Character Pathology Research Articles

A Psychoanalytic Approach to Internet Gaming Disorder.

Internet Gaming Disorder (IGD) is now an official diagnosis and significant public health challenges have been already identified regarding the provision of appropriate care to patients of all ages and the preparedness of mental health professionals to manage the disorder. Despite the existence of psychotherapeutic treatment modalities available for some time now, there is a paucity of any psychoanalytically driven treatments and the disorder is widely regarded and classified as being 'behavioral'. This has profound implications for patients with long-standing character pathology and psychiatric comorbidities, who are underserved by the provision of health services that could efficiently address their issues. This study presents a psychoanalytic perspective on IGD, based on Kohut's Self Psychology as applied in the treatment of other addictions. An outline of the theory, assessment and treatment modalities is presented with two case reports that illustrate its application. The presentation outlines the challenges in treating IGD, expanding on the concept of guided imagery, resistance to treatment, selfobject transference and comorbidity with marijuana use and bipolar disorder. A psychoanalytically driven protocol can be effective in treating IGD, especially in cases with marked character pathology and low motive to engage in other treatment modalities.

Truth, anxiety and the contribution of Heidegger’s phenomenological ontology to psychoanalytic conceptualization and practice

ABSTRACT The present paper is an attempt to explore the actual and potential convergences and divergences of the ontological-existential philosophy of Martin Heidegger and Freud’s analytic thinking as well as later developments in psychoanalysis. The first part of the paper compares and contrasts Freud’s and Heidegger’s thinking on issues of truth and anxiety, which are central to their respective doctrines and highly relevant to working with difficult patients. It is shown that both Freud’s psychoanalytic theory and Heidegger’s ontological philosophy stress the process of opening up to the anxiety-evoking truth and the individual’s responsibility to uncover the truth as a source of freedom. The second part of the paper examines the impact of Heidegger’s thought on the psychoanalytic understanding of individuals with severe character pathology, on the spectrum from malignant narcissism, through perverse organizations, to psychosis. In this context, the authors discuss the notion of ‘anxieties of being,’ a shift towards a more ontological psychoanalysis and the phenomenologisation of psychoanalytic language. Viewing people as interpretive creatures, the authors believe that Heidegger’s hermeneutic outlook may enable psychoanalysts to approach their patients in a more open and accepting manner.

Trans-diagnostic determinants of psychotherapeutic treatment response: The pressing need and new opportunities for a more systematic way of selecting psychotherapeutic treatment in the age of virtual service delivery.

Numerous forms of psychotherapy have demonstrated effectiveness for individuals with specific mental disorders. It is, therefore, the task of the clinician to choose the most appropriate therapeutic approach for any given client to maximize effectiveness. This can prove to be a difficult task due to at least three considerations: (1) there is no treatment approach, method or model that works well on all patients, even within a particular diagnostic class; (2) several treatments are equally efficacious (i.e., more likely to be effective than no treatment at all) when considered only in terms of the patient's diagnosis; and (3) effectiveness in the real-world therapeutic setting is determined by a host of non-diagnostic factors. Typically, consideration of these latter, trans-diagnostic factors is unmethodical or altogether excluded from treatment planning - often resulting in suboptimal patient care, inappropriate clinic resource utilization, patient dissatisfaction with care, patient demoralization/hopelessness, and treatment failure. In this perspective article, we argue that a more systematic research on and clinical consideration of trans-diagnostic factors determining psychotherapeutic treatment outcome (i.e., treatment moderators) would be beneficial and - with the seismic shift toward online service delivery - is more feasible than it used to be. Such a transition toward more client-centered care - systematically considering variables such as sociodemographic characteristics, patient motivation for change, self-efficacy, illness acuity, character pathology, trauma history when making treatment choices - would result in not only decreased symptom burden and improved quality of life but also better resource utilization in mental health care and improved staff morale reducing staff burnout and turnover.

The interplay between antisocial and obsessive‐compulsive personality characteristics in cult‐like religious groups: A psychodynamic decoding of the DSM‐5

AbstractThe antisocial and violent behaviors of cult‐like religious groups (CRGs) and the maladaptive social consequences of their activities suggest clinical or character pathology and invite diagnostic and dynamic formulations of their members' personalities. The current study utilized secondary reports in the commercial media about CRG members, combined with the lived experience method of two of the authors. The resulting core characteristics of CRG members were then classified following the alternative DSM‐5 alternative model for personality disorders. The overall clinical picture is then discussed in terms of the shared psychodynamic sources that undergird the behaviors of the antisocial‐obsessive‐compulsive personality disorders. By tracing the personality characteristics into their unconscious sadomasochistic conflicts, these insights shed light on the paradoxical frequent co‐occurrence of antisocial and obsessive‐compulsive characteristics among extremists, in contrast to the patient population at large.

Debate: Pediatric bipolar disorder - divided by a common language?

