THE STRUCTURAL DIAGNOSIS AND THE STRUCTURAL INTERVIEW FOR

“OTTO KERNBERG” PERSONALITY DISORDERS

Structural diagnosis : the structural characteristics of the borderline personality organization have important
prognostic and therapeutic implications, the quality of object relations and the degree of integration of the
superego are important prognostic criteria for the intensive psychotherapy of borderline patients.

MENTAL STRUCTURES AND PERSONALITY ORGANIZATION: Structures are relatively stable

configurations of mental processes; superego, ego and id are structures that dynamically integrate substructures,
such as the cognitive and defensive configurations of the ego.

Structural analysis: it describes the relationship between the structural derivations of internalized object
relations and the various levels of organization of mental functioning, it also refers to the analysis of the
permanent organization of the content of unconscious conflicts, particularly the Oedipus complex as a
organizational trait of mind with a history of development that is dynamically organized in the sense that it is
more than the sum of its parts, and incorporates early experiences and drive organizations in specific phases into
a new organization.

Kernberg proposes the existence of three broad structural organizations corresponding to the neurotic,
borderline and psychotic organization of personality.

The structural organization develops the function of stabilizing the mental apparatus, mediating between the
etiological factors and the direct behavioral manifestations of the disease.

These types of organization are reflected in the predominant characteristics of the patient, particularly with
respect to:

1. Your degree of identity integration.

2. The types of defensive operations that it usually employs.
3. Your ability to test reality.

Additional criteria for differentiating borderline personality organization from neurosis include the presence or
absence of nonspecific manifestations of ego weakness, particularly anxiety tolerance, impulse control, the
capacity for sublimation, and for purposes of a differential diagnosis of the Schizophrenia, the presence or
absence of a clinical situation of the primary thought process.

The degree and quality of superego integration are additional prognostically important structural characteristics
in differentiating neurotic and borderline organization.

THE STRUCTURAL INTERVIEW AS A DIAGNOSTIC METHOD

Structural interview: highlights the structural characteristics of the three main types of personality organization.
This focuses on the symptoms, conflicts or difficulties that the patient presents and the particular ways in which
they reflect them in the here and now interaction with the interviewer.

Clarification: exploration with the patient of all the elements of the information that he has provided that are
vague, unclear, contradictory, incomplete, it is the patient himself who clarifies his behavior and intrapsychic
experience, thus guiding us to the present limits of his conscious and preconscious self-knowledge, cognitive
medium.

Confrontation: the patient is pointed out to those aspects of the interaction that seem to indicate the presence of
conflictive functioning and, by implication, the presence of defensive operations, contradictory representations
of oneself and objects, and a reduced awareness of reality.
Interpretation: establishes links between conscious and preconscious material and here-and-now unconscious
functions or motivations, explores the conflicting origins of dissociative ego states, the nature and motives for
activated defensive operations and defensive abandonment of reality testing Interpretation focuses on
underlying anxieties and activated conflicts.

Interpretation of Transference: the presence in the diagnostic interaction of inappropriate behavior that reflects
the reconstruction of pathogenic and conflictive relationships with significant others from the patient's past.

Structural interviews subject the patient to a certain degree of stress, the interviewer tries to bring out the
pathology in the organization of the patient's ego functions to obtain information related to the structural
organization of the disease.

STRUCTURAL CHARACTERISTICS OF THE ORGANIZATION PERSONALITY LIMIT

Descriptive symptom as presumed evidence:

1. Chronic, diffuse, free-floating anxiety.

2. Polysymptomatic neurosis (multiple phobias, obsessive-compulsive symptoms, multiple conversion
symptoms, dissociative reactions, hypochondriasis, paranoid and hypochondriacal tendencies).
3. Polymorphic perverse sexual tendencies.
4. Classic prepsychotic personality structures: paranoid personality, schizoid personality, hypomanic and
cyclothymic personality with strong hypomanic tendencies.
5. Neuroses and impulse addictions (alcoholism, drug addiction, psychogenic obesity, kleptomania).
6. Lower level character disorders: chaotic and impulsive type.

Lack of an integrated identity: identity diffusion syndrome: poorly integrated concept of self and significant
others, subjective experience of chronic emptiness, contradictory self-perceptions, contradictory behavior. In
the borderline organization of personality there is a clear delimitation between the self and others, but
integration fails and both the representations of the self and of the objects remain as multiple and contradictory
affective-cognitive representations of the self and others. In the limit organization, what is not integrated is the
internal vision of the self and others, the quality of object relations: the stability and depth of the patient's
relations with significant others. The quality of object relations is largely dependent on identity integration,
which includes the temporal continuity of the patient's concept of self and others. In borderline organization this
temporal continuity is lost and there is little capacity for realistic evaluation of others.

