Practical Diagnostic and Conceptual Models

The Diagnostic and Statistical Manual (DSM) offers symptom and behaviorally focused categories of diagnoses that are generally agreed upon and provide a shared language between clinicians, as well as a way to communicate to clients. However, there are shortcomings.

1. Behavioral and symptom based criteria are at best only part of the picture, and at worst - according to some arguments - inadequate. Behaviors and symptoms are surface-level presentations - they have the benefit of being easily observable, but lack depth and understanding the presentation in the context of the individual.

2. The DSM only includes some diagnoses, and some presentations within that diagnosis.

3. Some diagnoses are misleading, for example, I frequently see clients with borderline personality organizations (BPO - a designation for the severity of the personality pathology) who are diagnosed with borderline personality disorder (BPD, a typology) due to the severity of pathology, namely emotion regulation and impulse control, yet lack the core feature: fear of abandonment.

4. Lacks the complexity of real-world presentations. In reality, few people fit into one diagnostic category neatly, without any other symptoms or clinical factors that should be considered in a conceptualization. Researchers, and consequently care providers who come from that background, are used to seeing "clean" or clear-cut diagnoses as more common, complex presentations are excluded from those studies. If and when these individuals start practicing outside of the research setting, they become confused and insecure about how to a) conceptualize and b) treat individuals (versus treating a specific diagnosis with a manualized approach).

Intro

The following is not intended to be conscious consideration during therapy, but practiced until it is second nature and guides your work without vying for your attention during sessions, and between sessions. Consider creating conceptualizations one client at a time from your caseload, going through each of the following sections. Here is a table of contents to help with a cognitive road-map:

• Single Factor Model

• Cognitive Style

• Temperament

• Defense Mechanisms and Coping Strategies

• Polarities of Experience: Self-Definition vs Relatedness

• Passive vs. Active Strategies

• Cognitive Distortions and Core Beliefs

• Interpersonal

• Intrapersonal and Internal Systems

• Barriers to Treatment, Ambivalence and Stages of Change

• Emotion Regulation, Insight and Resilience

[An excellent book on the subject is Millon's Personality Disorders in Modern Life]

Single-Factor: Antisocial Spectrum example

With a caseload including a number of clients referred from court mandates due to violent offenses during a doctoral practicum, I decided to present on recidivism assessment in the forensic population. The Hare PCL-R, psychopathy checklist stood out at the time, including 2 subscales: one seemingly focused on impulse control deficits of antisocial personality disorder and the other on the lack of remorse telltale of psychopathy.

Reflecting on a client who had been doing well in therapy, he expressed little remorse, but something akin to this: self-consciousness about his sadism. Sadism, I would define as, hurting others as an ends in itself, as opposed as a means to an end. The client's growth in therapy was solidly rooted in an, albeit underdeveloped, existent object relatedness: a wish for a paternal figure from his brother whom he felt he lost to zombifying bipolar disorder medications, a desire to be appreciated by me in therapy (I felt like an uncle at times), a desire to be seen favorably by his pregnant girlfriend's father (who gave him a truck by the end of treatment), a desire to protect his absentee mother from abusive men she dated.

This highlighted his narcissistic needs: constantly combating the deflation of not being important to any paternal figure or enough to keep his mom away from crack cocaine and violent men who brought it to her, while searching unconsciously for acceptance and recognition. The importance of this is the role of narcissism in the antisocial spectrum in which protecting the ego, even at violent costs, and the penchant to rationalize those behaviors plays a roll in potential for recidivist behaviors.

While this client had a concerning dearth of remorse, it wasn't absent, and in fact, what was present in his prosocial desires was the engine for his therapeutic recovery. The concerning factors was his sadism, an underlying wish to demolish the men who hurt him and his mother and his impulsivity that overrode adherence to any rules.

The moral of this story was that attending to the core factor of these conditions was important conceptually, just as (mentioned above) abandonment fear is a must-have feature for the diagnosis of BPD. This is an important departure for the DSM - a single-factor model, not for complete diagnosis of a condition, but certainly a deal-breaker if it is not present.

