Blog / Levels of personality organization: neurotic, borderline, psychotic

Kaplan and Sadok

Definition

Borderline states are characterized by extremely unstable affect, mood, behavior, object connections, and self-image.

Clinical characteristics

Certain psychotic episodes may occur. There may be depression or complaints of lack of feelings. The behavior is extremely unpredictable. The unhealthy nature of their lives is reflected in their repeated acts of self-destruction. They are restless in their interpersonal relationships. They can be highly dependent on those with whom they want to be close, and tend to unleash anger on their friends when in a state of frustration. They destroy interpersonal relationships by placing everyone in the category of either “good in everything” or “bad in everything.” They cannot bear loneliness. They often complain of a chronic feeling of emptiness and boredom, and a lack of a stable sense of authenticity.

In clinical studies, abnormalities were found only on unstructured projective tests.

Course and prognosis

There is no tendency to progress towards schizophrenia, but severe depressive disorders are common in these patients.

Differential diagnosis

With this understanding, difficulties arise in differential diagnosis, for example, with hysterical and antisocial personalities.

Treatment

Such patients easily experience regression because they play on their impulses and find a slight transference, labile or fixed, negative or positive, which is difficult to analyze. A reality-oriented approach suits them better than deep unconscious interpretations. Placing the patient in special supportive institutions has a good effect.

Authors such as Nancy McWilliams and Otto Kernbeg do not consider borderline personality disorder (hereinafter BPD) as such. For them, “making a structural diagnosis” and “identifying the level of personality functioning” is more important. In their model, any single personality disorder (PD) can be a disorder at the neurotic, borderline, or psychotic level. In Kaplan and Sadok’s version, PD still belongs to the neurotic spectrum, and PD bordering on psychosis will be Borderline PD.

O. Kernberg and N. McWilliams use special diagnostic methods. Both authors distinguish psychotic, borderline and neurotic levels of personal organization. And I would like to elaborate on what criteria they use to separate these levels.

Classification

Let's look at the most common types of neurotic disorders:

1. Phobias are a condition characterized by intense, uncontrollable and often unreasonable fear. It extends to future situations, objects, animals, people.
2. Anxiety disorder is characterized by the presence of an increased, constant feeling of worry or anxiety that is not related to the actual situation.
3. Panic attack refers to a special form of anxiety neurotic disorders. A person cannot explain the reason for the sudden paralyzing feeling of danger.
4. Obsessive-compulsive disorder or obsessive-compulsive disorder. It is characterized by the presence of thoughts, movements, and feelings. They arise regardless of the desires and will of a person, and it is impossible to stop this condition on your own.
5. Hysteria is accompanied by bouts of demonstrative emotional behavior. Hysterical neurosis can occur in children, women, and men.
6. Somatoform form of neurosis. When characterizing neurotic disorders of this type, the main manifestation is the patient’s constant complaints of poor health despite good physical health.
7. Neurasthenia - accompanied by severe irritability, physical weakness, and lack of strength for normal existence.

Any of these forms of neurosis requires consultation with a specialist, as it complicates life not only for the person himself, but also for those around him.

O. Kernberg

Differentiation criteria:

• degree of identity integration
• level of functioning of defense mechanisms
• reality testing

Neurotic level

Integrated identity. Holistic self-concept and holistic images of significant others. In some cases, a borderline narcissistic personality may have a self-concept that is holistic, pathological, and possesses traits of grandiosity. At the same time, there is insufficient integration of the concept of significant others.

Border level

Diffuse identity. Primitive protective furs (mainly splitting). Capable of testing reality. Interpretation of primitive defense mechanisms, as well as confrontation and clarification, temporarily increases the level of functioning. May feel empathy for the therapist's “confusion” and use new data obtained constructively later in the interview. Capable of introspection and insight regarding the reasons for their contradictory behavior. The ego boundary is established (there is a clear barrier between self and other), but there is a clear dissociation between the “good” and “bad” Self and object representations, which protects love and the “good” from being destroyed by the overwhelming hatred and “bad”.

