Application of psychological diagnosis in the process of establishing criteria for psychodynamic therapy designed for patients with personality disorders

Discussion. The structure of personality characteristics and their impact on a patient’s eligibility to participate in a particular type of psychotherapy was assessed based on the major assumptions of psychodynamic approach, with special focus on the criteria put forward by Gabbard; the Big Five personality dimensions; as well as on the diagnostic criteria for personality disorders, developed by the American Psychiatric Association.


INTRODUCTION
From the perspective of modern psychiatry, as well as clinical psychology, personality disorders belong to the pathological conditions which seem to be defined and described in many different ways [1][2][3][4][5][6][7][8].Also, psychotherapeutic diag-Archives of Psychiatry and Psychotherapy, 2015; 4: 5-16 nosis proves to be a complex multifaceted and long-term process.Its initial stage takes place prior to the therapeutic process, while the further phases continue in the course of therapeutic treatment, aimed at confirming the original diagnosis and gaining a deeper insight into psychopathological symptoms exhibited by a patient, and evaluating the person's current progress in the therapeutic process.This paper provides an overview of the study aimed at establishing an initial diagnostic procedure applicable in psychotherapy, which would allow to facilitate recognition of the specific nature of the particular personality disorders, as well as qualify patients for group or individual short-term insight-oriented psychodynamic psychotherapy, or long-term attachment-based outpatient treatment programmes, provided in the "Dąbrówka" Neurosis and Eating Disorders Treatment Centre in Gliwice.The centre incorporates the Mental Health Clinic and the Neurosis Treatment Centre, where psychological examination was performed aimed at qualifying individuals for the present research.
Within the field of contemporary psychiatry, personality disorders are classified based on two major international systems: ICD10 (International Classification of Mental and Behavioural Disorders) and DSM IV (Diagnostic and Statistical Manual of Mental Disorders).Both general and specific criteria sets used to identify various categories of personality disorders display numerous limitations.Thus, a medical diagnosis of the aforementioned disorders is believed to be least accurate in clinical practice [3].As Grabski and Gierowski [3] maintain, the criteria used in classification of personality disorders display deficiency in reliability as well as in diagnostic validity.Majority of research studies and clinical experiments presented in subject literature, describe personality disorders from the perspective the assumptions of selected constitutional, typological, psychodynamic, systemic and trait theories [3].What is more, the vast majority of psychological theories explain the issues regarding various areas of psychopathology of personality (intrapsychic conflicts, defense mechanisms, traits, personality structure and other areas of inner experience); and outline diagnostic procedures.However, they rarely describe treatment programmes and their effectiveness [3,7].
Definitions of personality disorders point to certain enduring maladaptive patterns of perceiving, relating to, and thinking about social environment.The patterns are believed to disturb social and behavioral functioning [3].
In clinical practice, psychological diagnosis requires developing a profile of personality structure characteristics displayed by a patient who has already received a medical diagnosis of the specific type of personality disorder (according to the ICD10 classification), or who has never been diagnosed and requires psychological evaluation in order to receive a medical diagnosis of the specific type of personality disorder.Due to the fact that a considerable number of patients with a wide range of symptoms of various (often yet unknown) types of personality psychopathologies seek treatment in psychiatric institutions, psychological diagnosis of personality is constantly gaining more importance in the field of psychiatry and clinical psychology.It plays a significant role in the process of selecting appropriate treatment methods, the most important of which is psychotherapy.Medical diagnosis together with psychological evaluation proves to underpin a diagnostic process in psychodynamic psychotherapy [19][20][21].It is relatively common that a medical diagnosis of the specific type of neurotic disorders (classified according to the criteria included in the ICD 10 and diagnosed as categories F40-F41) or personality disorders (according to the ICD 10 category F60) is incompatible with psychological diagnosis since it does not confirm the existence of the same set of neurotic or personality disorder characteristics.
Psychological diagnosis of personality disorders focuses on disturbances in the integration and regulation mechanisms, as well as on dysfunctions in the structure of personality characteristics [9,10].Medical diagnostic models do not consider the aforementioned elements in such broad terms; however, they are important in the process of psychotherapy, which is a primary method of treatment for the aforementioned disorders.
