Lecture 4 Flashcards
Personality Organization
Article McWilliams (2011): CH3. Overview of neurotic-borderline-psychotic spectrum. In psychoanalytic diagnosis: understanding personality structure in the clinical process
McWilliams (2011) CH3
- Characteristics of neurotic-level personality structure
- Characteristics of psychotic-level personality structure
- Characteristics of borderline personality organization
Characteristics of neurotic-level personality structure
Now and then: how was neurotic seen back in the day?
McWilliams (2011) CH3
In Freud’s time: individuals with emotional distress short of psychosis = neurotic
Now: it’s called borderline or even psychotic features
Characteristics of neurotic-level personality structure
Neurotic people rely on what kind of defense (oposite from healthy people)
McWilliams (2011) CH3
Neurotic rely on more mature or second-order defense (primitive defense is used but not prominent)
Healthier people use repression as basic defense, in preference to more indiscriminate solutions (denial, splitting)
Characteristics of neurotic-level personality structure
Ego alien
McWilliams (2011) CH3
= Egodystonic = pertaining behavior/attitudes that are inconsistent with one’s fundamental beliefs and personality
Much of psychopahtology of neurotically organized people is ego alien or capable of being addressed so that it becomes so.
Characteristics of neurotic-level personality structure
Therapeutic split
McWilliams (2011) CH3
Capacity of patient to distinguish between the observing and experiencing parts of the self
A paranoid man who is organized neurotically will be willing to consider the possibility that his suspicions derive from an internal disposition to emphasize the destructive intents of others, while a paranoid man at the bordeline or psychotic level will putt intense pressure on the therapist to join their conviction that their difficulties are external in origin.
Characteristics of neurotic-level personality structure
Neurotic-level people have more or less succesfully traversed Erikson’s first 2 stages:
McWilliams (2011) CH3
- Basic trust
- Basic autonomy
And they have made at least some progress toward identity integration and a sense of initiative.
Characteristics neurotic-level personality structure
Why do they seek treatment?
McWilliams (2011) CH3
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.
Characteristics neurotic-level personality structure
How does therapists feels after 1st session?
McWilliams (2011) CH3
Feels that client and therapist are on the same side and that their mutual antagonist is a problematic part of patient
Characteristics of psychotic-level personality structure
What are characteristics at psychotic end of spectrum?
McWilliams (2011) CH3
People are much more:
- Internally desperate
- Disorganized
Characteristics of psychotic-level personality structure
How is it with people who are not in an overt state of psychosis?
McWilliams (2011) CH3
There are many people walking around whose basic psychotic-level does not surface unless they are under considerable stress
Characteristics of psychotic-level persoanlity structure
What are defenses they tend to use?
McWilliams (2011) CH3
- Withdrawal
- Denial
- Omnipotent control
- Primitive idealization and devaluation
- Primitive forms of projection and introjection
- Splitting
- Extreme dissociation
- Acting out
- Somatization
Characteristics psychotic-level
Waar hebben ze moeite mee?
McWilliams (2011) CH3
- Identity: so much, they may not fully be sure that they exist. deeply confused about who they are, struggle with: body concept, age, gender, sexual orientation.
- They lack reflective functioning, trouble getting perspective on psychological problems –> maybe due to difficulties with abstraction
- Energic aspects: they were expending so much energy fighting off existential terror that none was left to use in the service of coping with reality.
- Boundary confusion: between outside en inside experience, and deficits in attachment that make it subjectively too dangerous for the psychotic person to enter the same assumptive world as the interviewer.
- The nature of the primary conflict in people with a potential for psychosis is literally existential: life vs death, existence vs obliteration, safety vs terror
Characteristics psychotic-level
Wat is positief?
McWilliams (2011) CH3
- May induce a positive countertransference. This differs a bit from warm countertransference reactions to neurotic-level clients: one may feel more subjective omnipotence, parental protectiveness, and deep soul-level empathy toward psychotic people than toward neurotic ones. Psychotic people are so desperate for respect and hope that they may be derential and grateful to any therapist who does more than classify and medicate them. Their grattitude is naturally touching
- They are particularly appreciative of sincerity.
Characteristics of psychotic-level personality structure
Why is it not difficult to diagnose patients who are in overt state of psychosis?
McWilliams (2011) CH3
They express hallucinations, delusions, and ideas of reference, and their thinking strikes the listener as illogical
Characteristics of psychotic-level personality structure
What is a fear they have?
McWilliams (2011) CH3
People with psychosis have a core, immobilizing dread of their fantasied superhuman potential for destructiveness
Characteristics psychotic-level
Hoe komen ze over?
