Borderline personality organization new

1

From psychoanalytical point of view and related to DSM IV Axis II

22

Psychopathology 1Psychopathology 1

Biology and PsychologyBiology and Psychology Behavior is the result of the mutual Behavior is the result of the mutual

relation between “nature” and relation between “nature” and “nurture”.The result of a complicated “nurture”.The result of a complicated interaction between “genes” and interaction between “genes” and “environment”→ integration Mind “environment”→ integration Mind and Brain.and Brain.

33


Consequences for looking at Consequences for looking at pathologypathology

1.1. No causal relation between risc factors No causal relation between risc factors and the development of pathology; the and the development of pathology; the amount of risc factors is in a way amount of risc factors is in a way predictable.predictable.

2.2. The quality of the early attachment The quality of the early attachment relationships is important for the possible relationships is important for the possible development of pathologydevelopment of pathology

4


The process of internalising early experiences The process of internalising early experiences and the creation of an internal psychological and the creation of an internal psychological model of the interpersonal world → model of the interpersonal world → mentalization/ creation of a mind or mental mentalization/ creation of a mind or mental representations.representations.

Internal representations of the earlier Internal representations of the earlier experiences with the primairy care givers experiences with the primairy care givers will influence later relationships and the will influence later relationships and the development of psychopathology later ondevelopment of psychopathology later on

5


There are 2 types of There are 2 types of psychopathologypsychopathology

1.1. Related to conflicting mental Related to conflicting mental representations: neurotic pathologyrepresentations: neurotic pathology

2.2. Related to the failing of the mentalizing Related to the failing of the mentalizing process itself: personality disorders this process itself: personality disorders this is the area of the borderline personality is the area of the borderline personality organizationorganization

6

Difference between BPD and BPO Difference between BPD and BPO 11

Borderline Personality DisorderBorderline Personality Disorder

1.1. A descriptive diagnosis. Manifest and A descriptive diagnosis. Manifest and observable behaviorobservable behavior

2.2. An enduring pattern of internal An enduring pattern of internal experiences that manifest themselves in experiences that manifest themselves in a broad area of personal and social a broad area of personal and social situations.situations.

3.3. DSM IVDSM IV

77

Difference between BPD and BPO Difference between BPD and BPO 22

Borderline Personality Borderline Personality OrganizationOrganization

Structural Diagnosis/ KernbergStructural Diagnosis/ Kernberg Underlying structure which is not Underlying structure which is not

directly observable.→ directly observable.→ Dyade/Schema/I.W.M./I.I.M.Dyade/Schema/I.W.M./I.I.M.

Includes the whole area of Includes the whole area of personality disorderspersonality disorders

8

Two types of pathologyTwo types of pathology

Mental process disordersMental process disorders

Inability to represent inside what is Inability to represent inside what is outsideoutside

The dependency from the external world The dependency from the external world is thereis there

Anxieties are interpersonal instead of Anxieties are interpersonal instead of intra personalintra personal

99

Two types of pathologyTwo types of pathology

Mental Process disordersMental Process disorders

No psychological Self but the body is the No psychological Self but the body is the selfself

No Somatization as a defense but SomaNo Somatization as a defense but Soma Alexithymia: medically unexplained Alexithymia: medically unexplained

physical symptoms/ conversionsphysical symptoms/ conversions They live in a frightened world instead of a They live in a frightened world instead of a

world they are experiencing as frighteningworld they are experiencing as frightening

10

Mental Process DisordersMental Process Disorders

1.1. Anxiety neurosisAnxiety neurosis

2.2. External Regulated / MotivatedExternal Regulated / Motivated

3.3. Developmental pathology Developmental pathology

4.4. Building structuresBuilding structures

5.5. The area of the personality disorders Axis The area of the personality disorders Axis 2 cluster A and B2 cluster A and B

6.6. Axis 1 Somatization, Somatoform Axis 1 Somatization, Somatoform disorder, Panic disorder Dissociative disorder, Panic disorder Dissociative disorder and PTSD.disorder and PTSD.