A model of psychological diagnosis and its application in the process of selecting appropriate therapy programmes for patients suffering from personality disorders can be based on psychometric and clinical methods.Personality struc-Archives of Psychiatry and Psychotherapy, 2015; 4: [5][6][7][8][9][10][11][12][13][14][15][16] ture is commonly assessed be means of psychometric instruments, which include the Minnesota Multidimensional Personality Inventory (MMPI) [11,12], or the NEO PI-R Inventory [12], based on theoretical assumptions o a widelyknown concept of the Big Five, created by Costa and R. R. McCrea [13,14]; clinical methods (an interview, observation, or a clinical experiment); as well as projective techniques such as the Rorschach Inkblot Test [15][16][17][18].Psychological studies and theories concerning personality psychopathology much more commonly refer to diagnostic procedures which facilitate diagnosing personality structure, whereas they rarely focus on treatment programmes and their effectiveness [3].The research data presented in this paper concern a model of empirically verified criteria describing the characteristics of neurotic patients as well as individuals who exhibit symptoms of a more destabilized personality organization, commonly referred to as borderline personality structure.The criteria applied in a clinical diagnosis for psychotherapy of personality disorders are in line with theoretical conceptions of psychodynamic approach as well as the DSM 5 criteria.Furthermore, the data provide empirical evidence in support of the legitimacy of applying the Rorschach Test in clinical practice for diagnosing personality disorders and determining the course of therapy for patients with the aforementioned conditions.
Due to the vast quantity of research data, the Rorschach test findings, together with statistical data analysis were outlined in a monograph Modele psychologicznego opiniodawstwa w sprawach karnych, published in 2015 by Wydawnictwo Uniwersytetu Śląskiego in Katowice, and edited by Danuta Rode.Empirical data gathered as a result of the research were outlined by one of the co-authors in a chapter entitled: Model klinicznej diagnozy zaburzeń osobowości osób dorosłych w opiniodawstwie sądowym.
The monograph describes a model of psychological diagnosis applicable in psychotherapy, based on the data obtained using clinical methods as well as the Rorschach test.Hence, the indicators of the Rorschach variables, which constitute the major criteria for establishing a model of psychological diagnosis, were described in the present paper.
The diagnostic procedure applied in the outpatient psychotherapy conducted in the Mental Health Clinic and in the Neurosis Treatment Centre, designed for patients suffering from various types of mental disorders (predominantly neurotic and personality disorders), was established based on two main criteria.When qualifying patients for psychotherapy, a psychologist and therapist took into consideration not only the individuals' medical diagnoses and psychological (psychometric and clinical) assessment of their personality characteristics, performed with regard to the main criteria of the five-factor model; but also the main principles of a psychodynamic diagnostic model.Psychodynamic diagnosis involves multidimensional understanding of the mechanisms of personality pathology and is based on a continuum model which distinguishes undisturbed personality structure (characterized by the so-called healthy identity, dominance of mature and neurotic defense mechanisms, and accurate reality testing) from the most severely destabilized personality organization (characterized by identity pathology, dominance of primitive defense mechanisms and distorted reality testing, often accompanied with a psychotic decompensation).Evaluation of personality structure characteristics and their impact on a person's eligibility to participate in psychotherapy was performed based on the major theoretical assumptions of psychodynamic therapy, with special focus on the criteria established by Gabbard [19,20].
The main assumptions of the proposed assessment of the structure of personality characteristics most frequently involve evaluation of the following categories: (1) level of maintained identity (the sense of self and reality), (2) level of defense mechanisms (prevailing strategies of dealing with stress and (3) inner conflict), (4) reality testing (recognition of conventional views on reality), (5) interpersonal relationships, (6) functioning of a moral system -especially the level of guilt [19][20][21].According to psychodynamic approach, diagnosis of personality disorders is characterized by a way of thinking about the examined person, who is regarded as a subject establishing a bond with a psychologist or clinician, and experiencing unconscious conflict and deficits; it is an individual who displays distortions of intrapsychic structures and develops external object relations.Moreover, the approach integrates the aforementioned elements with contemporary findings in the field of neurosciences, which provide data concerning neurobiological causes of personality disorders [19, p.18].According to Gabbard, "mind is not governed by the laws of perception; it can only be known from the inside.Mind is an "intimate being" [19, p.19].Therefore, psychodynamic diagnosis is gaining more significance as a valid method of subjective description of the inner (mental) world of an individual, his or her conscious as well as unconscious mental structure.

