Differentiation Between Schizophreniform Configurations and Psychotic Personality Structures

The symptom overlap between primary psychotic and severe personality disorders renders timely diagnosis challenging, which often results in ambiguous treatment and poorly defined outcomes. Kernberg's (1984) structural model of personality, treating symptoms as a non-pathognomonic higher order construct, has much contributed to our understanding of the nature of some severe disorders, highlighting fundamental facets of personality function. However, the model's main focus is on borderline personality organization and thus offers an incomplete formulation of psychotic structure. With regard to the psychotic structure, two distinct pathological disorders are currently confounded and need to be distinguished: (1) the authentic psychotic structures, mainly resulting from failures in early relational and affective development, and (2) schizophreniform configurations, mostly derived from a neurodevelopmental etiology. This differentiation, while specifying the notion of psychotic personality structure, takes into consideration: (a) the role of temperament bias, hypersensitity in particular; (b) dissimilar productions in response to projective testing, such as the Rorschach inkblot test; (c) differential processes in response to psychotherapy, including typical transferential manifestations; (d) differential symptom presentation. Key criteria to facilitate the differential diagnosis with severely regressed borderline structures are suggested. Clinical material illustrates the application of the proposed revised model. Therapeutic implications are discussed.