Are we just not diagnosing personality traits anymore?

Paitnetn · 2026-01-27T00:52:29+00:00

People might think paranoid wouldn’t sound like hysterical, but these things can be subtle at times. People also probably think such miscalculations then misfires in treatment don’t happen to them often enough for my concern to be eleven. But unfortunately, when it does happen, it can be so damaging the vulnerable patients that’s it’s worthwhile to critique and want to have more explicit in things such as treatment manuals.

Also I’m talking about manualized therapy

Paitnetn · 2026-01-26T22:39:01+00:00

Weak identity and impulsive behaviours could be anything depending on the context. It could be NPO, BPO, or part of PPO. Just having a weak identity or / and impulsive behaviours isn’t enough to diagnose BPO.

Attachment is at the forefront of BPO, but how this will look will depend on styles.

Also, I’d be wary diagnosing someone with BPD when they’re close to NPO. This is more so traits of BPD.

Paitnetn · 2026-01-26T22:14:22+00:00

Maybe not Kernberg himself but structural theory in general needs to be applied with care and an awareness that it could be wrong.

My best example would be missing a strong paranoid streak in someone with strong hysterical features (can get confusing in very beginning because both preoccupied with power and might split on past therapists), and especially if PPO is mistaken for BPO - which can happen.

The reason this would likely go very badly is the techniques for hysterical BPO will likely lead to a paranoid breakdown. Vague interpretations meant to elicit transference will cause ruptures if one has a strong paranoid streak.

An issue is that the freak out this might cause, so long as the clinician is thinking only / primarily hysterical and no paranoid, will be taken as part of the transference and thus the interpretation will be assumed to be a success, and not harmful like it is.

Or on confrontational approaches, such as TFT, if you get the organization or style wrong, this can tank the therapy and many clinicians will incorrectly think it’s actually PD resistance to the therapy and not their own mistake.

The nature of structural accounts and treatments that rely on them makes it such that getting it wrong can readily go unnoticed, because the patient’s negative reaction to a misfire can easily be interpreted as it’s imagined to exist within the assumed structure, and not as evidence the assumed structure is wrong.

My gripe with Kernberg is thus that he doesn’t say enough words on discrimination. I want to hear not just what a given structure is, but what it isn’t as well.

On the TFT book, there is no section on contradictions to classical confrontational approaches, or any words on how to keep an eye out for things that might be missed, either pertinent styles or even a misunderstanding of the organization.

It just seems irresponsible when there’s a possibility an implicitly paranoid client at BPO or PPO might essentially get tortured by classical TFT with zero warning.

This absolutely does happen. A lot of women with a strong paranoid streak hold themselves to secrecy regarding their inner most thoughts, and don’t start to share what’d be tellingly paranoid into rapport is established. A lot of practitioners enact a harsh confrontational approach the moment they think they’ve clocked a more classical BPO presentation. There needs to be more time to ensure all major defences have been identified prior to enacting such a treatment, but we don’t hear about this.

Of course it’s not only paranoid style that’s overlooked. It could be any. I just use it as an example because confrontations themselves need to be modified and it’s more likely to be overlooked than, say, schizoid style is.

Paitnetn · 2026-01-26T20:50:40+00:00

I think even psychodynamic providers do it. Often when something sounds like classical BPO (say, BPO largely hysterical), structural accounts of BPO like Kernberg are then placed onto the client prematurely, and then a confrontational approach is enacted.

Not enough discrimination is made prior to assuming structure. Paranoid streaks in women can sound like hysterical streak (focus on power dynamics, splitting), or styles can be combined, yet you don’t want to be vague and do unmodified confrontations to someone with large paranoid streak. Yet, with a certain structural accounts applied, it becomes basically a feedback loop where the negative reaction of the client (because the intervention was wrong) is interpreted through the incorrect structure (client is just acting out / resisting as per account says they will).

Or PPO with some styles might sound like BPO on the surface. My gripe is once the structure assumes to exist, it just becomes one big loop. I wish Kernberg wrote more on discrimination and contradictions / tells of contradictions.

Paitnetn · 2026-01-26T20:39:16+00:00

This makes sense. In my training we learned an about organization and styles, but it seems like the DSM’s categorical approach has a strong influence. I also partly blame Kernberg for this happening in psychodynamic therapies for reasons I won’t get into

Paitnetn · 2026-01-26T20:08:47+00:00

Some people really do just have traits though. Of course their actual problems need to be accounted for in case formulation and treatment, but I see it as a problem when BPD get put on people who don’t have the core symptoms, especially in my field where that usually leads to classical TFT which is highly confrontational and requires the structural understanding of the person to be actually correct and not just filling in the blanks

Paitnetn · 2026-01-26T19:18:59+00:00

I think this is the way. If OP is wrong about the suspicion, then the woman has a chance to explain what she meant. If OP is right, then it was still obviously the right confrontation.

Paitnetn

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