Such patients tend to confuse information about their past with their current difficulties.

Psychotic level

Primitive protective furs (mainly splitting). Inability to test reality. Interpretation of primitive defense mechanisms leads to even greater disorganization. Ego boundaries are fragile or absent.

Primitive thinking

People with borderline organization may perform well in structured work or professional environments. But beneath the shiny surface, there are usually serious self-doubts, suspicions and fears. The internal thought process of such a person can be surprisingly artless and simple, masking behind a stable façade of memorized and rehearsed platitudes. Any circumstance that penetrates the borderline personality's defense structure can unleash a flood of chaotic emotions. Marjorie's example (above) illustrates this point perfectly.

Projection psychological tests also reveal the primitive thought processes of people with BPD. These tests—such as the Rorschach and the Thematic Apperception Test (TAT)—provoke associations with ambiguous stimuli, such as inkblots or pictures, around which the patient builds a story. Borderline reactions usually resemble those of schizophrenics or other psychotic patients. While neurotic patients are more likely to give coherent, organized responses, BPD patients often describe bizarre, primitive images—they may see evil animals devouring each other where neurotics see a butterfly.

Nancy McWilliams

Differentiation criteria:

• preferred defenses
• level of identity integration
• reality testing + the ability to observe your pathology
• nature of the main conflicts
• Features of transference and countertransference

Neurotic level of personality organization

1. rely on mature, secondary defenses; primary defenses are used either “invisibly” against the general background, or during decompensation.
2. integrated sense of identity. Their behavior has some consistency, and their inner experience is characterized by the continuity of their own self over time
3. reality testing; early demonstrate the ability to “therapeutically split” into the observing and feeling parts of their own “I”. They do not require the therapist to explicitly confirm his neurotic way of perceiving.
4. such patients seek therapy not because of problems related to safety or ideas of influence, but because they are involved in conflicts between their desires and those obstacles that they suspect are their own doing
5. whatever the therapist’s transference sign, it will not be excessive; a client of a neurotic level does not evoke in the listener either a desire to kill or a compulsive desire for salvation.

Borderline level of personality organization

1. Primitive defenses: denial, projective identification, splitting. Prone to hostile defense: “How can anyone know what to do with this crap?”
2. Their self-image is full of contradictions and discontinuities. When asked to describe their own personality, they have difficulty and are usually hostile when it comes to their identity. But unlike psychotics, they do not have existential horror about their existence.
3. capable of testing reality, lack of observing ego.
4. separation-individuation problems, when they feel close to another person, they panic due to fear of absorption and total control; outside of intimacy they feel abandoned.
5. the therapist is perceived as either completely bad or completely good; countertransferences are often strong and unbalancing. The therapist may feel like a stressed-out mother of a two-year-old who doesn't want help but becomes irritable when she doesn't get it.

Psychotic level of personality organization

1. Defenses used by psychotic individuals: withdrawal into fantasy, denial, total control, primitive idealization and devaluation, primitive forms of projection and introjection, splitting and dissociation.
2. Have serious difficulties with identification, so much so that they are not completely sure of their own existence. They are deeply confused about who they are. These patients typically grapple with important issues of self-determination such as body concept, age, gender, and sexual orientation. “How do I know who I am and that I exist?”
3. Lack of reality testing. Interpret reality with highly individualized meaning. They are unable to temporarily distance themselves from their problems and treat them dispassionately. Unable to observe themselves from the outside (lack of an observing ego). Although sometimes they can say about themselves what others once said about them, and this may even look plausible at first glance. “They spend too much time struggling with existential dread and have little energy left to evaluate reality.”
4. existential conflict - life or death, existence or destruction, safety or fear. They deeply doubt their right to exist as a separate person.
5. countertransference is often positive, and parental protectionism is awakened. Patients are prone to primitive fusion and idealization of the therapist. They, like children, are delightful in their affection, but frightening in their helplessness and needs, straining the therapist's resources to the limit.

