LAURA VAN RIEL, MSc, MD
Research Article
Borderline or Schizotypal? Differential Psychodynamic
Assessment in Severe Personality Disorders
Considerable overlap in symptoms between patients
with borderline personality disorder (BPD) and
schizotypal personality disorder (STPD) complicates
personality diagnostics. Yet very little is known about
the level of psychodynamic functioning of both per-
sonality disorders. Psychodynamic assessment pro-
cedures may specify personality characteristics
relevant for differential diagnosis and treatment
planning. In this cross-sectional study we explored
the differences and similarities in level of personality
functioning and psychodynamic features of patients
with severe BPD or STPD. In total, 25 patients with
BPD and 13 patients with STPD were compared
regarding their level of personality functioning
(General Assessment of Personality Disorder), cur-
rent quasipsychotic features (Schizotypal Personality
Questionnaire), and psychodynamic functioning
[Developmental Profile (DP) interview and Devel-
opmental Profile Inventory (DPI) questionnaire].
Both groups of patients showed equally severe
impairments in the level of personality functioning
and the presence of current quasipsychotic features.
As assessed by the DP interview, significant differ-
ential psychodynamic patterns were found on the
primitive levels of functioning. Moreover, subjects
with BPD had significantly higher scores on the
adaptive developmental levels. However, the self-
questionnaire DPI was not able to elucidate all of
these differences. In conclusion, our study found
significant differences in psychodynamic functioning
between patients with BPD and STPD as assessed
with the DP interview. In complicated diagnostic
cases, personality assessment by psychodynamic
interviewing can enhance subtle but essential differ-
entiation between BPD and STPD.
(Journal of Psychiatric Practice 2017;23;101–113)
KEY WORDS: borderline personality disorder, schizo-
typal personality disorder, personality functioning,
personality diagnostics, psychodynamic assessment,
Developmental Profile, Developmental Profile Inventory
In clinical practice there is a considerable overlap of
symptoms between the different personality disorders.
Depressive moods, inappropriate anger, impulsive
Journal of Psychiatric Practice Vol. 23, No. 2
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
THEO J.M. INGENHOVEN, PhD
QUIN D. VAN DAM, PhD
MARIKE G. POLAK, PhD
MEINTE G. VOLLEMA, PhD
ANNE E. WILLEMS, MSc
HAN BERGHUIS, PhD
HAROLD VAN MEGEN, PhD
behaviors, suspiciousness, and cognitive-perceptual
symptoms can alternately dominate the actual clinical
picture. These symptoms may occur in patients with
borderline personality disorder (BPD), but also in
those with schizotypal personality disorder (STPD).
Many studies describe the classification of both
BPD and STPD in patients with complex personality
disorders.1–3 In Diagnostic and Statistical Manual of
Mental Disorders (DSM)-IV and DSM-5 (section II),
these overlaps in symptomatology are still found.4 In
clinical practice, this complicates differential diag-
nosis and often leads to dilemmas in the indications
for treatment, especially with respect to treatment
recommendations for psychotherapy.
Although personality assessment by a semi-
structured interview [eg, the Structured Clinical
Interview for DSM-IV-TR Personality Disorders
(SCID-II)] has been found to enhance reliability,5–8
Axis II has been strongly criticized. Descriptive diag-
nostic constructs have limited clinical validity,
VAN RIEL: Novarum Centre for Eating Disorders and
Obesity, Arkin Institute of Mental Health, Amsterdam, The
Netherlands; INGENHOVEN: Centre for Psychotherapy, Pro
Persona, Lunteren, The Netherlands; VAN DAM: Centre for
Psychology and Psychotherapy Q.D. van Dam, Leiden, The
Netherlands; POLAK: Institute of Psychology, Erasmus
University Rotterdam, The Netherlands; VOLLEMA: Centre
for Psychology, De Binnenkijk, Centre for psychotherapy,
diagnostics and supervision, Ermelo, The Netherlands;
WILLEMS: Research Centre GZZ Centraal, Amersfoort, The
Netherlands; BERGHUIS: Institute of Mental Health, Pro
Persona, Tiel, The Netherlands; VAN MEGEN: Institute of
Mental Health GGZ Centraal, Ermelo, The Netherlands
Copyright © 2017 Wolters Kluwer Health, Inc. All rights
reserved.
Please send correspondence to: Laura van Riel, MSc, MD,
Novarum Centre for Eating Disorders and Obesity, Arkin Institute
of Mental Health, Jacob Obrechtstraat 92, 1071 KR Amsterdam,
The Netherlands (e-mail: laura.van.riel@novarum.nl).
Funded by Institute of Mental Health GGZ Centraal and the
Developmental Profile Foundation, The Netherlands.
The authors declare no conflicts of interest.
Supplemental Digital Content is available for this article.
Direct URL citations appear in the printed text and are
provided in the HTML and PDF versions of this article on the
journal's Website, www.psychiatricpractice.com.
DOI: 10.1097/PRA.0000000000000225
March 2017 101
 PSYCHODYNAMIC DIFFERENCES BETWEEN BPD AND STPD
diagnostic overlap between categories is substantial,
and a large proportion of cases cannot be classified
specifically.9,10 In addition, there is limited evidence
for the clinical utility of Axis II diagnoses in individual
case formulations or in clinical decision-making (eg, in
planning appropriate psychotherapeutic treatment).11
Also lacking is a developmental perspective on per-
sonality pathology, as well as a description of normal
adaptive personality functioning. Solid personality
assessment includes the determination of both a
patient’s strengths and vulnerabilities, rather than
merely determining whether or not signs or symptoms
are present.12
As DSM-IV-TR did not systematically operation-
alize useful clinical concepts such as self-esteem,
interpersonal functioning, and habitual coping
strategies, criticisms led to several proposals to
improve or replace the DSM-IV-TR categorical Axis
II diagnoses. An alternative approach to the diag-
nosis of personality disorders was developed for
DSM-5 and is included in section III, which pres-
ents “Emerging Measures and Models.”13 The
emphasis placed on the level of personality func-
tioning is in agreement with a psychodynamic
approach to personality diagnostics. In this alter-
native DSM-5 model, a diagnostic procedure that
assesses the level of personality functioning is
essential for diagnosing a personality disorder. For
this purpose, it seems important to investigate the
clinical meaning of distinguishing levels of psycho-
dynamic functioning in different types of person-
ality disorders.
The Developmental Profile (DP)14,15 comprises a
hierarchical organization of levels of psychodynamic
personality functioning, based on the degree to which
they interfere with psychosocial functioning (Appen-
dix A, Supplemental Digital Content, http://links.lww.
com/JPP/A21). Four adaptive developmental levels
describe mature behavioral patterns and attitudes as
they cover habitual “healthy functioning,” and 6
developmental levels reflect habitual patterns that
can be classified as “maladaptive functioning.” We
hypothesized that, in contrast to overall personality
functioning [as assessed with the General Assessment
of Personality Disorder (GAPD)] and quasipsychotic
features [as assessed with the Schizotypal Personality
Questionnaire (SPQ)], there are distinctive differ-
ences in the level of psychodynamic functioning
between patients with STPD and BPD. The goal of
this study was to explore similarities and differences
102 March 2017
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
in patients with severe STPD or BPD in their habit-
ual psychodynamic functioning, as assessed using the
DP interview and the Developmental Profile Inven-
tory (DPI) self-questionnaire.
METHODS
Study Design
In this explorative cross-sectional study, we exam-
ined the differences and similarities in general
personality dysfunctioning, quasipsychotic features,
and habitual psychodynamic functioning in patients
classified as having a DSM-IV diagnosis of STPD or
BPD.
Subjects
Subjects were adult patients, 18 to 55 years of age,
with BPD (n=25) or STPD (N=13) as assessed by a
semistructured DSM-IV interview (SCID-II).
Patients were currently in treatment at GGZ Cen-
tral Mental Health Care, Centre of Personality
Disorders in Amersfoort, or in the Centre of Clinical
Psychotherapy Jelgersma, Rivierduinen Mental
Health Care in Oegstgeest, both in the Netherlands.
The sample of patients was recruited randomly
from these treatment programs for personality
disorders in the period between July 2012 and July
2013. All patients who were in treatment during
this period who met the inclusion criteria for BPD
or STPD as assessed during the intake phase of
their treatment were asked to participate in the
study. Participants’ sociodemographic character-
istics (age, sex, marital status, and educational
level) and current DSM-IV diagnoses on Axis I and
Axis II were systematically assessed. Subjects with
a severe Axis I disorder (severe depression, mania,
psychosis, severe dependence on alcohol or drugs) or
intellectual impairment (IQ score <80) were
excluded. All participants were from original Dutch
descent.
Of the 13 patients with STPD, 46% were male
and 54% female. Of the 25 patients with BPD, 12%
were male and 88% female. The mean age of the
patients with STPD was 40 years (SD=7.9; range,
24 to 50 y), whereas the mean age of the subjects
with BPD was 29 years (SD=8.9; range, 19 to 47 y).
More patients with BPD than STPD patients lived
Journal of Psychiatric Practice Vol. 23, No. 2
 PSYCHODYNAMIC DIFFERENCES BETWEEN BPD AND STPD