Primitive defense mechanisms: Borderline and psychotic structures are characterized by a predominance of
primitive defensive operations, especially the splitting mechanism, which protects the ego by actively keeping
apart the contradictory experiences of the self and significant others. Other mechanisms: primitive idealization,
primitive types of projection, denial, omnipotence and devaluation. These defenses protect the borderline
patient from intrapsychic conflict but at the cost of weakening the functioning of his ego (although it improves
immediate functioning, temporarily, unlike the psychotic patient).

 Splitting: division of external objects into completely good and completely bad.
 Primitive idealization: treating the object as ideal, omnipotent or deified.
 Early forms of projection, especially projective identification: the tendency to continue experiencing
the impulse projected onto the other person, fear of the other person and the need to control him or her
under the influence of this mechanism.
 Denial: the denial of two emotionally independent areas of consciousness.
 Omnipotence and devaluation: a grandiose self is reflected in relation to a despised and emotionally
degrading representation of others.

Reality testing: Both neurotic and borderline organizations exhibit maintenance of reality testing. Reality
testing is defined by the ability to differentiate self from non-self, the intrapsychic from the external origins of
perception and stimuli, and the ability to realistically evaluate the content of our own affect, behavior, and
thought, in terms of ordinary social norms, clinically recognized by: the absence of hallucinations or delusions;
a strongly inappropriate emotion, thought or behavior; and the ability to empathize with and clarify other
people's observations of what seem to them to be inappropriate or disconcerting, in the context of ordinary
social interactions.

Non-specific manifestations of ego impairment: These include absence of anxiety tolerance, impulse control,
and developed sublimation channels. Anxiety tolerance refers to the degree to which the patient can tolerate a
stress load greater than normal. that is habitually experienced without developing heightened symptoms or
regressive behavior, impulse control refers to the degree to which the patient can experience strong instinctive
desires or strong emotions without having to act on them immediately. Sublimatory effectiveness refers to the
degree to which the patient can commit to values that go beyond his or her immediate self-interest or self-
preservation. These manifestations differentiate borderline organization and psychoses from neurotic structures.

Lack of superego integration: Borderline and psychotic organizations reflect impairment in superego
integration and are characterized by unintegrated precursors of the superego, particularly primitive, sadistic and
idealized representations of objects. The quality of object relations and the functioning of the superego are
probably the two most important prognostic criteria that emerge from a structural analysis.

Genetic-dynamic characteristics of instinctive conflicts

The borderline organization presents a pathological condensation of genital and pregenital instinctive struggles
with a predominance of pregenital aggression, there is a great discrepancy between the patient's real historical
development and his fixed internal experience, the more serious the character pathology, the less reliable the
initial history ( of early development)

Excessive aggressive formation of oedipal complexes; exaggerated idealizations of the love object in the
Oedipal relationship; unrealistic nature of the threatening and idealized Oedipal rival; existence of condensed
father-mother images; the genital struggles of patients with predominant preoedipal complexes serve important
pregenital functions; premature oedipalization of preoedipal complexes and relationships; Oedipalization of
object relations.

The structural diagnostic interview combines a psychoanalytic approach to the patient-therapist interaction, with
a psychoanalytic technique to interpret the conflict points and defensive operations of the interaction to
simultaneously highlight the classic anchoring symptoms for descriptive psychopathology and the underlying
personality structure.

The cyclical nature: it is an important feature in the proposed model of structural interview, the concept of
anchoring symptoms located in a circle along its perimeter makes it possible for the interviewer to return to the
starting point and restart a new interrogation cycle. Returning to the cycle allows the interviewer to return as
often as necessary to the same points in various contexts, re-checking preliminary findings in later stages of the
interview.

INITIAL PHASE OF THE STRUCTURAL INTERVIEW

It is useful to start the interview with some questions (direct or indirect) presented in sequence, providing an
idea of what is expected of the patient and their various possible forms of responses. This ability of the patient
to understand the questions and be able to answer them, puts tests its operation on various anchoring symptoms.

Typical initial survey "I am interested in hearing what brought you here, what the nature of your difficulties is,
what you expect from treatment and where you are at." If you have prior information, you can add comments
such as "I have I've had the opportunity to meet you, but I'm interested in knowing how you see all of this.