Research objectives and questions.
The purpose of this paper is to present a model of clinical diagnosis which could be applied in psychodynamic psychotherapy, particularly short-term (group or individual) insight-oriented psychodynamic psychotherapy, or longterm attachment-based outpatient treatment programmes.The model was applied in a group of patients suffering from various types of personality disorders, coming to the Mental Health Clinic and the Neurosis Treatment Centre in order to undertake psychodynamic psychotherapy at the "Dąbrówka" Neurosis and Eating Disorders Treatment Centre in Gliwice.The patients included individuals diagnosed with various personality disorders, including neurotic, psychotic and borderline personality disorder.The aforementioned types of personality structure determine application of various forms of psychodynamic psychotherapy, ranging from insight therapy to the therapeutic procedures focused on building a positive, (corrective) bond, which are indispensible for conducting further insight therapy (aimed at eliminating disorder symptoms and mechanisms).
The following research questions were addressed in the current study: 1) Are there any significant differences between the aforementioned patients diagnosed with neurotic disorders (according to ICD10 F40 -F48 criteria of psychiatric clas-sification) or personality disorders (ICD 10: F60) in terms of the configuration of personality structure characteristics; and if so, to what extend could this be a criterion for determining appropriate psychotherapeutic interventions for the aforementioned patients?2) Which of the examined indicators describing the characteristics of personality functioning would constitute the criteria for selecting insight-oriented therapy, and which would constitute a contraindication for this type of treatment and suggest that psychodynamic therapy based on the therapeutic bond is indicated (and should be followed by insight therapy in further stages of treatment)?The model of psychological diagnosis applied in the psychotherapy conducted in the "Dąbrówka" Neurosis and Eating Disorders Treatment Centre was based on the assumption that a medical diagnosis of neurotic, stress-related, and somatoform disorders (classified according to the ICD 10 criteria), as well as disorders of adult personality and behaviour is not always synonymous with a neurotic level of personality organization in the examined patients.It was hypothesized that the individuals who are medically diagnosed with the aforementioned disorders are likely to exhibit symptoms of more severe destabilization of personality organization, which in Gabbard's classification is referred to as borderline organization of personality structure [20,21], and which MC Williams defines as a psychotic level of personality structure [22].Another hypothesis was made which predicted that patients with a medical diagnosis of disorders of adult personality and behaviour are likely to display various personality structures, ranging from neurotic to borderline [19,20] or psychotic [21].
Due to the fact that psychodynamic therapy (both insight-oriented and attachment-based) plays a significant role in treatment of patients with personality disorders, the criteria of psychological diagnosis applied in psychotherapy were described based on the diagnostic criteria for personality disorders developed in psychodynamic approach and in object relation theories [20][21][22].
Archives of Psychiatry and Psychotherapy, 2015; 4: 5-16 The criteria for the description of dysfunctions in the structure of personality were also established based on the Big Five personality dimensions (i.e.neuroticism, openness to experience, agreeableness, extraversion and conscientiousness), proposed by Costa and McCrea [3,13]; as well as on the basis of the diagnostic criteria for personality disorders, developed by the American Psychiatric Association, included in DSM 5 classification [3,22].
Definitions of the psychological variables investigated in this study, which allowed to describe the criteria for diagnosing dysfunctions in personality structure exhibited by the examined patients, referred to the process of measuring the level of dysfunctions of the structure of personality characteristics displayed by the individuals.Table 1 displays research variables together with their definitions and measurement methods.A theoretical, conceptual construct, allowing to establish the criteria for describing various dysfunctions of the person's personality structure was divided into two dimensions: intrapsychic and interpersonal.An intrapsychic dimension (maturity level of the self-structure and the subject's identity) is a variable defined as Identity in the DSM 5 classification system, and described in a psychodynamic paradigm.Its major compo-nents, which were measured in this study using the Rorschach Inkblot test, included: (1) Level of cognitive and emotional maturity of the subject's identity (the person's capacity to think appropriately and recognize the boundaries between the self and the world), appropriate self-evaluation and self-esteem, as well as the capacity to experience and regulate various emotions.The variable was measured based on the mean values of the following indicators describing interpersonal perception: • cooperative interaction (COP), • flexibility of thinking and behaviour (a: p) -the ability of an individual to consider other perspectives and to be cognitively flexible, • immature, childish need for dependency (Food), • involvement in social life (SumH), • expectations of other people (PureH), • social isolation (Isolate), • aggressive responses and hostile attitude towards the social environment (AG and COP: AG).