at home with their parents (26.1% vs. 16.7%), pos-
sibly related to their younger age. In the group with
STPD, the majority of patients lived alone (58.3%),
whereas only a third of those with BPD (30.4%)
lived alone.
More than half (56%) of the patients with BPD
and 15% of those with STPD had a mild to moderate
depressive disorder. Posttraumatic stress disorder
(PTSD) was also quite prevalent and equally dis-
tributed in the 2 groups (20% in the group with BPD
and 15% in the group with STPD). In the group with
BPD, 36% of the patients had an eating disorder
compared with almost 8% in the group with STPD.
Fifteen percent of the patients in the group with
STPD had an anxiety disorder, whereas none of the
patients in the group with BPD did. Demographic
features and comorbid psychiatric diagnoses in the
2 groups of patients are presented in Table 1.
0.77 and 0.94, with a mean value of 0.84, have been
reported for the SCID-II, indicating excellent
interrater reliability.20
Impairments in Level of Personality Func-
tioning: GAPD
The GAPD21 is a 144 item self-report questionnaire
that measures 2 core components of personality
pathology as proposed in Livesley's22 “adaptive
failure model of general personality disorders.”
Within this model, personality consists not only of
so-called “traits,” but also of an intrapsychic
TABLE 1. Demographic Features and
Comorbid Psychiatric Diagnoses of Patients
With BPD or STPD

BPD STPD
Diagnostic Procedures (n=25) (n=13)

