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Borderline personality organization

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  • 1. From psychoanalytical point of view and related to DSM IV Axis II 11
  • 2. Psychopathology 1Biology and Psychology Behavior is the result of the mutual relation between “nature” and “nurture”.The result of a complicated interaction between “genes” and “environment”→ integration Mind and Brain. 22
  • 3. Psychopathology 2 Consequences for looking at pathology2. No causal relation between risc factors and the development of pathology; the amount of risc factors is in a way predictable.3. The quality of the early attachment relationships is important for the possible development of pathology 33
  • 4. Psychopathology 3 The process of internalising early experiences and the creation of an internal psychological model of the interpersonal world → mentalization/ creation of a mind or mental representations. Internal representations of the earlier experiences with the primairy care givers will influence later relationships and the development of psychopathology later on 44
  • 5. Psychopathology 4There are 2 types of psychopathology4. Related to conflicting mental representations: neurotic pathology6. Related to the failing of the mentalizing process itself: personality disorders this is the area of the borderline personality organization 55
  • 6. Difference between BPD and BPO 1 Borderline Personality Disorder3. A descriptive diagnosis. Manifest and observable behavior4. An enduring pattern of internal experiences that manifest themselves in a broad area of personal and social situations.5. DSM IV 66
  • 7. Difference between BPD and BPO 2 Borderline Personality Organization Structural Diagnosis/ Kernberg Underlying structure which is not directly observable.→ Dyade/Schema/I.W.M./I.I.M. Includes the whole area of personality disorders 77
  • 8. Two types of pathologyMental process disorders Inability to represent inside what is outside The dependency from the external world is there Anxieties are interpersonal instead of intra personal 88
  • 9. Two types of pathologyMental Process disorders No psychological Self but the body is the self No Somatization as a defense but Soma Alexithymia: medically unexplained physical symptoms/ conversions They live in a frightened world instead of a world they are experiencing as frightening 99
  • 10. Mental Process Disorders1. Anxiety neurosis2. External Regulated / Motivated3. Developmental pathology4. Building structures5. The area of the personality disorders Axis 2 cluster A and B6. Axis 1 Somatization, Somatoform disorder, Panic disorder Dissociative disorder and PTSD. 10 10
  • 11. Conflicting Mental Representations.2. Psychoneurosis3. Intrapsychic Conflicts4. Conflicting pathology5. Restructuring6. Internal Regulated / Motivated7. Neurotic pathology and Axis 2 cluster C 11 11
  • 12.  Mental process / mental representations Paranoid/Schizoid versus Depressive Pos. Primary love versus Basic Fault Primary versus Secondary Process Pre Oedipal versus Oedipal Neurotic versus Structural Neurotic versus Personality dis. 12 12
  • 13. M.KleinPar. Schizoid Position Annihilation anxiety Identity undermining defenses No adequate self/object differentiation No adequate object constancy Archaic Object Relations Ambivalences are not bearable “doing” instead of “containing”/”feeling” 13 13
  • 14. M.KleinPar.Schizoid Position Interventions related to the inner experiencing are raising the anxiety and by that stimulating “acting out” Interventions should relate inner and outer sources of stress → facilitating mentalization Therapist as external Obs.Ego → being introjected / mirroring 14 14
  • 15. M.KleinDepressive position Anxieties related to inner ambivalences Defenses in favour of identity Adequate S/O differentiation Adequate Object constancy Realistic Object Relations Containing instead of doing 15 15
  • 16. AttachmentA safe attachment style supposes Adequate sensitivity: being aware that there is something going on in the other person Adequate responsivity: reacting to the other in such a way that it is clear what is from me and what from the other 16 16
  • 17. Failing sensitivity: Externalizing pathology They minimize their need for relatedness. As a strategy against the pain of the separation and the feeling not been seen. Predisposition for Externalizing pathology because there is no attention for the self, and the solution of negative inner representations is not there → faling sensitivity(Dozier 1999) 17
  • 18. Failing responsivity: Internalizing pathology They maximalizing their need for relatedness and they are continually occupied with the emotional pain and the not being available of the attachment figures. Predisposition for Internalizing pathology: attention will be fixated to the availability of the caring other and negative representations stay painfully alive → failing responsivity 18