Personality	Single-Factor
Borderline	Abandonment Fear
Narcissism	Protect, bolster, or maintain esteem at all costs
Psychopathy	No remorse - feeling would be a threat
Sadism	Pleasure from causing pain
Paranoid	Others aren't trustworthy or are dangerous
Schizoid	Relationships are messy, I'm safer alone and disinterested
Dependent	I'm incapable and I need others, doing for myself is a threat
Avoidant	If they see me, they'll shame me, so I must hide
Passive Aggressive	Get needs met subversively, harbor resentment, unhelpful
Compulsive	Self-control and perfectionism gives a sense of security
Depressive	Sense of "badness" maintained by overwhelming internal critic

Cognitive Style

David Shapiro, in his book, Neurotic Styles, followed the Beckian voyage from Psychanalytic thought to the cognitive realm. While Ego Psychologists focus on defense mechanisms and see these as the foundation of character - character referring to characteristic defensive or coping strategy, or marked overuse of a constellation of these is characterological, a character disorder or, in contemporary language, a personality disorder. Conversely, Shapiro posits that these are seated within an underlying cognitive style, akin to the Jugnian notion of temperament - the introversion-extroversion continuum - being fundamental to personality. An innate cognitive style would, ostensibly, underlying the characteristic defenses we would later use as coping mechanisms, and consequently the typology of Psychological illness that individual would be prone to.

Our cognitive or neurotic style might range from overly intellectual, in which emotional experiences are pushed out of conscious awareness and the world is experienced rationally and cognitively, to highly emotive individuals who might wear their emotions on their sleeve but at times have difficulty seating their experiences in fact and thought (in fact, those experiences may be pushed out of conscious awareness).

Presentations that shun both thought and emotional information from our conscious awareness involve denial and projection, creating the context for psychotic experiences and extreme or severe distortion of reality, or departure from reality. Conversely, individuals who have the ego-strength to maintain both cognitive and emotive information integrated in their conscious mind would be considered the most psychologically well or healthy. We could liken this to Linehan's notion of the Wise Mind from Dialectical Behavior Therapy (DBT).

Temperament

Carl Jung posited that temperament, the continuum from Introversion to Extroversion was a fundamental component of personality innate from birth. This notion has carried forward as core to contemporary theories including the Big 5 Factor Model of personality. Temperament is frequently slightly misunderstood as simply the degree to which someone desires social interaction (vs. time alone). However, the caveat is that desire isn't the driver, but the degree to which socializing versus time alone refills our psychological, emotional battery. During my doctoral assessment coursework, my cohort mates, who knew me well and were quite close to me, were very surprised to find out that I tested as (and identified as) introverted. A room full of (near) psychologists got me wrong!

Kernberg demonstrates a model of personality that puts temperament at the foundation, and how it relates to typology and severity of illness.

Kernberg's model of personality disorders, seated in Jung's notion of temperament.

Defense Mechanisms, Coping Strategies and Character

As discussed above, each personality disorders was historically referred to as a character disorder, defined by characteristic or characterological overuse of a narrow range of defense mechanisms. This means the individual has a small repertoire of way to handle and cope with challenges in life. Broadening this gives more options - I think of this as increasing free will.

Ego psychology utilizes defense analysis as its main intervention, which involves recognizing, interpreting (communicating to the client) and ostensibly altering defensive strategies. By helping the client to see their characteristic defenses, they can understand why they use them (what the trigger was), where they learned them, and determine whether to do something different (free will). While different sources site different constellations of defenses for each personality disorders, here are some examples:

Personality	Defense Mechanisms
Borderline	Splitting and projective identification, regression, acting out, anger turned inwards
Histrionic	Regression, repression
Narcissism	Rationalization, spitting (idealization and devaluation) and projective identification
Psychopathy	Acting out, rationalization, isolation of affect
Compulsive	Intellectualization and isolation of affect, reaction formation, asceticism, undoing
Depressive	Anger turned inwards, introjection, asceticism
Passive Aggressive	Anger turned inwards
Dependent	Regression
Paranoid	Projection, reaction formation vs splitting

Polarities of Experience: Self Definition vs Relatedness

While extended to apply to the full array of psychological conditions, Blatt published on a polarity he noted when treating individuals with depression. Some had concerns about relatedness, which he called anaclitic, and, despite the stigma about working with folks who have abandonment fears (BPD), responded quickly to therapeutic rapport and basic, humanistic or Rogerian aspects of treatment. However, clients struggling with self-definition, which he call introjective, were much slower to improve. They were exhausted by their introjection - harsh negative self-talk, but also ambivalent: another part of them self weak and inadequate to handle themselves and the world without it's oversight and guidance.

