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Summary 4.2 Personality Disorders
Summary of the articles of the 4.2 course on personality disorders please note: the book chapter of Martin & Young is not included in this summary.
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Summary 4.2 – Personality DisordersThis text contains direct quotes, pieces of text and phrases from scientific articles. The title
and authors of each article are mentioned and highlighted.
Psychoanalytic Diagnosis Understanding Personality Structure in the Clinical Process
Nancy McWilliams – Chapter 3, Developmental Levels of Personality Organization
A traditional overview of ways to think about character as well as more recent efforts to account for
general differences in psychological health and personality structure.
Many of the theories continue to reflect the conclusion that current psychological preoccupations
reflect infantile precursors, and that interactions in our earliest years set up the template for how we
later assimilate experience. Conceptualizing someone’s unmet developmental challenges can help in
understanding that person.
Interestingly, the same three phases of early psychological organization keep reappearing in
psychoanalytic developmental theories:
1. The first year and a half to two years (Freud’s oral phase).
2. The period from 18-24 months to about 3 years (Freud’s anal phase).
3. The time between 3 or 4 and about 6 (Freud’s oedipal phase).
HISTORICAL CONTEXT: DIAGNOSING LEVEL OF CHARACTER PATHOLOGY
- Kraepelinian Diagnosis: neurosis versus psychosis; Kraeplin is seen as the father of
contemporary diagnostic classification. He developed theories and aetiologies of conditions. Freud
used to only differentiate between neurotic and psychotic levels of pathology. This differentiation
led to a very simple treatment model of either supporting defences or breaking them down. It
offered a start at a useful inferential diagnosis.
- Ego psychology diagnosis: symptom neurosis, neurotic character, psychosis; next to the
distinction between neurosis and psychosis, differentiations of the extent of maladaptation began
to appear. They began to differentiate between symptom neurosis or a character problem. If it was
a symptom neurosis, prognosis was favourable, this would be treated in therapy. If it was a
character neurosis or personality problem than the therapeutic task would be more complicated
and time consuming.
o Concept of working alliance: The concept of the working or therapeutic alliance refers to
the collaborative dimension of the work between therapist and client, the cooperation that
endures in spite of the strong and often negative emotions that may surface during
treatment. → much more difficult to establish with people who have personality problems.
For a long time, the categories of symptom neurosis, character neurosis, and psychosis
constituted the main constructs by which we understood personality differences on the dimension
of severity of disorder. This does have some issues as this idea is both incomplete and misleading.
- Object relations diagnosis: the delineation of borderline conditions; in the mid 20th century
people began noticing a group of people that were ‘borderline’ between two dimensions. Not quite
psychotic, not quite neurotic, but very distressed. This is where the concept of a borderline
personality organization attained widespread acceptance in the psychoanalytic community and
later as a personality disorder.
, o Erikson’s three infantile stages: patients can be conceptualized as fixated at either primary
dependency issues (trust vs. mistrust), secondary separation-individuation issues
(autonomy vs. shame and doubt), or more advanced levels of identification (initiative vs.
guilt). → These developmental-stage concepts made sense of the differences therapists
were noticing among psychotic-, borderline-, and neurotic-level patients.
Recent empirical studies of borderline personality disorder have looked at all kinds of aspects that
can influence the development of this disorder. There is some evidence for constitutional
predispositions, some for mistuned parenting, some for trauma, sexual abuse.
- Despite the complexity of the etiologies of borderline conditions, I think it can still be useful to
view people with a vulnerability to psychosis as unconsciously preoccupied with the issues of the
early symbiotic phase (especially trust), people with borderline personality organization as focused
on separation–individuation themes, and those with neurotic structure as more “oedipal” or
capable of experiencing conflicts that feel more internal to them. The most prevalent kind of
anxiety for people in the psychotic range is fear of annihilation (Hurvich, 2003), evidently an
activation of the brain’s FEAR system (Panksepp, 1998) that evolved to protect against predation;
the central anxiety for people in the borderline range is separation anxiety or the activation of
Panksepp’s PANIC system that deals with early attachment needs; anxiety in neurotic people
tends to involve more unconscious conflict, especially fear of enacting guilty wishes.
OVERVIEW OF THE NEUROTIC-BORDERLINE-PSYCHOTIC SPECTRUM
This is about neurotic, borderline and psychotic levels of character structure, in terms of favoured
defences, level of identity integration, adequacy of reality testing, capacity to observe one’s pathology,
nature of one’s primary conflict, and transference and counter transference.
Characteristics of neurotic-level personality structure (NPO)
- Neurotic now means someone has a high level of capacity to function despite emotional suffering.
- They rely more on the mature or second-order defences. They also use primitive defences, but
these are not prominent in their overall functioning.
- The absence of mature defences rules out a neurotic level of character structure.
- They maintain some level of rational, objective capacities in the middle of whatever emotional
storms and associated distortions occur.
- Integrated sense of identity. Their behaviour shows some consistency, and their inner experience
is of continuity of self through time.
- Are usually in solid touch with what most of us call ‘reality’.
