Gazzillo, F., Lingiardi, V., Del Corno, F., Genova, F., Bornstein, R.F., Gordon, R.M., McWilliams, N. (2015). Clinicians’ Emotional Responses and PDM P Axis Personality Disorders: A Clinically Relevant Empirical Investigation. Psychotherapy, Special Section: Personality and Psychotherapy, 52(2),238- 246.
Clinicians’ Emotional Responses and PDM P Axis Personality Disorders: A Clinically Relevant Empirical Investigation
Franco Del Corno
Robert F. Bornstein
Robert M. Gordon
The aim of this study is to explore the relationship between level of personality organization and type of personality disorder as assessed with the categories in the Psychodynamic Diagnostic Manual (PDM; PDM Task Force, 2006), and the emotional responses of treating clinicians. We asked 148 Italian clinicians to assess one of their adult patients in treatment for personality disorders with the Psychodiagnostic Chart (PDC; Gordon & Bornstein, 2012) and the Personality Diagnostic Prototype (PDP; Gazzillo, Lingiardi, & Del Corno, 2012), as well as to complete the Therapist Response Questionnaire (TRQ; Betan, Heim, Zittel-Conklin, & Westen, 2005). The patients’ level of overall personality pathology was positively associated with helpless and overwhelmed responses in clinicians, and negatively associated with positive emotional responses. A parental and disengaged response was associated with the depressive, anxious and dependent personality disorders, an exclusively parental response with the phobic personality disorder, and a parental and criticized response with narcissistic disorder. Dissociative disorder evoked a helpless and parental response in the treating clinicians, while somatizing disorder elicited a disengaged reaction. An overwhelmed and disengaged response was associated with sadistic and masochistic personality disorders, with the latter also associated with a parental and hostile/criticized reaction; an exclusively overwhelmed response with psychopathic patients, and a criticized response with paranoid patients. Finally, patients with histrionic personality disorder evoked an overwhelmed and sexualized response in their clinicians, while there was no specific emotional reaction associated with the schizoid and the obsessive-compulsive disorders.
We compared our results with the results of previous studies on this topic, and clinical implications of these findings were discussed.
Key words: personality assessment, PDM, PDC, PDP, therapists’ emotional responses, countertransference
Clinicians’ Emotional Responses and PDM P Axis Personality Disorders: A Clinically Relevant Empirical Investigation
During the last 20 years, research has emerged showing how emotions experienced by clinicians working with patients that have been diagnosed with personality disorders may help to inform the diagnosis and treatment process. Brody and Farber (1996), as well as McIntyre and Schwartz (1998), demonstrated how patients with Diagnostic and Statistical Manual of Mental Disorders – IV edition (DSM-IV; APA, 1994) Axis II disorders, and particularly Cluster B and borderline patients, elicited more anger and irritation, as well as a lower level of likeability, empathy, and nurturance than patients with different personality disorders. In addition, these patients tended to be perceived as being more dominant and aggressive than are patients with depressive disorders.
A third study, conducted by Betan, Heim, Zittel-Conklin, and Westen (2005), demonstrated that patients with Cluster A disorders tend to evoke therapists’ feelings of being criticized and mistreated, while clinicians treating patients with Cluster B disorders often feel overwhelmed, helpless, sexually aroused, and/or disengaged. Finally, patients with Cluster C disorders induce feelings of protectiveness and having a warm connection in their therapists.
In the same year, Bradley, Heim, and Westen (2005) pointed out how it is possible to empirically differentiate the relationships that patients with personality disorders from different DSM-IV Axis II clusters tend to develop with clinicians. In particular, patients with Cluster A disorders tend to not feel a secure engagement with their clinicians, patients with Cluster B disorders tend to develop an angry/entitled or a sexualized relationship, and patients with Cluster C disorders tend to develop an anxious/preoccupied relationship.
A fourth study, conducted by Røssberg, Karterud, Pedersen, and Friis (2007), demonstrated how clinicians’ emotional responses to patients with Cluster A and B disorders are generally more negative and troublesome than their emotional responses to patients with Cluster C personality disorders, which are less mixed and less complex. These results dovetail with findings suggesting that overall, clinicians are more comfortable with patients diagnosed with anxious personality disorders than they are with those who are more dysregulated and show signs of cognitive slippage under stress.