As part of the study inclusion procedure, Axis II Sex (%)

diagnoses were made based on the SCID-II inter- Male 12 46
view for DSM-IV personality disorders, before the Female 88 54
DP interview and completion of the self-report Age (y)
Mean (SD) 29 (8.9) 40 (7.9)
questionnaires. Patients were identified as having
Minimum 19 24
STPD or BPD based on these SCID-II interviews. Maximum 47 50
Diagnostic procedures for Axis I disorders were Level of education (%)
conducted at admission according to the so-called Elementary school 0 8.3
LEAD principle: Longitudinal Expert evaluation Lower vocational 17.4 41.7
that uses All Data.16,17 High school 26.1 16.7
The DP15,18 was administered after informed Vocational 30.4 16.7
consent was obtained and recorded on tape by the Undergraduate school 21.7 16.7
first author (L.v.R.). The verbatim text of the Graduate school 4.3 0
interview was then scored by 2 well-trained thera- Living situation (%)
pists (coauthors T.J.M.I. and Q.D.v.D.), who were At home with parents 26.1 16.7
With partner 26.1 16.7
blind to the DSM-IV SCID-II diagnosis, and collat-
Alone with children 4.3 8.3
eral information. Whenever necessary, a consensus Alone without children 30.4 58.3
score was made by discussion among the Other 13.1 0
2 raters. Three self-report questionnaires were also Comorbid Axis I disorders (%)
completed: the DPI, the GAPD, and the SPQ. Bipolar disorder 8 7.7
Depressive disorder 56 15.4
PTSD 20 15.4
Instruments Eating disorder 36 7.7
Anxiety disorder 0 15.4
The Structured Clinical Interview for DSM-IV ADHD 8 23
Axis II Disorders (SCID-II)
The SCID-II19 is a semistructured interview cover- ADHD indicates attention-deficit/hyperactivity disorder;
BPD, borderline personality disorder; PTSD, posttraumatic
ing a reliable assessment of 10 DSM-IV Axis II
stress disorder; STPD, schizotypal personality disorder.
personality disorders. κ values that varied between