11

Conflicting Mental Conflicting Mental RepresentationsRepresentations..

1.1. Psychoneurosis Psychoneurosis

2.2. Intrapsychic ConflictsIntrapsychic Conflicts

3.3. Conflicting pathologyConflicting pathology

4.4. Restructuring Restructuring

5.5. Internal Regulated / MotivatedInternal Regulated / Motivated

6.6. Neurotic pathology and Axis 2 cluster CNeurotic pathology and Axis 2 cluster C

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

13

M.KleinM.Klein

Par. Schizoid PositionPar. Schizoid Position

Annihilation anxietyAnnihilation anxiety Identity undermining defensesIdentity undermining defenses No adequate self/object differentiationNo adequate self/object differentiation No adequate object constancyNo adequate object constancy Archaic Object RelationsArchaic Object Relations Ambivalences are not bearableAmbivalences are not bearable ““doing” instead of “containing”/”feeling”doing” instead of “containing”/”feeling”

14

M.KleinM.Klein

Par.Schizoid PositionPar.Schizoid Position

Interventions related to the inner Interventions related to the inner experiencing are raising the anxiety and experiencing are raising the anxiety and by that stimulating “acting out”by that stimulating “acting out”

Interventions should relate inner and outer Interventions should relate inner and outer sources of stress sources of stress → facilitating → facilitating mentalizationmentalization

Therapist as external Obs.Ego → being Therapist as external Obs.Ego → being introjected / mirroringintrojected / mirroring

15

M.KleinM.Klein

Depressive positionDepressive position

Anxieties related to inner ambivalencesAnxieties related to inner ambivalences Defenses in favour of identityDefenses in favour of identity Adequate S/O differentiationAdequate S/O differentiation Adequate Object constancyAdequate Object constancy Realistic Object RelationsRealistic Object Relations Containing instead of doingContaining instead of doing

16

AttachmentAttachment

A safe attachment style supposesA safe attachment style supposes

Adequate sensitivityAdequate sensitivity: being aware : being aware that there is something going on in that there is something going on in the other personthe other person

Adequate responsivityAdequate responsivity: reacting to : reacting to the other in such a way that it is the other in such a way that it is clear what is from me and what from clear what is from me and what from the otherthe other

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

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 Drives

1. Relatedness

2. Autonomy

(Blatt 1998)

Anaclytical pathology Preoccupied/Ambivalent Faling responsivity/not marked

mirroring I can not be on my own

Introjective pathology Avoiding Failing sensitivity I do it myself

2020

Anaclytical PathologyAnaclytical Pathology

Internalizing PathologyInternalizing Pathology

Borderline Personality DisorderBorderline Personality Disorder Histrionic Personality DisorderHistrionic Personality Disorder Dependant Personality DisorderDependant Personality Disorder

2121

Introjective PathologyIntrojective Pathology

Externalizing pathologyExternalizing pathology

Schizoid/Schizotypical Personality Dis.Schizoid/Schizotypical Personality Dis. Narcissistic Personality DisorderNarcissistic Personality Disorder Antisocial Personality DisorderAntisocial Personality Disorder Avoidant Personality DisorderAvoidant Personality Disorder Somatization,Somatoform dis. DID, PTSDSomatization,Somatoform dis. DID, PTSD

22

InternalisationInternalisation

incorporationincorporationintrojectionintrojectionidentificationidentification

23

IntrojectionIntrojection

object permanencyobject permanencyobject constancyobject constancy

internal objectinternal objectindependent of external independent of external

objectsobjects

24

ObjectconstancyObjectconstancy

Internal representationsInternal representationsContaining ambivalenciesContaining ambivalenciesRelated to someone who Related to someone who

is not is not actual thereactual thereMourningMourning

AutonomousAutonomous

25

IdentityIdentity - 1 -- 1 -

Object constancyObject constancyAutonomous objectAutonomous objectInternal Internal

representationsrepresentationsTime perspectiveTime perspectiveFeeling instead of doingFeeling instead of doing