McWilliams (2011) CH3
One feels that a patient is not anchored in reality
Characteristics psychotic-level
Waarom willen therapeuten niet met ze werken?
McWilliams (2011) CH3
They are wonderful in their attachment, yet terrifying in their needs.
The consuming feature is one reason why many therapists prefer not to work with them
Characteristics BPD
What are their defenses?
McWilliams (2011) CH3
Use of primitive defenses:
- Denial
- Projective identification
- Splitting
–> They can be hard to distinguish from psychotic patients
Characteristics BPD
Difference BPD - psychotic
McWilliams (2011) CH3
- Primitive defense: when therapist confronts BPD with defensiveness: temporary respons. When therapist confronts psychotic: become further agitated
- Reality testing: BPD demonstrate appreciation of reality no matter how crazy their symptoms look.
Characteristics of borderline personality organization
How to make differential diagnosis between BPD and psychosis
McWilliams (2011) CH3
Sense of reality
Kernberg (1984): investigating the person’s appreciation of reality by picking out some unusual feature of his or her self-presentation, commenting on it and asking if the patient is aware that others might find that feature peculiar.
The borderline person will acknowledge that the feature is unconventional and that outsiders might not understand its significance.
The psychotic person is
likely to become frightened and confused because the sense that he or she is not understood is deeply disturbing.
Characteristics BPD
What do they think of therapist’s interest in their complixities
McWilliams (2011) CH3
They dismiss interest in complexities of themselves and others
Characteristics BPD
How do they experience the self?
McWilliams (2011) CH3
Full of inconsistency and discontinuity
Characteristics BPD
What do they “miss”?
McWilliams (2011) CH3
- They are insecurely attached
- Lack “reflective function” that finds meaning in own behavior and of others
- They cannot mentalize –> lack theory of mind
Characteristics BPD
What do they find difficult?
McWilliams (2011) CH3
- Affect tolerance and regulation –> go quickly to anger in situations others feel: shame, envy, sadness
- Identity confusion –> but they know they exist
- Observe own pathology –> come to therapy for other problems, such as depression
- BPD clients seem to be in dilemma: when they feel close to other person, they panic (fear of engulfment and total control); when alone, they feel traumatically abandoned
Characteristics BPD
Wat zijn eerste clues dat client BPD heeft?
McWilliams (2011) CH3
Interventions that therapist intends to be helpful are perceived as attacks
Characteristics BPD
Waar komt het vandaan volgens Masterson?
McWilliams (2011) CH3
He saw BPD patients as fixated at the rapprochement sub phase of the separation-individual process, when the child has attained some autonomy yet still needs reassurance that a caregiver remains available and powerful.
Characteristics BPD
Countertransference
McWilliams (2011) CH3
Countertransference is tegenreactie van therapist op transference van patient
Countertransference reactions tend to be strong and upsetting. Even when positive they may have a disturbing, consuming quality
Characteristics BPD
Transference
McWilliams (2011) CH3
This tends to be strong, unambivalent, and resistand to ordinary kinds of intervention.
Therapist os perceived as all good or all bad.
Article: Granieri et al. (2017) “The relationship between defense patterns and DSM-5 maladaptive personality domains
Granieri et al. (2017)
- Defense mechanisms (which kinds)
- Negative affectivity
- Detachment
- Antagonism
- Disinhibition
- Psychoticism
Defense mechanism
Granieri et al. (2017)
Mental operation, usually unconscious, directed against the expression of drives and impulses
- Serve to control the expression of unacceptable impulses and as reactions to external/internal sources of stess
- Have specific function to protect self from anxiety, conflict, shame, loss of self-esteem, other unacceptable feelings/negative thoughts
Defense mechanism on a continuum in degree of maturity
Granieri et al. (2017)
- More mature: great ability to adapt to reality, so they can effectively distance threatening feelings without distorting reality (sublimation, humor, suppression, altruism)
- Immature/primitive: severe alteration of painful contents and/or radical distortions of external reality (projection, splitting, acting out, autistic fantasy)
Zie SV studeersnel (blauwe) voor hele tabel met alle soorten defence
Findings
Granieri et al. (2017)
- Immature defence predicted higher scores on maladaptive personality domains
- Increased use of immature DMs were positive predictor of psychopathology (PID-5-BF score)
- Mature DMs were negative predictors of psychopatholohy (PID-5-BF score)
Negative affectivity
Nega affectivity was predicted by:
Granieri et al. (2017)
An increased use of:
- Reaction formation
- Pseudo-altruism
- Isolation
- Displacement and projection
- Acting out
- Reduced use of humor
- Suppression
Negative affectivity is associated with which PDs?