A recent study conducted by Colli, Tanzilli, Dimaggio, and Lingiardi (2014), using the Shedler Westen Assessment Procedure-200 (SWAP-200; Westen & Shedler 1999a) for the diagnosis of personality disorders, demonstrated how different personality styles seem to be associated with specific emotional responses experienced by their therapists. In particular, paranoid and antisocial personality disorders were associated with criticized/mistreated feelings on the part of therapists. Schizoid personality disorder is associated with helpless responses, while schizotypal disorders are associated with disengaged responses. Antisocial personality disorders were connected with feelings of helplessness/inadequacy. Borderline personality disorders were associated with helpless/inadequate, overwhelmed/disorganized, and special/overinvolved emotional reactions. Narcissistic disorder was associated with a disengaged response, while histrionic disorder showed the opposite pattern, being negatively associated with this kind of emotional reaction. Dependent and obsessive personality disorders were both negatively associated with a disengaged and an overinvolved response. Finally, avoidant personality disorder was associated with a positive emotional reaction, similar to that of a good therapeutic alliance, in addition to a parental/protective emotional response. In general, therapists’ negative emotional responses were most strongly associated with a lower level of personality functioning in the patients, as well as with more severe forms of personality pathology.
These studies, while compelling, were based on the DSM or SWAP assessment of personality disorders, and so far no studies have been conducted assessing the emotional responses of clinicians working with patients classified using the Psychodynamic Diagnostic Manual’s (PDM Task Force, 2006) personality disorder diagnoses. Given the PDM’s emphasis on understanding the patient’s underlying dynamics and expressed behaviors, as well as the broader interpersonal context within which the patient functions (e.g., McWilliams, 2011), further exploration of the links between particular personality styles/disorders and therapist responses may be particularly fruitful.
The PDM is the first complete assessment manual of healthy and pathological functioning that explicitly follows a psychodynamic model, based on the integration of clinical and research evidence. PDM diagnoses are both dimensional and categorical and follow a prototype format, taking into account both implicit and explicit psychological processes and contents. The manual differentiates diagnoses according to the different life stages of patients: adulthood, adolescence, childhood and infancy. It is worth noting that the next edition of the manual will have a section focused on the assessment of elderly patients as well (Lingiardi, McWilliams, Bornstein, Gazzillo, & Gordon, in press). Adult patients are assessed along three axes in the PDM: the P axis for personality organization and patterns, the M axis for the assessment of mental functioning, and the S axis for the assessment of the subjective experiences of symptoms and syndromes.
Since this paper focuses on the PDM’s P Axis, we will describe it in more detail. The P Axis of the PDM asks the clinician to first assess the overall level of the patient’s personality organization according to Kernberg’s (1984) model (healthy, neurotic, high level borderline, and low level borderline). Second, the clinician is asked to assess the personality disorders most descriptive of the patient’s clinical presentation. The disorders taken into account are: schizoid, paranoid, psychopathic (passive parasitic and aggressive subtypes), narcissistic (arrogant/entitled and depressive/depleted subtypes), sadistic and sadomasochistic (with an intermediate manifestation, sadomasochistic), masochistic (moral and relational subtypes), depressive (introjective and anaclitic subtypes, with the converse manifestation of hypomanic personality pattern), somatizing, dependent (with a passive-aggressive subtype and with the converse manifestation of a counter dependent pattern), phobic (converse manifestation: counter phobic), anxious, obsessive compulsive (obsessive and compulsive subtypes), hysterical (inhibited and demonstrative subtypes), and dissociative.
For each level of personality organization, as well as for several personality disorders, the PDM specifies the treatment implications and the potential emotional reactions a therapist may experience. Finally, for all of the principal personality disorders, the manual specifies potential contributing temperament factors, prevalent affects and defense mechanisms, the core tension/preoccupation, associated pathogenic beliefs, and the subtypes of that syndrome, if present.