26

Identity - 2 -Identity - 2 -

Fragmentation Fragmentation - cohesive- cohesiveActing outActing out - containing - containingMomentaneous - time Momentaneous - time

perspectiveperspectivepanic panic - signal - signal

anxietyanxietySplitting - repressionSplitting - repression

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

28

Structural Personality Structural Personality OrganizationOrganization

KernbergKernberg (1984)(1984)

NeuroticNeurotic BorderlineBorderline PsychoticPsychotic

IdentityIdentity integratedintegrated diffuusdiffuus fragmentatedfragmentated

DefenseDefense maturemature archaicarchaic archaicarchaic

Reality Reality TestingTesting

in tactin tact in tact in a in tact in a wayway

absentabsent

29

Ego identityEgo identity

S/O DifferentiationS/O Differentiation Mature Object Mature Object

RelationsRelations Mature DefensesMature Defenses Reactive AgressionReactive Agression

internal structureinternal structure autonomousautonomous

30

Identity diffusionIdentity diffusion

FusionFusion Primitive Object Primitive Object

RelationsRelations Archaic DefenseArchaic Defense Primitive AgressionPrimitive Agression

external external regulatedregulated

dependentdependent

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Weak internal structure versus Strong Weak internal structure versus Strong internal structureinternal structure

Archaic defensesArchaic defenses PanicPanic Regression of the egoRegression of the ego No ambivalencies No ambivalencies DeficitsDeficits Acting out Acting out StructuringStructuring

““Borderline”Borderline”

Mature defensesMature defenses Neurotic anxieties Neurotic anxieties

(signal)(signal) regression in favour of regression in favour of

the egothe ego AmbivalentAmbivalent ConflictConflict ContainingContaining RerstructuringRerstructuring

““Neurotic”Neurotic”

Nonspecific manifestations of ego weakness

Specific manifestations of ego weakness → splitting

Shift towards primary process thinking Pathalogical internalized object relations

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33

34

35

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

Apart from DSM IV

Depressive P.D.

Somatization P.D.

Dissociative P.D.

37

Cluster A

38

A pervasive pattern of detachment from social relationships

Introjective/externalizing pathology

39

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

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

42

PersonalitPersonalityy

DisorderDisorder

SchizoidSchizoid

View of View of selfself

Self-sufficient. LonerSelf-sufficient. Loner

View of View of othersothers

IntrusiveIntrusive

Main Main beliefsbeliefs

Others are unrewarding.Others are unrewarding.

Relationships are messy, undesirable.Relationships are messy, undesirable.

Main Main strategystrategy

Stay away!Stay away!

TherapeutTherapeutic ic

strategiesstrategies

Realize that he is basically very insecure and that Realize that he is basically very insecure and that contact with people is a real threat.contact with people is a real threat.

So let him decide how much contact he wants.So let him decide how much contact he wants.

Do everything to increase his sense of self-efficacy.Do everything to increase his sense of self-efficacy.

The same as Schizoid but also: Ideas of reference Suspicious/paranoid,excessive social

anxiety Magical thinking Eccentric and odd behavior

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DisorderDisorder

SchizotypalSchizotypal


Unreal, detached, loner.Unreal, detached, loner.

Vulnerable, socially conspicuous.Vulnerable, socially conspicuous.

Supernaturally sensitive and gifted.Supernaturally sensitive and gifted.


Untrustworthy. Malevolent.Untrustworthy. Malevolent.


(irrational, odd, superstitious, magical thinking; e.g. (irrational, odd, superstitious, magical thinking; e.g. belief in clairvoyance, telepathy or ‘sixth sense’.)belief in clairvoyance, telepathy or ‘sixth sense’.)