The paediatric bipolar disorder (pBD) debate is seen as a prototypical transatlantic controversy. But this is a Eurocentric view that ignores just how big a country the United States is - it contains multitudes, to paraphrase Walt Whitman writing in the aftermath of the Civil War. Indeed, such are the multitudes that a child can receive a diagnosis of bipolar in one State, but not in a neighbouring one. It was the force of this intra-American division that swept over the Atlantic. As this has been the case for many other goods imported from the United States, the European high-brow response was that pBD was just a New World fad. This response was evidently wrong. Of course, there are young children who have full-blown manic and depressive episodes and who need treatment. And the bitter truth was (and continues to be in parts of the United Kingdom) that often such children are dismissed as having 'character pathology' and their families accused of all sorts of inadequacies. Clearly, here was an important problem hidden under layers of Old-World crustiness.

Body Modification and Personality: Intimately Intertwined?

Body Modification and Personality: Intimately Intertwined?

Changes arteries and veins in patients with hypertension with undifferentiated connective tissue dysplasia

In the article elaborated prognostic criteria of severity of hypertension (АH) by studying the manifestations of undifferentiated connective tissue dysplasia (UCTD).The objective: the study involved 72 patients with hypertension stage II–III 1–3 degrees (47 women, 25 men) aged 63,5±4,2. A study of mor phological changes, performance of laboratory examinations (blood lipid profile, C reactive protein, seromucoid) instrumental techniques (echo CG, ultrasound examination of the carotid and vertebral artery ultrasound vessels of the pelvis and lower extremities) consult special ists (ophthalmologist, otolaryngologist, neurologist, trauma, vascular surgeon).Results. Revealed widespread undifferentiated connective tissue dys plasia, based on the pathology of connective tissue.Conclusion. Patients with hypertension and visceral phenotypic char acteristics different from hypertensive patients with no signs of CTD changes character pathology of blood vessels, affecting the course and prognosis of hypertension, increases the number of complications. The presence of CTD in conjunction with those active inflamma tion (C reactive protein, seromucoid) and dyslipidemia in patients with hypertension increases the severity of clinical dis ease that must be considered when planning treatment and pre ventive measures.

Interpretation and Contemporary Reinterpretation

In basic psychoanalytic theory of technique, interpretation and insight reveal the latent content beneath the manifest appearance of symptoms, character pathology, and disturbed irrational behavior. The understanding of the neutrality and objectivity of the analyst, however, has been modified with new formulations of interpersonal, intersubjective influence and dyadic unconscious communication. Transference is often regarded as coconstructed in the present in a transference-countertransference field, emphasizing the analytic relationship and experience as a two-person analytic process. Nevertheless, the analyst is capable of good enough objectivity and neutrality for analytic work. Countertransference interpretation expands insight into the patient, as well as the analyst. Interpretation is not only resisted, but is reinterpreted by the analytic dyad with gradual partial insight and integration. The infantile unconscious, genetic interpretation, and reconstruction are often devalued in some object relations frameworks. A clinical vignette illustrates the continued importance of the past in the present without neglect of current determinants and perspectives. While integrating newer considerations of the two-person analytic field, interpretation and insight into the dynamic unconscious are here regarded as the sine qua non of psychoanalysis.

Psychodynamic profile and reflective functioning in patients with bulimia nervosa

ObjectiveThe aim of this study was to examine the general psychological functioning of patients suffering from bulimia nervosa (BN) using the Karolinska Psychodynamic Profile (KAPP). Furthermore, KAPP data and data from the Reflective Functioning scale (RF), measuring the ability to mentalize, were combined in order to examine differences in alexithymia, impulse control and affect regulation in patients with high or low RF. MethodSeventy patients with BN were interviewed with both the KAPP and the Adult Attachment Interview (AAI) from which RF is coded. Differences in KAPP scores of patients with high or low RF were analyzed. ResultsMost of the patients with BN were found to have a personality structure within the normal or neurotic range (n=50 of 70). BN patients with a high RF had significantly lower scores on KAPP's alexithymia scale than patients with a low RF score, demonstrating that poor mentalizing is related to alexithymia. Concurrently, patients with high RF showed problems with impulse control and coping with aggressive affects according to KAPP scores. ConclusionAlthough BN patients with high RF showed good capacities for describing their mental states, they still had difficulties regulating the emotions and impulses related to these states. Significant outcomeAmong patients suffering from BN, patients with high RF were significantly less alexithymic than low RF patients. LimitationsThe findings of this study are limited by the relatively small numbers of participants especially in the RF subgroups, posing a danger of not finding as significant existing differences in character pathology between high and low RF groups.