Journal of Psychiatric Practice Vol. 23, No. 2 March 2017 103

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 PSYCHODYNAMIC DIFFERENCES BETWEEN BPD AND STPD
adaptational system relying on 2 components: self
and interpersonal function. The primary scale, self-
pathology, covers items related to the structure of
personality (eg, problems of differentiation and
integration) and agency (eg, conative pathology).
The Interpersonal Dysfunction scale includes fail-
ure of kinship functioning and societal functioning.
These 2 primary domains are covered in 19 sub-
scales (15 for self-pathology, 4 for interpersonal
dysfunction). The Dutch GAPD demonstrated
favorable psychometric properties in a mixed psy-
chiatric sample.23 Our study used the 83 items in
the authorized Dutch translation.24
Severity of Quasipsychotic Symptoms: The SPQ
The SPQ25 is a 74-item self-report questionnaire
with a dichotomous response format (yes/no). The
SPQ was developed as a screener as well as an
assessment questionnaire for STPD. It also serves
as a severity measure of quasipsychotic symptoms
and schizotypal features. The SPQ measures 9
schizotypal features, based on the criteria for STPD
in the DSM-III-R: ideas of reference, magical
thinking, unusual perceptual experiences, paranoid
ideation, social anxiety, no close friends, constricted
affect, odd behavior, and odd speech. The SPQ has
been found to have high sampling validity, internal
reliability, test-retest reliability, convergent val-
idity, discriminant validity, and criterion validity.26
Vollema and Hoijtink27,28 revised the SPQ by
making 3 changes (SPQ-R) that improved the clas-
sification of the SPQ items according to Raine's
3-dimensional model.
Psychodynamic Functioning: The DP Interview
Habitual psychodynamic functioning in ordinary
daily life was assessed with the DP interview.29 On
the basis of psychodynamic developmental psy-
chology, the DP describes the degree to which psy-
chosocial functioning is determined by mature
adaptive and by “early” maladaptive behavioral
patterns.29–32 The DP standardizes psychodynamic
personality diagnostics to make it more convenient
for clinical diagnosis and treatment planning, and
enables empirical validation.33–38
The DP consists of a matrix (Appendix A, Supple-
mental Digital Content, http://links.lww.com/JPP/A21)
of 10 developmental levels (rows) and 9 developmental
lines (columns). Each developmental level describes a
central characteristic in the development of
104 March 2017
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
psychosocial capacities: lack of structure, fragmenta-
tion, self-centeredness, symbiosis, resistance, rivalry,
individuation, solidarity, generativity, and maturity
(Appendix B, Supplemental Digital Content, http://
links.lww.com/JPP/A21). All DP level scores are made
on the basis of 9 psychosocial domains representing the
developmental lines (columns): social attitudes, object
relations, self-images, norms, needs, cognitions, prob-
lem-solving (thoughts and feelings), problem-solving
(actions), and miscellaneous themes (Appendix C,
Supplemental Digital Content, http://links.lww.com/
JPP/A21).
The developmental levels in the DP matrix are
hierarchically organized, according to the degree to
which they affect psychosocial functioning, and
range from a primarily primitive level (lack of
structure, 00) to ultimately mature level (maturity,
90). These levels are not assumed to be mutually
exclusive. The lowest 6 developmental levels (00 to
50: lack of structure, fragmentation, self-centered-
ness, symbiosis, resistance, and rivalry) refer to
maladaptive behaviors, whereas the highest 4
developmental levels (60 to 90: individuation, sol-
idarity, generativity, and maturity) refer to adap-
tive functioning.
The DP is assessed using a semistructured
interview to obtain a detailed description of the
patients’ daily functioning over the past 10 years,
by focusing on the way the patient functions in the
context of family and friendships, education and
work, sports and hobbies. Other questions explore
distressing events and feelings of fear, anger, guilt,
shame, and self-esteem. The interview usually lasts
2 to 3 hours. The interpretation of the information
derived from the interview is based on a scoring
protocol that describes in observational terms all 90
items comprising the DP matrix (10 DP levels×9 PD
lines). The rater indicates on a 4-point scale the
extent to which the behavior of the patient corre-
sponds with the relevant operational definition. The
operational definition is denoted as not applicable
(code 0), marginally applicable (code 1), largely
applicable (code 2), or fully applicable (code 3). Data
on the psychometric properties of the DP indicate
good interrater reliability, sufficient internal con-
sistency, good construct validity, and good discrim-
inant validity.12,39
The DP has been found to predict clinically rele-
vant outcome measures, such as dropping out, ther-
apy interfering behaviors, and outcome of intensive
Journal of Psychiatric Practice Vol. 23, No. 2
 PSYCHODYNAMIC DIFFERENCES BETWEEN BPD AND STPD
psychotherapy40,41 Scores on the developmental
levels were used to estimate interrater reliability,
with 2 studies42,43 showing sufficient interrater
reliability for scoring the various levels of the DP
[with quadratically weighted κ44 values ranging from
0.53 to 0.84 (mean=0.70); and ranging from 0.60 to
0.79 (mean=0.67)].39
In addition to the 10 single scores on the DP levels,
we computed aggregate psychodynamic variables.
By summing the scores on the developmental levels
in the adaptive (60 to 90) and maladaptive (00 to 50)
realms, respectively, adaptive functioning (ADAP)
and maladaptive functioning (MALADAP) scores
were calculated. Maladaptive functioning was then
divided into 2 variables: the sum score of the 3 most
primitive developmental levels (00, 10 and 20, called
PRIM), and of the more advanced neurotic devel-
opmental levels (30, 40 and 50, called NEURO).
Psychodynamic Functioning: The DPI Self-
report Questionnaire
The DPI45 has recently been developed as a self-
report questionnaire based on the framework of the
DP. Like the DP, the DPI assesses habitual psy-
chodynamic functioning in ordinary daily life. The
108 items (statements on which the patient indi-
cates whether it is more or less applicable to himself
or herself on a 4-point scale) refer to behavioral
patterns within 3 domains (self, interpersonal
functioning, and problem-solving behaviors) and
generate scores over the hierarchically ordered
levels of the DP. Data on the psychometric proper-
ties of the DPI indicate good internal consistency,
reliability, and test-retest reliability for all sub-
scales in both patients with personality disorders
(N=179) and healthy controls (N=110) (Polak et al,
unpublished data). Furthermore, effect sizes for
differences between patients with personality dis-
orders and healthy controls were large and sig-
nificant (P<0.001) for all of the subscales (with the
exception of the subscale egocentricity), showing
good concurrent validity (Polak et al, unpublished
data).
Statistical Analysis
We tested the outcome variables, which were con-
tinuous, for normality with the Kolmogorov-Smirnov
test. Subsequently, we presented the normally dis-
tributed variables with mean, SD, and 95% confidence
Journal of Psychiatric Practice Vol. 23, No. 2
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
intervals. Independent samples t tests were used for
comparison of normally distributed continuous varia-
bles between the 2 groups, with P<0.05 as the level of
significance. Effect sizes were expressed as Cohen d
and interpreted using the provided norming.46 Stat-
istical analyses were performed using IBM SPSS
version 22.0 software.
RESULTS
Formal Diagnosis and Sociodemographic
Characteristics
Minor differences were found in educational level
between the BPD and STPD groups (with a slightly
higher level of education in the BPD group); how-
ever, these differences were not significant
(w25 ¼ 5:23, P=0.388). The differences in living sit-
uation were also not significant (w24 ¼ 3:93,
P=0.415). Depressive disorders (mild-moderate)
were more prevalent in the group with BPD than in
the group with STPD and this difference was sig-
nificant (w21 ¼ 5:788, P=0.016). Anxiety disorder not
otherwise specified was significantly more preva-
lent in the group with STPD than in the group with
BPD (w21 ¼ 4:06, P=0.044).
In the group with BPD, 2 patients also had some
schizotypal features (2 items on the SCID-II: paranoid
ideas and quasipsychotic symptoms). One patient
received diagnoses of both BPD and STPD, and, based
on the number of features present, this patient was
classified in the STPD group. Two patients with BPD
and 1 patient with STPD failed to complete the self-
report questionnaires GAPD and SPQ.
GAPD
No statistically significant differences were found
between the BPD and STPD groups in general per-
sonality dysfunction as assessed with the GAPD sub-
scales (Table 2). Normative comparison showed that
both the BPD and STPD groups scored on the GAPD in
the 80th through 100th percentile (high to very high) on
all scales as compared with a normal population norm
group (Berghuis, unpublished data). Compared with
the norm group of psychiatric clinical patients, (Ber-
ghuis, unpublished data) both groups scored in the
range of the 20th through 80th percentile (average) on
the 3 GAPD scales, reflecting a moderate to severe level
of personality dysfunction.
March 2017 105
 PSYCHODYNAMIC DIFFERENCES BETWEEN BPD AND STPD