One of the problems in implementing PDM-based assessments in clinical research studies was the lack of empirical instruments designed to assess the PDM-related constructs. To overcome this limitation, we developed two empirical instruments: the Psychodiagnostic Chart (PDC; Gordon & Bornstein, 2012) and the Psychodynamic Diagnostic Prototypes (PDP; Gazzillo, Lingiardi, & Del Corno, 2012), to aid clinicians in the assessment of patients according to the PDM dimensions.
The aim of this paper is to explore the relationships between patients’ levels of personality organization and the specific personality disorders/patterns of the PDM P Axis, in addition to exploring the emotional responses experienced by the therapists working with the patients. Given that there are no previous studies investigating these relationships from an empirical perspective, this preliminary work is intended as an exploratory study.
The sample included 148 clinicians, 87 (58.4%) female and 61 (40. 9%) male, and one clinician who did not give gender data. There were 68 clinicians (45.5%) that were 30–40 years old, and on average had 13.7 years of clinical experience after licensing (ranging from 1 to 38 years). Of all of the clinicians, 61 (40.9%) had a dynamic theoretical orientation, 48 (32.2%) an eclectic, but mainly dynamic, orientation, 20 (13.4%) an eclectic, but mainly biological orientation, and 15 (10.1%) a cognitive behavioral orientation, with the remaining therapists having other orientations. Of our therapists, 131 worked in public settings and 17 in private settings. All clinicians working in public settings were treating their patients with a once weekly psychotherapy sessions. Seven clinicians working in private settings treated their patients three times per week on the couch, seven treated patients two times a week, and three treated once a week. On average, our clinicians were treating their patients for 19 months, (SD = 18.2, ranging from 1 to 72 months) and for this reason we can infer that they knew their patients quite well.
Of our 148 patients, 82 were female (55%), 67 (45%) male. Their average age was 36.5, ranging from 17 to 75. There were 21 (14.1%) patients in the sample that were conceptualized as having a psychotic personality organization, 81 (54.4%) a borderline personality organization, and 44 (29.5%) a neurotic personality organization. These percentages are similar to those found in a previous study on more than 600 patients from US and Italy (Gazzillo et al., 2014).
Using the categorical score of the PDP, the most highly represented personality disorder was the anxious type, (55), followed by depressive (37), dependent (33), narcissistic (30) and hysterical (26); the least represented disorders were hypomanic (6), followed by phobic (5) and counter phobic (2). These data are similar to the frequencies found in a previous broader sample (Gazzillo et al, 2014). The fact that the number of diagnosed personality disorders is higher than the overall number of the patients assessed is due to several patients being diagnosed with more than one personality disorder. All of our patients received at least one diagnosis of a personality disorderbecause we asked our clinicians to assess one of their patients in treatment for enduring maladaptive patterns of motivation, cognition, emotion, and behavior (i.e. for personality disorders).
In terms of DSM-IV Axis I disorders, 67 had an anxiety disorder, 46 a mood disorder, 25 a somatoform disorder, 8 a psychotic disorder, 5 an impulse control disorder, 4 a sexual disorder, 2 an eating disorder, and 1 an adjustment disorder. Clinicians assigned all of the diagnoses according to the categories of the DSM-IV-TR (APA, 2000), but we should note that these are based on the therapists’ evaluations and no independent ratings were conducted to confirm the accuracy of the diagnoses. As with personality disorders, the fact that the number of diagnosed Axis I disorders is higher than the overall number of the patients assessed is due to several patients being diagnosed with more than one Axis I disorder.
Psychodiagnostic Chart. The Psychodiagnostic Chart (PDC; Gordon & Bornstein, 2012) is a quick, easy-to-use clinician report instrument used for assessing patients according to the Psychodynamic Diagnostic Manual (PDM; PDM Task Force, 2006). Among other relevant psychopathological dimensions, PDC asks the clinician to assess the patient’s level of personality organization, as well as the seven basic capacities detailed on the PDM M Axis (identity, object relationships, affect tolerance, affect regulation, morality, reality testing and ego resiliency) using a 10-point Likert scale (1 = severe, 10 = healthy). The PDC gives a synthetic description of each level of personality organization (healthy, neurotic, borderline, or psychotic) to help the clinician with the assessment procedure.
