This paper reviews the fascinating case material of Freud's "Fragments of an Analysis of a Case of Hysteria" and the subsequent material that has come to light about Dora. The analytic material is reinterpreted in the light of more contemporary analytic perspectives. The difficulties can be considered in terms of the problem of diagnosis, in terms of the dynamics inherent in Dora's personality structure, and finally in terms of the difficulties in the transference-countertransference interaction that played such a significant role in the premature termination of the case. Dora is far from simply a case of hysterical neurosis, but her pathology not only reflects the dynamics of the paranoid process, but also falls within the range of the borderline spectrum of personality disorders that have been described previously (Meissner 1982b.). Moreover, the borderline quality of her psychopathology gave rise to certain transference-countertransference interactions that lend themselves to more adequate formulation in terms of the paranoid process (Meissner 1978b). This gives rise to a variety of theoretical and therapeutic considerations that bear on our understanding of the nature of hysteria and of the psychoanalytic process itself.

Adolescent↗

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Notes on the potential differentiation of borderline conditions.

It is argued that the borderline personality organization as now conceived embraces a spectrum of differentiable diagnostic groupings. Lumping these diagnostic clusters under a single descriptive heading contributes to continuing conceptual ambiguities and theoretical confusion in the understanding of borderline psychopathology. A potential differentiation of borderline entities on clinical grounds is suggested. The bases for discrimination of higher-order borderline conditions versus lower-order conditions are explored. Current accounts of borderline pathology tend to focus on lower-order pathology as characteristic, but do not account for the full range of the borderline spectrum. Other potential discriminations between an hysterical continuum and an obsessional-schizoid continuum are explored. Differential diagnoses suggested include pseudoschizophrenia, psychotic character, borderline personality, and primitive hysteric in the hysterical continuum; schizoid personality, false-self organization, and as-if personality in the schizoid continuum. The syndrome of identity diffusion is also suggested as part of the borderline spectrum.

Borderline Personality Disorder↗

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Notes on countertransference in borderline conditions.

"When dealing with borderline or severely regressed patients, as contrasted to those presenting symptomatic neuroses and many character disorders," Kernberg (1975) observed, "the therapist tends to experience rather soon in the treatment, intensive emotional reactions having more to do with the patient's premature, intense and chaotic transference and with the therapist's capacity to withstand psychological stress and anxiety, than with any specific problem in the therapist's past" (pp. 16-17). The argument in the present paper contends that Kernberg's description of countertransference reactions to borderline patients is a caricature that applies only within a limited range of borderline conditions, specifically the most primitive or poorly organized level of borderline functioning or regressive borderline states. The description does not apply to the full range of borderline psychopathology, and in many cases can be misleading. It has generally been recognized that countertransference vicissitudes play an extremely important role in the therapy of borderline patients at one or another phase of the treatment. At critical points in the development of transference (TR) and countertransference (CT) and their interaction, the therapist's recognition of and capacity to deal with CT issues become crucial to the treatment progression. The present paper explores the dimensions of CT experience and provides a tentative model for the understanding of transference-countertransference (TR/CT) interactions. The central points emphasized are: (1) that borderline disorders form a spectrum of character pathology falling between the psychoses on one side and the narcissistic personality disorders on the other; (2) that these conditions reflect varying degrees of pathological disruption and varying levels of personality integration; (3) that, depending on the form of pathological organization, these conditions manifest a variety of types and degrees of intensity of TR involvement and elicit corresponding CT reactions; and, finally (4) that these forms and degrees of TR/CT call for corresponding modifications in therapeutic response.

Aggression↗

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Treatment problems of the hospitalized physician.

Treatment problems arise both when the physician or other health care professional must be hospitalized for psychiatric disturbance and, even prior to hospitalization, in the process by which the physician comes to recognize and accept in himself an emotional illness of severe proportions. Hospitalization can represent a severe narcissistic trauma, which entails a radical role reversal (from caretaker to patient) and severely undermines the physician-patient's sense of personal and professional identity. Conflicts around these issues tend to become externalized within the hospital setting up characteristic patterns of conflict within the therapy (between patient and therapist) and within the ward community (between patient and ward staff, as well as between treating physician and ward staff). The expression of these conflicts and patterns of interaction are discussed in two cases-both psychotic and suicidal physicians-who, though the patterns of resistance and externalization took divergent forms, nonetheless expressed the same underlying issues.

Career Choice↗

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Addiction and paranoid process: psychoanalytic perspectives.

Multiple aspects of the problem of drug abuse and addiction are formulated in terms of the dynamics of the paranoid process, specifically emphasizing the complex interactions of introjection, projection, and the paranoid construction. The effect of projection is to modify the experience of the drug substance so qualities and capacities, often powerful and magical, are attributed to it, allowing it to serve as an external agency contributing to the maintenance of internal introjective configurations and correspondingly to the preservation of an inner sense of self-cohesion. The projective dynamics deal primarily with the vicissitudes of aggression and narcissism, and are given a sense of organization and meaningful integration by the cognitive elaboration of the paranoid construction. They also serve to locate the drug-taking behavior in a larger matrix of familial, social, and other environmental influences, which tend to give support to the projective system. The interaction of these projective psychological dynamics with the pharmacological action of drug substances completes the drug equation and helps to shed further light on the selection of specific drug substances as having addictive potential.

Adult↗