(2) Empathy level (according to the DSM V classification system) -a psychological variable which describes an individual's awareness of the impact of his or her own behaviour on others, as well as the person's capacity to recognize other people's inner experience.The variable was measured based on the mean value of Sum T (interpersonal perception and behaviour) and FD (a capacity for introspection -the ability of an individual to recognize the impact of his or her own behaviour on other people).
(3) Degree of intimacy (according to the DSM V classification system) -a psychological variable which describes an individual's capacity to establish and maintain stable relationships with other people (the ability to develop emotional intimacy with others, which is based on mutual respect, and reflected in interpersonal relations).
The variable was measured based on the mean values of: • a special index (CDI), whose high value denotes social immaturity, interpersonal • problems, and superficial character of relationships; • cooperation index (COP); • empathy index (T); • the a: p ratio (a>p indicating an active role in developing interpersonal relationships; • a<p denoting passivity in the aforementioned process.).(4) Social alienation (defined as Detachment, DT, in the DSM V classification system) • a psychological variable describing the degree of detachment from social interactions and avoidance of emotional intimacy in relationships.The variable was described by the mean value of the Isolate index.(5) Expressing aggression and hostility in social interactions (referred to as Antagonism in the DSM V classification system) -a psychological variable which describes the behaviours which are believed to trigger difficulties in relations with other people and manifest themselves as manipulativeness, untruthfulness, self-importance (narcissism), attention-seeking, callousness, or hostility.The variable was measured based on the mean values of the indicators of interpersonal perception and behaviour, mentioned above.

Research subjects and procedures
The Dąbrówka Neurosis and Eating Disorders Centre in Gliwice).The research was conducted among individuals applying for treatment in the aforementioned centre.The study participants had a medical diagnosis of F40-F60 (according to the ICD10 classification).None of the subjects had a documented psychological diagnosis of personality structure.This explains the fact that the research participants had never undergone psychological evaluation for personality disorders (for instance, they had never taken the Rorschach test).The programme of psychological treatment at the Dąbrówka Neurosis and Eating Disorders Centre in Gliwice requires conducting psychological examination of personality structure in individuals with various medical diagnoses, which is conditioned by clinical psychodynamic procedures allowing to select the most appropriate type of psychotherapy for a particular patient.The procedure of psychological examination of patients, aimed at making a diagnosis for psychotherapy in this group of individuals was preceded by medical examination of the patients and making a nosological diagnosis for F40-F60 (according to the ICD10 classification).During the next stage, the study subjects underwent individual psychological examination.The results of psychological examination (the data concerning the values of indicators of intra -and interpersonal dimension described in the present paper) served as the main criteria in the process of choosing an appropriate type of therapy for the examined individuals: a short-term (group or individual) insight-oriented psychodynamic psychotherapy or a longterm (group or individual) psychodynamic psychotherapy based on attachment.80 Polish individuals participated in the research.A major study population comprised 38 males (47.5%) and 42 females (52.5%).A mean age in the group of women was 30.4 (SD = 7.67).The men's mean age was 35.1 (SD = 8.73).The examined females turned out to be somewhat younger than the male subjects.Due to the issues addressed in this study, the subjects were selected intentionally.The selection criteria included symptoms of medically diagnosed disorders classified as F40 and F60 (according to the ICD 10 criteria).The study participants were also qualified for treatment (psychotherapy) according to the psychodynamic categories established by Gabbard [19,20].The main criteria applied in the process of qualifying the examined patients for the particular type of psychodynamic psychotherapy included the criteria of two main psychological dimensions.
