From a psychoanalytical perspective, there are two main types of psychopathology: those related to conflicting mental representations which result in neurotic pathology, and those related to failures of the mentalizing process which result in personality disorders. Borderline personality disorder is characterized by instability in interpersonal relationships, self-image, and affect as well as impulsivity, while paranoid personality disorder involves a pervasive mistrust and suspiciousness of others. Both disorders stem from failures early in life to develop stable and coherent mental representations of oneself and others.

1. From psychoanalytical point of view
and related to DSM IV Axis II
11

2. Psychopathology 1
Biology and Psychology
 Behavior is the result of the mutual
relation between “nature” and
“nurture”.The result of a complicated
interaction between “genes” and
“environment”→ integration Mind and
Brain.
22

3. Psychopathology 2
 Consequences for looking at
pathology
2. No causal relation between risc factors and the
development of pathology; the amount of risc
factors is in a way predictable.
3. The quality of the early attachment
relationships is important for the possible
development of pathology
33

4. Psychopathology 3
 The process of internalising early experiences
and the creation of an internal psychological
model of the interpersonal world →
mentalization/ creation of a mind or mental
representations.
 Internal representations of the earlier
experiences with the primairy care givers will
influence later relationships and the
development of psychopathology later on
44

5. Psychopathology 4
There are 2 types of psychopathology
4. Related to conflicting mental representations:
neurotic pathology
6. Related to the failing of the mentalizing
process itself: personality disorders this is the
area of the borderline personality organization
55

6. Difference between BPD and BPO 1
 Borderline Personality Disorder
3. A descriptive diagnosis. Manifest and
observable behavior
4. An enduring pattern of internal experiences
that manifest themselves in a broad area of
personal and social situations.
5. DSM IV
66

7. Difference between BPD and BPO 2
 Borderline Personality Organization
 Structural Diagnosis/ Kernberg
 Underlying structure which is not directly
observable.→
Dyade/Schema/I.W.M./I.I.M.
 Includes the whole area of personality
disorders
77

8. Two types of pathology
Mental process disorders
 Inability to represent inside what is outside
 The dependency from the external world is
there
 Anxieties are interpersonal instead of intra
personal
88

9. Two types of pathology
Mental Process disorders
 No psychological Self but the body is the self
 No Somatization as a defense but Soma
 Alexithymia: medically unexplained physical
symptoms/ conversions
 They live in a frightened world instead of a
world they are experiencing as frightening
99

10. Mental Process Disorders
1. Anxiety neurosis
2. External Regulated / Motivated
3. Developmental pathology
4. Building structures
5. The area of the personality disorders Axis 2
cluster A and B
6. Axis 1 Somatization, Somatoform disorder,
Panic disorder Dissociative disorder and PTSD.
10
10

11. Conflicting Mental Representations.
2. Psychoneurosis
3. Intrapsychic Conflicts
4. Conflicting pathology
5. Restructuring
6. Internal Regulated / Motivated
7. Neurotic pathology and Axis 2 cluster C
11
11

12.  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
12

13. M.Klein
Par. Schizoid Position
 Annihilation anxiety
 Identity undermining defenses
 No adequate self/object differentiation
 No adequate object constancy
 Archaic Object Relations
 Ambivalences are not bearable
 “doing” instead of “containing”/”feeling”
13
13

14. M.Klein
Par.Schizoid Position
 Interventions related to the inner experiencing
are raising the anxiety and by that stimulating
“acting out”
 Interventions should relate inner and outer
sources of stress → facilitating mentalization
 Therapist as external Obs.Ego → being
introjected / mirroring
14
14

15. M.Klein
Depressive position
 Anxieties related to inner ambivalences
 Defenses in favour of identity
 Adequate S/O differentiation
 Adequate Object constancy
 Realistic Object Relations
 Containing instead of doing
15
15

16. Attachment
A safe attachment style supposes
 Adequate sensitivity: being aware that
there is something going on in the other
person
 Adequate responsivity: reacting to the
other in such a way that it is clear what is
from me and what from the other
16
16

17. 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

18. 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
3. Relatedness  Anaclytical pathology
 Preoccupied/Ambivale
nt
 Faling responsivity/not
marked mirroring
9. Autonomy  I can not be on my
own
 Introjective pathology
 Avoiding
 Failing sensitivity
(Blatt 1998)
 I do it myself
19

20. Anaclytical Pathology
Internalizing Pathology
 Borderline Personality Disorder
 Histrionic Personality Disorder
 Dependant Personality Disorder
20
20

21. Introjective Pathology
Externalizing pathology
 Schizoid/Schizotypical Personality Dis.
 Narcissistic Personality Disorder
 Antisocial Personality Disorder
 Avoidant Personality Disorder
 Somatization,Somatoform dis. DID, PTSD
21
21