STPD Questionnaire than those with STPD on the adaptive levels of

No significant differences were found between BPD
and STPD patients in quasipsychotic symptoms as
measured by the SPQ self-report questionnaire
(Table 2). However, normative comparison showed
that both the BPD and STPD groups scored in the
80th through the 100th percentile (high to very
high) on all scales of the SPQ compared with a
normal population norm group (Berghuis, unpub-
lished data). In addition, both groups scored high on
the SPQ compared with clinical norms of a group of
psychiatric patients, but not as high as a group of
patients with chronic psychosis who met DSM-IV
criteria for schizophrenia (Berghuis, unpublished
data). To conclude, the groups with BPD and STPD
both had high scores on quasipsychotic symptoms,
reflecting the severity of both disorders.
DP (Interview Assessment)
Several significant differences between the patients
with STPD and those with BPD were found on
specific developmental levels as well as on the
aggregated variables (Table 3). The group with BPD
scored significantly higher than the group with
STPD on the aggregated adaptive levels (ADAP).
Patients with BPD also scored significantly higher
individuation and solidarity. For the adaptive DP
levels generativity and maturity, scores were very
limited and the variances in both groups were too
low for a meaningful comparison.
The group with BPD also scored higher than the
group with STPD on the aggregated scores for the
maladaptive levels. A high score on the neurotic
developmental levels NEURO (rivalry, resistance,
and symbiosis) in the BPD group contributed to this
difference because patients with BPD had sig-
nificantly higher scores on rivalry and symbiosis.
With respect to primitive functioning, the BPD
group had a significant higher score than the STPD
group on the developmental level of fragmentation.
In contrast, the STPD group scored significantly
higher on the developmental level of lack of struc-
ture. These findings are consistent with our
hypothesis that there are distinctive differences in
the level of psychodynamic functioning between
patients with STPD and BPD.
DPI Self-report Questionnaire
Several significant differences were found between
patients with STPD and BPD on both the devel-
opmental levels and their aggregated variables on

TABLE 2. Average Item Score on Subscales of the GAPD and SPQ of Patients With BPD or
STPD

Comparison of
BPD (N=23) STPD (N=12) Group Means

Mean (SD) 95% CI Mean (SD) 95% CI P Effect size (d)

Domains
GAPD self-pathology 3.18 (0.63) 2.90-3.46 2.80 (0.76) 2.25-3.39 0.140 0.54
GAPD interpersonal 2.40 (0.64) 2.12-2.69 2.57 (0.73) 2.03-3.12 0.483 0.25
functioning
GAPD total score 3.02 (0.56) 2.77-3.27 2.75 (0.66) 2.27-3.27 0.243 0.43
SPQ positive schizotypy 15.87 (7.95) 12.43-19.31 18.33 (6.40) 14.27-22.40 0.361 0.32
SPQ negative schizotypy 21.74 (8.21) 18.19-25.29 26.17 (8.45) 20.80-31.54 0.143 0.52
SPQ disorganization 7.13 (5.11) 4.92-9.34 10.25 (5.43) 6.80-13.70 0.103 0.58

Cohen46 effect sizes: d=0.20 small; 0.50=medium; 0.80=large.

After adjusting the analyses for sex and age, the reported differences remained nonsignificant.
BPD indicates borderline personality disorder; CI, confidence interval; GAPD, General Assessment of Personality Disorder;
SPQ, Schizotypal Personality Questionnaire; STPD, schizotypal personality disorder.

106 March 2017 Journal of Psychiatric Practice Vol. 23, No. 2

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 PSYCHODYNAMIC DIFFERENCES BETWEEN BPD AND STPD

TABLE 3. Average Item Score on the Developmental Profile Interview Subscales of Patients
With BPD or STPD

Comparison of
BPD (N=25) STPD (N=13) Group Means

Mean (SD) 95% CI Mean (SD) 95% CI P Effect size (d)

Aggregate variables
ADAP 5.52 (2.33) 4.65-6.48 2.92 (1.85) 1.81-4.04 0.001** 1.24
MALADAP 30.44 (6.06) 27.94-32.94 26.38 (4.23) 23.83-28.94 0.038* 0.69
NEURO 19.60 (6.06) 17.10-22.10 13.15 (5.74) 9.68-16.62 0.003** 1.09
PRIM 10.84 (6.14) 8.30-13.38 13.23 (4.46) 10.54-15.92 0.223 0.45
Developmental levels
Maturity 0 0 0.15 (0.38) −0.70 to 0.38 NA NA
Generativity 0.44 (0.65) 0.17-0.71 0.37 (0.51) 0.08-0.69 NA NA
Solidarity 1.48 (1.09) 1.03-1.93 0.54 (0.78) 0.07-1.10 0.009** 0.99
Individuation 3.60 (1.19) 3.11-4.09 1.85 (1.07) 1.20-2.49 <0.001*** 1.55
Rivalry 2.92 (2.12) 2.05-3.79 1.38 (0.77) 0.92-1.85 0.017* 0.97
Resistance 6.12 (2.93) 4.91-7.33 4.92 (0.26) 4.16-5.68 0.171 0.53
Symbiosis 10.56 (3.79) 9.00-12.12 6.85 (5.24) 3.68-10.01 0.017* 0.81
Self-centeredness 1.76 (0.49) 0.75-2.77 2.62 (2.50) 1.10-4.13 0.316 0.48
Fragmentation 6.48 (2.74) 6.35-7.61 4.15 (1.91) 3.00-5.31 0.010* 0.99
Lack of structure 2.60 (2.35) 1.63-3.57 6.46 (2.96) 4.67-8.25 <0.001*** 1.44

Cohen46 effect sizes: d=0.20 small; 0.50=medium; 0.80=large.