  • 19.  S. Blatt: Two Basic Drives3. Relatedness  Anaclytical pathology  Preoccupied/Ambivale nt  Faling responsivity/not marked mirroring9. Autonomy  I can not be on my own  Introjective pathology  Avoiding  Failing sensitivity(Blatt 1998)  I do it myself 19
  • 20. Anaclytical PathologyInternalizing Pathology Borderline Personality Disorder Histrionic Personality Disorder Dependant Personality Disorder 20 20
  • 21. Introjective PathologyExternalizing pathology Schizoid/Schizotypical Personality Dis. Narcissistic Personality Disorder Antisocial Personality Disorder Avoidant Personality Disorder Somatization,Somatoform dis. DID, PTSD 21 21
  • 22. Internalisation incorporation introjection identification 22 22
  • 23. Introjectionobject permanencyobject constancyinternal objectindependent of external objects 23 23
  • 24. Objectconstancy Internal representations Containing ambivalencies Related to someone who isnot actual there Mourning Autonomous 24 24
  • 25. Identity - 1 - Object constancy Autonomous object Internal representations Time perspective Feeling instead of doing 25 25
  • 26. Identity - 2 - Fragmentation - cohesive Acting out - containing Momentaneous - timeperspective panic - signal anxiety Splitting - repression 26 26
  • 27.  Structural Diagnosis/ Kernberg Underlying structure which is not directly observable. Object Relational Dyade; Schema Internal Working Model. Intersubjective.Interpretive Mechanism. Includes the whole area of personality disorders 27 27
  • 28. Structural Personality Organization Kernberg (1984) Neurotic Borderline PsychoticIdentity integrated diffuus fragmentatedDefense mature archaic archaicReality in tact in tact in a way absentTesting 28 28
  • 29. Ego identity S/O Differentiation  internal structure Mature Object  autonomous Relations Mature Defenses Reactive Agression 29 29
  • 30. Identity diffusion Fusion  external regulated Primitive Object Relations  dependent Archaic Defense Primitive Agression 30 30
  • 31. Weak internal structure versus Strong internal structure Archaic defenses  Mature defenses Panic  Neurotic anxieties (signal) Regression of the ego  regression in favour of the No ambivalencies ego Deficits  Ambivalent Acting out  Conflict Structuring  Containing  Rerstructuring “Borderline” “Neurotic” 31 31
  • 32.  Nonspecific manifestations of ego weakness Specific manifestations of ego weakness → splitting Shift towards primary process thinking Pathalogical internalized object relations 32 32
  • 33. 33 33
  • 34. 34 34
  • 35. 35 35
  • 36. DSM IV: Axis 2 Cluster A Eccentric: paranoid schizoid; and schizotypical Cluster B Dramatic: borderline; narcissistic; anti-social and histrionic Cluster C Anxiety: avoident; obsessive compulsive and dependent 36 36
  • 37. Apart from DSM IV Depressive P.D. Somatization P.D. Dissociative P.D. 37 37
  • 38.  Cluster A 38 38
  • 39.  A pervasive pattern of detachment from social relationships Introjective/externalizing pathology 39 39
  • 40.  Restricted range of expression of emotions in interpersonal relationships No desire or missing or enjoying close relationships Indifferent to praise or criticism Like being alone 40 40
  • 41.  In the internal world intense relations Anxiety of being rejected;of being persecuted;of desintegration A lot of splitting Fairbairn: internal life compensates deficits in external life → inner life is pathological Balint: Inadequate mothering → basic fault 41 41
  • 42. Personality SchizoidDisorderView of self Self-sufficient. LonerView of IntrusiveothersMain Others are unrewarding.beliefs Relationships are messy, undesirable.Main Stay away!strategyTherapeutic Realize that he is basically very insecure and that contact with people is a real threat.strategies So let him decide how much contact he wants. Do everything to increase his sense of self-efficacy. 42 42
  • 43. The same as Schizoid but also: Ideas of reference Suspicious/paranoid,excessive social anxiety Magical thinking Eccentric and odd behavior 43 43
  • 44. Personality SchizotypalDisorderView of self Unreal, detached, loner. Vulnerable, socially conspicuous. Supernaturally sensitive and gifted.View of Untrustworthy. Malevolent.othersMain (irrational, odd, superstitious, magical thinking; e.g. belief inbeliefs clairvoyance, telepathy or ‘sixth sense’.) “It is better to be isolated from others.”Main Watch for and neutralize malevolent attention from others.strategy Stay to self. Be vigilant for supernatural forces or events.Therapeutic See next slide.strategies 44 44
