Characteristics of neurotic-level personality structure
- high level of capacity to function despite emotional suffering
- integrated sense of identity
- behaviours show consistency and inner experience is of continuity of self
- in touch of reality
- therapeutic split
- successfully traversed Erikson’s first two stages => integration and sense of initiative
Therapeutic split
- capacity of a patient to distinguish between the observing and the experiencing parts of the self
Therapeutic split example in paranoid people
Neurotic Paranoid: consider the possibility that the suspicions derive from an internal disposition to emphasize the destructive intent of others
Borderline or Psychotic Paranoid: convince the therapist about his convinctions
Erikson’s stages of life
Stage 1: Trust vs. Mistrust. Stage 2: Autonomy vs. Shame and Doubt. Stage 3: Initiative vs. Guilt. Stage 4: Industry vs. Inferiority. Stage 5: Identity vs. Confusion. Stage 6: Intimacy vs. Isolation. Stage 7: Generativity vs. Stagnation.
Psychotic level of personality structure McWilliams
- internally desperate and disorganized
- difficult to diagnose because overt state of psychosis: hallucination, delusions, ideas of references and illogical thinking
- psychotic level expressed mostly under considerable stress
- function sometimes effectively but strike as confused and deeply terrified
- dizorganised and paranoid thinking
- immobilizing dread of their fantasied superhuman potential for destructiveness
- no sense of continuity in identity: body concept, age, gender, sexual orientation
- not anchored in reality
- lack reflective functioning
- boundary confusion between outside and inside experience
- mortal fear and confusion
- existential crisis
- appreciate sincerity and respond well to normalization
Useful to conceive people who may not be diagnosed with psychotic level as
living in a symbiotic psychotic internal world or in a consistently paranoid schizoid state
Psychotic personality level people use techniques of defense, like:
- withdrawal
- denial
- omniponent control
- primitive idealization
- devaluation
- primitive forms of projection and introjection
- splitting
- extreme dissociation
- acting out
- somatization
Despite being unusual and sometimes frightening, patients in the psychotic range induce a
positive countertransference because psychotic patients need respect and hope and induce parental protectiveness
omnipotent control
phantasy that the source of everything that happens is oneself
Splitting
the failure in a person’s thinking to bring together the dichotomy of both positive and negative qualities of the self and others into a cohesive, realistic whole
Acting out
behavioral expression of emotions that serves to relieve tension associated with these emotions or to communicate them in a disguised, or indirect, way to others. Such behaviors may include arguing, fighting, stealing, threatening, or throwing tantrums
Characteristics of Borderline Personality Organization McWilliams
- use of primitive defenses: denial, projective identification, splitting
- experience of self is full of inconsistency and discontinuity
- lack theory of mind and mentalizing
- are insecurely attached
- trouble with affect tolerance and regulation
Projective identification
individual projects qualities that are unacceptable to the self onto another person, and that person introjects the projected qualities and believes him/herself to be characterized by them appropriately and justifiably
The difference when confronting a patient with psychotic or borderline personality
is that a borderline patient will at least show temporary responsiveness, while a psychotic patient will get more agitated
Psychotic and borderline patient differ in reality testing hence
borderline patients, during interview, demonstrate an appreciation of reality no matter how crazy their symptoms look
Kernberg approach to differentiate between diagnosis of borderline and psychotic level of organization
- investigating the person’s appreciation of conventional notions of reality by picking out some unusual feature of self-presentation, commenting on it and asking if the patient is aware that others might find this feature peculiar
=> B acknowledges that the feature is unconventional and that outsiders might not understand it
=> P will become frightened because they don’t understand their symptoms are disturbing
For a borderline level personality, they have a limited capacity to
observe their own pathology
Borderline level of organization patients have little emotional basis for
having identity integration mature defenses the capacity to defer gratification tolerance for ambivalence and ambiguity ability to regulate effects
First clue for a therapist that the patient has a borderline structure is that they perceive interventions as
attacks
The dilemma of borderline structure
- when close to a person => panic because they fear engulfment and total control
- when alone => traumatically abandoned
Materson view on the fixation of borderline patients
fixated at the rapprochement sub phase of separation-individuation process, when the child has attained some autonomy but still needs reassurance that a caregiver remains available
Transference for borderline patients
strong
unambivalent
resistant to intervention
therapist perceived as all good or all bad
Defense mechanisms Granier
mental operation, usually unconscious, directed against the expression of drives and impulses
Defense mechanisms serve to
control or modulate the expression of unacceptable impulses and as reactions to external as well as internal sources of stress