Overall, the personality organization scale of the PDC shows very good two-week retest reliability (.92) and good convergent validity, as assessed with the Minnesota Multiphasic Personality Inventory-2 (MMPI-2; Butcher & Williams, 2009), the Karolinska Psychodynamic Profile (KAPP; Weinryb, Rössel, 1991), and the Operationalized Psychodynamic Diagnosis (OPD; Dahlbender, Rudolf, & OPD Task Force, 2006; Zimmermann et al., 2012). Given that in this study we only used the overall personality organization scale of the PDC, we will not describe the other dimensions or their validation data as assessed by this measure (see Gordon & Stoffey, 2014, for a summary of these findings).
Psychodynamic Diagnostic Prototypes. The Psychodynamic Diagnostic Prototypes (PDP; Gazzillo et al., 2012) are 19 jargon-free descriptions of the personality patterns/disorders of Axis P of the PDM, along with their converse and intermediate manifestations. Each of these descriptions was taken from the PDM while deleting all references to the published literature and rephrasing sentences in which professional jargon might be problematic (see Figure 1 for an example). In order to operationalize the theoretical terms, we took inspiration from wellvalidated empirical instruments such as the Shedler-Westen Assessment Procedure (SWAP; Westen & Shedler, 1999a,b; Westen, Shedler, Bradley, & DeFife, 2012), the Analytic Process Scales (APS; Waldron et al., 2004), and the Defense Mechanisms Rating Scale (DMRS; Perry, 1990).
INSERT FIGURE 1
Each of the PDP prototypes was assessed on a 5-point Likert scale by a treating clinician or by a clinician who knows the patient well (i.e. who has seen him/her for at least 3–5 sessions or has assessed him/her with a systematic interview, such as the Clinical Diagnostic Interview [CDI; Westen & Muderrisoglu, 2003]). The PDP follows a prototype-matching approach to the diagnosis of personality disorders (Spitzer, First, Shedler, Westen, & Skodol, 2008) that enables both a dimensional (1–5) and a categorical assessment, with a score of 3 indicating clinically significant traits of the prototype assessed and a score of 4 or 5 implying a categorical diagnosis of the disorder (see Figure 2).
INSERT FIGURE 2
The PDP shows good face validity; the average inter-rater reliability when categorically implemented (disorder/no disorder) is kappa .61, ranging from .45 to .75. The average intra-class correlation coefficient (ICC) of the PDP dimensionally assessed is .74, ranging from .63 to .85. The PDP also showed good convergent and discriminant validity with analogous DSM1 disorders, at .62 and .05 respectively, and good convergent validity with measures of antisocial behavior, health problems, and quality of close relationships (for a detailed discussion of evidence on validation of the PDP, see Gazzillo et al., 2012). In this study, we only examined the 11 principal PDP personality disorders.
Therapist Response Questionnaire (TRQ; Betan et al., 2005). The TRQ is a clinician report questionnaire designed to assess the emotional responses of therapists to their patients. It consists of 79 items measuring a wide range of thoughts, feelings, and behaviors, written in jargon-free language so that clinicians of different theoretical orientations can easily understand the concepts. Each item has to be assessed on a 5-point Likert scale (1 = not true; 5 = very true). The TRQ items can be synthetized into eight factors/dimensions of the therapist’s emotional response to the patient: overwhelmed/disorganized, helpless/inadequate, positive/alliance, special/overinvolved, sexualized, disengaged, parental/protective, and criticized/mistreated.
The overwhelmed factor is marked by items describing a desire to avoid the patient, along with strong negative feelings, including dread, repulsion, and resentment. The helpless factor includes items describing feelings of inadequacy, incompetence, hopelessness, and anxiety. Items indicating the experience of a positive working alliance and close connection with the patient mark the positive factor. The special factor includes items describing a sense of the patient as being special, relative to other patients, as well as items describing mild problems in maintaining boundaries, including difficulties in ending sessions on time and feeling overly concerned about the patient. The sexualized factor is marked by items describing sexual feelings toward the patient, while the disengaged factor includes items describing feeling distracted,