Borderline personality disorder, bipolar disorder, depression ...

Borderline personality disorder,bipolar disorder, depression,attention deficit/hyperactivity disorder,and narcissistic personality disorder:Practical differential diagnosisOtto F. Kernberg, MDFrank E. Yeomans, MD

The challenge of accurate diagnosis remains at the heart of goodpsychiatric treatment. In the current state of psychiatry, a confluenceof forces has increased this challenge for the clinician. These includepractical pressures—such as limited time for diagnostic evaluation,the question of what is reimbursed by insurance, and the issue ofdirecting patients to acute treatments—and also trends in nosology,such as the descriptive focus on signs and symptoms in the cur-rent official diagnostic system. The authors offer observations thatwe hope will help clinicians who have to make difficult diagnosticdifferentiations often under pressured circumstances. The paper ismotivated both by the high frequency of diagnostic errors observedunder such conditions and also by the belief that considering sym-ptoms in the context of the patient's sense of self, quality of interper-sonal relations, and level of functioning over time will help guide thediagnostic process. (Bulletin of the Menninger Glinic, 77[1], 1-22)

Dr. Kernberg is Director, Personality Disorders Institute, The New York PresbyterianHospital, Payne Whitney Westchester; Professor of Psychiatry, Joan and Sanford I.Weill Medical College of Cornell University; and Training and Supervising Analyst,Columbia University Center for Psychoanalytic Training and Research. Dr. Yeomansis Clinical Associate Professor of Psychiatry at the Weill Medical College of CornellUniversity; Director of Training at the Personality Disorders Institute at the New YorkPresbyterian Hospital, Payne Whitney Westchester; and Director of the PersonalityStudies Institute in New York City.Correspondence may be sent to Dr. Otto Kernberg, New York Presbyterian Hospital,21 Bloomingdale Rd., White Plains, NY 10605; e-mail: [email protected].(Copyright © 2013 The Menninger Foundation)

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Kernberg and Yeomans

What follows are clinical observations directed to psychiatristswho have to make difficult diagnostic differentiations, often un-der circumstances of pressured time. These differentiations ofteninvolve decisions regarding immediate interventions and treat-ment planning. This article is motivated by the high frequency ofdiagnostic errors observed under such conditions, an observationthat emerges only when the patient is seen under more stable con-ditions, particularly during more extended evaluation. We shallnot review systematically the diagnostic criteria for the variousconditions to be jointly explored, but only highlight those aspectsof mental status examination that facilitate a differential diagno-sis under the conditions mentioned.

We have observed that about 50% of patients who enter thepersonality disorders unit of our hospital with the diagnosis ofbipolar disorder or major depression turn out to present neither,but rather a severe personality disorder organized at the border-line level (Kernberg, 1975, 1984), particularly borderline person-ality disorder (BPD), severe narcissistic personality disorder, orvarious disorders in which recurrent suicidal ideation, parasui-cidal traits, and/or antisocial behavior are the main symptoms,or where an acute drug dependency or alcoholism dominates thepicture. Erroneous diagnostic conclusions have frequently beenreached, particularly in the case of patients with strong negativis-tic features, who refuse or are unable to provide adequate infor-mation about themselves, or, occasionally, may wish to exagger-ate certain symptoms in order to obtain hospitalization.

Bipolar disorder

The clinical range of bipolar illness remains a subject of de-bate (Paris, 2009). The diagnosis of a bipolar disorder requires,in DSM-IV-TR, the presence of at least one episode of a majordepression and one manic (Bipolar I) or hypomanic (Bipolar II)episode. The accurate assessment of the presence of manic or hy-pomanic episodes is essential. The experience of multiple priorevaluations may predispose patients to give a history that fits amanic or hypomanic episode because of the standard nature ofquestions asked, and we have frequently observed some patients'

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Differential diagnosis

tendency to conform to questions that have a "leading" qualitywith regard to standard manic or depressive symptoms. It is im-portant to patiently ascertain whether the patient has indeed hadone or several periods of at least 3 to 4 days in which an unusu-ally euphoric, angry, or irritated mood predominated, togetherwith a sense of heightened energy, affective dyscontrol, signifi-cantly reduced need to sleep, hyperactivity, and unusual behaviorin sharp contrast to the usual personality of the patient. Suchbehavior may involve inappropriate sexual exposure or behavior,grave mismanagement of money or other properties, socially in-appropriate approaches to others, and possibly increase of sexualdrive together with a general expansiveness of mood and behav-ior. Symptoms of a true manic episode often involve loss of real-ity testing as manifested by behavior that does not correspond tosocially accepted norms without awareness of the deviation fromthe norm.

