Table 1.
Severity of personality pathology: implications for assessment and treatment parameters [10]
| Neurotic organization | High borderline personality organization | Mid borderline personality organization | Low borderline personality organization | |
|---|---|---|---|---|
| Level of Personality Functioning Scale (LPFS) | Level 1 | Level 2 | Level 3 | Level 4 |
| Typical categorical diagnosis | Obsessive compulsive PD; depressive PD; hysterical PD | Dependent PD; histrionic PD; avoidant PD; narcissistic PD | Narcissistic PD; borderline PD; paranoid PD; schizoid PD | Narcissistic, borderline, and paranoid PDs with antisocial features; antisocial PD |
| Nature of self-other functioning | Integrated, realistic, and continuous experience of self in relation to others; relationships characterized by mutuality | Somewhat superficial and/or polarized experience of self in relation to others; some capacity for dependency but with conflict | Superficial, extreme, polarized, and unstable sense of self in relation to others with gross distortion; need-fulfilling relationships | Caricature-like, extreme, highly polarized, and chaotic sense of self in relation to others with gross distortion; exploitative relationships |
| Clinical objectives of treatment | Flexible functioning in area of conflict | Greater depth and stability in experience of self and others | Resolution of destructive behavior; greater depth in experience of self and others | Behavior control; modulation of aggression |
| Prognosis | Excellent | Good | Fair | Very guarded |
| Structuring of the treatment | Less need for structured contract | Explicitly agreed-upon treatment contract promotes productive clinical process | Carefully constructed treatment contract is essential | Contracting must be extensive; focus on secondary gain and safety of patient and therapist |
| Treatment process | Little to no risk of acting out | Risk of low-level acting out (e.g., poor attendance) | Risk of dangerous acting out (e.g., suicide gestures or attempts, substance misuse) | Potentially lethal acting out (e.g., threats of violence to therapist, lethal suicide attempts) |
| Alliance | Clarity about seeking help from expert; open to alliance | Ambivalence about seeking help and depending on expert interference with initial alliance; early alliance unstable or superficial | Suspicion, with fear of critical attack or exploitation by therapist interferes with alliance; alliance built during course of treatment | Relatively fixed view of therapist as corrupt, arrogant, and exploitative limits capacity to form an alliance |
PD, personality disorder.