If we compare the classification criteria of the two authors, we can see that the first three points of Nancy McWilliams completely coincide with the assessment criteria of O. Kernberg. In addition to the criteria he has already described, Nancy McWilliams also examines the nature of conflicts and the characteristics of transference-countertransference.

Neurotic level of personality organization

The term "neurotic" is applied to relatively healthy people who experience some difficulties associated with emotional disorders. During the early stages of development, in the oral and anal stages, no serious character disturbances were observed. However, during the oedipal stage (3-6 years), problems arose that led to the organization of a neurotic structure. According to J. Berger (see textbook 13.2), depending on how problematic the development of the adolescent stage is, the reorganized neurotic can either form a neurotic-organized self and develop into a neurosis, or a psychotic-organized self and develop into psychosis

• Neuroticism relies on more mature defense mechanisms, although it can also actualize more primitive defense mechanisms. The presence of primitive defense mechanisms in no way excludes the diagnosis of character structure at the neurotic level, but the absence of mature defense mechanisms excludes such a diagnosis. Neurotics also use mature ones - repression, intellectualization, rationalization, etc. - as well as primitive defense mechanisms - refusal, projective identification, isolation, etc.
• They have a complex sense of identity, meaning they can easily describe themselves by identifying their personality traits, preferences, interests, temperament, and strengths and weaknesses. Neurotics are also good at describing other people.
• Neurotics are in reliable contact with reality, they have no hallucinations, no manic interpretation of experience, and they live in the same world as the psychotherapist. Some part of their ego that bothers the patient and about which he has consulted the psychotherapist is treated by the psychotherapist as a separate part. This is a selfish dyston. Thus, a paranoid person on a neurotic level will assume that their suspicions stem from their internal predisposition to perceive other people as hostile and aggressive. A patient with borderline paranoia or psychosis believes that his difficulties come from outside and are determined by the characteristics of his environment, his illness and anxiety.
• The nature of the difficulties is not a problem of security or attachment, but a problem of personality formation and initiative. According to Erikson, this is a problem of the Oedipus stage of development. Triadic object relations are typical for the neurotic personality.
• The neurotic personality is able to adequately interpret defense and transference, so psychotherapists, when working with people with a neurotic temperament, use intensive analysis, including the disclosure of feelings of conflict, defense and interpretation of transference.

Kernberg Structural Interview (for making a structural diagnosis)

The structural organization (neurotic, borderline, psychotic) performs the functions of stabilizing the mental apparatus.

Concentrating attention on the patient's main conflicts creates the necessary tension, which allows his basic protective and structural organization of mental functions to manifest. The therapist strives to ensure that the patient shows pathology in the organization of ego functions.

Clarification

there is an exploration, together with the patient, of everything that is uncertain, unclear, mysterious, contradictory or incomplete in the information presented to him.

Confrontation

exposes the patient to information that seems contradictory or inconsistent. Where there are inconsistencies, defense mechanisms work there, there are conflicting selves and object-representations + reduced awareness of reality. At this moment there is a comparison of parts that the patient experiences as unrelated to each other.

Interpretation

. It explores the origin of conflicts between dissociated ego states, the nature and motives of the defense mechanisms at work, as well as the defensive refusal to test reality.

Grade:

1) Level of identity organization

Lack of identity integration (diffuse identity) is manifested in the fact that the patient has contradictions in the perception of himself, combined with a poor, meager and flat perception of others + the patient is not able to convey his significant interactions with others to the therapist. At the same time, while listening to him, the therapist has significant difficulties in presenting the patient as one holistic person.

Quality of object relations

The quality of object relations is determined by the stability and depth of relationships with significant others, as well as the ability to tolerate frustration and conflicts in relationships, while maintaining them.

the degree of integration of the superego is considered separately

(important for prognosis). Neurotics - a rigid but integrated superego, borderline and psychotics - disturbances in the organization of the superego

2) The level of functioning of protective mechanisms.