The most frequent mistake, in our experience, consists in con-fusing the chronic emotional instability and affect storms of per-sonality disordered patients with a truly hypomanic or manic be-havior. In the casé of manic behavior, the differentiation is easier;here the clear loss of reality testing, the presence of hallucinationsand/or delusions, or inappropriate social behavior usually leadsto intervention by others to control the patient, interventions thatare typical enough to confirm loss of reality testing and to war-rant the diagnosis of a bipolar disorder. Therefore, the confusionbetween bipolar illness and BPD is usually reduced to cases of as-sumed hypomanic behavior used as the basis to diagnose bipolarII in patients.

In about 19% of patients with borderline personality disorder,however, a comorbidity with bipolar disorder may be present,and the patient shows both severe, chronic affective instabilityand clear hypomanic episodes (Gunderson et al., 2006). To as-certain the presence or absence of BPD in these cases, it is help-ful to evaluate the general nature of the patient's relationshipswith significant others. Cases of pure bipolar symptomatologydo not show severe pathology of object relations during periodsof normal functioning, and even chronic bipolar patients, whosuffer from both manic episodes and major depressive episodes.

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maintain the capacity for relationships in depth, stability in theirrelations with others, and the capacity for assessing themselvesand the most significant persons in their life appropriately (Stone,2006).

In contrast, in severe personality disorders with the syndromeof identity diffusion, there is a marked incapacity to assess oth-ers in depth, a lack of integration of the concept of self, withsevere, chronic discrepancies in the assessment of self and others,and chronic interpersonal conflicts, together with the difficulty ofmaintaining stable commitments to work and profession as wellas to intimate relationships.

The combination of absence of affective stability, absence ofsignificant and mature relations with others, and instability inwork or profession, in love relations, and in self-assessment con-firms the diagnosis of a severe personality disorder even if, at thesame time, bona fide symptomatology of a bipolar I, or bipolarII type is effectively present. In short, the presence of a consistentand marked immaturity of all object relations, and emotional im-maturity in general, outside bona fide episodes of manic, hypo-manic, or depressive symptomatology is characteristic of border-line personality disorder.

The therapeutic implications of this differentiation reside inthe essential indications of psychopharmacological treatmentwith mood stabilizers in the case of bipolar patients and, in gen-eral, in major affective illness, in contrast to the predominant re-quirement for appropriate psychosocial and psychotherapeuticinterventions in the case of severe personality disorders (Ameri-can Psychiatric Association, 2001).

Major depressive episode

The differential diagnosis between an episode of major depres-sion and a chronic dysthymic reaction in borderline personalitydisorder is more difficult, but eminently feasible—if enough timeis available to clarify the four major areas of symptoms.

First are the psychic symptoms of a depressive spectrum of ill-ness. In major depressions, there is a significant slow-down ofthe patient's thought processes and the patient's psychomotor

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behavior, severe depression of mood that varies between pro-found sadness to the total unavailability of any subjective senseof feeling—a sense of total freezing of all emotional experiencein the most severe cases. Typically, thought processes are severelyself-demeaning and self-accusatory—rather than focused on ac-cusing and blaming others. The patient may present severe guiltfeelings that may range from chronic exaggeration of whateverreal deficits or faults the patient has detected in himself or her-self to extreme, delusional self-devaluations and self-accusations.This combination of chronic slowing down in behavior, loweringin mood, and self-devaluation over a period of weeks to severalmonths, combined with consistent daily fluctuations of symp-toms—the patient feeling worse in the mornings and mood im-proving gradually every evening, with a relentless repetitivenessof such daily cycles over weeks—characterizes a typical majordepressive episode.

"While it may be clear that these symptoms are typical of amajor depressive episode, in our experience, many patients tendto respond to the routinized questions on hurried mental statusexaminations in a way that conveys the impression to the exam-iner that they suffer from this syndrome. The clinicians and/orthe patients wish to diagnose an Axis I condition because theseconditions fit more readily into acute treatment plans based onpharmacological interventions and also have less stigma than per-sonality disorders. Frequently patients may state that they feelchronically hopeless and helpless, which would reflect a totaldepressive despondency. However, when one asks patients whatthey feel hopeless about and in what way do they feel helpless,patients have difficulty conveying a response that is harmoniouswith a general self-devaluation, and, to the contrary, in the caseof severe personality disorders with characterologically baseddystbymic reactions, patients may respond with accusations andrage against others with an affect that seems more angry thandepressed.

This predominance of rageful reactions while professing totalself-devaluating depression is quite characteristic of personalitydisorders, and should raise questions about the assumed majordepression. In the case of major depressions, patients withdraw

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from social contacts and may feel worse when efforts are made tostimulate them to socialize; premature efforts of encouragementmay have the opposite effect and, in fact, increase suicidal tenden-cies in patients with major depression. The depressive reactionsin personality disorders are usually less severe and are irregularin their appearance and duration. They may shift abruptly fromone day to the next, even from one hour to the next, and areclearly influenced, in positive or negative ways, by the patient'simmediate social environment. Shifts of the symptomatology ac-cording to different social circumstances—for example, if the pa-tient is apparently more deeply depressed during the week but onweekends, in the presence of friends, engages in animated socialinteractions, only to reverse to a state of depression on the fol-lowing days—are characteristic of a personality disorder with acharacterological depression—dysthymic disorder^—and not of amajor depression.