  • 45. How to deal with Schizotypicals Realize that he is basically very insecure and that contact with people is a real threat. So let him decide how much contact he wants. Do everything to increase his sense of self-efficacy and his reality testing. Don’t argue about telepathy, but simply state that you don’t have such experiences. 45 45
  • 46.  A pervasive mistrust and suspiciousness of others Fixated in the paranoid/schizoid position Reads hidden meanings in everything Externalizing, others are aggressors No trust in others → problems with basic trust 46 46
  • 47.  The dominant dyade is that of victim and persecutor Emotional cold in intimate relations Arrogant on the outside feelings of inferiority in the inside Hyperalert In a way they are right the problem is in the enlargement 47 47
  • 48.  Splitting as defense mechanism Continuous Anxiety Concrete Magic Thinking → Taking things at face value Projective Identification Problems with Object Constancy Relations are in it self dangerous and discontinuous 48 48
  • 49. Personality ParanoidDisorderView of self Righteous, innocent, noble, vulnerableView of Interfering, malicious, discriminatory, abusive motivesothersMain Others’ motives are suspect.beliefs I must always be on guard. I cannot trust people.Main Be wary. Look for hidden motives.strategy Accuse. Counterattack.Therapeutic Realize that he is basically very insecure.strategies So accept the suspiciousness. Accept that you have to earn his trust, by being extremely transparant and open about what you are doing. Do everything to increase his sense of self-efficacy. 49 49
  • 50.  Cluster B 50 50
  • 51.  Pervasive pattern of instability of interpersonal relationships, self image and affects and marked impulsivity Anaclytical / internalizing pathology 51 51
  • 52.  Alternating between idealizing and devaluating Chronic feelings of emptiness Inappropriate intense anger Self-mutilation 52 52
  • 53.  Frantic efforts to avoid real or imagined abandoment Identity disturbances Impulsivity / problems with bounderies Affective instability/ moodswings including anxiety Paranoid ideation 53 53
  • 54. Personality BorderlineDisorderView of self Vulnerable (to rejection, betrayal, domination) Deprived (of needed emotional support) Powerless. Out of control. Defective. Unlovable. Bad.View of (idealized:) poweful, loving, perfect.others (devaluated:) rejecting, controlling, betraying, abandoning.Main I cannot cope on my own. I need someone to rely on.beliefs If I rely on someone I will be mistreated, found wanting, and abandoned. The worst possible thing would be to be abandoned. I cannot bear unpleasant feelings. It is impossible for me to control myself. I deserve to be punished.Main Subjugate own needs to maintain connection.strategy Protest dramatically, threaten and/or become punitive toward those that signal possible rejection. Relieve tension through self-mutilation and self-destructive 54 54
  • 55. How to deal with borderlines. They provoke intense countertransference feelings: Anxiety , Compassion, Powerlessness,Rage. They constantly test the limits. So stop them in time, in spite of their vehement emotions, reproaches, suicide threats. The basic rule is: setting clear and consistent limits. Keep in mind that their life-long dilemma is: fear of utter loneliness ↔ fear of engulfment and loss of identity. This causes the instability between intense need for contact and intense rejection when you try to be helpful. Be clear about the conditions by which you can help her. Be consistent in maintaining these conditions and setting limits. This helps you to prevent your anger. 55 55
  • 56.  Pervasive pattern of grandiosity, need for admiration, for being loved Introjective / Externalizing pathology 56 56
  • 57. Oblivious: need for being loved / admiredarrogant; thick skinned; phallic narc. char. No awareness of reactions of others Arrogant / Agressive Self centered, need to be the center Lack of empathy untouchable 57 57
  • 58. Hypervigilant: need to be loved / admiredDepressed; thin skinned; shy narcissist. Highly sensitive to reactions of others Inhibited or shy Directs attention to others instead of himself Shuns to be the center Listens to others for evidence or criticism Easily hurt 58 58
  • 59. Personality Narcissistic.DisorderView of self Special, unique, superior. Deserves special rules. Is above the rules.View of Inferior.others Admirers.Main Since I am special I deserve special rules.beliefs I am above the rules. I am better than others.Main Use others. Transcend rules, manipulate, compete.strategyTherapeutic See next slide.strategies 59 59
  • 60. How to deal with narcissists. Keep in mind that their arrogance is needed in order not to feel inferior. Therefore accept the fact that there can be only one grandiose person in the room. So overcome your own narcissistic hurt and use praise and flattery to get things done. But resist unreasonable demands, for then they loose respect. But tolerate their rage when you don’t fulfil their demands. 60 60