22. Internalisation
incorporation
introjection
identification
22
22

23. Introjection
object permanency
object constancy
internal
object
independent of external objects
23
23

24. Objectconstancy
Internal representations
Containing ambivalencies
Related to someone who is
not
actual there
Mourning
Autonomous 24
24

25. Identity - 1 -
Object constancy
Autonomous object
Internal representations
Time perspective
Feeling instead of doing
25
25

26. Identity - 2 -
Fragmentation - cohesive
Acting out - containing
Momentaneous - time
perspective
panic - signal anxiety
Splitting - repression
26
26

27.  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
27

28. Structural Personality
Organization
Kernberg (1984)
Neurotic Borderline Psychotic
Identity integrated diffuus fragmentated
Defense mature archaic archaic
Reality in tact in tact in a way absent
Testing
28
28

29. Ego identity
 S/O Differentiation  internal structure
 Mature Object  autonomous
Relations
 Mature Defenses
 Reactive Agression
29
29

30. Identity diffusion
 Fusion  external regulated
 Primitive Object Relations  dependent
 Archaic Defense
 Primitive Agression
30
30

31. Weak internal structure versus Strong
internal structure
 Archaic defenses  Mature defenses
 Panic  Neurotic anxieties (signal)
 Regression of the ego  regression in favour of the
 No ambivalencies ego
 Deficits  Ambivalent
 Acting out  Conflict
 Structuring  Containing
 Rerstructuring
“Borderline” “Neurotic”
31
31

32.  Nonspecific manifestations of ego weakness
 Specific manifestations of ego weakness →
splitting
 Shift towards primary process thinking
 Pathalogical internalized object relations
32
32

33. 33
33

34. 34
34

35. 35
35

36. 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
36

37. Apart from DSM IV
 Depressive P.D.
 Somatization P.D.
 Dissociative P.D.
37
37

38.  Cluster A
38
38

39.  A pervasive pattern of detachment from social
relationships
 Introjective/externalizing pathology
39
39

40.  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
40

41.  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
41

42. Personality Schizoid
Disorder
View of self Self-sufficient. Loner
View of Intrusive
others
Main Others are unrewarding.
beliefs Relationships are messy, undesirable.
Main Stay away!
strategy
Therapeutic Realize that he is basically very insecure and that contact
with people is a real threat.
strategies
So let him decide how much contact he wants.
Do everything to increase his sense of self-efficacy.
42
42

43. The same as Schizoid but also:
 Ideas of reference
 Suspicious/paranoid,excessive social anxiety
 Magical thinking
 Eccentric and odd behavior
43
43

44. Personality Schizotypal
Disorder
View of self Unreal, detached, loner.
Vulnerable, socially conspicuous.
Supernaturally sensitive and gifted.
View of Untrustworthy. Malevolent.
others
Main (irrational, odd, superstitious, magical thinking; e.g. belief in
beliefs clairvoyance, telepathy or ‘sixth sense’.)
“It is better to be isolated from others.”
Main Watch for and neutralize malevolent attention from others.
strategy Stay to self.
Be vigilant for supernatural forces or events.
Therapeutic See next slide.
strategies 44
44

45. How to deal with Schizotypicals
 Realize that he is basically very insecure and that
contact with people is a real threat.
 So let him decide how much contact he wants.
 Do everything to increase his sense of self-efficacy and
his reality testing.
 Don’t argue about telepathy, but simply state that you
don’t have such experiences.
45
45

46.  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
46
46

47.  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
47

48.  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
48

49. Personality Paranoid
Disorder
View of self Righteous, innocent, noble, vulnerable
View of Interfering, malicious, discriminatory, abusive motives
others
Main Others’ motives are suspect.
beliefs I must always be on guard.
I cannot trust people.
Main Be wary. Look for hidden motives.
strategy Accuse. Counterattack.
Therapeutic Realize that he is basically very insecure.
strategies So accept the suspiciousness.
Accept that you have to earn his trust, by being extremely
transparant and open about what you are doing.
Do everything to increase his sense of self-efficacy. 49
49

50.  Cluster B
50
50

51.  Pervasive pattern of instability of interpersonal
relationships, self image and affects and
marked impulsivity
 Anaclytical / internalizing pathology
51
51

52.  Alternating between idealizing and devaluating
 Chronic feelings of emptiness
 Inappropriate intense anger
 Self-mutilation
52
52

53.  Frantic efforts to avoid real or imagined
abandoment
 Identity disturbances
 Impulsivity / problems with bounderies
 Affective instability/ moodswings including
anxiety
 Paranoid ideation
53
53