In general, the patient's gross physical neglect of appearance,the incapacity to carry out ordinary activities of daily living, stay-ing in dirty clothes, and indicating an unusual neglect of his orher appearance are more characteristic of a major depression inthe context of all the psychic symptoms mentioned. Again, thepatient's rapid shifting in behavior under conditions of desirablesocial interactions is more characteristic of the symptoms of char-acterological depression in a personality disorder.

A second area of exploration of the differential diagnosis isthe evaluation of the personality structure that predated the be-ginning of the depressed episode. Patients with severe narcissisticpersonality disorder, borderline personality disorder, histrionicpersonality disorder, and masochistic/depressive personality dis-order are prone to severe dysthymic reactions characterized byfrequent days with symptoms of depression without reaching theintensity, consistency, and duration of major depressive episodes.In these cases, there is usually a history of chronic minor depres-sive episodes or dysthymic reactions extending over many years,a lack of clear periods of at least months' duration in which thepatient evinced no depression at all, so that dysthymic symptomshave acquired a relative stability in the psychic equilibrium of

1. A prevalent form of chronic, characterologically based depression.

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such patients. There are patients who report that they have beendepressed all of their lives, and these patients usually present se-vere personality disorders. But these symptomatic features haveto be differentiated from the characterological features of themasochistic/depressive personality. However, a certain percentageof patients with major depression, probably around 30%, maybecome chronic with refractory depression persisting over manyyears (McGrath &c Miller, 2008; Rush et a l , 2006). These re-fractory cases may present well-documented symptoms of majordepression and a remarkable lack of response to all psychophar-macological and other, physical treatment interventions. Withelectroconvulsive treatment, some of these patients may signifi-cantly improve for several weeks and then often revert to chronicdepression again. It is especially important to make a correct di-agnosis in such cases because some patients with "refractory"depression may have a characterological depression that wouldbenefit from appropriate psychotherapy, and it is important todifferentiate these latter features in cases of "double depression."Gunderson et al. (2004) found that the rate of remission frommajor depressive disorder was significantly reduced in cases withco-occurring BPD. However, the rate of remission from BPD wasnot affected by co-occurring major depressive disorder.

A third area of inquiry facilitating the differential diagnosisbetween major depression and characterologically based dysthy-mic reactions involves the following neurovégétative symptomsthat point to major depressions: severe insomnia, particularlyconsistent early awakening hours before the usual waking time;loss of appetite with severe weight loss; consistent loss of sexualdesire; possibly impotence in men and suspension of menstru-al periods in women; chronic, severe constipation (considering,naturally, that this may be secondary to the use of antidepressivemedication); a heightened sensitivity to cold temperature and, insevere cases, a typical "mask like" facial expression of severe de-pression. There are patients with atypical major depression forwhom the depressed mood is worse in the evenings rather thanin the mornings, and who present a tendency to hyperphagia andgaining weight. These cases have to be evaluated very carefullyregarding the psychic symptoms of depression mentioned ear-

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lier before reaching a definite conclusion. Patients with geneticpredisposition to affective disorders may show neurovégétativesymptoms even under conditions of relatively lighter depressionwithin the frame of a major depressive illness.

A fourth area of diagnostic relevance for the evaluation of de-pression is the analysis of environmental triggers that may havepreceded a depressive episode. Typically, in chronic dysthymic,characterological reactions, environmental conditions may trig-ger depressive reactions, and these environmental conditions areoften remarkably minor, while the patient pays a disproportion-ate attention to their symbolic value. Major depressions usuallydo not show such a direct relationship between environmentaltriggers and depression, although the combination of strong ge-netic disposition and environmental triggers can occur.

In conclusion, regarding these four areas of inquiry, the moresevere the psychic symptoms and the neurovégétative symptoms,the more likely there is a major depression; the more predomi-nant the personality disposition and the environmental triggers,the more likely there is a dysthymic disorder (characterologicaldepression). There are patients, however, who present a "doubledepression," that is, an acute episode of a major depression inthe context of a chronic characterological depression. These casesrequire, first, the treatment of the episode of major depression.Only after the resolution of that episode by psychopharmacologi-cal and/or other physical treatments will a complete and accuratediagnosis, prognosis, and treatment plan for the characterologi-cally based dysthymic disorder become feasible.

