It’s generally acknowledged that an early diagnosis of personality disorder isn’t always completely accurate, because all people have their occasional schizoid, borderline, and narcissistic moments. A more accurate diagnosis is made with numerous therapy sessions. An initial personality disorder diagnosis is often called a working hypothesis, to which later information is added to form a bigger picture.
The first goal in personality disorder diagnosis is differentiating between personality disorders and neurosis. Clinicians look for features suggesting a neurotic patient like curiosity in the viewpoint of the therapist, self-curiosity, ability to show affect (emotion) or to tolerate and explore affect, and interest in the therapy session with plenty of things to contribute. Neurotics have a tendency to reflect on their sessions during the week and expand on anything discussed in them; they usually come to sessions ready to continue a conversation and explore their issues.
In contrast, clients with personality disorders are often distinctly uncurious. They can hold all or nothing views of the world, and show a number of defenses when faced with serious affect. Many of them may not show up at therapy with reasonable and full explanations of why they’re seeking it, or they may not think about issues between sessions and come to a session with new thoughts and information.
A history of the client’s life taken during the first few sessions may be useful in determining if a personality disorder diagnosis fits, along with observations the therapist makes about the client’s responses. Discussion of family structure and history, present relationships, and how difficult events have been handled in the past are important. These can give real clues about whether a person tends toward neuroticism or a personality disorder in behavior.
Clearly, it can be hard to ascertain all of these features from a first session with a client, but lack of curiosity and strong emotional avoidance through a variety of defensive behaviors can help form a working hypothesis. The therapist’s countertransferential response is sometimes useful in achieving diagnosis also. A therapist unable to stay interested in a client might be working with a narcissist. Rescue feelings are common for those therapists who care for people with borderline personality disorder, and a sense of inadequacy may be common for psychotherapists caring for schizoid types.
Each of the three main personality disorders has different characteristics. Therapists might arrive at a personality disorder diagnosis of borderline when they note a client’s tendency to take a black and white view of the world. Such clients also may be overly dependent on the therapist and have a tendency to respond to difficult emotions by acting out. Generally, borderline personality disorder clients begin with strong feelings of good will toward the therapist, but if sufficiently challenged, they are subject to splitting into the black and white view and may become extremely angry with therapists. With splitting, clients are unable to see the therapist as anything but a rescuer or an enemy; they cannot accommodate an in-between view.
The narcissist tends to defend by grandiose behavior that can easily seem condescending Such clients have extreme challenges when they think they fail and are very self-critical, but they can also appear to simultaneously boast about their accomplishments and worry about losing any quality or thing they prize. Schizoid types may express paranoia, tend to have few relationships, and respond extremely negatively to therapeutic confrontation. Their self-contained quality may make it appear that they really don’t need therapy or lack of affect can suggest they aren’t benefiting from it at all.
Therapists can use other diagnostic criteria, such as from the Diagnostic and Statistical Manuals to make a clear diagnosis. Many clinicians develop their own set of standards from their studies in this area, and may draw from several therapeutic schools. In the beginning, a first diagnosis should be looked at as malleable, until the therapist has further sessions with the client.
There are some schools of thought positing the worthlessness of any form of diagnosis. A counterargument is that especially with personality disorders, being unaware of their potential existence delays the right sort of help. Due to the unique properties of these disorders, it’s easy to alienate clients or not give them the help they need if their challenges aren’t recognized, and they’re instead treated as neurotics. Such an argument supports at least some personality disorder diagnosis, not to label clients, but so that the best and individualized care is given to them.