This startup allows you to:

A. Patient:
 1. Talk about your symptoms.
2. Main reasons for coming to treatment.
3. Expand on the nature of other difficulties.
B. Interviewer:
1. Indirectly evaluate the patient's awareness of their illness.
2. Assess the need for treatment.
3. Realistic nature or not of your expectations regarding said treatment.
4. Reactions or treatment recommendations and suggestions.

In response to these questions:

Patients without psychotic or organic psychopathology : They can talk freely about neurotic symptoms and
difficulties in the psychological aspects of their social life, which would indicate pathological character traits;
and thus indirectly, they provide a good test of reality.

The ability to remember these questions, to answer them in a coherent and integrated way, indicates a good
sensorium, good memory, probably normal or high intelligence. It represents, therefore, the first automatic
cycle along the complete perimeter of anchoring symptoms.

Patients with alterations in the sensorium (decreased attention, orientation, awareness, understanding or
judgment), patients with memory or intellectual deficits and patients with acute or chronic organic brain
syndromes:

1. They have difficulty answering such questions.

2. Limited capacity for abstraction.

There are patients who are very specific, vague, confused, evasive in their answers. In these cases, the
interviewer can openly clarify the discrepancy between the questions and the answers.

If difficulties are recognized in the patient to follow or understand the interviewer, the questions will be
repeated. If this difficulty persists, the interviewer must explore its nature, entering into clarification,
confrontation and interpretation of the difficulty, which allows the interviewer to differentiate confusion that
originates from intense anxiety and psychotic misinterpretation of the total situation, negativity and alteration of
the sensorium, or serious deficits in memory or intelligence.

Clarifying questions is used to obtain more information about the nature of the difficulty that the questions
evoke. In this way, early manifestations of loss of reality testing, psychotic symptoms, and acute or chronic
organic symptoms can be obtained along with premature transference developments characteristic of patients
with severe character pathology.

Clarification and exploration of the difficulties presented in the patient's responses, after confrontation, tentative
exploration of the reasons for the difficulty of communication [in other words, after interpretation] can draw
attention to one or the other of anchoring symptoms and provide early clues to the structural and descriptive
characteristics of the patient.

If the patient:
1. He is able to understand and respond fully and clearly to the initial questions and at the same time, presents
a picture consistent with the main symptom that brought him to consultation. The interviewer can ask
subsidiary questions that give him information about neurotic symptoms and a normal sensorium. , without
memory deficit and a normal functioning level of intelligence.
2. If the patient presents difficulties in concentration, memory, and cognitive functions, the interviewer could
focus on symptoms of acute or chronic organic brain syndromes, but indices of preserved reality testing
(organically affected patient, not demented).
3. Responses that do not lead to an organic direction, with excellent sensory functioning, memory and
intelligence, would lead to the assumption that the most important information regarding neurotic symptoms
has been obtained. For this reason, the focus of the interview will shift along the perimeter towards the
investigation of pathological character traits.
Investigation of pathological character traits is essential to evaluate not only the type of character or personality
pathology, but also its severity [Presence or absence of borderline personality organization, with its key
anchoring symptom of identity diffusion] .

The first question:

Could you describe yourself, your personality, what you think is important for me to know so that I can have
a real feeling for you as a person?

This question presents a deeper level of questioning that leads to self-reflection . It leads to describing feelings
about oneself, important areas of one's life (free time, studies or work, family, social life, sex, political and
cultural interests) and relationships with significant others:

 If the patient presents information about himself, it provides adequate reality testing.
 In psychotic patients, answering these types of questions is virtually impossible since this requires a
certain empathy with ordinary aspects of social reality.
 Thus, the ability to deeply explore one's own personality gives indications of an adequate reality test
and leads the interviewer to rule out psychotic illness from the spectrum of diagnostic possibilities.
 If the patient fails to answer this question it would be an indication of serious character pathology and
the interviewer will then investigate identity diffusion and even reevaluate the reality test.

Procedure to evaluate identity diffusion: The "diagnostician" should point out to the patient that he seems to
have difficulties talking about himself. Then ask to what extent the patient believes this is due to the
circumstances of the interview itself, or whether the difficulty reflects a general problem the patient has in
clarifying to himself who he is or what his relationships with the world are. In response to this exploration, it
can be seen that patients with borderline organization may present primitive defensive operations.

Reality testing: If the patient's behavior or thought content is clearly inappropriate and indicates the possibility
of a major psychotic or organic illness, it should be explored more directly. There would be no need to explore
reality testing.