““It is better to be isolated from others.”It is better to be isolated from others.”


Watch for and neutralize malevolent attention from Watch for and neutralize malevolent attention from others.others.

Stay to self.Stay to self.

Be vigilant for supernatural forces or events.Be vigilant for supernatural forces or events.



See next slide.See next slide.

45

How to deal with How to deal with SchizotypicalsSchizotypicals

Realize that he is basically very insecure and that Realize that he is basically very insecure and that contact with people is a real threat. contact with people is a real threat.

So let him decide how much contact he wants. So let him decide how much contact he wants. Do everything to increase his sense of self-Do everything to increase his sense of self-

efficacy and his reality testing.efficacy and his reality testing. Don’t argue about telepathy, but simply state Don’t argue about telepathy, but simply state

that you don’t have such experiences.that you don’t have such experiences.

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

4646

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

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

49


DisorderDisorder

ParanoidParanoid


Righteous, innocent, noble, vulnerableRighteous, innocent, noble, vulnerable


Interfering, malicious, discriminatory, abusive Interfering, malicious, discriminatory, abusive motivesmotives


Others’ motives are suspect.Others’ motives are suspect.

I must always be on guard.I must always be on guard.

I cannot trust people.I cannot trust people.


Be wary. Look for hidden motives. Be wary. Look for hidden motives.

Accuse. Counterattack.Accuse. Counterattack.



Realize that he is basically very insecure.Realize that he is basically very insecure.

So accept the suspiciousness.So accept the suspiciousness.

Accept that you have to earn his trust, by being Accept that you have to earn his trust, by being extremely transparant and open about what you are extremely transparant and open about what you are doing.doing.

Do everything to increase his sense of self-efficacy.Do everything to increase his sense of self-efficacy.

Cluster B

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Pervasive pattern of instability of interpersonal relationships, self image and affects and marked impulsivity

Anaclytical / internalizing pathology

51

Alternating between idealizing and devaluating

Chronic feelings of emptiness Inappropriate intense anger Self-mutilation

52

Frantic efforts to avoid real or imagined abandoment

Identity disturbances Impulsivity / problems with bounderies Affective instability / moodswings

including anxiety Paranoid ideation

53

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DisorderDisorder

BorderlineBorderline


Vulnerable (to rejection, betrayal, domination)Vulnerable (to rejection, betrayal, domination)

Deprived (of needed emotional support)Deprived (of needed emotional support)

Powerless. Out of control. Powerless. Out of control.

Defective. Unlovable. Bad.Defective. Unlovable. Bad.


(idealized:) poweful, loving, perfect.(idealized:) poweful, loving, perfect.

(devaluated:) rejecting, controlling, betraying, abandoning.(devaluated:) rejecting, controlling, betraying, abandoning.


I cannot cope on my own. I need someone to rely on.I cannot cope on my own. I need someone to rely on.

If I rely on someone I will be mistreated, found wanting, and If I rely on someone I will be mistreated, found wanting, and abandoned.abandoned.

The worst possible thing would be to be abandoned.The worst possible thing would be to be abandoned.

I cannot bear unpleasant feelings.I cannot bear unpleasant feelings.

It is impossible for me to control myself.It is impossible for me to control myself.

I deserve to be punished.I deserve to be punished.


Subjugate own needs to maintain connection.Subjugate own needs to maintain connection.

Protest dramatically, threaten and/or become punitive Protest dramatically, threaten and/or become punitive toward those that signal possible rejection.toward those that signal possible rejection.

Relieve tension through self-mutilation and self-destructive Relieve tension through self-mutilation and self-destructive behavior.Attempt suicide as an escape.behavior.Attempt suicide as an escape.

55

How to deal with borderlines.How to deal with borderlines.

They provoke intense countertransference feelings: They provoke intense countertransference feelings: Anxiety , Compassion, Powerlessness,Rage.Anxiety , Compassion, Powerlessness,Rage.