While many clients struggle with aspects of both polarities, most have a core concern that leans to one side or the other. What is interesting to me is the implied connection between defensive and interpersonal style. Blatt's use of the term introjective clearly references the defense mechanism, but also ties this to self-definition over relatedness. As you can see above, Kernberg associates introversion (someone who would be by definition lower on the need for relatedness) similarly with introjective character disorders including compulsive (depressive is in the middle of introversion and Extroversion on this chart, as Blatt indicates there are be two different underlying needs: self-definition or relatedness problems leading to the depression). In other words, while defense mechanisms, temperament, polarities of Experience and cognitive style can all be separate parts of consideration of a conceptualization, they are also correlated. However, it would be a mistake to assume they are identical phenomonon with different names - consider someone who functions and self-maintains with a primarily compulsive strategy, but is seeking therapy for fear of shame of performing unacceptably and consequently being abandonded and judged. While self-definition is a factor, and maybe more a chronic one, the immediate symptoms the client is endorsing are about relatedness.

Passive vs. Active Strategies

Passive Dependent	Active Dependent (Histrionic)
Passive Aggressive	Compulsive
Depressive	Narcissistic

Each of Freud's psychosexual stages had two possible phenotypes when hangups occur. The oral stage includes oral receptive and oral aggressive presentations. The former is the child who is never wean, is continually shocked as an adult not to be fed (cared for), and garners care through passivity. While active dependency is another term for histrionic, we don't see the level of aggression until the typology reaches the borderline personality organization severity range, at which point individuals frequently meet criteria for borderline personality disorders (as the two typologies are on a continuum). Anorexia could be considered an ambivalence between the two: passivity (restrictive starvation) requires and elicits others to step in and forcibly take care, and the client responds with aggression at the thought of being controlled and forced to eat. This is the definition of a projective identification (the parental figures is strongly pulled into a parental role and the role of a controlling aggressor is projected onto them, while the parental figures experiences the client as aggressive and controlling).

The anal stage includes anal expulsive (passive aggressive) and anal retentive (compulsive) characters. The experience of being forced or told to control one's bowels in potty training elicits a passive aggressive reaction. They passively fight back. Conversely, the individual who powerfully internalizes the parental figures who is teaching (bowel) self-control becomes self-controlling, referred to as anal retentive or compulsive. They actively control themselves to achieve a high-bar standard they've internalized, approach tasks with perfectionism, and, while on the surface approach others conscientiously, unconsciously hold others to the same standard. While the compulsive client is perfectionist, the passive aggressive client will do so poorly on a task assigned to them, they won't ever be told what to do again.

A condition the DSM falls significantly short with is narcissism, only encapsulating the grandiose presentation. Arguably due to the development of prophylactics, powerful internalizations and the church (which may have been a source of internalization) that caused enough guilt to act as a psychological prophylaxis, became less important and consequently less prevalent psychologically. Therapists started to see more shame and self-esteem issues, which were not adequately addressed in previous psychoanalytic literature. Kohut's works on Self-Psychology were heralded as elucidating these new client needs, therapist experiences and approaches to heal esteem issues. The greatest take away was arguably that every conceptualization requires understanding the client's self-esteem, how they maintain it, and our (the therapists) role in their esteem. Probably more common than the grandiose narcissist with a dearth of object relatedness (underdeveloped superego), is the deflated narcissist, which would arguably be considered a form of depression. Their hurt ego is constantly berated by an overwhelming and self-critical superego - the grandiosity is a fantasy.

Cognitive Distortions and Core Beliefs

There are a wide range of cognitive distortions, which arguably function analogously to defense mechanisms - they both distort reality and while defenses are coping strategies, cognitive distortions are believed to be habitual ways of processing that cause symptoms. Among the most common are black and white thinking and catastrophization: everything is perfect or awful, and since perfect is nearly impossible, it is awful which means the end of the world.

Saffron, in his book Widening the Scope of Cognitive Therapy, highlights a pitfall of cognitive therapy without integrating a psychodynamic conceptual lens: we are at risk of intervening on peripheral (non-central) distortions that aren't directly related to the client's underlying pathology. See the next two sections on interpersonal and intrapychic to help guide cognitive interventions to central rather than peripheral distortions, and also consider the core beliefs. Core beliefs are intrinsically a part of interpersonal psychology: beliefs about self and others. They may also be broad beliefs about how to navigate our social world that are characteristic to specific personality types.