  • 61.  Pervasive pattern of disregard for and violation of the rights of others Introjective /Externalizing pathology 61 61
  • 62.  Failure to conform to social norms Impulsivity or failure to plan ahead Irratability / agression No empathy No responsability for their behavior 62 62
  • 63.  Strong genetic factor Failing in emotional attunement → no caring/soothing objects Lack of remorse Grandiose Self is an agressive introject Lack of basic trust 63 63
  • 64. Passive or Parasitic Anaclitic Dependent, less agressive, relatively non- violent manipulatorAgressive Introjective Explosive, violent offender 64 64
  • 65. Personality AntisocialDisorderView of self A lonerView of VulnerableothersMain “I am entitled to break rules.”beliefsMain Attack. Rob. Steal.strategyTherapeutic See next slide.strategies 65 65
  • 66. How to deal with antisocials Don’t let yourself be flattered by his charm. Be aware that he always wants something from you. So be especially suspicious if he offers you to participate in some partly illegal, but very profitable offer. As he has no conscience, teaching morals makes no sense. So teach him to become a better psychopath, more clever and long-sighted, directed to his best interests. 66 66
  • 67.  Pervasive pattern of excessive emotionality and attention seeking Anaclytical / Internalizing pathology 67 67
  • 68. Histrionic Weak internal structure Dyadic relations Archaic defense Need satisfying relations Flamboyant; seductiveness; sexual impulsiveness; dramatization 68 68
  • 69. Hysterical Adequate internal structure Triadic relations Mature defense Take and give relations Emotional reserve; sexual naiveté; conversions and somatizations 69 69
  • 70. Personality Histrionic.DisorderView of self Glamorous. Impressive.View of Seducible. Receptive. Admirers.othersMain People are there to serve me or to admire me.beliefs People have no rights to deny me what I deserve. I can go by my feeling.Main Use dramatics, charm, temper tantrums, crying, suicidestrategy gestures.Therapeutic See next slide.strategies 70 70
  • 71. How to deal with histrionics. Natural reactions to them are: Rescuer phantasies, Sexual desire, Irritation. So be wary of the intense emotional contact they seem to promise. Resist the temptation to become the all-powerful rescuer. Interrupt their impressionistic, dramatic style of thinking. Teach them to think through, in order to be able to make their own decisions, and to decatastrophize the future and to improve their problem solving skills. 71 71
  • 72.  Cluster C 72 72
  • 73.  Pervasive pattern of preoccupation with orderliness, perfectionism, mental and interpersonal control. Less flexibility, openness and efficiency. In Control Details, rules, procedures, organization Rigid, stubbornness 73 73
  • 74.  Intimacy is dangerous They were never good enough Severe internal parental objects Workaholics Love is related to high performances Selfdoubt deep depression when they realize that perfection doesn’t exist 74 74
  • 75. Personality Obsessive-compulsive.DisorderView of self Responsible. Accountable. Fastidious. Exacting. Competent.View of Irresponsible. Casual. Incompetent. Self-indulgent.othersMain I know what is best.beliefs Details are crucial. People should do better, try harder.Main Apply rules. Perfectionism. Evaluate, control.strategy “shoulds”. Criticize. Punish.Therapeutic See next slide.strategies 75 75
  • 76. How to deal with obsessive-compulsives. Respect his meticulousness, but state clearly when things are clear enough. Do behavioral experiments to let him discover that doing something less-than-perfect does not bring the feared catastrophy. 76 76
  • 77.  Pervasive pattern of social inhibition, feelings of being inadequate, hypersensitive for negative evaluation Introjective /Externalizing pathology 77 77
  • 78.  Anxious for being related because of the anxiety to be rejected Avoids getting involved with people unless certain of being liked Low self esteem, intense need for affection and appreciation 78 78
  • 79.  Feelings of inferiority related to shame → related to narcissistic p.d. → sensitive type Shame related to Self Exposure which is avoided Neurotic variant of the Schizoid P.D. Phobic Personality Often in conjunction with Axis I diagnosis 79 79
  • 80. Personality AvoidantDisorderView of self Vulnerable to depreciation, rejection. Socially inept. Incompetent.View of Critical. Demeaning. Superior.othersMain It is terrible to be rejected or put down.beliefs If people know the ‘real’ me, they will reject me. I cannot tolerate unpleasant feelings.Main Avoid evaluative situationsstrategy Avoid unpleasant feelings or thoughts by keeping everything vague.Therapeutic See next slide.strategies 80 80