Self-destructive behaviors in major depressionand in personality disorders

One major prognostic and therapeutic issue, both in the case ofall depressions and in severe personality disorders, is the pres-ence of suicidal tendencies and parasuicidal behavior. In general,acute or chronic parasuicidal behavior, such as repeated cuttingor burning—particularly under conditions of intense emotionalagitation, temper tantrums, or acute frustrations—is typical ofsevere personality disorders, particularly borderline personality

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disorder. Intense suicidality can present in the context of depres-sion, but is not limited to that condition. An example of suicidal-ity in a nondepressed patient is the dangerous, chronic, methodi-cal preparation for a severe suicide attempt that can be seen inpatients with no symptoms of depression but with the syndromeof malignant narcissism in which suicide may be experienced asa final triumph over others, which may be motivated by intenseenvy. Both this type of chronic suicidal tendancy and the acute, re-petitive suicidal attempts under conditions of frustration or angerof borderline patients are typical of severe personality disorders.The latter type can seem "out of the blue" and can correspondto an outburst of temper without the background of symptomsof a major depression. Patients who present chronic suicidal andparasuicidal behavior without depression require highly special-ized psychotherapeutic treatment. Many of these patients may behelped effectively with an integrative cognitive-behavioral treat-ment (Dialectical Behavior Therapy; Linehan, 1993), a psycho-dynamic psychotherapy (Transference Focused Psychotherapy;Clarkin, Yeomans, &c Kernberg, 2006), or Mentalization BasedTherapy (Bateman & Fonagy, 2004).

In contrast to this picture in personality disorders, suicide at-tempts in the context of symptoms of severe depression are typi-cal of major depressive disorders and require a careful diagnosticassessment of the conditions under which suicidal behavior oc-curred. The types of suicidality generally found in patients withpersonality disorders that we have just discussed can most oftenbe treated with outpatient psychotherapy. However, suicide at-tempts in the context of major depression have severe prognosticimplications; require immediate, systematic psychopharmaco-logical treatment; may require hospitalization; and, with patientswho do not respond to other treatments, may need electrocon-vulsive treatment. In spite of this overall distinction between thepresentation and treatment of patients with characterological de-pression and those with major depression, there are some patientswith a severe personality disorder who may present severe depres-sive mood accompanied by suicidal behavior that also requirespsychopharmacological treatment of the depression togetherwith starting a psychotherapeutic treatment for the personality

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disorder. It bas to be kept in mind tbat up to approximately 10%of patients witb borderline personality disorder commit suicide.

Tbe diagnosis of a concrete episode of depression, in terms ofwbetber it is a major depressive syndrome or a cbronic dystbymicreaction corresponding to a characterological predisposition in asevere personality disorder, requires more time and is more dif-ficult than the assessment of wbetber tbe patient has or bas notbad an episode of bypomanic or manic bebavior. While tbe dif-ferentiation of a severe personality disorder from a bipolar disor-der requires, in practice, only tbe precise differentiation regardinga hypomanic or manic episode, tbe differentiation of character-ological depression and major depression requires considerationof all tbe criteria. Witb adequate review of these criteria, tbediagnostic distinction should not remain a major problem. Tbetreatment of all affective disorders is centered on antidepressantsand mood stabilizers, witb tbe addition of neuroleptic medicationin cases witb extreme anxiety or complications witb hallucina-tory or delusional symptoms. In our experience, the treatment ofsevere depressive reactions in personality disorders, particularlywitb suicidal tendencies, also warrants tbe use of antidepressivemedication, but psycbotberapeutic treatment, as mentioned be-fore, is tbe central focus of tbe clinicians' effort.

Sometimes, sadly, erroneous diagnoses do not reflect clinicalcriteria, but social pressures, for example, tbe refusal of tbird-party payers to reimburse treatment for personality disorders,limiting tbemselves to payment for affective disorders. Also, still-prevalent biases and fears regarding tbe diagnosis of personalitydisorder, and a general reluctance on tbe part of patients as wellas families to look into tbe psycbological conflicts related to se-vere personality disorders, may foster tbe diagnosis of a majordepression or bipolar illness as a "cbemical imbalance," expe-rienced as a "preferable" diagnostic conclusion. Yet Lequesneand Hersb (2004) found tbat BPD patients do better wben tbediagnosis is named and described. Insofar as, at tbis time, effec-tive treatment metbods for personality disorders are available,sucb erroneous diagnostic conclusions are definitely damaging.Tbey postpone tbe time of adequate treatment and expose pa-tients witb severe personality disorders to additional, unnecessary

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risks, such as those involved in some psychopharmacological ap-proaches that provide patients who are unable to be responsibleregarding the use of such medications with an additional poten-tial for suicidal and parasuicidal behavior. It may seem trivial tostate it once again: An adequate diagnosis is the first step to aneffective treatment.