• Antisocial: rationalize asocial behavior because it is a "dog-eat-dog" world, and if I don't break the rules to get what I want, someone else will to get ahead - might as well be me!

• Narcissism: I am special and I deserve people to recognize this, and laud my specialness

• Dependent: I need other to take care of me, I'm inadequate and incapable to do it myself, and that is what others are supposed to do. If I don't do it, someone else will.

• Passive Aggressive: Speaking my mind will be met with invalidation or even more aggressive, so I need to get my needs met subversively. Others are controlling, so and however I can maintain control is fair game.

• Compulsive: I need to do everything right, that is who I am, and I can't bear the judgement of being seen differently. I'm kind to others, but also frustrated when I'm unappreciated and people don't meet me in the middle with the same effort and conscientiousness.

Interpersonal and Relational

Interpersonal theory started with Harry Stack Sullivan, and when reintegrated with it's psychoanalytic ancestral theories, it is referred to as relational. These theories posit that we are at the core social beings - what is an ant without a colony? Consequently, we cannot understand the individual or their psychology outside of the interpersonal or social context. Our personality includes beliefs about yourself as they relate to others, beliefs about others are those others relate to us, defenses to protect us or help us navigate the social work, and our symptoms occur and must be understood within this social context. While most psychodynamic therapists do not lean on worksheets and other problem-focused interventions, an interpersonal intervention is the Cyclical Maladaptive Pattern (CMP). I use an altered version:

Likely it stands out that this model - as many psychodynamic models - lean heavily on identifying beliefs and thought patterns, which offers an intersection with cognitive theory.

An interpersonal or relational therapist's realm is "what is happening right now between us?" They consider:

• How is the client acting towards me?

• How does the client seem to feel about me?

• How do they relate to me?

• What role and impact do I seem to have on their self-esteem?

• How do I feel about the client and when with the client?

• How do I want or feel pulled to act toward the client?

• What is co-created between us?

• What patterns are we acting out?

• How does the client see and portray themselves, and what things are denied or projected?

While arguably overly circumscribed, a useful model is Structural Analysis of Social Behavior, focused on aggression vs sexuality on one axis, and enmeshment vs differentiation. Frequently, a goal of therapy is moving toward the middle, upper right quadrant. Typically, we act in ways that are identified with or complementary to others in our lives or how we are treated, and likewise, the way we treat ourselves.

As my clients tell me stories involving interactions with other outside the session and as I consider the way the client interacts with me in session, I imagine writing each of these examples around a circle, and then asking myself what belongs in the circle in the middle? What ties each of those stories together? Almost like a Venn diagram: what overlaps between each story. My clients can usually quickly put words to this that are highly meaningful to them and resonate with their internal experience.

Intrapsychic and Internal System

The interpersonal model, above, incorporates how we experience and treat our self - this is an intrapsychic process that is often a mirror image of the interpersonal. How do we see ourselves, related to ourselves, talk to our selves and self-manage? Most people experience self-talk and internal dialogue, and consequently we can see one part of ourselves acting up on another. This opens the door to parts work - most psychological theories accept this notion (such as critical self-talk in cognitive therapy). The general belief is that parts of our self is crystallized in our psychology during developmental milestones (not necessarily developmental stages, but emotionally salient experiences and hurdles). One model is from Internal Family Systems (IFS) - as implied by the word system, there is an internal homeostasis that is familiar and provides a version of stability, but not necessarily adaptive or optimizes functioning.

Early life stressors cause the emotions and self-images that becomes, protectively, relegated to the exile. By definition of the term exile, this part is largely shunned though it follows us like a shadow, and thereby not resolved. The manager ostensibly serves to help the exile, but realistically causes shame by continuing to relegate it to a shunned position, and protecting our conscious self from feeling that way, stating "its not us, its that exile that is so bad." The manager is exhausted of it's role, but also a true believer - it thinks its role and functions as essential, and there is a truth that it maintains a homeostasis, but it is wrong that there isn't another, more adaptive and tenable homeostasis in which it learns to trust the core self to manage the roles it has taken on. While the exile is a repository of all the things we don't want to feel and be, the manager is a repository of the coping skills we learned shortly thereafter feeling that way (the way the exile feels) to manage those feelings and avoid feeling that way again.