They constantly test the limits. So stop them in time, in They constantly test the limits. So stop them in time, in spite of their vehement emotions, reproaches, suicide spite of their vehement emotions, reproaches, suicide threats.threats.

The basic rule is: The basic rule is: setting clear and consistent limits.setting clear and consistent limits.

Keep in mind that their life-long dilemma is: fear of utter Keep in mind that their life-long dilemma is: fear of utter loneliness loneliness ↔ fear of engulfment and loss of identity.↔ fear of engulfment and loss of identity.

This causes the instability between intense need for This causes the instability between intense need for contact and intense rejection when you try to be helpful.contact and intense rejection when you try to be helpful.

Be clear about the conditions by which you can help her.Be clear about the conditions by which you can help her. Be consistent in maintaining these conditions and setting Be consistent in maintaining these conditions and setting

limits.limits. This helps you to prevent your anger.This helps you to prevent your anger.

Pervasive pattern of grandiosity, need for admiration, for being loved

Introjective / Externalizing pathology

56

Oblivious: need for being loved / admired

arrogant; 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

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

59


DisorderDisorder

Narcissistic.Narcissistic.


Special, unique, superior.Special, unique, superior.

Deserves special rules.Deserves special rules.

Is above the rules.Is above the rules.


Inferior.Inferior.

Admirers.Admirers.


Since I am special I Since I am special I deservedeserve special rules. special rules.

I am above the rules.I am above the rules.

I am better than others.I am better than others.


Use others. Transcend rules, manipulate, compete.Use others. Transcend rules, manipulate, compete.




60

How to deal with narcissists.How to deal with narcissists.

Keep in mind that their arrogance is needed in Keep in mind that their arrogance is needed in order not to feel inferior. order not to feel inferior.

Therefore accept the fact that there can be only Therefore accept the fact that there can be only one grandiose person in the room. one grandiose person in the room.

So overcome your own narcissistic hurt and use So overcome your own narcissistic hurt and use praise and flattery to get things done. praise and flattery to get things done.

But resist unreasonable demands, for then they But resist unreasonable demands, for then they loose respect. loose respect.

But tolerate their rage when you don’t fulfil their But tolerate their rage when you don’t fulfil their demands.demands.

Pervasive pattern of disregard for and violation of the rights of others

Introjective /Externalizing pathology

61

Failure to conform to social norms Impulsivity or failure to plan ahead Irratability / agression No empathy No responsability for their behavior

62

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

Passive or Parasitic Anaclitic Dependent, less agressive, relatively non-

violent manipulator

Agressive Introjective Explosive, violent offender

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65


DisorderDisorder

AntisocialAntisocial


A lonerA loner


VulnerableVulnerable


““I am entitled to I am entitled to breakbreak rules.” rules.”


Attack. Rob. Steal.Attack. Rob. Steal.




666666

How to deal with antisocialsHow to deal with antisocials

Don’t let yourself be flattered by his charm.Don’t let yourself be flattered by his charm. Be aware that he always wants something from Be aware that he always wants something from

you.you. So be especially suspicious if he offers you to So be especially suspicious if he offers you to

participate in some partly illegal, but very participate in some partly illegal, but very profitable offer.profitable offer.

As he has no conscience, teaching morals makes As he has no conscience, teaching morals makes no sense.no sense.

So teach him to become a better psychopath, So teach him to become a better psychopath, more clever and long-sighted, directed to his best more clever and long-sighted, directed to his best interests.interests.

Pervasive pattern of excessive emotionality and attention seeking

Anaclytical / Internalizing pathology

67

Histrionic

Weak internal structure Dyadic relations Archaic defense Need satisfying relations Flamboyant; seductiveness; sexual

impulsiveness; dramatization

68

Hysterical

Adequate internal structure Triadic relations Mature defense Take and give relations Emotional reserve; sexual naiveté;

conversions and somatizations

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70


DisorderDisorder

Histrionic.Histrionic.