54. Personality Borderline
Disorder
View of self Vulnerable (to rejection, betrayal, domination)
Deprived (of needed emotional support)
Powerless. Out of control.
Defective. Unlovable. Bad.
View of (idealized:) poweful, loving, perfect.
others (devaluated:) rejecting, controlling, betraying, abandoning.
Main I cannot cope on my own. I need someone to rely on.
beliefs If I rely on someone I will be mistreated, found wanting, and
abandoned.
The worst possible thing would be to be abandoned.
I cannot bear unpleasant feelings.
It is impossible for me to control myself.
I deserve to be punished.
Main Subjugate own needs to maintain connection.
strategy Protest dramatically, threaten and/or become punitive toward those
that signal possible rejection.
Relieve tension through self-mutilation and self-destructive 54
54

55. How to deal with borderlines.
 They provoke intense countertransference feelings: Anxiety ,
Compassion, Powerlessness,Rage.
 They constantly test the limits. So stop them in time, in spite of
their vehement emotions, reproaches, suicide threats.
 The basic rule is: setting clear and consistent limits.
 Keep in mind that their life-long dilemma is: fear of utter
loneliness ↔ fear of engulfment and loss of identity.
 This causes the instability between intense need for contact and
intense rejection when you try to be helpful.
 Be clear about the conditions by which you can help her.
 Be consistent in maintaining these conditions and setting limits.
 This helps you to prevent your anger.
55
55

56.  Pervasive pattern of grandiosity, need for
admiration, for being loved
 Introjective / Externalizing pathology
56
56

57. 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
57

58. Hypervigilant: need to be loved / admired
Depressed; 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
58

59. Personality Narcissistic.
Disorder
View of self Special, unique, superior.
Deserves special rules.
Is above the rules.
View of Inferior.
others Admirers.
Main Since I am special I deserve special rules.
beliefs I am above the rules.
I am better than others.
Main Use others. Transcend rules, manipulate, compete.
strategy
Therapeutic See next slide.
strategies
59
59

60. How to deal with narcissists.
 Keep in mind that their arrogance is needed in order not
to feel inferior.
 Therefore accept the fact that there can be only one
grandiose person in the room.
 So overcome your own narcissistic hurt and use praise
and flattery to get things done.
 But resist unreasonable demands, for then they loose
respect.
 But tolerate their rage when you don’t fulfil their
demands.
60
60

61.  Pervasive pattern of disregard for and violation
of the rights of others
 Introjective /Externalizing pathology
61
61

62.  Failure to conform to social norms
 Impulsivity or failure to plan ahead
 Irratability / agression
 No empathy
 No responsability for their behavior
62
62

63.  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
63

64. Passive or Parasitic
 Anaclitic
 Dependent, less agressive, relatively non-
violent manipulator
Agressive
 Introjective
 Explosive, violent offender
64
64

65. Personality Antisocial
Disorder
View of self A loner
View of Vulnerable
others
Main “I am entitled to break rules.”
beliefs
Main Attack. Rob. Steal.
strategy
Therapeutic See next slide.
strategies
65
65

66. How to deal with antisocials
 Don’t let yourself be flattered by his charm.
 Be aware that he always wants something from you.
 So be especially suspicious if he offers you to participate
in some partly illegal, but very profitable offer.
 As he has no conscience, teaching morals makes no
sense.
 So teach him to become a better psychopath, more
clever and long-sighted, directed to his best interests.
66
66

67.  Pervasive pattern of excessive emotionality
and attention seeking
 Anaclytical / Internalizing pathology
67
67

68. Histrionic
 Weak internal structure
 Dyadic relations
 Archaic defense
 Need satisfying relations
 Flamboyant; seductiveness; sexual
impulsiveness; dramatization
68
68

69. Hysterical
 Adequate internal structure
 Triadic relations
 Mature defense
 Take and give relations
 Emotional reserve; sexual naiveté; conversions
and somatizations
69
69

70. Personality Histrionic.
Disorder
View of self Glamorous. Impressive.
View of Seducible. Receptive. Admirers.
others
Main People are there to serve me or to admire me.
beliefs People have no rights to deny me what I deserve.
I can go by my feeling.
Main Use dramatics, charm, temper tantrums, crying, suicide
strategy gestures.
Therapeutic See next slide.
strategies
70
70

71. How to deal with histrionics.
 Natural reactions to them are: Rescuer phantasies,
Sexual desire, Irritation.
 So be wary of the intense emotional contact they seem
to promise.
 Resist the temptation to become the all-powerful
rescuer.
 Interrupt their impressionistic, dramatic style of thinking.
 Teach them to think through, in order to be able to
make their own decisions, and to decatastrophize the
future and to improve their problem solving skills.
71
71

