How We Diagnose Personality Disorders as Professionals

Personality Couch is all about personality, including personality disorders (you can read about what personality disorders are here, here, or listen in podcast form here). Personality disorders are among the most difficult disorders to diagnose, especially because they are very complex and can be quite tricky. Personality is like a gobstopper - there can be multiple shells and layers and colors before seeing the core. So how is a personality disorder actually diagnosed??

Personality disorders can be diagnosed by a mental health professional, but generally personality disorders require extra training or specialization to be competent in diagnosing and treating. Because of the complexity and relational nature of personality disorders (like being pulled into a drama triangle), psychological testing is extremely helpful for diagnostic information. What does this look like?

Starting the Process

Data collection for testing (and therapy) starts at the first contact. This means the process of seeking care, filling out paperwork, and referral question(s) are all data to be sifted through - especially for personality dynamics! Does the client give any pushback on payment or policies? Take forever to fill out paperwork? Ask a bunch of questions like they’re suspicious/mistrusting? Immediately idealize or cross boundaries? When clients don’t follow the rules, there’s likely to be further difficulties in the later parts of the testing process. AKA: “Problems in the front = problems in the back.”

Further, the referral question or why the client is seeking testing at this time is also helpful data. Does the client have a ton of diagnoses that they dislike or disagree with and want clarification? Are they seeking to add on to their collection of diagnoses? Is there a history of multiple unsuccessful medication attempts (which points to possible misdiagnosis)? These are all questions to consider when personality factors may be at play.

The Intake (and Initial Sessions)

To begin the process, there is an intake session where information is gathered. Besides the main questions involving things like symptoms, family dynamics, social functioning, or academic/occupational functioning, there are some more “invisible” variables to consider. Openness or how much information a client is willing to give (oversharing?) or not give (defensive?), as well as rapport, rigidity, nonverbals (facial expressions, voice tone), social scripts, and attachment (quick? intense? difficult?) are all important to pay attention to. It’s also helpful to assess for patterns of major ruptures in relationships and any personality drama triangle dynamics. While the verbal information collected is super necessary, it’s extremely important for providers to also listen to the information their gut is telling them.

Psychological Testing

Psychological testing includes administering multiple research-backed tests to explore what is going on clinically. This is called a “battery,” and may include objective measures and/or projective measures (taps into what’s going on in the unconscious). Specifically for personality disorders, I love the Millon tests and projective tests. The data provided is assessed for things that are clinically significant, which means it’s meaningfully on the fringes or sidelines of “normal.” It’s also important to consider collateral data, as well as the provider’s own internal process and reactions. The provider then looks for themes in the data and creates a big picture from all the puzzle pieces. Of note, diagnoses should not be based on only one test.

Feedback and the Report

The outcome of all this testing is presented in a formal report that includes diagnosis(es). It’s common to also have a summary of the findings as well as treatment recommendations and referrals. Though the process of the report presentation varies, it’s common that the report is provided after a feedback session. A feedback session is when the provider goes over all the data and information with the client and addresses any questions the client might have. Its main purpose is for the client to understand the findings and report.

If you are interested in psychological testing, you can look on Psychology Today to find a qualified provider in your area. Our private practice, Quest Psychological and Counseling Services, offers psychological testing in Virginia. We specialize in “deep dive evaluations” with a special emphasis on personality dynamics and their function in the overall psyche. You can also check out what Quest offers here to better understand the evaluation process.