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

This article was written based on the report of the President of the Moscow Gestalt Institute D. Khlomov. Let's consider the main provisions of this model. The note will be of interest not only to people who are interested in studying practical psychology, but also to clients. It can be assumed that the higher the level of awareness of a person, the more successful and happier he is. One of the goals of a psychological session is to improve the quality of life. The more we know about the mechanisms that influence this, the higher our chances of getting what we want.

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.

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.

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.

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 personality organization

The criteria for borderlineness according to DSM-4 as a personality disorder are as follows (5 or more indicators must be stated):

• the tendency to use excessive efforts in order to avoid a real or imaginary danger of abandonment,
• tendency to become involved in unstable or tense relationships
• alternating extremes of idealization and devaluation,
• sense of self identity disorder - unstable self-image,
• impulsivity in at least 2 areas that can cause harm (sex, psychoactive substances, breaking rules, overeating, etc.),
• recurrent suicidal behavior, self-harm,
• affective instability, mood swings. Periods of dysphoria, irritability (up to several hours),
• feeling empty
• inadequate manifestation of a strong feeling of anger and difficulty in controlling this feeling, irritability, aggressiveness.

The main task of a neurotically organized person is to cope with the presence of another person. In this regard, they can notice the development of patience, suppressing reactions so as not to destroy the relationship. The main task is to expand opportunities for dialogue to occur. As a rule, this occurs through the suppression of activity in favor of attention.

If I move, I feel less. Suppression of activity leads to increased sensitivity.

I am already complete enough to desire contact with another person. And I can feel a sense of loss in the absence of the other. If you did it, you survived the period well. And if a person copes in a primitive way or does not notice something, then the person remains “hungry” and is ready to cling to someone. The most important thing here is attachment to something. This need is fundamental at this stage of development. The meta-need is different; it is the guarantor of my existence.

And where mine is not so important. I am ready to sacrifice my interests, if only there was someone nearby. Such clients tell the psychologist during the session about their helplessness and need for other people.

Borderline splitting into good and bad. A missing object is marked as bad. The bad is like the other side of an object. The task is to project it somewhere after detection. It will already be outside the boundaries of one’s own body, then the need for something else appears.

A borderline organized person is constantly looking for where the enemies are. This makes it possible to structure your life. One of the poles is being repressed - if we are together, then you are right in everything, since we are together.

A borderline limited person is ready to sacrifice any reality to attachment. At the same time, all negative qualities are attributed to enemies.

I'm not good enough, but the one around me is good enough.

It’s difficult for me to have a separate opinion; it’s easier to clarify this with someone. The psychologist’s support for such a person will be to ensure that he has his own personal judgment.

Collective responsibility in Soviet times - due to this you can survive in an aggressive environment. This is where heroic deeds take place when public interests are higher than personal interests. There are attempts to join something, to merge with someone.

The avoided experience of neurotically organized individuals is abandonment. They are afraid of being abandoned, abandoned. In a psychologist's office, such clients talk mainly about other people.

They break the distance towards getting closer. They demand contact from other people at any cost, are very clingy, annoying, and create a lot of noise. This occurs due to the desire to remain in fusion with other people.

The adjustment to the person with whom such a person communicates is carried out perfectly.

They are frightened by emotions of depression, depression and guilt. Guilt replaces relationships. If I feel guilty about this person, then I experience feelings of attachment to this person.

The main resistances are introjection and confluence. Relationships dependent on other people are noted.

Behavior in the psychologist's office in neurotically organized individuals - reactions in different forms. The first emotional response is to stick through empathy. Together we find enemies, we can merge here. This is a borderline reaction. The psychologist’s task is to leave room for the client to live his own life. Supporting the client's autonomy from others is very important.

The position of the psychologist is confrontational. Without it, it is impossible to “unstick” a person from yourself.

For such individuals, supporting self-sufficiency and self-sufficiency is very important.

The diffusion of personal identity is determined through the identification of an object. Identity is built through checking what is currently happening in the session. A single image when a client tells a story about himself in a session - as a criterion for identity diffusion. Determining the degree of assistance in a psychological session.

Suicidal or self-damaging behavior is a marker of the border zone. According to statistics, about 8% are completed. Triggers for suicide are interpersonal relationships.

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.

Signs

In a neurotic disorder, symptoms depend on the form of the disease. At the initial stage, the first alarming manifestation may be sleep disorders. A person has difficulty falling asleep, often wakes up, and the sleep itself is superficial and restless. As a result, the nervous system does not get enough time to recover, and the person’s general well-being deteriorates.

Frequent manifestations of the body during neurosis include:

• feeling of suffocation or a lump in the throat;
• heart rhythm disturbances;
• nausea;
• heartburn, belching;
• pain in different parts of the body;
• increased sweating;
• numbness of the limbs or cramps;
• constant low-grade fever.

The person is so mentally exhausted and irritated that he cannot be at rest. He knocks with his pen, fiddles with his clothes, jerks his leg or hand. In neurotic disorders, symptoms in adults may be associated with a change in social circles, a change of place of residence, seclusion, or alcohol abuse.

If you don’t seek help from a specialist, you can live in this state for years. This will lead to the emergence of a protracted chronic neurotic state, and as a result, a neurotic change in character. Coping with this will be much more difficult; psychotherapy is only effective over a long period of time.