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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↗
PubMed1988

The development of scales to measure the experience of self-participation in sleep.

Recent literature suggests that how the self is represented is a cardinal aspect of the dream experience. A review of studies of phasic-tonic distinctions within rapid eye movement (REM) sleep revealed that increasing self-participation marked awakenings from phasic intervals. Five scales specifically designed to measure absorption in dreaming were compared with three scales previously shown to discriminate phasic from tonic awakenings within REM sleep. Eight reports per night (two stage REM, six stage 2) were collected from each of 20 subjects on 4 baseline nights. Awakenings were controlled for time into the REMP and time of night, correcting the methodological flaws of previous studies in this area. Scales developed to measure self-participation were able to discriminate phasic from tonic awakenings better than those already in the literature. Results are discussed in terms of the psychometric properties of the individual scales.

Affect↗
PubMed1977

Brentano's Psychology from an Empirical Standpoint and Freud's early metapsychology.

Brentano's Psychology from an Empirical Standpoint and Freud's early metapsychology, particularly the Project for a Scientific Psychology, show some interesting similarities. In psychological theory, both men stressed the motivated nature of thought and a conception of a "psychological reality" that is superior to "material reality." Both saw consciousness of one's own mental activity as arising retrospectively and having a calming effect on emotions. Both emphasized a process of "judgment" or "reality testing," made possible only by the presence of a strong unity of consciousness of ego. Methodologically, both agreed that the retrospective analysis of subjective experience is the principal tool of psychology. Freud eventually agreed with Brentano that psychology proceeds best when separated from physiology. They applied similar criteria to "proofs" of the unconscious, with Brentano concluding negatively, and Freud, positvely, after considering new evidence. This article considers the similarities and concludes that they suggest some sort of influence of Brentano on Freud.

Austria↗
PubMed1985

Management of PCP intoxication.

Phencyclidine has a wide range of deleterious effects. Drug users may not even know that they have taken PCP since it is so easily disguised. Physicians should look for decreased reality testing, erythema, dry skin and other manifestations. The varied signs and symptoms of acute intoxication can be dealt with quickly and effectively. Management strategies include acidification of the urine and diuresis, as well as more specific antidotes, depending on the neurotransmitter system most affected.

Humans↗
PubMed1984

Clinical differentiation of borderline syndromes from the psychoses.

The discrimination of borderline syndromes from the psychoses is often a difficult task clinically. The problem most often arises in the acute setting in which a crisis has arisen--the typical example being that of acute hospitalization. The clinician's task is to assess the patient's apparently psychotic symptoms and behaviors to determine whether they are the manifestations of an underlying psychotic process, or whether they reflect a more or less transient regression from a somewhat higher level of habitual functioning. Some discrimination between these categories is possible even in the acute presentation, since borderline patients only exceptionally demonstrate Schneiderian first-rank symptoms or any other discriminating indices of psychosis. While the differentiation may be clear cut between the psychotic and the higher-order, better functioning borderline, there may be less precision in discriminating between the lower-order borderline forms or transient borderline states and psychoses. We have focused on this area of differentiation in this study. The discriminating indices are both short- and long-term. The differentiation cannot be adequately made without longer-term evaluation of the patient. Nonetheless, on a short-term basis, evaluation of the patient's behavior can point the diagnosis in one direction or other. The presence of a clear precipitant; the presence of intense (often verbalized) anger; the patient's attempts to engage the therapist in an intense, dependent, clinging and demanding relationship, usually in manipulative fashion; the partial, fragmentary, often circumscribed and ego-alien quality of the patient's psychotic productions; the marked tendency to act-out feelings, particularly anger, in a way that gains increased attention and concern from doctors, family, friends, or hospital staff; the persistence of some degree of reality testing and areas of significant realistic functioning; the transient nature of regressive manifestations and the ready reversal of regression in structured environments and with appropriate therapeutic management, particularly adequate limit-setting--all point toward a borderline diagnosis. Moreover, these factors carry an accumulative weight so that the more of these factors that can be validated, the more secure the diagnosis of borderline psychopathology. On a longer-term basis, beyond a few days, one would expect the above indices to be better discriminated. In addition, there is greater opportunity to study patterns of patient behavior--both his interaction with staff and other patients and with the therapist.(ABSTRACT TRUNCATED AT 400 WORDS)

Borderline Personality Disorder↗
PubMed1984

[Self healing attempts by schizophrenic patients].

There has effectively been no investigation, at a systematic empirical level, whether schizophrenics possess self-help capability. Clinical observation and self description would seem to make its existence likely. This will first be shown on hand of the pertinent clinical literature. In an own investigation, which was based on a "Model of Vulnerability" (Zubin and Spring, 1977), 40 schizophrenics were questioned in accordance to the formulation provided in the Frankfurt Complaint Questionnaire (Süllwold, 1977) about their compensatory efforts concerning subjectively experienced basic disorders Reaction time measurements served as indicators of schizophrenic vulnerability. All 40 patients reported awareness about compensatory efforts in regard to experienced disorders which they conceived to be danger signals. A clearly greater number of problem solving oriented (active) than non problem solving (passive avoidance) attempts were reported. They can provisionally be classified as "reinterpretation", "restructuring", "reality testing", "action displacement" or "search for action stereotypes".

Adaptation, Psychological↗
PubMed1984

[Fluctuations in the "evenly hovering attention" and their therapeutic processing].

