An Integrated Developmental Approach to Personality Disorders in Adolescence: Expanding Kernberg’s Object Relations Theory

Drawing on Melanie Klein’s object relations theory (11), Kernberg theorizes that the child, from infancy onward, forms internal mental representations of the self in relation to others or attachment figures who are considered the object of the child’s needs and wishes. In Kernberg’s model (12, 13), affects play a central role in the development of internal object relations. Affects are the basic building blocks of the psychological structures that come to constitute identity and organize an individual’s affective life, motivations, desires (especially toward attachment figures), and habitual behaviors. Internalized object relations are theorized to be composed of affects linked to representations of a specific interaction between the self and an other. Examples include affectionate feelings linked to the representation of oneself as a loved child and to an other as a caring mother; the affect of rage linked to the self-representation of being a coerced adolescent in relation to a powerful and inflexible parental figure; and shame linked to the self-image of an enamored, vulnerable adolescent relating to an other who is indifferent and uncaring toward the adolescent.

Use of the concept of internal representations of the self and others is not unique to Kernberg; it is also central to the attachment framework. For example, Bretherton and Munholland (14), when describing John Bowlby’s concept of internal working models (IWMs) in attachment behavior, see internal representations of the self and others as a “dynamic representation system” of self and others based on early responsiveness of attachment figures that comes to be used to “imagine habitually experienced social interactions.”

In Kernberg’s theory (15–17), internal object relations are derived from the interplay between the baby’s temperament and genetic affective predispositions, in interaction with an attachment figure (usually the mother). Consistent with attachment theory and research, early mother-infant interactions are theorized to produce affective procedural memories that are assimilated into “memory traces” of positively or negatively charged representations of the self in interaction with an other. These positive and negative affective procedural memories are theorized to develop separately at first but later actively split or become dissociated from each other to maintain “ideal all-good experiences” and to avoid “persecutory all-bad experiences.” As children develop cognitively and become increasingly able to explore and assess external reality, all-good and all-bad experiences are integrated because the child increasingly becomes aware that the attachment figures have both good and bad aspects. It is theorized that if the child has a predominance of positive experiences, the negative experiences become more tolerable and are progressively integrated into a comprehensive, realistic view of the self and other. Influenced by Mahler (18), Kernberg sees an early primitive integrated self as crystalizing between ages 3 and 5 (Kernberg, 2012, unpublished manuscript). When this process fails, the child’s sense of identity becomes diffuse, which Kernberg associates with risk of developing a personality disorder. Risk factors for the development of identity diffusion include negative affect, impulsivity, and deficits of effortful control (19–21), which may occur in combination with exposure to physical or sexual trauma, parental antipathy, abandonment, or chronic family chaos characteristic of disorganized attachment (21).

Theorizing and conducting research on attachment have provided concurrent support for the concepts that are fundamental to Kernberg’s object relations model. For example, the formation of IWMs begins early in life, before speech develops. As cognitive, language, and social abilities develop, IWMs are revised and become increasingly more complex (14). As with the object relations dyad, Bretherton and Munholland (22) note that attachment relations are never affectively neutral. Furthermore, the importance given to early experiences of parenting in the object relations model is consistent with convergent findings from attachment research showing that differences in maternal sensitivity and responsiveness are associated with distinct attachment styles in children as young as 15 months (23). A vivid example is provided by Lyons-Ruth and Jacobvitz’s work with children with disorganized attachment styles (24). Infants with disorganized attachment manifest behaviors during the reunion phase of the strange situation paradigm that do not correspond to one of three more typical organized attachment patterns. These behaviors are indicative of “contradictory intentions” (e.g., approaching parents with the head averted) that present as confusing combinations of approach and avoidance. Disorganized infant attachment was first described in infants of mothers who had experienced recent bereavement. It is also frequently associated with abuse or neglect, in which case the attachment figure whom the child turns to for safety when distressed is also the source of fear, thus leaving the infant caught in an impossible bind. These descriptions are consistent with formulations of the early development of splitting. Furthermore, Lyons-Ruth and Jacobvitz’s work indicates that disorganized attachment among infants is also associated with hostile or helpless parenting styles, where the parent fails to provide the minimally expected responsiveness to infant distress. In their review, Lyons-Ruth and Jacobvitz (24) note that infants with disorganized attachment also show a variety of disturbances in affective communication and develop IWMs characterized by emotional incoherence. For Kernberg and attachment theorists, these internal mental representations undergo elaboration and modification on the basis of the subsequent emergence of new capacities and experiences with others.