If the patient has not shown signs of psychosis or delusions, the interviewer should focus on what seems
inappropriate or strange, bold, affect, content of thought or behavior of the patient.

If the interviewer asks the patient about what he does not understand or finds "unusual" and asks him to explain,
the latter's response may shed light on his reality test.

The reality test is reflected in the patient's ability to empathize with the interviewer's perception of these
characteristics of the interaction (that there are aspects that are not understood), it is constantly being clarified,
confronted and interpreted, even more so when evaluating reality test and identity diffusion.
1. Clarify whether the patient has a psychotic structure, that is, absence of reality testing.
2. The sense of identity differentiates borderline pathology from non-borderline pathology, characterized
by identity diffusion.
3. If when exploring the patient's personality characteristics or pathological traits, no loss of reality
arises, the interview enters the middle phase, where the evaluation focuses on the diffusion of identity,
that is, on the differential diagnosis of the borderline organization. .
4. If when assessing personality, it emerges that reality testing has been lost, the interview focuses on the
nature of the patient's psychosis.

MIDDLE PHASE OF THE STRUCTURAL INTERVIEW

Neurotic personality organization

The patient gives a pertinent summary of what brought him to treatment, what his main difficulties are, what he
expects from treatment and where he is at this point.

 His reality test rules out psychotic illness and organic brain syndrome.
 They manage to expand on their present symptoms or difficulties in a way that makes sense.
 They understand the manifest meaning and implications of the interviewer's questions.
 The interviewer focuses on anchoring symptoms and pathological character traits .
 Questions focus on the patient's difficulties with interpersonal relationships, adapting to the
environment, and his or her internally perceived psychological needs.

Any hint of difficulty in any of these areas should be explored now and followed with a general question:

"I would like to know more about you as a person now, the way you perceive yourself, the way you feel
others perceive you, whatever you think could help me form a deeper image of you at this time." limited"

This question gives information about:

1. Characterological problems.
2. More specific diagnosis regarding the predominant type of pathological character traits.
3. Pathological constellation.
4. Evaluation of identity diffusion.

The interviewer must assess the degree to which contradictory representations of the self are present or the
degree to which the patient presents a solid, well-integrated conception of the self.

Total harmony is not expected in neurotic patients, even so there should be a central subjective integration of
the self-concept on which the interviewer can build a mental image of the patient.

Then, the degree of integration of object representations v/s the lack of integration and the degree of pathology
of the patient's interpersonal life is explored with questions about their interpersonal relationships and the
significant people in their life.

Identity integration or diffusion as the nature of the patient's object relations can be clarified in this process.

If internal contradictions arise in the patient's narrative, the interviewer must clarify and confront and evaluate
the patient's capacity for reflection and introspection. If after this, conflict points arise in the contradictory
evaluated areas, the tentative interpretation can continue, of the here and now, of the patient's conflicting
implications.

The exploration of these areas of confusion will lead the neurotic patient to show opportune high-level defenses.
In patients who do not show identity diffusion or primitive defensive operations, the interviewer can formulate
speculative and dynamic hypotheses regarding the patient's unconscious intrapsychic conflicts, while The
healthier the patient, the easier it is for the interviewer to make hypotheses about connections between the
patient's past and present, but for the latter it is more difficult to link present and past because these links are
repressed.

Borderline personality organization: Patients contaminate information about the past with current personality
difficulties.

The exploration of the patient's current life, identity diffusion syndrome, and the nature of his or her object
relations will reveal the type and severity of his or her character pathology.
Borderline organization, Narcissistic Personality, Presents an integrated but pathological and grandiose self-
concept, lack of integration of the concept of significant others, facilitating the diagnosis of identity diffusion
and the predominance of primitive defenses omnipotence and devaluation

Structural characteristics of the borderline narcissistic personality: They arise in the middle phase and in a
subtle way, it can be seen in the descriptions of significant others, expression of self-aggrandizement and
derogatory or contemptuous attitude towards the interviewer. They present good proof of reality.