Glamorous. Impressive.Glamorous. Impressive.


Seducible. Receptive. Admirers.Seducible. Receptive. Admirers.


People are there to serve me or to admire me.People are there to serve me or to admire me.

People have no rights to deny me what I deserve.People have no rights to deny me what I deserve.

I can go by my feeling.I can go by my feeling.


Use dramatics, charm, temper tantrums, crying, Use dramatics, charm, temper tantrums, crying, suicide gestures.suicide gestures.




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How to deal with histrionics.How to deal with histrionics.

Natural reactions to them are: Rescuer Natural reactions to them are: Rescuer phantasies, Sexual desire, Irritation.phantasies, Sexual desire, Irritation.

So be wary of the intense emotional contact they So be wary of the intense emotional contact they seem to promise.seem to promise.

Resist the temptation to become the all-powerful Resist the temptation to become the all-powerful rescuer.rescuer.

Interrupt their impressionistic, dramatic style of Interrupt their impressionistic, dramatic style of thinking.thinking.

Teach them to Teach them to think throughthink through,, in order to be able in order to be able to make their own decisions, and to to make their own decisions, and to decatastrophizedecatastrophize the future and to improve their the future and to improve their problem solving skills.problem solving skills.

Cluster C

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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

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

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DisorderDisorder

Obsessive-compulsive.Obsessive-compulsive.


Responsible. Accountable. Fastidious. Exacting. Responsible. Accountable. Fastidious. Exacting. Competent.Competent.


Irresponsible. Casual. Incompetent. Self-indulgent.Irresponsible. Casual. Incompetent. Self-indulgent.


I know what is best.I know what is best.

Details are crucial.Details are crucial.

People People shouldshould do better, try harder. do better, try harder.


Apply rules. Perfectionism. Evaluate, control.Apply rules. Perfectionism. Evaluate, control.

““shoulds”. Criticize. Punish.shoulds”. Criticize. Punish.




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How to deal with obsessive-How to deal with obsessive-

compulsivescompulsives..

Respect his meticulousness, but state clearly Respect his meticulousness, but state clearly when things are clear enough.when things are clear enough.

Do behavioral experiments to let him discover Do behavioral experiments to let him discover that doing something less-than-perfect does not that doing something less-than-perfect does not bring the feared catastrophy.bring the feared catastrophy.

Pervasive pattern of social inhibition, feelings of being inadequate, hypersensitive for negative evaluation

Introjective /Externalizing pathology

77

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

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

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DisorderDisorder

AvoidantAvoidant


Vulnerable to depreciation, rejection.Vulnerable to depreciation, rejection.

Socially inept. Incompetent.Socially inept. Incompetent.


Critical. Demeaning. Superior.Critical. Demeaning. Superior.


It is terrible to be rejected or put down.It is terrible to be rejected or put down.

If people know the ‘real’ me, they will reject me.If people know the ‘real’ me, they will reject me.

I cannot tolerate unpleasant feelings.I cannot tolerate unpleasant feelings.


Avoid evaluative situationsAvoid evaluative situations

Avoid unpleasant feelings or thoughts by keeping Avoid unpleasant feelings or thoughts by keeping everything vague.everything vague.




81

How to deal with avoidant How to deal with avoidant patients.patients.

How much you do your best to be accepting, keep How much you do your best to be accepting, keep in mind that they can only see you as critical, and in mind that they can only see you as critical, and so they will try to be as vague as possible, in so they will try to be as vague as possible, in order not to be caught.order not to be caught.

Show them the price they pay by avoiding and Show them the price they pay by avoiding and help them to confront the feared situations in help them to confront the feared situations in small steps, and to tolerate the tension.small steps, and to tolerate the tension.