- They show a ‘therapeutic split’ between the observing and the experiencing part of the self.
- They tend to seek therapy not because of problems in essential security or agency, but because
they keep running into conflicts between what they want and obstacles to attaining it that they
suspect are of their own making.
- There is a working alliance between therapist and client.
,Characteristics of a psychotic-level personality structure (PPO)
- Here people are much more internally desperate and disorganized.
- They express hallucinations, delusions, and ideas of reference, and their thinking strikes the
listener as illogical.
- They function, sometimes quite effectively, but they strike one as confused and deeply terrified,
and their thinking feels disorganized or paranoid.
- Defences used: withdrawal, denial, omnipotent control, primitive idealization and devaluation,
primitive forms of projection and introjection, splitting, extreme dissociation, acting out, and
somatization.
- Big difficulties with identity, so much so that they may not be fully sure that they exist, much less
that their existence is satisfying. Deeply confused about who they are.
- Often times they are not anchored in reality.
- They have trouble getting perspective on their psychological problems and they lack reflective
functioning.
- There is a lack of internal differentiation between the observing and experiencing aspects of the
ego.
- The nature of the primary conflict is literally existential: life versus death, existence versus
obliteration, safety versus terror.
- They may induce a positive countertransference, that of parental protectiveness and deep soul-
level empathy.
- They tend to have a ‘consuming’ feature of their psychology which is one of the reasons that many
therapists prefer not to work with schizophrenics or people with psychoses.
Characteristics of borderline personality organization (BPO)
- One of the most striking features is their use of primitive defences, when confronted with this they
will show at least a temporary responsiveness to this.
- Their experience of self is likely to be full of inconsistency and discontinuity. They often give
global, dismissive descriptions.
- They lack reflective function and cannot ‘mentalize’, they cannot appreciate the separate
subjectivities of other people, they lack a theory of mind.
- In general they have trouble with affect tolerance and regulation, and quickly go to anger in
situations where other might feel shame or envy or sadness or some more nuanced affect.
- They demonstrate an appreciation of reality no matter how crazy or florid their symptoms look.
- The capacity of someone to observe their own pathology is quite limited.
- When they feel close to another person, they panic because they fear engulfment and total control;
when they are alone, they feel traumatically abandoned. This central conflict of their emotional
experience results in their going back and forth in relationships, including the therapy relationship,
in which neither closeness nor distance is comfortable.
- Transference tend to be strong, unambivalent, and resistant to ordinary kinds of intervention. The
therapist may be perceived as all good or all bad. Countertransference tends to be strong and
upsetting. Even when positive, they may have a disturbing and consuming quality.
, The Relationship between Defense Patterns and DSM-5 Maladaptive Personality
Domains Antonella Granieri, Luana La Marca, Giuseppe Mannino, Serena Giunta, Fanny
Guglielmucci and Adriano Schimmenti
Aimed to investigate the relationship between defence mechanisms (DMs) and DSM-5 maladaptive
personality domains.
The concept of defence mechanism (DM) was that of a mental operation, usually unconscious,
directed against the expression of drives and impulses. The original idea was that DMs serve to control
or modulate the expression of unacceptable impulses, to protect the individual from being
overwhelmed by the anxiety that would result from conscious recognition of these impulses.
- Expanded to include the use of defences as reactions to internal and external sources of stress.
- DMs have the specific function to protect the self from anxiety, conflict, shame, loss of self-
esteem or other unacceptable feelings and negative thoughts.
- They develop according to predictable sequences with the maturation of the child.
- They are part of normal personality functioning.
- They can lead to psychopathology, if one or more are used excessively.
- They are distinguishable from one another.
DMs that are considered more mature imply a greater ability to adapt to reality, so that they can
effectively distance threatening feelings without distorting the reality. DMs that are considered
immature or even primitive are characterized by severe alteration of painful mental contents and/or
radical distortion of external reality.
- Women tend to use more internalizing DMs, while men tend to use more externalizing DMS.
- An almost exclusive use of immature defence is a risk factor for the development of different
forms of psychopathology.
Kernberg has identified three types of personality organizations that reflect the individual’s
predominant psychological characteristics and that are based on the individual’s identity integration,
DMs, and reality testing.
- The neurotic organization of personality is characterized by identity integration (object
constancy), a conserved capacity for reality testing and a prevalent use of mature and neurotic
DMs.
- Borderline personality organization is characterized by a failure in identity integration(identity
diffusion), a conserved reality testing when not in condition of distress, and use of immature DMs.
- The psychotic organization of personality is characterized by lack of ego boundaries, loss of
reality testing, and use of immature and primitive DMs.
In this context the PID-5-BF assesses five domains of personality, according to the alternative DSM-5
model for personality disorders:
- Negative affectivity; includes personality features such as emotional liability and hostility.
- Detachment; includes personality features such as intimacy avoidance and suspiciousness.
- Antagonism; includes personality features such as grandiosity and manipulativeness.
- Disinhibition; includes personality features such as impulsivity and risk taking.
- Psychoticism; includes personality features such as cognitive perceptual dysregulation, usual
beliefs and experiences.
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