After adjusting the analysis for sex and age, the reported differences for resistance (P=0.020) became significant, whereas the
differences for the level symbiosis became nonsignificant (P=0.310).
ADAP indicates adaptive functioning sum score; BPD, borderline personality disorder; CI, confidence interval; MALADAP,
maladaptive functioning sum score; NA, not applicable; NEURO, neurotic developmental levels sum score; PRIM, primitive
developmental levels sum score; STPD, schizotypal personality disorder.
*P<0.05.
**P<0.01.
***P<0.001.

the basis of the self-report DPI (Table 4). The group
with BPD had significantly higher scores than the
group with STDP on the aggregated maladaptive
levels (MALADAP). Moreover, the BPD group
scored significantly higher than the STPD group on
the aggregated primitive level scores (PRIM). The
BPD group had a significant higher score on the
developmental levels of fragmentation and lack of
structure, which contributed to this significant dif-
ference on the primitive levels (PRIM).With respect
to the maladaptive neurotic developmental levels,
patients with BPD had significantly higher scores
on rivalry than those with STPD. On the adaptive
developmental levels, the differences between the
2 groups were not significant.
As can be seen in Table 4, significant between-
group differences on the DPI agreed with significant
between-group differences as measured by the DP
interview for 4 variables, whereas 5 between-group
differences were not significant for the DPI
questionnaire but were significant for the DP inter-
view.
DISCUSSION
In this cross-sectional study, we explored the sim-
ilarities and differences in level of personality func-
tioning, psychodynamic features, and quasipsychotic
symptoms in patients with DSM-IV BPD or STPD.
As assessed by self-report questionnaires, both
patients with BPD and those with STPD presented
with equally severe personality pathology (as
assessed by the GAPD) and were suffering equally

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 PSYCHODYNAMIC DIFFERENCES BETWEEN BPD AND STPD

TABLE 4. Average Item Scores on the DPI Subscales of Patients With BPD or STPD

Comparison of
BPD (N=25) STPD (N=13) Group Means

Mean (SD) 95% CI Mean (SD) 95% CI P Effect size (d)

Aggregate variables
ADAP 55.27 (13.86) 48.76-61.79 57.82 (16.86) 49.35-66.30 0.631 0.17
MALADAP 105.70 (22.85) 94.74-116.66 85.97 (29.01) 71.72-100.23 0.033* 0.78
NEURO 58.17 (14.14) 50.89-65.44 50.36 (20.57) 40.90-59.82 0.192 0.47
PRIM 47.53 (13.20) 41.75-53.31 35.62 (13.53) 28.10-43.13 0.015* 0.89
Developmental levels
Generativity 18.58 (5.53) 15.98-21.17 22.38 (6.70) 19.01-25.76 0.078 0.64
Solidarity 20.32 (6.01) 17.58-23.06 20.44 (6.83) 16.87-24.00 0.958 0.02
Individuation 16.38 (5.88) 13.59-19.17 15.00 (7.31) 11.37-18.63 0.544 0.21
Rivalry 18.50 (5.90) 15.88-21.12 12.28 (6.28) 8.87-15.69 0.006** 1.03
Resistance 20.94 (5.39) 18.24-23.64 18.92 (7.44) 15.41-22.43 0.361 0.32
Symbiosis 18.73 (5.65) 15.60-21.85 19.15 (9.32) 15.09-23.22 0.867 0.06
Self-centeredness 11.17 (6.40) 8.64-13.70 8.54 (4.67) 5.25-11.83 0.207 0.45
Fragmentation 18.77 (6.52) 16.17-21.37 13.15 (4.96) 9.77-16.54 0.011* 0.94
Lack of structure 17.59 (4.22) 15.58-19.60 13.92 (5.27) 11.31-16.53 0.030* 0.79

After adjusting the analyses for sex and age, the reported differences for MALADAP (P=0.207), Prim (P=0.058), Rivalry
(P=0.083), Lack of Structure (P=0.059) became nonsignificant, whereas the difference for the level generativity became significant
(P=0.045).
Cohen46 effect sizes: d=0.20 small; 0.50=medium; 0.80=large.
ADAP indicates adaptive functioning sum score; BPD, borderline personality disorder; CI, confidence interval; DPI,
Developmental Profile Inventory (self-report questionnaire); MALADAP, Maladaptive functioning sum score; NEURO, neurotic
developmental levels sum score; PRIM, primitive developmental levels sum score; STPD, schizotypal personality disorder.
*P<0.05.
**P<0.01.

from serious quasipsychotic symptoms (as assessed
by the SPQ-R).
Our results show that there are significant dif-
ferences in personality functioning in terms of psy-
chodynamic features between patients with BPD
and those with STPD. Within the adaptive realm,
the group of patients with BPD scored better on the
DP levels individuation and solidarity, whereas the
group with STPD showed almost no such adaptive
features or behavioral patterns. Within the malad-
aptive realm, we observed a significantly higher
score in the group with BPD on the “neurotic” DP
levels of symbiosis and rivalry compared with the
group with STPD. On the “primitive” levels, the
BPD group scored higher on the level of fragmen-
tation, reflecting the underlying borderline person-
ality structure as described by Kernberg.47 These
findings are in line with result of the study by
Ingenhoven et al,41 which demonstrated that scores
on the lowest developmental level of lack of struc-
ture are rare in patients with BPD. In contrast, in
the group with STPD, scores on the DP level lack of
structure were significantly higher, reflecting
severe and enduring psychological deficits.
Abraham et al29,30,32 noted that the 2 lowest or
most primitive developmental levels, lack of struc-
ture and fragmentation, correspond to Kernberg’s
psychotic and borderline personality organization.47
Earlier studies with the DP have confirmed the
associations between BPD and the developmental
level fragmentation41,48 and STPD and the devel-
opmental level lack of structure,41 and our results
are consistent with these earlier findings. Moreover,
our study showed that patients with BPD also dis-
play adaptive behavioral patterns and problem-
solving strategies, which enable them to develop
some sense of individuality and the ability to form
more or less reciprocal relationships (also reflected