72.  Cluster C
72
72

73.  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
73

74.  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
74
74

75. Personality Obsessive-compulsive.
Disorder
View of self Responsible. Accountable. Fastidious. Exacting. Competent.
View of Irresponsible. Casual. Incompetent. Self-indulgent.
others
Main I know what is best.
beliefs Details are crucial.
People should do better, try harder.
Main Apply rules. Perfectionism. Evaluate, control.
strategy “shoulds”. Criticize. Punish.
Therapeutic See next slide.
strategies
75
75

76. How to deal with obsessive-compulsives.
 Respect his meticulousness, but state clearly when
things are clear enough.
 Do behavioral experiments to let him discover that doing
something less-than-perfect does not bring the feared
catastrophy.
76
76

77.  Pervasive pattern of social inhibition, feelings
of being inadequate, hypersensitive for
negative evaluation
 Introjective /Externalizing pathology
77
77

78.  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
78

79.  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
79
79

80. Personality Avoidant
Disorder
View of self Vulnerable to depreciation, rejection.
Socially inept. Incompetent.
View of Critical. Demeaning. Superior.
others
Main It is terrible to be rejected or put down.
beliefs If people know the ‘real’ me, they will reject me.
I cannot tolerate unpleasant feelings.
Main Avoid evaluative situations
strategy Avoid unpleasant feelings or thoughts by keeping everything
vague.
Therapeutic See next slide.
strategies
80
80

81. How to deal with avoidant patients.
 How much you do your best to be accepting, keep in
mind that they can only see you as critical, and so they
will try to be as vague as possible, in order not to be
caught.
 Show them the price they pay by avoiding and help
them to confront the feared situations in small steps,
and to tolerate the tension.
 Confront them with the fact that others will judge them
anyway.
 Offer social skills training.
81
81

82.  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
82

83.  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
83

84.  Enormous need for nurturance and support
 By being so dependent they provoke what they
want to avoid
 Passive-Agressive versions of dependent p.d.
84
84

85. Personality Dependent
Disorder
View of self Needy. Weak. Helpless. Incompetent.
View of (Idealized:) Nurturant. Supportive. Competent.
others
Main I need people to survive and be happy.
beliefs I need to have a steady flow of support and encouragement.
Main Cultivate dependent relationships.
strategy
Therapeutic Resist the invitation to take the initiative and to become the
all-powerful magical helper, but make a deal:
strategies
“I can only help you if you gradually do things on your own.”
Promote small steps toward autonomy.
Offer assertiveness training.
85
85

86. Personality Passive-aggressive
Disorder
View of self Self-sufficient.
Vulnerable to control, interference.
View of Intrusive, demanding, interfering, controlling, dominating.
others
Main Others interfere with my freedom of action.
beliefs Control by others is intolerable.
I have to do things my own way.
Main Passive resistance.
strategy Surface submissiveness.
Evade, circumvent rules.
Therapeutic Avoid power struggles and being pushed into the
authoritarian role. Focus explicitely on collaboration.
strategies
86
86

87.  Based on psychoanalytical theory
87
87

88. 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
88

89. 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
89

90.  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
90

91. Introjective
 Concerned with self definition, autonomy, self
worth,self critical thoughts
Anaclitic
 Concerned with relatedness, trust, preservation
of attachments
91
91

92. Somatization P.D.
Anxiety neurosis (Actual Neurosis)
 Somatic (hartbeating; sweating; trembling;
nausea; problems with respiration etc.)
 Not related to mental representations
 Related to mental process disorders
 DSM IV; somatization,somatoform disorders
panic disorders and PTSD.
92
92

93. Somatization P.D.
Mental Process disorders
 No psychological Self but the body is the
self
 No Somatization as a defense but Soma
 Alexithymia: medically unexplained
physical symptoms/ conversions
 They live in a frightened world instead of
a world they are experiencing as
frightening
93
93

94. Somatization P.D.
1. Anxiety neurosis instead of psycho-
neurosis
2. Panic / momentaneous anxiety
3. External Regulated / Motivated
4. The area of the personality disorders
Axis 2 cluster A and B
5. Somatization, Somatoform disorder,
Panic disorder and PTSD.
94
94

95. 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
95

96. Dissociative P.D.
Appearance of alters
 Distinct identities or personality states each
with his own relatively enduring pattern of
percieving,relating to andP.D.
Dissociative
thinking about the
environment and the self.
 They recurrently take control of the persons
behavior
96
96

97.  Ever met a normal person ??? And did
you like it ???
 mdw@wxs.nl
97