Diagnosing Personality Disorders

At one time, persons with Borderline Personality Disorder (BPD) were considered untreatable. Then, in the 1960s, Dr. James Masterson developed a method that was generally successful with adolescents in an inpatient setting.

As behavioral psychology gained influence, behaviors became diagnostic criteria for mental disorders. Masterson was an outspoken critic of behavior-based diagnosis of personality disorder. An almost limitless range of behaviors can be used in an attempt to regulate emotion or to cover up unwanted feelings.

Research by Benjamin Johnson and Kenneth Levy at Pennsylvania State University finds the behavior of many persons with Borderline Personality Disorder does not line up well with the behaviors listed in the DSM. They say, as Masterson did, that the behaviors result from inability to regulate emotion and a need to deal with inner emptiness. If a list of typical behaviors is not diagnostic, then what is? Masterson insisted personality disorder should be diagnosed based on intrapsychic structure as revealed by what triggers the person's distress and how they defend against distress. To help his students understand his way of reaching a diagnosis, Masterson offered what he called the Personality Disorder Triad:

1. Self-activation leads to:
2. Dysphoric Affect, which leads to
3. Defense.

Borderline Example

1. Self-activation. An unemployed person decides to look for a job. (Masterson defined self-activation as action based on one's own best self-interest.)
2. Dysphoric Affect. As he goes to the job interview, he is alone. The person he depends on for calming is not with him. He realizes that if he takes the job, the person he depends on will not be with him. That person may also feel abandoned, and may do something destructive or take revenge for his acting in his best interest. Anxiety develops.
3. Defense. To deal with the anxiety, he blows off the interview and engages in an activity to distract himself from thoughts that trigger anxiety or an activity intense enough to override his discomfort. A broad range of activities could be used. It is not the activity he chooses that is diagnostic, but that some activity is used to avoid the feelings that developed from self-activation.

Schizoid Example

A schizoid person does not depend on interaction for emotional regulation, but rather on an abstraction of interaction. He holds the idea that there is someone in his life and thus he is not abandoned. When uncomfortable because the relationship is too separate, he becomes interested in actual contact.

1. Self-activation. He makes physical contact with an emotionally significant person.
2. Dysphoric Affect. He develops terror that he will be taken over by the person, or engulfed by emotion.
3. Defense. To defend against these threats, he increases the physical or the emotional distance. A number of behaviors can be used to distance himself from feeling threatened by the person he has brought too close, such as sex with someone else, pornography, stamp collecting, isolation, work, etc.

Narcissist Example

1. Self-activation. He sets up a frank discussion with a friend.
2. Dysphoric Affect. Anxiety develops that the friend will not be of one mind with him.
3. Defense. To defend against anxiety, he turns away from a spontaneous discussion to what appears to be spontaneous but is a performance: saying things or doing things from his repertoire.

An overview of the Penn State research can be found here on Psychology Today in Susan Whitbourne's blog "Looking Below the Threshold in Borderline Personality."

Masterson argued that personality disorder results from a combination of three factors: nature, nurture, and fate. He believed everyone has some degree of personality disorder. "No one," he said, "escapes childhood unscathed."

Whitbourne appears to agree. She writes, "Even without a diagnosis, people who have symptoms of borderline personality disorder (BPD) can experience challenges in their daily lives."