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 PSYCHODYNAMIC DIFFERENCES BETWEEN BPD AND STPD

L0=DPI lack of structure, L1=DPI fragmentation, L2=DPI egocentricity, L3=DPI symbiosis, L4=DPI resistance, L5=DPI rivalry, L6=DPI individuation, L7=DPI
by their marital status). This is consistent with the

Generativity/
results of earlier research by Ingenhoven et al,40

Maturity

−0.088
−0.040
−0.044
0.045
0.032
−0.128
0.181
0.133
0.015
Mean
who found a similar psychodynamic profile in
patients with BPD. In contrast, our patients with
STPD lacked such adaptive capabilities. The psy-

Sum Score
chodynamic profile of the patients with BPD in our

Maturity

0.376*
−0.071
−0.009
0.119
−0.062
0.017
−0.068

0.173
0.319
study reflects a vulnerable personality structure of
primitive features, which is consistent with the
descriptions of BPD in DSM-IV and DSM-5. The

Generativity
group with STPD showed an even more vulnerable

Sum Score

−0.104

−0.206
0.151
0.046
−0.187
−0.014
0.093
−0.018
TABLE 5. Correlations Between DPI Self-report and DP Interview in the Pooled Sample (N=38)

−0.07
psychodynamic profile than the group with BPD,
with fewer adaptive features and more pronounced
primitive dynamics and structural deficits.

DP interview indicates Developmental Profile interview; DPI, Developmental Profile Inventory (self-report questionnaire).
Scores on the DPI self-report questionnaire showed

Sum Score
Solidarity

0.407*
0.421*
some agreement with the DP interview: patients with

0.116
0.196
−0.132
0.262

0.154
0.307
0.134
BPD scored significantly higher than patients with
STPD on the DP and DPI levels of fragmentation and

Italicized values indicate correlations between scores on the DP and DPI on the same developmental levels.
rivalry (d=0.94 and 1.03, respectively, for the DPI

Individuation
Sum Score
values). Furthermore, both the DPI and the DP

0.146
−0.008
−0.085
0.163
0.158
0.332
0.215
0.084
interview showed nonsignificant differences between

0.2
groups on the developmental levels of self-centered-
ness, resistance, and generativity (P>0.05). However,
with respect to other developmental levels (symbiosis,
Rivalry

−0.036
−0.226
−0.079
0.054
0.241
−0.107
−0.005
−0.075
Score

individuation, and solidarity) differences on the DP

Sum

−0.01
interview were not reflected on the DPI self-report
questionnaire.
Resistance
Sum Score

As can be seen in Tables 5 and 6 (values in italics),

−0.059
0.006
−0.111
−0.102
0.272
0.160
0.125
0.126
0.142
the convergence between the DP interview and the
DPI questionnaire was fair. That is, the results in
Table 5 suggest that the correlations between the DPI
Sum Score
Symbiosis

and DP developmental level scores vary between poor

0.504**
0.561**
0.451**

Significant results are marked as follows: *P<0.05; **P<0.01.

0.189
0.004

0.038
0.335
0.215

(0.09) and adequate (0.55), with an average correlation

0.06

of 0.28. The correlations between DPI and DP cluster

scores vary between fair (0.19) and adequate (0.44),
Egocentricity

with an average correlation of 0.30. This is consid-

Sum Score

−0.676**
−0.418*

−0.445*

erably higher than the correlations between different

0.085

−0.235
0.107
−0.12
−0.09

−0.34

developmental levels measured with both methods

solidarity, L8=DPI generativity/maturity.

(mean 0.01) and shows a relatively high shared var-

iance for both methods on the 9 developmental levels,
Fragmentation

and clusters of levels. The fact that the off-diagonal

Sum Score

0.547**

correlations are in general negative or close to 0, and

0.403*

0.163
−0.016
0.073
0.237
−0.122
−0.076
−0.357

in general lower than the average convergent corre-

lation of 0.28, can be interpreted as a sign of dis-
criminant validity (Smith et al49). Compared with
other studies of convergent validity in research on
Sum Score

Structure
Lack of

−0.422*

personality disorders,49 in which mean correlations

0.086
−0.128
−0.056
−0.193
−0.176
−0.233
−0.197

0.054
DP Interview

were ∼0.40, the correlations in our study fell slightly

short, especially for the developmental levels of lack of
structure and egocentricity, although on the aggregate
L0
L1
L2
L3
L4
L5
L6
L7
L8
DPI

levels the convergence seems acceptable.

Journal of Psychiatric Practice Vol. 23, No. 2 March 2017 109

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 PSYCHODYNAMIC DIFFERENCES BETWEEN BPD AND STPD

TABLE 6. Correlations of the Aggregated Developmental Levels Between DPI Self-report and
DP Interview in the Pooled Sample (N=38)

DP Interview

PRIM NEURO MALADAP ADAP

DPI
PRIM 0.193 0.025 0.232 0.092
NEURO −0.292 0.435* 0.197 0.231
MALADAP −0.072 0.282 0.250 0.193
ADAP −0.325 0.212 −0.095 0.309

ADAP indicates aggregated sum scores of all adaptive developmental levels (individuation, solidarity, generativity/maturity);
DP Interview, Developmental Profile interview; DPI, Developmental Profile Inventory (self-report questionnaire); MALADAP,
aggregated sum scores of all maladaptive levels; NEURO, aggregated sum scores of the neurotic developmental levels (symbiosis,
resistance, rivalry); PRIM, aggregated sum scores of the primitive developmental levels (lack of structure, fragmentation,
egocentricity).
Significant results are marked as follows:
*P<0.05.

