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PubMed1984

Denial in fantasy and hypomania: an exploration.

There is a spectrum of normality and psychopathology in which we see the presence of denial in fantasy, action, and word. The underlying ego distortions, such as the overuse of a denying fantasy in reality testing, will determine the clinical appearance of this mechanism. Traumatic experiences in the first 18 months are a determining factor in the development of these ego distortions. Clinical material is presented that supports a theory of elation put forward by Lewin (1950) who suggests that denying elations are repetitions of childhood dreams with their adult elaborations. In Mrs. A., the denying elations occurred particularly when experiences of castration anxiety or object loss became intolerable.

Adult↗

PubMed1987

The consciousness of being conscious.

Starting with the therapeutic advantage gained when insight acquires consciousness, an investigation of the nature and function of consciousness is undertaken. Consciousness is a state of awareness, having a range of higher mental functions serving a regulatory, controlling, and integrating role in mental activity. There are high levels of thinking, reality testing, experiencing, judging, anticipating; self-awareness and self-reflection enter into these controlling activities. Psychoanalysis has rightly been a science that studies the workings and contents of the unconscious portions of the mind. It has perhaps overlooked the important role that consciousness plays in ordinary life and in providing the levels of control and self-awareness individuals both experience and require. That pathology and disturbances of function may accompany normal states of consciousness as well as altered states of consciousness is a common clinical phenomenon. Psychoanalysis as a therapy widens the scope of the conscious control systems.

Awareness↗

PubMed1984

Play in the psychotherapy of selfobject relating.

Current literature dealing with narcissistic character disorder attempts to differentiate between mature relating with consensually validated whole objects and immature, more primitive relating with mirroring and validating selfobjects. In the latter case the object is especially valued for its role in buttressing a damaged or fragile self. The persistence into adult life of this more primitive relating to selfobjects can be viewed as a restitutive attempt, a healing by second intent. Through such a mechanism, attempts are made to make good deficits left by perceived failures of the primary object. These attempts include the setting up of relationships with figures whose empathic capacity is in some way sensed to be corrective, and the setting up of relationships with selfobjects which are in part created by the subject to provide himself with the kind of validating selfobject which has been longed for, yet never experienced. Winnicott conceives of transitional experience as an intermediate area allowed to the infant between primary creativity and objective perception based on reality testing. Transitional relating usefully clarifies the concept of selfobjects in emphasizing its common features with the transitional object. Transitional objects and selfobjects both contain the idea that the psychic apparatus is equipped with self-healing capacities. They tell us something about the nature of those self-healing capacities. The mental apparatus, as the physical apparatus, can attempt to heal itself in the face of injury or disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1979

Psychodiagnosis and psychoanalytic psychotherapy.

Patients with conditions in the intermediate range of severity often show adequate capacity to test reality but poor ego integration. To many, a modified psychoanalytic method is often applied. These patients are not easily classified within the standard nomenclature. The term "borderline" has been applied, in an illdefined manner at first; more recently, Kernberg has outlined, in more precise terms, the characteristics of this group from a psychostructural viewpoint. Genetic factors are important in this group also: a family history positive for mental illness is frequently noted. Amenability to analytic therapy is also related to the characterologic subtype, which carries prognostic implications as well. A multidimensional diagnostic approach is therefore crucial in this range of patients. A triaxial model is proposed and described, stressing (a) traditional diagnosis from the standpoint of genetic predisposition, (b) psychostructural diagnosis, and (c) characterological subtype. This method may help resolve confusion about diagnosis in the borderline realm and may lead to more accurate selection of treatment strategy.

Bipolar Disorder↗

PubMed1988

Violent and homicidal behavior in primitive mental states.

I have presented a psychodynamic construct that is useful in the assessment of violent and homicidal behavior. It further refines diagnostic and treatment endeavors when combined with other individual and situational correlates of homicide and violence. Object relations, reality testing, and mode of aggression are the three variables within the construct that can be empirically measured through the use of the clinical interview, psychodiagnostic testing, and corroborative history. They should contribute to our further psychoanalytic understanding of violent and homicidal behavior in primitive mental states.

Adolescent↗

PubMed1988

Rorschach indices for discriminating between two schizophrenic syndromes.