Granieri et al. (2017)
- avoidant pd
- schizotypical pd
- borderline pd
- OCPD
Negative affectivity is characterized by personality facets such as:
Granieri et al. (2017)
- anxiousness
- emotional liability
- hostility
- perseveration
- lack of or restricted affectivity
- separation insecurity
- submissiveness
Negative affectivity
Reaction formation
Granieri et al. (2017)
= gevoelens onderdrukken door het tegenovergestelde gedrag aan te nemen.
Observed in APD and OCPD to control and transform disturbing emotional or cognitive components into the opposite to make it less threatening.
Negative affectivity
Pseudo-altruism
Granieri et al. (2017)
= a pattern of behavior used by people who have a problem in coping satisfactorily with repressed rage. Observed in both individual and group psychotherapy, it allows the discharge of unacceptable impulses through professed concern about others
Significant and positive predictor of negative affectivity.
–> Displaying altruistic and prosocial might be an attempt to obtain approval and support from others in people with high levels of negative affectivity
Negative affectivity
Isolation
Granieri et al. (2017)
Allows individuals to manage anxiety/other painful states by separating the affective features of an experience or idea from its cognitive dimension
Negative affectivity
Displacement and projection
Granieri et al. (2017)
Displacement and projection of impulses, emotions, worries, behaviours, and inner aspects of the self may help people hide in negative affectivity to defend themselves from overwhelming feelings that are unconsciously perceived as potentially disorganizing.
Negative affectivity
Acting out
Granieri et al. (2017)
Is a general DM in BPD
A tendency to an immediate discharge of feelings or impulses for the inability to endure them and to reflect on the painful circumstances that determined them.
Negative affectivity
Reduced use of humor and conscious suppression
Granieri et al. (2017)
May further reinforce the presence of negative feelings and the difficulty to deal with them.
Detachment was predicted by:
Granieri et al. (2017)
- Older age
- Higher levels of autistic fantasy
- Isolation
- Projection and lower levels of humor
- Reaction formation
Detachment seems to be associated with which PDs?
Granieri et al. (2017)
- APD
- OCPD
- schizotypical pd
Detachment expresses personality facets such as:
Granieri et al. (2017)
- anhedonia
- depressivity
- intimacy avoidance
- suspiciousness
- withdrawal
detachment
Autistic fantasy
Granieri et al. (2017)
= an autistic retreat into an imaginary life to avoid facing unacceptable feelings or the unpleasant reality (imagining a bulb around you which makes it unable for anyone to touch you)
Represents schizoid pd defense against a conflict between the desire to get in touch with others and the fear of being engulfed and overwhelmed by others –> leads to social withdrawal
Detachment
Reduced use of reaction formation
Granieri et al. (2017)
Could indicate a lower tendency of these individuals to deny ambivalence
Detachment
Isolation
Granieri et al. (2017)
Organizing defense of OCPD
–>They overestimate mental and cognitive activity and avoid emotionally charged situations for fear if losing control and being vulnerable
Detachment
Projection
Granieri et al. (2017)
Concerns a wrongly attribution of one’s own unrecognized impulses, feelings and thoughts to others, so that the individual can avoid to deal with internal experienced that could make him/her feel excessively vulnerable.
Antagonism was predicted by:
Granieri et al. (2017)
Antagonisme= manipulatief, grandiositeit, aandacht zoeken, ongevoeligheid, vijandigheid
- male gender
a combination of higher levels of:
- isolation
- dissocation
- autistic fantasy
- pseudo-altruism
- acting out
and lower levels of:
- idealization
- reaction formation
Antagonism
Includes personality facets such as:
Granieri et al. (2017)
- attention seeking
- callousness (ongevoeligheid)
- deceitfulness
- grandiosity
- manipulativeness
Antagonism
associated with which PDs?
Granieri et al. (2017)
- ASPD
- NPD
Antagonism
what does the pseudo-self-sufficiency alow?
Granieri et al. (2017)
it allows individuals with increased antagonism traits to deny any need for care and love, and to defensively exclude from disturbing feelings (anger, resentment) toward a needed but frustrating or rejecting figure.
Antagonism
autistic fantasy
Granieri et al. (2017)
sig predicted antagonism, suggesting general tendency of individuals with antagonistic traits to not engage emotionally with other people.