Attention deficit/hyperactivity disorder

One other relatively frequent and often difficult differential diag-nosis is that between a severe personality disorder, particularly aborderline personality disorder or a narcissistic personality disor-der functioning on an overt borderline level with antisocial fea-tures, and an attention deficit/hyperactivity disorder (ADHD) inadolescent or adult patients. The prominence of inattentiveness,the inability to concentrate, the presence of school or work fail-ure, and/or the hyperactivity/impulsivity of ADHD may be con-fused with the breakdown of the capacity to study or to work,the impulsivity and emotional lability of a severe personality dis-order. The two types of disorder occasionally present comorbidly,but in the large majority of cases only one of these diagnosescharacterizes the patient, and the risk of misdiagnosis is high.

A diagnosis of ADHD should be confirmed by informationfrom home and school regarding symptoms of inattention and/or impulsive hyperactivity from early childhood, predating othersymptoms that characterize a severe personality disorder. Thecapacity for a relatively normal adjustment to the social life atschool and to a good relationship with the parents within thestress given by the academic difficulties would suggest the diag-nosis of ADHD. The absence of significant antisocial behaviorfrom early childhood, the capacity to establish in-depth friend-ships and loyalties, and the presence of normal identity integra-tion favor the diagnosis of ADHD, even if irritability, depressivereactions, and explosive resentment when faced with the conse-quence of the cognitive disabilities are present. The capacity fordeep interpersonal relations, concern over one's functioning andrelationships, and the capacity to establish an honest and reli-able relation with a therapist characterize the simple ADHD pa-

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tient's presentation in adulthood, in addition to the therapeutictest given by stimulant medication that usually improves ADHDsymptoms significantly and rapidly.

Severe pathology of object relations with marked incapacityto establish friendships from early childhood on, significant dif-ficulties at home with parents and siblings that are present to-gether with severe identity disturbance as evaluated in the clinicalinterviews, and possible chronic antisocial behavior from earlychildhood on speak for a personality disorder, particularly if thediagnosis of ADHD has only been suggested in late adolescenceor early adulthood, as one more attempt to explain severe schoolfailure, emotional lability, and irresponsibility regarding tasksand human relations.

The differential diagnosis of ADHD from a bipolar disorderis facilitated by the episodic nature of bipolar illness, which hasclearly marked periods of normal functioning disrupted by well-documented hypomanic or manic episodes, in addition to theusual differential diagnosis of major depression from chronic dys-thymic disorder. Narcissistic personality disorder should also beconsidered in cases where there is difficulty learning. In the caseof a narcissistic personality functioning on an overt borderlinelevel, the grandiosity, entitlement, inordinate envy, and extremeseverity of the lack of intimate in-depth relations differentiate thiscondition from ADHD. In addition, in the case of narcissistic per-sonality disorder, one sees a characteristic discrepancy betweenexcellent cognitive functioning in areas where the patient consid-ers himself or herself superior and is gifted enough to carry outtasks without any efforts, in contrast to complete failure in otherareas where intense learning and the overcoming of difficultiesare required, and where the patient responds by devaluing whathe or she cannot achieve easily.

Neuropsychological and projective psychodynamic testing mayprovide additional significant evidence in this clinical assessment.Projective psychodynamic testing would add important informa-tion regarding the nature and severity of the personality disorder,while significant, nonspecific, but diffuse indications of cognitivelimitations and a learning disorder would point in the directionof ADHD. It is questionable whether a diagnosis of ADHD, first



considered during the adulthood of a patient, can be justified inthe absence of confirmatory evidence from neuropsycbologicaltesting.

Posttraumatic stress disorder

Another important differential diagnosis is that between a bor-derline personality disorder and a posttraumatic stress disorder.A movement in the 1990s argued that BPD was not an entityunto itself, but a misunderstood form of PTSD (Herman, 1992).However, a review of the literature finds that only a third of theBPD population has a history of severe and extended abuse and,furthermore, that only 20% of individuals with a history of seri-ous abuse go on to have serious psychopathology as adults (Paris,2008). Potential confusion between BPD and PTSD derives fromthe fact that traumatic experience or ongoing, repeated trauma-tization, which can be sexual, physical, or psychological, par-ticularly in early childhood, constitutes an important etiologicalfactor in the development of a severe personality disorder, par-ticularly borderline personality disorder.

The typical symptoms of PTSD arise within the first 6 monthsafter a traumatic event and may last up to 2 or 3 years follow-ing the event. Symptoms include insomnia, irritability, angryoutbursts, difficulty concentrating, hypervigilance, exaggerat-ed startle response, and intensive reliving of the trauma in theform of nightmares, "flashbacks," and repeated memories of thetrauma. The development of further symptoms many years af-ter the actual, real, or assumed trauma, including somatizationsymptoms, dissociative symptoms, emotional lability, impulsiv-ity, self-destructive behavior, and, particularly, chronic interper-sonal difficulties with manifestations of emotional immaturityare symptoms of a structured personality disorder, which mayderive from trauma or a combination of personality dispositionand traumatic experiences.