Thinking disturbance and disorder of affects may be different in two subtypes of schizophrenia, the "florid" and the "withdrawal" syndromes. In Exner's approach to the Rorschach system, the diagnostic indicators of disordered thinking may point out large differences not only between schizophrenic and control subjects but also between different types of schizophrenics. The Rorschach protocols of 45 subjects (15 "florid" schizophrenics, 15 "withdrawn" schizophrenics, and 15 controls of the same age and education, matched by sex) were examined on several Exner indices. Compared with the control group, both schizophrenic types confirmed an impairment of perceptual accuracy and of reality testing as well as a reduced emotional control. Compared with the "withdrawn" group, the "florid" schizophrenic subjects showed significantly higher indices of poor perceptual functioning, of an inadequate organizational activity (more Whole and Z responses characterized by negative Form Quality) and greater disordered ideational production.

Adult↗

PubMed1991

Perceived risk and sources of information regarding cocaine.

A study was made of the perceptions of risk and of the sources of information about risk regarding cocaine. Subjects were adult (N = 90) and juvenile (N = 20) cocaine abusers in seven Baltimore area treatment programs. Using structured interview, it was found that 87.8% of adults and 80.0% of youth had experienced at least one negative consequence of their cocaine use, other than addiction, prior to entry into treatment. The most common negative experience reported by both groups was the loss of reality testing. Moreover, 86.6% of adults and 65.0% of youth reported becoming addicted to cocaine before entering treatment. While juveniles sampled had entered treatment within a year of first cocaine use, adults entered treatment 7.9 years after first use and reported an average of 6.6 years of cocaine use before experiencing the first negative consequences. Television received consistently high ratings as an accessible and credible source of information about cocaine. Adolescents rated schools relatively high on the amount and accuracy of cocaine-related information provided.

Adolescent↗

PubMed1976

Psychotherapeutic intervention with the addict-client.

In order for the nurse therapist to be most effective with the narcotic-addicted client, she should be aware that his behavioral style many times reflects dependence, low self-esteem, and impaired reality testing. The major defense mechanisms used by the client are denial, projection, and manipulation. An attitude of hopeful expectancy on the part of the nurse is most important therapeutically in the treatment of the addict. Some therapeutic interpersonal interventions between the nurse and client are contracting, goal-setting, limit-setting, and the sharing of the responsibility for growth between the client and the nurse. The total treatment program for the client must also be scrutinized, and more than physiologic detoxification and one-to-one therapy must be provided in order for the client to have the maximum opportunity for change.

Defense Mechanisms↗

PubMed1975

[Symptom-centered group therapy for phobias--the problem-oriented workshop in psychotherapy].

Short term psychotherapy is increasingly recognized as a socioeconomic necessity. Problem-oriented treatments, particularly if applied in problem-homogenous groups, are one means of economizing and sometimes even improving psychotherapy. They also require a re-evaluation of the nature of the patient-therapist dyad. The "task-oriented small group" as a basic field of human interaction has been studied intensively in experimental social psychology. Nevertheless, group psychotherapy and behavior therapy have largely neglected group-specific aspects of such variables as cohesion, task-orientation, modelling, mutual self-help, risk-taking, motivation and insight. This paper outlines some recent changes in this respect, and discusses in particular the "symptomoriented peer workshop" as a treatment milieu. The general therapeutic potential of the peer workshop is briefly assessed with regard to the application of the above mentioned group variables in peer self-help groups, rehabilitation programs for the chronically hospitalized, symptom or depth-treatment in short-term psychotherapy, and in re-education programs for problem-children. The main concern is with its specific application to the treatment of phobias. Phobias are comparatively easy to define, yet are often connected with other personality problems. This has made them a model-problem in the arguments about symptom-substitution between "psycho"- and "behavior" -therapists, and it has stimulated discussion as to how behavior-focused treatments affect cognition and emotion, and to what extend depth and insight-oriented therapies change behavior. The interaction between treated and non-treated problems, and the behavioral, cognitive and emotional effects of differential treatment ingredients are discussed with special reference to the first controlled study in behavior therapy, that applied behavior-focussed confrontation with reality (flooding in vivo) under the sociodynamics of the small gsoup. Problem-focussed retraining under real-life conditions (reality testing) as group-therapeutic fieldwork can be a means of treatment in its own right may open up the patient for subsequent attempts to tackle more complex problems, or may just be an adjuvant in a multi-level approach. This certainly applies for phobias and can probably be generalized to other problems.

Agoraphobia↗

PubMed1976

Transference regression and real experience in the psychoanalytic process.