Structural characteristics of the borderline NON-narcissistic personality: The initial survey immediately
brings a wealth of chaotic and unthought information about themselves, their expectations of treatment, strange
behaviors and emotions with the interviewer, which require a reality testing evaluation of said patients. .
 Intact reality testing: Seeking confirmation of identity diffusion in the patient's information about the self
and social life.
 When reality testing is assured, information can be sought about pathological character traits and more
information can be gathered about the patient's difficulties.
 The objective is to gather information regarding identity diffusion and primitive defenses, then link that
information with the exploration of the emotional implications of these manifestations in the "here and now"
of the consultation.
 The interviewer must assess the degree to which these patients are able to maintain empathy with the social
criteria of reality, asking them questions about their descriptions of relationships with other people and
exploring their socially inappropriate nature.
 It is difficult to link the prevailing current conflicts with psychodynamically significant material from the
past.
 In a narcissistic structure, antisocial behavior and the quality of object relationships must be evaluated since
they are crucial prognostic variables for intensive psychotherapy in borderline personalities.

Psychotic personality organization: The presence or absence of reality testing differentiates the borderline
organization of psychotic structures and patients who present loss of reality testing in the initial interview.

The entire perimeter of anchoring symptoms should be explored:

1. Sensory
2. Memory
3. Intelligence
4. Emotions
5. Conduct
6. Content and organization of thoughts
7. Hallucinations

When the patient demonstrates severe inability to respond to the initial set of questions, anchoring symptoms
that reflect abnormalities in sensorium, memory, and intelligence should be explored before returning to
examination of the major anchoring symptoms of functional psychosis.

If there is no alteration of the sensorium, the interviewer can return to the initial set of questions regarding what
brings the patient to treatment and where they are now.

If the responses to this second set of questions remain inappropriate, the interviewer should explore the degree
to which the patient can empathize with the therapist's experience of the patient's responses as strange or
disconcerting.

If it is clear that the reality test has been missed, a diagnosis of a functional psychosis should be considered, and
the interviewer can then switch to a focus directed toward the patient's altered manifestations, attempting to
explore with him the possible meanings of these manifestations in terms of current subjective experience of the
patient.
Further exploration of the patient's subjective experiences may lead to an understanding of the connections
between his or her affect, thinking, and behavior and open the way to a differential diagnosis.

Loss of reality testing = hallucinations and diagnosis of delusions, once reality testing is confirmed, the patient's
thought processes, reality distortion, and patient's internal experience are no longer challenged, they are
empathized.

The interviewer must develop a hypothesis about the nature of the dissociated fantastic primitive object
relations that are activated. Also develop a hypothesis about the defensive function of that primitive defensive
operation. Then share that hypothesis with the patient.

Acute and chronic organic brain syndromes: The patient's inability to respond appropriately to the initial set
of questions may indicate an alteration of the sensorium (acute organic brain syndrome) or a serious memory or
intelligence deficit (chronic organic brain syndrome).

When the patient is not responsive to the initial survey, reveals serious disorganization in his response, minimal
or inadequate reaction, attitude of confusion, it is indicated to take a tour through the cycle of problems that are
presented to the evaluation of the sensorium, memory and intelligence.

The evaluation of the sensorium will determine whether there is a state of confusion characteristic of an acute
organic brain syndrome or whether it is an acute functional psychosis.

COMPLETION PHASE OF THE STRUCTURAL INTERVIEW

Once the scan is complete:

1. Neurotic symptoms
2. Pathological character traits
3. Predominant defensive operations
4. Identity diffusion
5. reality check
6. Main symptoms of psychotic or organic anchoring

The interviewer should acknowledge to the patient that he has completed the task and should invite the patient
to provide information that is important to him and related to the additional points and that he thinks the
interviewer should know:

What do you think I should have asked you and haven't yet?

This question gives the patient the opportunity to express the anxieties activated during the interview and which
can now be explored and diminished by introducing considerations about reality.

Leaving time at the end to resolve questions and manage unexpected anxiety and other complications, you may
decide to take more time for a definitive diagnosis or to think before discussing treatment recommendations.

Completion of the structural interview is an opportunity to assess the patient's motivation to continue with the
diagnostic process, treatment, or both, management of diagnosed serious dangers requiring urgent attention
(acute risk of suicide in depressed patients), and the degree to which that the patient can tolerate and respond
positively to statements regarding problems as perceived by the interviewer.

SOME ADDITIONAL CONSIDERATIONS ABOUT THE ATTITUDE OF THE INTERVIEWER

 Take significant time for the initial interview.

 The diagnostician is faced with the simultaneous task of:
 1. Explore the patient's subjective inner world.
2. Observe the patient's behavior and interactions with him.
3. Use your own affective reactions toward the patient to clarify the nature of the underlying,
activated object relationship.

 This underlying object relationship is the basic material that should allow the interviewer to formulate
tentative interpretations in the here and now of the patient's defensive operations.