The criteria of the intrapsychic dimension: • level of maintained identity and reality testing -an appropriate level of the sense of self and others (the level of the person's cognitive and emotional identity, i.e. appropriate perception and experiencing boundaries in the process of perceiving oneself and the world, maintained capacity for self-observation and self-reflection), • level of defense mechanisms (appropriate modulation of emotions and instincts in dealing with stress and internal conflicts, appropriate experiencing guilt).
The criteria of the interpesonal dimension: • type of object relation (the maintained ability to establish and maintain a bond with others; empathy, i.e. proper understanding of other people's inner experiences; the level of paranoid fear; as well as interpersonal distrust and suspiciousness).
The procedure of examining personality structure described above proves to be in agreement with the views put forward by other researchers dealing with personality disorders [23][24][25].The selection criteria included symptoms of medically diagnosed disorders classified as F40-41 and F60 (according to the ICD 10 criteria).Among research subjects were individuals with medical diagnoses of neurotic disorders.10 research participants had a medical diagnosis of F40 (neurotic disorders such as phobia, including social phobia); 15 individuals were medically diagnosed with other neurotic disorders (F41); 5 subjects displayed symptoms of reaction to severe stress and adjustment disorders (F43); 10 research participants had a medical diagnosis of F44 (dissociative identity disorder and conversion disorder); and 5 patients displayed symptoms of somatoform disorders (F45).
The group of study participants also comprised 35 individuals who had a diagnosis of Archives of Psychiatry and Psychotherapy, 2015; 4: 5-16 F60 (specific personality disorders): 3 patients with a medical diagnosis of F60.1 (schizoid personality disorder), 10 subjects with a diagnosis of F60.3 (emotionally unstable personality disorder -impulsive and borderline type), 8 individuals with a diagnosis of F60.6 (avoidant personality disorder), 5 patients with a diagnosis of F60.7 (dependent personality disorder),and 9 subjects with a diagnosis of F60.8 (other specific personality disorders).
The aforementioned configuration of medical diagnoses in the group of study subjects is likely to result from the specific character of the Dąbrówka Neurosis and Eating Disorders Centre, which specializes in outpatient therapy programmes designed for patients suffering from the aforementioned disorders.Patients diagnosed with more severe destabilization of personality organization (i.e.dissociative, paranoid personality structure) and the individuals suffering from psychotic disorders, due to the peculiar nature of the symptoms they exhibit, are provided with a different type of treatment, namely inpatient therapy.
The criteria which excluded participation in the research included: symptoms of mental retardation; productive psychotic symptoms; organic changes in the CNS; symptoms of medically diagnosed psychosomatic diseases (cancer and others) which disqualified the individuals from participating in psychodynamic psychotherapy.
The research was conducted according to the principle of anonymity, as well as ethical principles of a psychologist's code of conduct.Informed consent was obtained from all patients and included in medical record.
In order to establish the basic criteria for the selection of appropriate methods of further treatment for the "Dąbrówka" patients suffering from various psychopathologies, the examined individuals underwent a general clinical evaluation ( the methods included an interview, observation and a psychological conversation).Additionally, the Rorschach Inkblot Test was administered to the research participants, which was aimed at measuring the indicators describ-ing the characteristics of the subjects' personality structure.The aforementioned methods, irrespective of their limitations, prove to be significant tools which are commonly applied to measure psychological characteristics and personality functioning [15,16].

RESEARCH RESULTS
Analysis of the data obtained as a result of this research allowed to develop a model of initial diagnosis applied in outpatient group or individual (long -and short-term) psychodynamic psychotherapy conducted in the Dąbrówka Neurosis and Eating Disorders Centre in Gliwice.As it was mentioned in the introduction to the present article, a complete statistical and psychometric analysis of the Rorschach test results was presented in a separate paper [26].In the first stage of statistical analysis of the research data, the mean values of the measured variable indicators were calculated.In the next step, statistical significance of differences between the individuals with neurotic or more destabilized personality structure in terms of the investigated variable indicators was determined using student's t-test.
It was also possible to establish a model of psychological diagnosis designed for psychotherapy applied in the initial stage of treatment.Based on the research data, it was possible to specify the major criteria of the initial psychological diagnosis applied in psychotherapy.