This differentiation is important from a therapeutic stand-point: Treatment of PTSD requires a psychotherapeutic approachthat facilitates the controlled reliving and working through of thetraumatic experience in the context of a safe and secure psycho-

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therapeutic relationship. In contrast, when traumatic experiencesare at the origin of a personality disorder, the unconscious con-flicts triggered by the trauma usually take the form of an uncon-scious identification with the traumatic relationship, that is, anunconscious identification with both victim and perpetrator ofthe trauma. In the transference focused psychotherapy of thesepatients, they have to be helped to acquire conscious awarenessof this double identification and resolve it in the course of trans-ference analysis. This represents a very different psychotherapeu-tic approach than that required for the treatment of PTSD (Koe-nigsberg et al., 2000).

Narcissistic as compared with borderline personality disorder

One final, important differential diagnosis of borderline person-ality disorder is that with the diagnosis of narcissistic personalitydisorder (NPD) functioning on an overt borderline level in termsof the lack of an integrated identity. In contrast to BPD patientswho present different aspects of their internal world from onemoment to the next, patients with NPD at the borderline levelmask the fragmentation and weakness of their identity under abrittle and fragile grandiose self that they present to the worldand to themselves (Kernberg, 1992). Patients with a severe nar-cissistic personality disorder may present symptoms strikinglysimilar to those of borderline patients: general impulsivity, severechaos in relations with significant others, severe breakdown intheir capacity for work and emotional intimacy, and parasuicidaland self-mutilating behavior. In addition, these patients are alsoprone to antisocial behavior that, therefore, also requires the dif-ferential diagnosis among different types of narcissistic pathologywith different levels of antisocial features (see below).

The most important differential features are, first, the NPD pa-tient's difficulty in accepting any dependent relationship, their se-vere lack of investment in relations with significant others exceptin exploitative or parasitic relationships, and an aloofness thatcontrasts with the highly ambivalent, yet clinging and dependentrelationships of patients with borderline personality disorder.Second, patients with NPD show rather extreme fluctuations be-



tween severe feelings of inferiority and failure, and correspondingdepressive reactions, on tbe one band, and, on tbe otber band, aninordinate sense of superiority and grandiosity tbat sbows in tbeircontemptuous and dismissing bebavior toward others, includingtbeir tberapist. Borderline patients may alter their relationshipbetween clinging dependency and idealization, on tbe one band,and angry rejection and dismissal, on tbe otber band, but tbey donot sbow tbe cbronically contemptuous and dismissive attitudetbat narcissistic patients present. Third, and as a consequence ofthese cbaracteristics, tbe most severe narcissistic patients func-tioning on an overt borderline level are usually isolated socially,even if tbey are externally part of an intense social network. Tbeylose tbeir friends and do not maintain relationsbips over an ex-tended period of time, and tbeir objective loneliness contrastswitb tbe complicated, contradictory yet enmeshed relationshipsof borderline patients.

Antisocial bebavior may also be a complicating symptom ofborderline personality disorder, but may be more central in lowerlevels of narcissistic personality disorder; it is always a negativeprognostic factor. Tbis is particularly true for tbe syndrome ofmalignant narcissism, tbe most most severe form of tbe narcis-sistic personality tbat is cbaracterized by ego-syntonic aggression,paranoia, and antisocial traits, and for tbe antisocial personalitydisorder proper. Tbese are important differential diagnostic con-siderations wben tbe clinical picture appears to be, at first sigbt,a borderline personality disorder, and tbey need to be consideredin tbe differential diagnosis of all patients within tbis spectrum ofpatbology wbo do present cbronic antisocial bebaviors.

Evaluation of antisocial bebavior and traits

Tbe combination of a history of ADHD, a learning disorder, andsignificant antisocial bebavior from early cbildbood on is not in-frequent, and raises tbe question as to wbat extent some gen-eral brain dysfunction may operate as an etiological factor forall tbese conditions. For practical purposes, however, one cannotconclude tbat tbe antisocial bebavior is a complication of ADHDor a learning disorder if it continues as a severe disturbance

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throughout adolescence and into adulthood, characterized by theprevalence of passive/parasitic or aggressive behavior directedagainst others and property, combined with an absence of thecapacity for feelings of guilt and concern, and lack of capacity forempathy with others.

In other words, when antisocial behavior is chronic, perva-sive, and dominates the psychopathology, it usually reflects asevere personality disorder regardless of whether ADHD wasdiagnosed in early childhood. We can consider the personalitydisorders in terms of most severe to least severe with regard to an-tisocial characteristics: the antisocial personality disorder proper;the syndrome of malignant narcissism; the narcissistic personal-ity with antisocial features; other severe but nonnarcissistic per-sonality disorders with antisocial features and identity diffusion;antisocial behavior in a neurotic personality organization; andantisocial behavior as a temporary symptom in adjustment disor-ders in adolescents. In addition, the antisocial behavior of young-sters who are members of an antisocial subculture, such as streetgangs, has to be evaluated in terms of whether it presents a per-sonality disorder or only an adaptation to a negative subculture,that is, a "dissocial disorder." Cases where severe, chronic anti-social behavior is the major presenting symptom require detailed,extensive work-up, including information from family and othersources.