For epistemological and empirical reasons, Freud's "evenly hovering attention" has to be understood as an advice that the analyst should remain open for new observation. It is a recommendation against having preconceived ideas and biases. In fact, the analyst's attention is regulated by conscious and unconscious selections. It is subject to considerable changes in the analyst's cognitive processes. His countertransference influences his attention. The patient in turn reacts consciously or unconsciously to the variations of the analyst's attention. It is therefore necessary to interpret those changes and sometimes to admit them. This recognition supports the reality testing of the patient in the analytic situation. Otherwise malign regressions or denials and other defensive processes might occur. We give an example of the changes in the "evenly hovering attention" of an analyst and their handling.

Adaptation, Psychological↗
PubMed1983

[Critical views on narcissism theories].

After having given an overview about the different definitions of the Self, I have defined it as the seat of narcissism which furnishes the instances of Ego, Id and Super-Ego as well as to the body this narcissistic investment or information which gives the individual the feeling that the different instances and his body are belonging to his own and giving him throughout his life a feeling of continuity. Otto F. Kernberg describes, contrary to Heinz Kohut, the primarily pathological nature of narcissism of individuals having an Ego prone to fragmentation and very rigid defense mechanisms, e.g. splitting, projective identification, blind rage, hostility etc. The pathological narcissism results out of an early pathological object-relationship and of an Ego prone to fragmentation with a consecutive disturbance of the development of the Self. From these borderline personalities with their pathology of narcissism I differentiate the narcissistic neuroses--called by Kohut narcissistic personality disorders or behavior disorders--in individuals with a strong Ego, which are due to a lack--or more rarely to a surplus--of warmth-, stimulation- and cognition-experiences in early childhood. They have a tendency of undergoing more than usual a fusion with a Self-object, mirror transferences and developing a grandiose Self in their fantasy as compensations or defense mechanisms. The schizoid personalities are intermediate forms, which show a rigid defense, however do not have like the borderline-personalities the tendency to occasional break-throughs of the primary process. Whereas in the treatment of narcissistically disturbed borderline conditions early interpretations of the rigid archaic defense mechanisms and furthering reality testing are necessary, in narcissistic neuroses primarily the building up of a consistent Self and then a working through of the named narcissistic compensations and defense mechanisms are necessary.

Adult↗
PubMed1981

Diagnosing borderline personality. A pilot study using multiple diagnostic methods.

The research described in this paper stemmed from the hypothesis that borderline personality organization can be differentiated from neurotic and psychotic levels of personality organization by means of three structural criteria: degree of identity integration, level of defensive operations, and capacity for reality testing. In order to elicit these criteria, the "structural" interview has been developed that focuses on the "here-and-now" patient-interviewer interaction. The patient's responses to the interviewer's attempts to clarify, confront, and interpret various aspects of the patient's interview behavior provide the basis for judgments as to the patient's structural diagnosis. Specifically, the paper reports a study of the differential diagnosis of 48 hospitalized patients in which structural diagnoses of borderline or psychotic personality organization were made according to this diagnostic interview approach. These diagnoses were compared with ones obtained from Gunderson's Diagnostic Interview for Borderlines, with psychological test diagnoses, and with clinical diagnoses based on past history and current illness. Results show substantial convergent agreement among all of the diagnostic methods and support the utility of the structural interview. In most discrepant cases, other methods reflected disagreement among themselves despite the diagnoses obtained from the structural interview, suggesting that there are some cases difficult to classify by any means. Further analysis suggests that the structural interview may be eliciting a different dimension of personality functioning in arriving at borderline diagnoses than do the other methods studied. The results also indicate that borderline structural diagnoses refer to patients described clinically as having severe character pathology, and do not overlap with patients described as having schizophrenic disorders. The structural interview appears to warrant further study, and, at the same time, shows promise as a research tool in further studies of structural diagnosis and its relevance for prognosis and treatment.

Adolescent↗
PubMed1995

The psychotherapeutic treatment of suicidal adolescents.

The therapeutic work with a suicidal adolescent begins with the therapist's recognition that there are a multitude of causes for suicidal behavior and that the risk of a serious suicide attempt lies in the patient's feeling of desperation about his situation, the feeling that he faces intolerable pain due to shame or embarrassment, degradation, guilt or loss. The patient can not assess whether his view of his situation is realistic or not, and he is unable to conceive of alternative solutions. The therapist must throw the patient a lifeline to give him hope of escaping from his belief that he is trapped in a world of unending pain. That lifeline may be an active intervention in the life of a patient, reality testing of the patient's perceptions that he is trapped, or both. The choice of interventions is based on an exploration of the psychodynamic and psychopathological constellations that have caused the patient to feel so trapped. Patients, in their anguish, will resort to extremes of coercion and manipulation; the therapist must be able to tolerate and work with these behaviors. The therapist must maintain his belief that he can find ways to help the patient, while accepting the possibility that some day he might fail. He can succeed only if he is prepared to fail. Meeks (1984) summed up his article on suicidal adolescents in the following way: Success in the therapy of these youngsters does not depend on brilliant insights as much as on persistence, patience, and a sustained hope for the future. The treatment process may become a demonstrated proof that the therapist can stand to feel the patient's feelings and live the patient's painful existence, without giving up on life or the patient [p. 5].

Adolescent↗
PubMed1977

A psychogeriatric activity group in a rural community.

Three senior students in occupational therapy and a faculty member collaborated with a community mental health center in implementing and conducting an Outreach Activity Group for socially isolated, psychogeriatric clients residing in an outlying rural community. The students gained experience in five areas: learning the structure, functions, and funding of a community program; identifying the role and function of occupational therapy in community-based mental health; making use of administrative and consultative role functions; leading a group; and, with other health professionals, identifying ways to lessen the problems faced by the psychogeriatric client in the community. The group was helpful in maintaining the psychogeriatric client in the community by promoting self-esteem, self-expression, new interests, constructive use of leisure time, reality testing, interpersonal relationships, and perceptual motor stimulation.

Aged↗