Statistical and clinical analysis of the mean values of the indicators of the intra -and interpesonal dimension allowed to establish an initial model of psychodynamic psychotherapy for the group of research subjects.Clinical interpretation of the data, involving examination of the strength values of the measured variable indicators, supported by the data gathered as a result of clinical interviews and the results of the Rorschach's Inkblot Test, referred to two categories of indication criteria for psychotherapy: relative criteria (supporting the process of psychotherapy) and essential criteria (necessary for application of psychotherapy).

DISCUSSION
The research data indicate that individuals who with appropriate maintained level of identity maturity; capacity for empathy, self-observation and self-reflection; as well as maintained capacity to experience the feeling of guilt exhibit neurotic personality structure, which proves to be an essential indication criterion for shortterm psychodynamic insight-oriented psychotherapy.Absence of the aforementioned psychological indicators is characteristic of individuals exhibiting a more destabilized personality structure (borderline or psychotic personality disorder).Similar findings, described in subject literature, were reported by Gabbard [19], Clarkin et al. [20] and MC Williams [21].If we take into account the present research data concerning interpesonal dimension, it can be noticed that the study participants with maintained capacity for empathy, appropriate level of interpersonal trust, as well as appropriate level of aggressiveness and hostility in interpersonal relations exhibit characteristics of neurotic personality structure.The findings provided by MC Williams, Gabbard and Clarkin et al, emphasize that the aforementioned variable indicators are believed to be essential diagnostic criteria applied in the process of selecting patients with neurotic or a more destabilized personality structure (i.e.borderline or psychotic personality disorder) for insight-oriented psychodynamic psychotherapy.
Finally, certain important limitations of the current study need to be considered.First, the methods applied in the present clinical research were suitable for measuring the clinical variables investigated in this study; however there were no standardized Polish norms for score interpretation, consequently the research findings are not objective and might not be transferable to a vast population.It is recommended that further research should be conducted in a population of patients with various personality disorders, using psychological tests, for instance, the MMPI 2 questionnaire which is provided with Polish norm values for score interpretation.It is also recommended that research is undertaken in the area of effectiveness of various forms of psychotherapy in a group of individuals diagnosed with personality disorders, in the context of indicators of intrapsychic and interpersonal dimensions described in the present paper.It was impossible to conduct such investigation in the current research; however it would undoubtedly contribute enormously to the process of planning therapy for the aforementioned group of patients.

CONCLUSIONS
The model of psychological diagnosis applied in the initial stage of the process of qualifying patients for psychotherapeutic treatment provided in the Mental Health Clinic and in the Neurosis Treatment Centre allows to establish fundamental, initial criteria which help to determine an appropriate model of psychotherapy for individuals exhibiting symptoms of personality disorders, and thus facilitate effective treat-Archives of Psychiatry and Psychotherapy, 2015; 4: 5-16 ment of the aforementioned patients, who constitute a considerable proportion of contemporary society.
It should be mentioned that nosological diagnosis of a disorder classified as neurosis, does not fully support psychological diagnosis of the same disorder.The findings of the present research indicate that the same patients, who exhibit psychopathological symptoms categorized as F40-F48, according to the ICD 10 classification, are likely to be classified into the category of disorders characterized by a more destabilized personality structure, e.g.borderline personality disorder, based on the diagnostic criteria applied for psychodynamic psychotherapy.Therefore it would seem that psychological symptoms together with the ICD 10 classification criteria do not constitute a suitable criterion applied in the process of planning psychotherapy for patients suffering from personality disorders.It should be emphasized that application of medical indication criteria for psychotherapy as well as the criteria based on measuring the indicators described in the present paper, seems to improve effectiveness of treatment in the group of patients with personality disorders.
research was conducted in the years 2010-2013 in the Neurosis Treatment Centre and in the Mental Health Clinic (incorporated in the Archives of Psychiatry and Psychotherapy, 2015; 4: 5-16

Table 1 .
Variable operationalization and measurement methods

Table 2 .
Descriptive characteristics of indication criteria for outpatient psychodynamic psychotherapy.