The most important differential diagnosis is that of antisocialpersonality proper, the most severe of the personality disorders,which has a very bad prognosis under any circumstances. In thesecases, at times treatment has to be limited to protecting familyand society and establishing firm social controls that control an-tisocial behavior and, under optimal conditions, that may eventu-ally permit a tentative psychotherapeutic approach. In practice,it should not be difficult to differentiate the occasional antiso-cial behavior that may be part of bona fide hypomanic or manicepisodes or an occasional complication of affect storms in severepersonality disorders from the chronic, pervasive antisocial be-havior that requires the complex differential diagnosis referred tobefore. We define an antisocial personality proper by a total lackof concern for others, in contrast to the DSM-IV diagnosis, which



is largely based on behaviors. The essential features are long-termpassive-parasitic and/or aggressive antisocial behavior from earlychildhood on, a lack of any capacity for authentic feelings of guiltor remorse over this behavior, a lack of concern for others thatimplies callous indifference, insensitivity, or simply occasionaloutbursts of hatred, if not sadistic pleasure at attacking or sadis-tically treating others. These more severe characteristics are inaddition to all the criteria of a narcissistic personality disorderitself. A chronic parasitic, exploitative lifestyle with irresponsi-bility regarding social obligations and financial reality typicallyis accompanied by a lack of any concern for or consideration ofthe future: It is as if the patients were living in an eternal pres-ent with total disregard for the implications of their behavior fortheir future life.

In antisocial personality disorder, patients show a lack of em-pathy with the moral dimension or ethical values of other peopleso that, even if they may shrewdly assess others' motivationsand manipulate them, they are not able to include an ethicaldimension in their assessment. The indifference toward othersis matched with a deep indifference toward their own lives, re-flected in recklessness, and, in our experience when driven into acorner, they present a potential suicidal tendency to escape fromexternal threats.

Malignant narcissism is the most serious level of personalitydisorder that can respond to treatment. The treatment must in-clude special emphasis on a strong treatment frame to maximallyprotect patient and therapist from the patient's capacity for ag-gression, and interpretation of the intense envy that could moti-vate the patient to attack himself or herself or the treatment as aproof of strength and as an attempt to triumph over the therapist.

In contrast to those with malignant narcissism, individualswith "ordinary narcissistic personalities," in spite of any antiso-cial behavior that may be part of their presentation, have the ca-pacity for experiencing feelings of guilt and concern, for loyalty,and for investment in relationships (Kernberg, 2004).

Still less severe cases present antisocial behavior that is not partof a personality disorder at all, but of an adjustment disorderof adolescence or as a secondary symptom in manic or hypo-

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manic episodes. Finally, one has to consider the presence of anti-social behavior in the members of socially isolated or marginal-ized groups, such as adolescent members of a criminal gang who,separated from the gang, would manifest no further antisocialbehavior.

Case illustration of a patient with narcissistic personality disordermisdiagnosed as refractory depression

C, a 31-year-old man, came for consultation after a having beendischarged from the hospital where he had received electrocon-vulsive therapy (ECT) for depression. His parents initiated tbeconsultation. They had supported C through a series of psycho-therapies and a number of hospitalizations for 14 years and werefrustrated with tbe lack of apparent progress. C bad worked 2years earlier as an assistant to a publisher and left that job whenbe entered a graduate program in journalism. His graduate stud-ies lasted only a few weeks before be withdrew due to "depres-sion and anxiety," with a particular anxiety about speaking up inclass. After that, be isolated bimself in bis apartment, sometimesbeing unable to get out of bed and rarely leaving bis apartmentexcept to see bis parents. During tbese visits, C described witbperseveration bis feelings tbat bis life was over and be migbt aswell be dead. After 6 montbs in this state, bis parents initiated tbeconsultation.

In tbe first consultation meeting, C presented as a good-look-ing, well-dressed, and well-groomed young man. His cbief com-plaint was depression witb suicidal ideation and inability to func-tion. He lived alone in an apartment and bad no source of incomeexcept bis parents. He spoke mostly about bis intense wisb tobecome a journalist and bis feeling tbat life would be worthlessand be would ratber be dead if be did not achieve tbis goal. Creported a limited social life witb a few friends.