At the patient's level of reality testing and integration in the transference neurosis, the analyst serves as an effective parent who halpd the 'child' master various danger situations. This results in the patients relearning and development as the analyst provides new experiences for the regressive childhood components of the patient's personality. There is also a sequential or simultaneous cognitive element which is important in the ultimate development of mastery and is particularly useful in the process of working through. This cognitive element, however, cannot be effectively used until there have been repeated new and real experiences for the fixated and/or regressive components of the patient's personality.

Affective Symptoms↗

PubMed1992

Some superego conflicts in the analyst who has suffered a catastrophic illness.

This paper, originally part of a panel (in a somewhat different form) on life stresses of the analyst, focuses on some of the superego conflicts of the analyst who has suffered a catastrophic illness. The interplay between ego and superego functioning is examined, particularly in reference to how superego conflicts cause the ego to become subordinated to drive-related aims and to superego demands from which it would ordinarily have more autonomous distance. Some of the issues which are conflictual for analysts who have suffered a catastrophic illness and which have a tendency to be played-out in the treatment include: problems of self-esteem regulation; regressive alteration of identifications; reinstinctualization of identifications and of object relations; alterations in the ego-ideal; disruptions of other narcissistic regulatory processes; and the above mentioned subordination of ego functions, especially in regard to its synthetic, reality testing, and other autonomous capacities. Examples are presented of how these conflicts may be dynamically operative in unconsciousness, how they may enter into consciousness, and how they might be expressed in the treatment.

Aggression↗

PubMed1991

The comorbidity of multiple personality disorder and DSM-III-R axis II disorders.

Our ability to differentiate MPD from DSM-III-R Axis I disorders has become increasingly refined. Differentiation of MPD from the Axis II personality disorders is an area of more recent clinical investigation. MPD can be found comorbidity with many other psychiatric conditions. It is found in association with each of the DSM-III-R personality disorders. At the present time, however, we lack research data that define the prevalence of the comorbidity of MPD with the personality disorders. Objective study of this area is complicated by the paucity of instruments available to assess personality dimensions in the presence of a DD. In addition, the currently available personality inventories tend to overdiagnose BPD in patients with a high level of distress and acuity of symptoms. The diagnosis of a personality disorder in a patient with MPD is made on the basis of the assessment of the "whole" human being. It is based on the presence of a pervasive and relatively inflexible pattern of behaviors that reflects the individual predominant mode of being. The diagnosis of a personality disorder is not made on the basis of personality traits contained within any single alternate personality or groups of personalities. The personality disorders defined by DSM-III-R are a heterogeneous group of conditions whose individual etiologies reflect a complex interplay of constitutional, genetic, environmental, interpersonal, and psychodynamic factors. The interplay is variable and diverse between these determinants of the personality disorders and the traumatic forces that result in the development of a DD. For the Cluster A personality disorders (schizoid, schizotypal, paranoid), there is evidence supporting a relationship with specific psychotic illnesses. The combination of dissociative pathology with these personality disorders commonly results in a greater impairment of reality testing than in either condition alone. The Cluster B personality disorders (histrionic, narcissistic, borderline, antisocial) and Cluster C personality disorders (avoidant, compulsive, dependent, passive-aggressive) are believed to be primarily developmental disturbances. Comorbidity of these personality disorders with MPD involves consideration of the interaction of many developmental processes with the psychological impact of severe childhood trauma. Many MPD patients present with an apparent mixed personality profile consisting of an array of avoidant, compulsive, borderline, narcissistic, dependent, and passive-aggressive features. Although this article explores comorbidity of MPD with each of the personality disorders defined in DSM-III-R individually, it seems likely that a number of posttraumatic personality organizations can be defined that commonly coexist with MPD.(ABSTRACT TRUNCATED AT 400 WORDS)

Borderline Personality Disorder↗

PubMed1990

[Primary and secondary process thinking in normal probands, neurotic and borderline patients].

In the present paper normals, neurotics and borderline patients were compared with respect to primary and secondary process thinking. The Holtzman Inkblot Technique was used to assess the different modes of functioning. As it was expected, normals had more indicators of the most severe levels of primary process thinking than neurotics, but less than borderline patients. On the other hand it could be demonstrated that in normals the reality testing ability and synthetic functioning were not impaired compared to neurotics. In the contrary, the normals exceeded the neurotics concerning indicators of abstractive abilities. The results are discussed with regard to the hypothesis of a continuum of normal and deviant thinking and with regard to the concept of adaptive regression in the service of the ego.

Borderline Personality Disorder↗

PubMed1987

[Narcissistic disorders in the light of modern psychoanalysis].