In the specific sample examined in our study, the
correlations between DP interview and DPI ques-
tionnaire may reflect a relative restriction of range.
Future validation studies that evaluate the con-
vergence between the DPI and the DP interview
methods should include a larger sample that varies
in severity of psychiatric complaints and adaptive
functioning, so that an optimal range of scores on
each developmental level is observed. Additional
validation of the DPI across a wider range of
clinical samples, for instance psychiatric out-
patients without a personality disorder, is needed to
provide generalizability and clinical utility. We
believe that both the DP and DPI are valuable
instruments; however, until complementary data
concerning the convergence between the DP and the
DPI are available, we need to be careful in inter-
preting the developmental levels scales on equal
terms when measured with different assessment
procedures.
This empirical exploration contributes to our
understanding of the psychodynamic devel-
opmental functioning of patients with BPD or
STPD. Personality assessment using the DP
includes a broad range of psychodynamic phenom-
ena in both the maladaptive and adaptive realms. It
offers a strength-weakness analysis that can be
helpful for meaningful case formulation, treatment
indication, and treatment allocation. In a former
study by Ingenhoven et al,40 psychodynamic per-
sonality variables, as assesed by the DP, were found
to significantly predict impulsive behaviors, out-
bursts of anger, and treatment contract violations
during psychotherapeutic treatment in patients
with personality disorders. The amount of
explained variance and incremental value was
substantial. Moreover, in contrast to DSM-IV
diagnoses and general symptom severity, psycho-
dynamic personality variables as assessed by the
DP significantly predicted treatment duration and
premature discharge.41 These findings support the
relevance of psychodynamic assessments in clinical
practice and the inclusion of level of personality
functioning in the Alternative DSM-5 Model for
Personality Disorders (section III). They also sup-
port the predictive validity of the DP.
Our study elucidated differences in personality
diagnostics between self-report questionnaires and
an extensive semistructured interview technique,
thereby emphasizing the importance, in compli-
cated cases, of including validated psychodynamic
assessment in addition to self-report questionnaires
in obtaining a thorough understanding of person-
ality functioning.
This study also had a number of limitations. First,
as the sample size in this exploratory study was
limited and the number of statistical tests was rel-
atively large, the results are tentative. Although the

110 March 2017 Journal of Psychiatric Practice Vol. 23, No. 2

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 PSYCHODYNAMIC DIFFERENCES BETWEEN BPD AND STPD
numbers of subjects in our study were consistent
with those in earlier comparable research48,50–52 and
95% confidence intervals and effect sizes are pro-
vided for every effect, it is recommend that the study
be replicated with a larger sample, with correction
for multiple comparisons.
Second, some patients had features of both BPD
and STPD. In the BPD group, 2 patients also had
schizotypal features (2 items of the SCID-II: paranoid
ideas and quasipsychotic symptoms). One patient had
both BPD and STPD diagnoses. Because this patient
had more STPD features than BPD features (8 vs. 5)
and quasipsychotic features and paranoid ideas were
not exclusively present when the patient was
stressed, this patient was allocated to the STPD
group. Third, our study included more patients with
BPD than STPD. This was mainly due to the fact that
more patients with BPD than with STPD were
referred to our center for treatment, which is con-
sistent with the prevalence of STPD and BPD found
in clinical outpatient settings.53,54 Fourth, we did not
develop a priori power calculations of the number of
patients needed to test our hypotheses. Moreover, the
groups were not matched on important confounders.
It is therefore recommended that the study be repli-
cated with a larger sample after adequate power
calculation and with limited confounders.
CONCLUSIONS
Our study found significant differences between
subjects with BPD and those with STPD in psy-
chodynamic functioning as assessed with the DP
interview. The self-report questionnaire DPI
reflected some but not all of these differences. In
complicated diagnostic cases, clinicians can con-
sider employing personality assessment using
extensive clinical psychodynamic interviewing. A
self-report questionnaire as a screener combined
with a comprehensive semistructured interview can
contribute to a more accurate, reliable, and mean-
ingful diagnostic case formulation.
Ongoing efforts are needed to assess the DP in
larger population samples to generate more sophis-
ticated epidemiological data on the psychodynamics
underlying the personality pathology of patients with
BPD and STPD. As BPD and STPD symptoms very
frequently overlap in day-to-day clinical practice,
future research should examine the ability of the DP
to differentiate between these 2 diagnoses in a mixed
Journal of Psychiatric Practice Vol. 23, No. 2
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
study population with overlapping symptoms. Future
studies can also use the DSM-5 Alternative Model as
a benchmark for personality diagnostics, especially
concerning meaningful case formulation and treat-
ment allocation.
Psychodynamic assessment of personality func-
tioning by the DP is thorough but time consuming.
Therefore, future research should study whether
psychodynamic developmental functioning can be
reliably assessed using the DPI questionnaire as a
screening instrument in combination with a short-
ened DP interview. Our study made a contribution
toward answering this question by including both
an interview (DP) and a self-report measure (DPI)
of psychodynamic constructs.
Although time consuming, a validated psychody-
namic assessment procedure can be effective in the
difficult differential diagnostics of BPD versus
STPD, especially when treatment with specialized
psychotherapies seems indicated or when a costly
and intensive treatment is being considered. Stud-
ies on the cost-effectiveness of the DP will ulti-
mately have to confirm or refute the thesis that it is
worthwhile to invest in a broad psychodynamic
personality assessment to address multifaceted
diagnostic issues in complex cases before offering
and initiating an expensive treatment.
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