Past bistory included a suicide attempt by overdose at age 16tbat led to bis first bospitalization and a series of psycbotbera-pies and trials of medication. C estimated tbat he bad bad 10previous tberapies witb no benefit, and be reported trials of 40medications—antidepressants, low-dose neuroleptics, and mood



stabilizers—also with no benefit. The only treatment that he felthad helped was ECT, but he was reluctant to try it again becauseof concerns about impairment of his cognitive functioning.

His current goal, which was almost an obsession, was to re-turn to a graduate program in journalism, but he felt paralyzed inhis efforts to take the steps to do so. He attributed this to depres-sion and, in spite of his reservations about the organic effects,was almost pleading for another course of ECT.

While C described his mood as depressed and anxious. Dr. Awas struck by the patient's angry and confrontative stance as rep-resented in his initial comment: "I've been seeing therapists sinceI was 16 and look at the result! I'm more depressed now than Iwas then."

In a review of symptoms, C reported being depressed "all hislife" with intermittent difficulty getting out of bed and a chronicinability to interact with others; he felt that everything he saidand did was "wrong" and that others found him bizarre. Dr.A carefully assessed the signs of depression. C did not presentwith motor retardation or unavailability of any feeling. WhileC reported extreme depression and inability to function, he wasquite energetic in his criticisms of therapy and of his parents.His thought processes were severely self-demeaning, but equallyharsh on others. His mood did not demonstrate diurnal variation,but changes were noted around other people where he could ap-pear polite and appropriate, if reserved, at family gatherings. Thiswas in contrast to his presentation when just with his parents,which was characterized by angry accusations that they were notproviding him enough support. In short, C often seemed moreangry than depressed. And while his depressed state was severeand appeared to be his baseline mood, it did demonstrate shiftsin response to his social environment.

With regard to neurovégétative symptoms, C reported periodicdifficulty falling and staying asleep. His appetite and libido wereintact.

In terms of triggers to depression, in addition to his chronicself-castigation for not being a journalist, C showed an exquisitesensitivity to his performance in any setting. For instance, if hemet with friends for dinner, the next day he would review and

Vol. 77, No. 1 (Winter 2013) 19


disparage bis participation in tbe conversation. Tbe anticipationof a family gatbering led to despair about bow incapable be feltat sustaining a conversation.

Diagnostic impression: Tbe combination of tbe cbronicity ofC's depression and bis attentiveness to bis appearance, reactivityto situations, and level of energy and anger in criticizing self andotbers, along witb a lack of multiple neurovégétative symptomssuggested a cbaracterological depression associated witb a per-sonality disorder. Nevertbeless, his psychiatric bistory was sig-nificant for years of treatment for a major depressive disorder. Itis possible tbat C suffered from a "double depression": a baselinecbaracterological depression witb superimposed episodes of ma-jor depression tbat justified tbe bospitalizations and ECT. How-ever, tbere was little evidence of past treatment efforts tbat ad-dressed bis cbaracter pathology as sucb.

After two consultation sessions witb tbe patient. Dr. A ex-plained bis diagnostic impression and discussed tbe possibility ofnarcissistic issues involving difficulty witb self-esteem regulationand barsb evaluations of self and otbers. C did not disagree tbattbese were issues but felt tbat Dr. A did not understand tbat tbemain issue was "a problem with bis brain." Dr. A did not disagreewitb tbat view but added tbat tbe most belpful treatment optionmigbt be an intensive psycbotherapy since tbe mind and tbe brainare intimately linked and psycbotberapy bas been sbown to ef-fect cbanges in tbe brain. After repeating bis earlier statementtbat bis years of psychotberapy bad been useless, C ambivalentlyagreed to begin an intensive tberapy focusing on cbaracterologi-cal depression. Tbus, tbe first pbase of tberapy bad begun since Cproceeded to regularly devalue Dr. A and bis tberapy tbrougboutthe first pbase of treatment. As tberapy proceeded. Dr. A used acombination of attention to tbe bolding environment of tberapyto allow for an alliance to build and "therapist-centered" inter-pretations (Diamond, Yeomans, ÔC Levy, 2011; Steiner, 1993)to explore tbe patient's internal devalued sense of self as it wasprojected onto tbe tberapist. After a year of treatment, C gaveevidence of a small but demonstrable increase in flexibility in biscapacity to deal witb tbe cballenges of life and witb others. Tbecase is ongoing at tbis point.



Conclusion

Diagnostic questions around bipolar illness, major depressiveepisodes, ADHD, and severe personality disorders are extremelyimportant for the clinician to make appropriate treatment recom-mendations. These questions can be resolved by careful evalua-tion of (1) the depressive symptomatology, (2) the presence andnature of suicidality, (3) the presence or absence of true manic orhypomanic episodes, (4) cognitive functions, (5) the quality of in-terpersonal relations, (6) characteristics of personality disorders,(7) the role of substance abuse, and (8) the presence or absenceand type of antisocial behavior. Adequate diagnosis facilitates op-timal treatment.

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