biological or traumatic event for Neurotically Organized personalities to lose touch with reality. Schizophrenia as well as any Axis I disorder can exist in a neurotically organized individual. Neurotically organized individuals with psychotic disorders will be able to identify psychotic symptoms as not reality based and quickly access mental health services as a result. They tend to be individuals who will demonstrate a stronger recovery from psychosis due to remaining on prescribed medications, being able to identify stressful triggers, and most important reality testing remains intact even when the individual begins to experience symptoms. The patient knows they are sick and seeks help long before psychiatric hospitalization occurs.
Borderline Personality Organization
Borderline Personality Organization (again I cannot stress enough this is NOT the personality disorder), relies on a less developed defensive repertoire. Splitting occurs frequently at this general borderline personality organization (BPO) as well as with borderline personality disorders. Black and white thinking can be a part of those organized at this level. There are only good and bad, “my” way or the wrong way. If a BPO is asked to describe who they are the description may seem to vacillate based on the situation they are in. Their own sense of identity is not formed so it is more likely to be shaped as a result of the current relationship or environmental situation. Those with BPO are more prone to “micropsychotic” dips in times of stress. One diagnostic consideration this can be particularly helpful with is major depression. A depressed NPO will likely be able to identify stressors and respond to psychotherapy and medication in an expected manner. A depressed BPO is likely to have psychotic features. The patient is less likely to be able to explain what preceded the depression and much less likely to identify any time in their life they were not depressed. They are more likely to see any pathology as ego syntonic and be brought in for treatment by family members or others. Depressed BPO patients have great difficulty identifying a gray area between depressed and non-depressed states. They may describe themselves as “bipolar” when the actual problem is their inability to identify and label affect. Patients who report they have been diagnosed as bipolar but do not respond to “any” medications should raise some suspicion for this particular organizational level. BPO is unstable and ever changing which can give the impression of a bipolar element. Those functioning at this level may have times of calmer more successful neurotic level functioning coupled with dips into psychotic level function.
Psychotic Personality Organization
Like the other organizational levels this is not a psychotic “disorder.” Psychotically Organized Personalities are less likely to respond to standard treatment and more difficult to build rapport with. They often will not know how to begin describing themselves or any personality traits they have. Psychotic level individuals have lacking insight into their difficulties. If they have a psychotic disorder they may even seem at times to be unaware of it. They are not distressed by what others from the outside may conceptualize as distress. It is rare for this personality organization to be able to assess reality. This is the patient that may seem to make one bad decision after another based on a fact pattern others cannot identify. Psychotically organized patients are more likely to use schizoid retreat as a defense. They isolate from others and engage in an internal fantasy world that becomes difficult for them to differentiate from reality. This inevitable leads to interpersonal difficulties and more frequent interaction with law enforcement. A depressed psychotically organized patient is more likely to act out violently and see this as a viable solution to their discomfort. This patient will be disorganized and unable to identify why they are depressed or if they ever have been before. Some have learned to state they “always” have been depressed in some effort at interacting with treating clinicians. Further evaluation may identify few things that make sense in the patient’s behavior. It is important to gain an understanding of what it is that this individual (not the clinician) describes as reality and start working from that point.
When treating patients many clinicians identify that not all depressed patients are alike. Why it is some seem to have insight and respond to treatment while others seem much more difficult? Identifying a patient’s personality organization can help clinicians in a variety of ways. It is less difficult to understand why a psychotically organized depressed patient will need a longer length of treatment and repeated treatment exposures. Understanding the personality context of a disorder may help decrease the clinician’s frustrations when treatment seems more difficult. The patient can be saved some degree of distress when they are aware of what their treatment may look like. The patient who is at a psychotic level of organization will need treatment patiently described over and over to understand the realities of treatment. Lapses in treatment make more sense when the clinician understands that they may be a result of the patient’s organizational level.
McWilliams, N. (1994) Psychoanalytic Diagnosis. Guilford Press, New York, NY.
Rain Blohm, MS
WKPIC Doctoral Intern