Barrier, Ambivalence and The Stages of Change

It may be clear in the section above that the manager in our internal system is a barrier to wellness. It is doing something that gets us by, it is treading water, but surviving isn't thriving. Yet it is terrified and resistant to change, untrusting that the core self can do the work. Everyone has barriers (resistance) and ambivalence to change, in fact that is arguably the core of the work because without those hurdles, most people can install change in themselves without therapy. So when you hit a barrier in your work as a therapist, try not to see it as a problem or something negative about your ability, but rather simply as the work.

Using parts language can be validating in exploring ambivalence: "there is part of you that is very ready to be living differently, but also naturally a part of you throwing on the breaks. What is that parts? What does it need?"

Motivational Interviewing is one method of validating and working with these barriers, and highlighting them helps the client to see that the nature of therapy is not some special skill or intervention the therapist should know and be able to use, but also requires their responsibility. Having a history of specialized experience with eating disorders, I occasionally see clients for over eating and many realize they are unready to change due to shame about people seeing them eat differently. They might determine they aren't ready to change, to further explore this shame and the decision, or to face it, but the important part is they realize the barrier and are no longer simply searching for a solution to their eating habit. We can help them in various ways including recognizing their stage of change.

Additionally, we can relieve our pressure to magically reach a therapeutic goal and the client's frustration with themselves for not simply being able to just "do" it and get to their goal by asking questions about barriers:

• What might get in the way of getting to your goal?

• That's a good goal for this week - what if anything would get in the way of you achieving it?

• What came up for you last week when you were trying to meet that goal? What got in the way? Walk me through it so we can understand.

Emotion Regulation, Insight and Resilience

Resilience is a complicated factor that incorporates our tangible coping skills, adaptiveness of defense mechanisms, emotion regulation and other innate factors that effect our disposition and risk of illness. There can be epigenetic risk of PTSD past from parent to child, for example. Two people can experience the same trauma and one can make meaning and experience post-traumatic growth while the other, at least initially, experiences PTSD.

As discussed above, various factors distort our reality, and by definition our insight as well. This includes defense mechanisms and cognitive distortions, as well as biological factors such as the stark loss of insight in florid psychotic (including manic) states. From a phenomenological stand point, the End of History phenomenon posits it would be threatening to see ourselves as unstable, so insight at times must be sacrificed for stability. For example, someone with depression may feel like a different person, maybe even like they can't recall what it was like before the depression, and that they can't imagine ever get back to that place. This causes hopelessness, yet maintains a sense of stability.

Lastly, we need to understand our client's emotion regulation, broadly and in relation to specific triggers. A previous blog article on Uncertainty covers supportive vs expressive interventions and the Yerkes Dodson curve. This curve demonstrates our ability to function or perform (including in therapy) because upon physiological arousal. Some people have a very peaked curve: they quickly become overwhelmed and feel little control over their ability to regulate emotion. Others have a wider peak and can self-regulate more easily. This could be due to the specific stimuli or trigger, PTSD, severe personality disturbance or acute symptoms. For a client with a peaked (narrow) curve, we need to engage in supportive therapy: teach coping skills, mentalization based therapy to increase awareness of emotional changes via mirroring, behavior chain analysis or similar techniques to understand minute aspects of the process otherwise outside of insight, and self-psychology to build ego strength / esteem. Those who have a wider peak can handle more therapeutic intensity including expressive or interpretive interventions.

Diagram

Finally, many cognitive behavioral treatment guides offer directions on how to diagram a flowchart of a client's conceptualization. These models primarily show a process, such as starting with a trigger and how the client reacts behaviorally, cognitive, and emotionally, as well as how this in turn reinforces the pattern (leads back to the trigger or is somehow cyclical). A recent example involves discussing with a client how they become symptomatic, often somatic, when stressed. This occurs when his wife stressed and puts pressure on him, or in therapy when he doesn't want address a topic (he reports being too tired). This gets him out of the situation, gets his wife attention and care, so it is self-reinforcing, but requires him to become psychologically and physically ill to get his needs met. We work on recognizing the early signs and verbalizing instead.