Identity consolidation is classically seen as a hallmark of healthy adolescent development and, in Kernberg’s model (Kernberg, 2021, personal communication to L.N.), is associated with typical reorganization of the infantile self-other representations and with the process of expanding identity toward an integrated sexuality, maturation in moral development, changes in ego ideal, and autonomy. Drawing on Erikson’s distinction between typical ego identity, identity crisis, and identity diffusion and on his notion of identity integration as underlying typical personality development (25, 26), Kernberg proposed that severe personality pathology is characterized by identity diffusion (15, 27). Furthermore, Kernberg proposed that identity diffusion underlies borderline personality disorder and the characteristic difficulties associated with this disorder: turbulent interpersonal relationships and interpersonal difficulties, emotional dysregulation, and impulsive behaviors such as suicidality and self-harm. In Kernberg’s conceptualization, identity diffusion is characterized by impoverished, split, or extreme representations of self and others so that the individual has no real sense of their unique self or of the personal qualities of themselves or others, including their strengths and weaknesses. This identity state is associated with an unstable sense of self and a lack of a sense of others as people who contribute both positively and negatively to relationships. Furthermore, identity diffusion is associated with primitive defenses, including splitting, dissociation, and projective identification. In contrast, the development of an integrated identity is characterized by a stable and realistic sense of self and others, where others are seen as individuals with their own unique qualities, motivations, and intentions. Therefore, an adolescent’s level of identity integration is an important indicator of their personality organization and distinguishes between identity diffusion (indicative of personality disorders), identity crisis, and typical development. Furthermore, identity integration can be used as an indicator to monitor progress in psychotherapy.

Biopsychosocial processes specific to adolescence challenge the adolescent to expand representations of the self and others and to develop increased concern and empathy for and awareness of others. This expansion is supported by cognitive maturation and is driven by neurobiological and hormonal changes that result in physical and sexual maturation and intensified aggressive and sexual impulses (28). Furthermore, the broadening of the adolescent’s social life, friendships, and love relationships challenges them to reexamine parental value systems, clarify their own values, integrate new idealized role models, and clarify their own moral system and ego ideal. This process of maturation is considered to continue until young adulthood, when a coherent and mature identity is usually attained in the context of typical development. These transformations, for many, are associated with a “normal” trajectory marked by effective adaptations to work, relationships, and a sense of self, whereas, for others, these transformations may result in identity crisis or identity diffusion and the emergence and intensification of a personality disorder. We describe each of these adolescent pathways below.

Another important contribution to the understanding of personality disorders by Kernberg and his group has been the development of two assessment tools, which were initially developed for adults (37) and have since been adapted for use with adolescents. The first, the Structural Interview (38), is an open-ended clinical interview used to diagnose borderline personality organization. The second, the Structured Interview of Personality Organization in Adolescence (STIPO-A; unpublished document, Personality Disorders Institute), was developed to assess the depth and level of identity integration within adolescent personality organization (39). The reliability and validity of the latest version of the STIPO-A is currently being examined.

Otto F. Kernberg’s legacy is evident in the current understanding of personality disorders in terms of identity diffusion and the view of identity integration as being associated with balanced representations of self and others. Pioneers like Paulina F. Kernberg (40, 42, 43) first drew attention to the early manifestations of personality disorders in children and adolescents, and Chanen et al. (44–46) and Sharp et al. (47–50) made major contributions to recognizing personality disorders in adolescence. Kernberg’s personality organization framework is especially pertinent for assessing personality disorders and for differentiating typical development from personality pathology among adolescents.