The borderline patient's defense mechanisms protect him from intrapsychic conflict, but at the expense of weakening the functioning of the ego, thereby reducing the effectiveness of adaptation and flexibility. Borderline patients and psychotics use the same defense mechanisms, but they serve different functions. Interpretation of primitive defense mechanisms temporarily increases the level of functioning. And in psychotics it leads to disorganization.

Split.

Sharp constant fluctuations between contradictory self-concepts.

Primitive idealization.

“Goodness” or “badness” is pathologically and artificially enhanced.

Primitive projection

• the tendency to continue to experience the very impulse that is projected onto another
• fear of this other under the influence of a projected impulse
• the need to control the person in question. impulse is projected.

3) Availability of reality testing

The ability to distinguish between “I” and “not”, to distinguish the intrapsychic from the external source of perception + ability to evaluate one’s affects, behavior and thoughts from the point of view of the social norms of an ordinary person.

It is expressed in the patient’s ability to experience empathy for how the therapist perceives inappropriate phenomena when interacting with the patient, i.e. to the psychic reality of another person.

Causes

A person faces numerous stressful situations every day, but not everyone develops neurosis. The following people are at risk for neurotic mental disorders:

• conservatives - those who find it difficult to accept new things;
• emotionally sensitive, vulnerable;
• dependent and unsure of their own abilities;
• pessimists prone to long-term depressive experiences;
• workaholics who cannot rest;
• having personality disorders;
• intolerant of heavy loads (asthenic type);
• having increased anxiety.

The causes of neurotic disorders are often associated with genetic predisposition. But only personal character traits (character accentuations) or heredity cannot lead to neurosis. Long-term exposure to external factors that are subjectively traumatic for a particular individual is necessary. For example, it could be an unloved or stressful job, a conflictual family situation, mental fatigue, or chronic lack of sleep.

Important. Stressful factors do not have to be debilitating, but they must be subjectively intolerable, regular and affecting a person for a long time. A short-term difficult situation rarely leads to neurosis.

Only the combined influence of hereditary and external unfavorable causes can lead to the occurrence of the disease.

Conducting a structured interview

The initial phase of the structural interview (we look at whether there is psychosis or organicity)

1) The interview begins with the patient being asked to briefly talk about the reasons that made him contact the therapist, what he expects from therapy, his main symptoms, problems and difficulties.

“Please tell us about what made you come here / contact the clinic; what do you see as your main difficulties at the moment, what do you expect from therapy?

The ability to remember questions and answer them clearly and completely indicates a developed sense, good memory and a normal level of intelligence.

2) Study of character traits.

“You told me about your problems, now I would like to know more about what kind of person you are. If you can, describe how you present yourself; What do you think I need to know to understand what kind of person you are?”

The ability to speak spontaneously about yourself in this way is a sign of good reality testing ability. Most psychotics are unable to answer an open question because it requires empathy towards

ordinary aspects
of social reality.
If the patient has difficulty:

“Describe your relationships with the most significant people, tell us about your life, study or work, family, sex life, how you spend your free time”.

Then ask the patient what he thinks about the fact that it is difficult for him to describe himself as a person.

We expect the borderline personality to display primitive defense mechanisms. When asked what made them come for a consultation, they often reveal a chaotic vinaigrette of data about themselves.

3) Study of the patient's ability to empathize

Can the patient explain why the therapist feels that there were strange or puzzling aspects to his story.

If the patient is able to do this, this means the ability to test reality, i.e. empathy

to
the therapist's experiences.
When it is obvious to us that the patient's ability to test reality is reduced, it makes sense to temporarily postpone confrontation and immerse ourselves in the study of the patient's subjective experiences corresponding to his behavioral manifestations. Those. we stop expressing our doubts about the patient's thinking process, distortions of reality, or internal experiences. On the contrary, we try to find empathy within ourselves.