Whereas psychoanalysis in its beginnings was based preponderantly on drive-theory, later on attention was paid essentially on ego-psychology and in the last years on self-psychology. This development is seen in the context of developments in society, especially of the fact of an increasing outer direction of man in the modern world with the danger linked with it of loss of ego and of self. The designed development may be understood as a reactive one. After an overview on the different concepts of the self it is defined as the narcissism which gives to the instances ego, id and super-ego as well as to the body the feeling and the impression, to be an individual capable for feeling and cognitive processes, forming an entity which is experienced continuously and in its continuity. Two different narcissistic disturbances are described: Narcissistic neuroses (= narcissistic personality disorders in the sense of Kohut) with a consistent ego, but a lack in self-representation because of deficiency experiences in early childhood, Borderline-conditions with a severe ego-pathology and, as a consequence of it, rigid defense-mechanisms, extreme fusion tendencies and projective identification, splitting etc. The development of normal narcissism is discussed. At the end the slightly modified psychoanalytic technique in the treatment of patients with narcissistic neuroses and the analytically oriented expressive psychotherapy of borderline-patients which is directed on reality testing is described.

Borderline Personality Disorder↗

PubMed1988

[Differential experience of anxiety conditions: a contribution to the diagnosis and pathogenesis of anxiety attacks. A case report].

By means of a case report about a depressive female patient suffering from clusters of attacks of various psychosomatic disorders associated with anxiety states of different degrees problems of diagnostic classification are discussed with regard to the DSM-III. The subjective experiences of anxiety during the various episodes of the patient's disease are described. A phenomenological difference between fear of death with preserved relation to reality on the one hand and "calamity anxiety" with a short-lasting breakdown of reality testing on the other hand is indicated. The neurobiological model of noradrenergic dysregulation is taken on trial to understand the various phenomenons of the disease.

Adult↗

PubMed1989

Long-term use of valproate in primary psychiatric disorders.

Thirty-five patients, all with major depressive illness, bipolar disorder, or schizoaffective disorder, were retrospectively identified as having received valproate either alone or in combination with lithium, after having failed to adequately respond to previous lithium and/or carbamazepine treatment. Clinical evaluation and Global Assessment Scale (GAS) scores indicated that at baseline all but 3 of the patients experienced serious psychiatric symptoms, serious impairment in social or professional functioning, or significant impairment in reality testing. Mean GAS scores after a mean duration of at least 1 year of valproate administration improved in 7 of 9 depressed patients, 12 of 12 patients with bipolar disorder, and 11 of 14 patients with schizoaffective states. Mean increases in GAS scores were 27.7 points for depressive disorder patients, 34.5 points for mixed bipolar disorder patients, and 17.1 points for patients with schizoaffective states. For patients with either depressive disorders or mixed bipolar disorders, that mean change represented a level of improvement sufficient to elevate the majority of the patients into the mild symptom range or the virtually asymptomatic state. That improvement was confirmed by the investigator's global evaluation of patient response with regard to affect: valproate administration produced significant affective responses in 7 of 9 depressed patients, 12 of 12 patients with mixed bipolar disorders, and 11 of 14 patients with schizoaffective states. The responses of patients with bipolar and schizoaffective disorders to valproate treatment compared with valproate plus lithium treatment were also evaluated. Patients in both diagnostic categories demonstrated very similar and quite substantial improvement in mean change in GAS ratings and global evaluations, regardless of whether valproate was administered alone or in combination with lithium.

Adult↗

PubMed1989

Early transferences and transference-like reactions.

Some patients manifest intense transferences or transference-like reactions in the earliest hours of psychotherapy. Although these reactions may actually represent transference, they may also arise from other sources, such as aspects of a patient's character, displacements from former therapists, impaired reality testing, information about the therapist, and therapist's behavior. Clinical examples are presented, and their management is discussed.

Anxiety↗

PubMed1989

The order of schizophrenic thought.

Analysis of schizophrenic thought disorder reveals structures and regulatory processes that govern its phenotypic expressions. In particular, the three primary variants of this thought disorder--combinative thinking, drive-dominated thinking, and loss of reality testing--can be viewed in terms of thematic structures. Schizophrenic communication is characterized by an affective rule-governing process that channels information into case-grammar thematic structures. The author elaborates an earlier proposal that transformational grammar subunits should be identified and modeled to schizophrenic thought and explicates the use of these specific structures and processes. He then suggests clinical interventions and future research applications.

Afferent Pathways↗