Confront them with the fact that others will judge Confront them with the fact that others will judge them anyway.them anyway.

Offer social skills training.Offer social skills training.

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

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

Enormous need for nurturance and support

By being so dependent they provoke what they want to avoid

Passive-Agressive versions of dependent p.d.

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85


DisorderDisorder

DependentDependent


Needy. Weak. Helpless. Incompetent.Needy. Weak. Helpless. Incompetent.


(Idealized:) Nurturant. Supportive. Competent.(Idealized:) Nurturant. Supportive. Competent.


I need people to survive and be happy.I need people to survive and be happy.

I need to have a steady flow of support and I need to have a steady flow of support and encouragement.encouragement.


Cultivate dependent relationships.Cultivate dependent relationships.



Resist the invitation to take the initiative and to Resist the invitation to take the initiative and to become the all-powerful magical helper, but make a become the all-powerful magical helper, but make a deal: deal:

““I can only help you if you gradually do things on I can only help you if you gradually do things on your own.”your own.”

Promote small steps toward autonomy.Promote small steps toward autonomy.

Offer assertiveness training.Offer assertiveness training.

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DisorderDisorder

Passive-aggressivePassive-aggressive


Self-sufficient.Self-sufficient.

Vulnerable to control, interference.Vulnerable to control, interference.


Intrusive, demanding, interfering, controlling, Intrusive, demanding, interfering, controlling, dominating.dominating.


Others interfere with my freedom of action.Others interfere with my freedom of action.

Control by others is intolerable.Control by others is intolerable.

I have to do things my own way.I have to do things my own way.


Passive resistance. Passive resistance.

Surface submissiveness.Surface submissiveness.

Evade, circumvent rules.Evade, circumvent rules.



Avoid power struggles and being pushed into the Avoid power struggles and being pushed into the authoritarian role. Focus explicitely on collaboration.authoritarian role. Focus explicitely on collaboration.

Based on psychoanalytical theory

87

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

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

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

Introjective Concerned with self definition, autonomy,

self worth,self critical thoughts

Anaclitic Concerned with relatedness, trust,

preservation of attachments

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Somatization P.D.Somatization P.D.

Anxiety neurosisAnxiety neurosis (Actual Neurosis (Actual Neurosis))

Somatic (hartbeating; sweating; trembling; Somatic (hartbeating; sweating; trembling; nausea; problems with respiration etc.)nausea; problems with respiration etc.)

Not related to mental representations Not related to mental representations Related to mental process disordersRelated to mental process disorders DSM IV; somatization,somatoform DSM IV; somatization,somatoform

disorders panic disorders and PTSD.disorders panic disorders and PTSD.

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Mental Process disordersMental Process disorders

No psychological Self but the body is the No psychological Self but the body is the selfself

No Somatization as a defense but SomaNo Somatization as a defense but Soma Alexithymia: medically unexplained Alexithymia: medically unexplained

physical symptoms/ conversionsphysical symptoms/ conversions They live in a frightened world instead of a They live in a frightened world instead of a

world they are experiencing as frightening world they are experiencing as frightening

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1.1. Anxiety neurosis instead of psycho- Anxiety neurosis instead of psycho- neurosisneurosis

2.2. Panic / momentaneous anxietyPanic / momentaneous anxiety

3.3. External Regulated / MotivatedExternal Regulated / Motivated

4.4. The area of the personality The area of the personality disorders Axis 2 cluster A and Bdisorders Axis 2 cluster A and B

5.5. Somatization, Somatoform disorder, Somatization, Somatoform disorder, Panic disorder and PTSD.Panic disorder and PTSD.

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

Appearance of alters

Distinct identities or personality states each with his own relatively enduring pattern of percieving,relating to and thinking about the environment and the self.

They recurrently take control of the persons behavior

96

Dissociative P.D.Dissociative P.D.

Ever met a normal person ? And did you like it ?

[email protected]

97

Borderline personality organization new

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