Middle phase of the structural interview (identity exploration - see if it could be that we have a neurotic in front of us?)

1) the patient’s difficulties in the sphere of interpersonal relationships, adaptation to the environment, how he perceives his psychological needs.

“Now I would like to know more about you as a person, about how you see yourself, and how you think others see you, anything that would help me gain a sufficiently deep understanding of you in this short time.” .

“Please tell us about the people who mean a lot in your life.”

We are looking for contradictory selves and the object of representation. When a patient's identity integration is impaired, it is often difficult to reconstruct a clear picture of his life. The more severe the character disorder, the less reliable and, therefore, less valuable his life story.

2) study of the ability to introspect. Determined by the extent to which the patient can reflect on the observations shared by the therapist.

Diagnosis and treatment of neurotic disorders

At the initial consultation, the psychotherapist collects anamnesis. It is important for the doctor to know about events that could cause the painful condition. Also tell us if you have relatives with this diagnosis. The diagnosis of neurotic disorders includes not only a survey, but external observation and psychological testing.

To make a correct diagnosis, organic diseases of the internal organs should be excluded. For this purpose, ECG, MRI, EEG, and ultrasound diagnostics of blood vessels are performed. It is recommended to consult a neurologist and psychiatrist to rule out diseases with similar symptoms.

The main difference between neurotic disorders in adults and the so-called endogenous mental illnesses - patients are aware of their condition, can accurately describe the symptoms and want to be cured.

Treatment uses an individual approach, which depends on the form of the disorder and the severity of the disease. At the initial stage, the doctor may prescribe drug therapy. This is necessary to reduce anxiety, normalize sleep and improve the patient’s overall well-being.

Treatment of neurotic disorders necessarily includes eliminating the traumatic situation that caused the disease. For this purpose, at the initial stage, psychotherapy is carried out in an individual form, and later it is useful to include group psychotherapy. During psychotherapeutic sessions, the patient, using various techniques, learns to reduce the importance of stressful situations, to recognize and resolve internal conflicts.

In group psychotherapy for neurotic disorders, the patient receives support from people who have the same or similar problems. This enhances the effectiveness of complete healing.

All manifestations of neurosis are reversible. The disease responds well to treatment, but only if treatment is prescribed by a qualified psychiatrist or psychotherapist.

Primitive defense mechanisms

The adaptive mechanism of splitting causes the borderline personality to perceive the world in terms of extremes - that is, people and objects can be either good or bad, either friends or enemies, or loved or hated, since ambiguity and uncertainty cause anxiety in the patient.

In Kernberg's scheme, splitting often leads to "magical thinking": superstitions, phobias, manias and obsessions are often used as talismans to ward off unconscious fears. Cleavage also leads to the emergence of derivative defense mechanisms:

Primitive idealization is the persistent classification of a person or object into the category of “absolutely positive” in order to avoid the anxiety associated with recognizing its shortcomings.

Devaluation is an unrelentingly negative perception of a person or object; the opposite of idealization. By using this mechanism, the borderline person avoids guilt for his rage - after all, the “absolutely bad” person deserves it.

Omnipotence is a feeling of unlimited power, in which a person feels invulnerable to failure and sometimes even death. (Omnipotence is also common in narcissistic disorder.)

Projection is the renunciation of traits that are not acceptable to oneself and attributing them to others.

Projective identification is a more complex form of projection in which the person projecting continues a manipulative relationship with the person being projected. The other person “wears” these unacceptable characteristics of the projector, who seeks to perpetuate their constant manifestation.

For example, Mark, a young married man diagnosed with BPD, finds his own sadistic and angry impulses unacceptable and projects them onto his wife, Sally. Because of this, Sally appears to Mark (in his black-and-white vision) as “an unusually evil woman.” All her actions are interpreted by him as sadism. He subconsciously “puts pressure on the patient” to provoke an angry reaction, thus confirming his projections. In this way, Mark fears and controls his image of Sally at the same time.