Antagonism
Acting out
Granieri et al. (2017)
sig predictor, indicating tendency of people with high antagonism to act in potentially aggressive and destructive ways toward others and even themselves
Antagonism
Pseudo-altruism
Granieri et al. (2017)
some people high in antagonism show a facade of altruistic attitudes –> facade hides that desires for power are enacted by unconsciously forcing other people to feel submissive and obliged toward the antagonistic indivual
Antagonism
Decreased use in idealization
Granieri et al. (2017)
highlights their lower investment in values and capabilities of others
Antagonism
Reduced use of reaction formation
Granieri et al. (2017)
could indicate a lower tendency of these individuals to feel guilt and to repair potential damage that they inflicted to others
Disinhibition
was predicted by:
Granieri et al. (2017)
- younger age
- lower levels of education
- higher levels of acting out
- dissocation
- isolation
- autistic fantasy
- pseudo-altruism
- lower levels of devaluation
- anticipation
Disinhibition
includes personality facets such as:
Granieri et al. (2017)
- distractibility
- impulsivity
- irresponsibility
- lack of rigid perfectionism
- risk taking
Disinhibition
Associated with:
Granieri et al. (2017)
- NPD
- ASPD
- BPD
disinhibition
acting out
Granieri et al. (2017)
considered one of most representative modalities of borderline functioning –> people with high disinhibition may act impulsively due to their difficulty integrating internal representations, reflecting on experience, and verbalizing feelings when they face stress and distrubing emotions.
Psychoticism were predicted by:
Granieri et al. (2017)
Higher levels of
- Isolation
- Autistic fantasy
Psychoticism
Includes personality facets such as:
Granieri et al. (2017)
- Eccentricity
- Cognitive perceptual dysregulation
- Unusual beliefs and experiences
Psychoticism
Is associated with:
Granieri et al. (2017)
- BPD
- Schizotypical pd
Psychoticism
What are difficulties for high psychoticism?
Granieri et al. (2017)
To effectively deal with emotional conflicts, which may lead to them compartmentalize the emotional aspects of the experience.
Conclusion
Granieri et al. (2017)
Study supports the hypothesis that maladaptive personality traits are modulated by dominant defense patterns.
Article: Perry & Bond (2012) “Change in defense mechanisms during long-term dynamic psychotherapy and five-year outcome”
Perry&Bond (2012)
Study investigates changes in DMs during long-term dynamic psychotherapy, and how these changes relate to long-term improvements in psychiatric symptoms and functioning.
Hypothesis= DMs evolve in hierarchical manner, from less adaptive to more mature defenses, and that this improvement correlates with better psychological outcomes.
Hierarchical levels of DMs
Perry&Bond (2012)
- Immature defense (lower-level defense)
- Neurotic defense (mid-level defense)
- Mature defense (higher-levels defense)
Immature defense
Perry&Bond (2012)
Least adaptive mechanisms and often more problematic in long term.
Involve: distorting reality or acting out that provides short term relief
Examples:
- action defenses (acting out, passive-aggressive): expressing internal conflict through actions, without conscious awareness of underlying emotions
- Disavowal and major image-distorting defenses (e.g., denial, projection): These involve rejecting or distorting reality in a way that protects the individual from difficult emotions but can worsen interpersonal relationships and emotional regulation.
Neurotic defenses
Perry&Bond (2012)
Still involve some level of distortion of internal experiences or reality.
They are more complex and allow greater daily functioning, but still prevent fully adaptive emotional responses.
EXAMPLES
- Repression: unconscious blocking of unpleasant thoughts and emotions
- Displacement taking it out on someone else
Mature defense
Perry&Bond (2012)
Allow to deal with stress and conflict in ways that are more aligned with reality and conducive to personal growth and healthy relationships.
EXAMPLES
- Suppression: consciously deciding to delay dealing with unpleasant emotions until more appropraite time
- Sublimation: redirecting unacceptable impulses into socially acceptable actions or goals (channeling aggression into sports)
Results
DMs changes
Perry&Bond (2012)
DMs improved significantly, with lower levels of immature defenses and higher levels of adaptive defenses after therapy.
Results
Predictors of change
Perry&Bond (2012)
Patients with more severe psychiatric histories OR early chilhood trauma (sexual abuse) showed slower rates of defensive improvement.
Results
Outcome correlation
Perry&Bond (2012)
Improvements in DMs were strongly associated with long-term improvements in both symptoms and overall functioning.
Changes in DMs during therapy predicted better outcomes at the 5-year follow-up
Discussion/conclusion
Perry&Bond (2012)
Study supports hypothesis that defensive functioning improves in a hierarchical manner during long-term dynamic psychotherapy.
Improvements in DMs are linked to better long-term outcomes –> suggesting that DMs play critical role in mediating therapeutic success
Results indicate importance of targeting defense mechanisms in therapy, particularly for individuals with complex psychiatric histories