  • 81. How to deal with avoidant patients. How much you do your best to be accepting, keep in mind that they can only see you as critical, and so they will try to be as vague as possible, in order not to be caught. Show them the price they pay by avoiding and help them to confront the feared situations in small steps, and to tolerate the tension. Confront them with the fact that others will judge them anyway. Offer social skills training. 81 81
  • 82.  Pervasive need to be taken care of that leads to submissive and clinging behavior related to fears of separation or being abandoned Anaclytical /Internalizing pathology 82 82
  • 83.  Difficulties in making decisions without enormous advices from others Enormous need for appreciation and encouragement Difficulties in expressing feelings of disagreement because of fear of loss of support or approval 83 83
  • 84.  Enormous need for nurturance and support By being so dependent they provoke what they want to avoid Passive-Agressive versions of dependent p.d. 84 84
  • 85. Personality DependentDisorderView of self Needy. Weak. Helpless. Incompetent.View of (Idealized:) Nurturant. Supportive. Competent.othersMain I need people to survive and be happy.beliefs I need to have a steady flow of support and encouragement.Main Cultivate dependent relationships.strategyTherapeutic Resist the invitation to take the initiative and to become the all-powerful magical helper, but make a deal:strategies “I can only help you if you gradually do things on your own.” Promote small steps toward autonomy. Offer assertiveness training. 85 85
  • 86. Personality Passive-aggressiveDisorderView of self Self-sufficient. Vulnerable to control, interference.View of Intrusive, demanding, interfering, controlling, dominating.othersMain Others interfere with my freedom of action.beliefs Control by others is intolerable. I have to do things my own way.Main Passive resistance.strategy Surface submissiveness. Evade, circumvent rules.Therapeutic Avoid power struggles and being pushed into the authoritarian role. Focus explicitely on collaboration.strategies 86 86
  • 87.  Based on psychoanalytical theory 87 87
  • 88. Introjective ( melancholic) Guilt, self criticism, perfection Depressive personality disorder those people suffer fromchronic dysphoric affect and have a disposition for feeling guilty and/or ashamed Looking inside to find explanations “Mood disorders” 88 88
  • 89. Anaclitical shame; high reactivity to loss and rejection; vague feelings of inadequacy and emptiness; weak capacity to be alone Looking in the outside for explanation Dependent; narcissistic or borderline personality disorder. 89 89
  • 90.  Depressive P.D . : a pervasive and repetitive pattern that intensifies under stress → more chronic state Major depression : the vegetative symptoms are on the foreground (decreased appetite,decreased sexual desire; sleep disturbances; psychomotor retardation etc) 90 90
  • 91. Introjective Concerned with self definition, autonomy, self worth,self critical thoughtsAnaclitic Concerned with relatedness, trust, preservation of attachments 91 91
  • 92. Somatization P.D.Anxiety neurosis (Actual Neurosis) Somatic (hartbeating; sweating; trembling; nausea; problems with respiration etc.) Not related to mental representations Related to mental process disorders DSM IV; somatization,somatoform disorders panic disorders and PTSD. 92 92
  • 93. Somatization P.D.Mental Process disorders No psychological Self but the body is the self No Somatization as a defense but Soma Alexithymia: medically unexplained physical symptoms/ conversions They live in a frightened world instead of a world they are experiencing as frightening 93 93
  • 94. Somatization P.D.1. Anxiety neurosis instead of psycho- neurosis2. Panic / momentaneous anxiety3. External Regulated / Motivated4. The area of the personality disorders Axis 2 cluster A and B5. Somatization, Somatoform disorder, Panic disorder and PTSD. 94 94
  • 95. Dissociative Identity Disorder Dissociation as reaction to trauma Vertical split Dissociative amnesia → problems in remembering specific episodes related to the trauma Dissociative fugue → problems in remembering the own history, past or identity confusion. 95 95
  • 96. Dissociative P.D.Appearance of alters Distinct identities or personality states each with his own relatively enduring pattern of percieving,relating to andP.D. Dissociative thinking about the environment and the self. They recurrently take control of the persons behavior 96 96
  • 97.  Ever met a normal person ??? And did you like it ??? mdw@wxs.nl 97

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