L’élaboration de l’agressivité à l’adolescence : étude structurale comparée basée sur le test de Rorschach

In adolescence, a component of a successful identity quest consists in elaborating the aggressiveness, be it endured or acted out, in an imaginary and symbolic manner. We will present a comparative study between anxious and violent adolescents, based on the Rorschach test. As the handling of aggressiveness by means of various defense mechanisms and coping strategies contributes to the construction of a sense of reality and of coherent representations of oneself and the others, the Rorschach test is a pertinent tool to study the vicissitudes of the identity quest of medium adolescence. On the other hand, many studies demonstrate that it is also a precious tool allowing diagnosis of the risks of evolution towards character pathology and personality disorders belonging to cluster B of the DSM, or towards emotional disorders and suicidal tendencies. Thus, it can help initiating appropriate therapeutic measures in a spirit of tertiary prevention. We present a comparative study between a sample of 20 adolescents suffering from anxiety and inhibition of aggressiveness (subgroup anxiety) and a second sample of 20 adolescents suffering from exteriorized aggressiveness and violent behavior (subgroup violence). The inclusion into the subgroups was based on clinical interviews and a thorough psychological assessment, using the criteria of categorical psychopathology. The comparative study between the two subgroups is based on an original rating scale constructed in the phenomenological and structural tradition, reflecting the global judgment of the experienced clinical psychologist. It permits using the Rorschach test as a research tool by making the step from qualitative analysis towards quantification and the use of inferential and multidimensional statistics. It also allows computing correlations between the Rorschach test and psychometric scales or other projective tests, using specific rating scales of the same type. After showing the descriptive demographic data, we present the results of the comparative between groups study (computed by means of Mann-Whitney's U test) and those of the multidimensional study (computed by means of the optimal scaling procedure HOMALS). The comparative study indicates that, with adolescents suffering from anxiety and inhibition, the emotional and relational needs are much greater, as is the tendency to direct one's aggressiveness against one self. Mentalization, documented by the richness, the originality, the level of integration and the maturity of associations is better developed in this subgroup. In the subgroup of adolescents characterized by exteriorized aggressiveness and violent behavior, the ambiguity of the stimulus causes perplexity, slowing down executive functions. The latent dimensions, extracted with the help of optimal scaling procedures, are meaningful at the light of current clinical psychology and create a typology of the adjustment to aggressive drives. They tend to illustrate the pertinence of the rating scale as a research tool and contribute in demonstrating its construct validity. The data of the comparative and multidimensional study are discussed in relationship with open questions in developmental and clinical psychology of adolescence. They highlight the role of the Rorschach test as a means to differentiate between temporary and long-term difficulties related to aggressiveness, as well as to show similarities and differences at the structural level of personality functioning between subgroups with interiorized and exteriorized aggressiveness. The psychological meaning of the latent dimensions, extracted with the help of optimal scaling techniques, are discussed in light of the recent research literature. Rorschach profiles can help indicate risks of evolution towards personality pathology at adult age. Let us stress that our latent dimensions are not focused on aggressiveness itself but rather on control functions liable to modulate its expression. Using the Rorschach test in pretest and posttest situation and exploring the change occurring during the psychotherapeutic interventions with the help of the rating scale (application of optimal scaling on Delta values) could open interesting tracks for future research in the realm of outcome and process evaluation of psychotherapies.

Self-Object Misuse in the Production of the False Self, with Comments on Victor Hugo’s The Man Who Laughs

This essay presents the case of a depressed, suicidal, but smiling “False-Self” character seen over four and one-half years of twice-weekly psychoanalytic psychotherapy. Countertransference reverie took the author to Victor Hugo’s phantastic novel, The Man Who Laughs , justly considered an arraignment of royalty, and the power, privilege, and capricious misuse of others. The analysis of that novel, about a child abused, narcissistically mortified, and surgically made to smile by order of a vengeful king is read as a case study on the production of False Self. Both “cases” demonstrate negatively tinged Self-esteem, impaired vitality and cohesion, and multiple discontinuities of the Self. Both follow Winnicott’s observation that coercion, mystification, and compliance across a malignant power differential are the breeding grounds of the False Self. The powerful—whether king or mother—misuse the powerless for purposes of mood regulation, producing a temporary lift in mood for the former and a more permanent character pathology in the latter.

Does psychoanalytic psychotherapy offset use of mental health services and related costs in severe borderline personality disorder? – A case study

Aims and methods: To show that long-term psychoanalytic psychotherapy can offset costs of psychiatric care when offered to a patient affected by borderline personality disorder with a severe presentation and co-morbid psychopathologies. Costs of mental health services were calculated for a nine-year period. Cost offset was calculated comparing the five years preceding therapy with the four years during and post-therapy. Results: In this case study the provision of long-term psychoanalytic psychotherapy has consistently and progressively reduced use of mental health services and related costs during the intervention and post-intervention period. Significant reduction in use of services and savings of approximately £5000 were obtained for the post-intervention year. Limitations: The research findings are limited by the lack of control conditions over confounding factors. Besides, cost-effectiveness could not be established. Clinical implications: Long-term psychoanalytic psychotherapy is rarely available in the modern National Health Service (NHS) and is unlikely to be offered to patients with severe character pathology. Although specialist tertiary services have been created to cater for this group, patients who cannot engage with these services risk not to be adequately treated. This case study suggests that long-term psychoanalytic psychotherapy could be used as a viable and cost-saving alternative for some of these patients.

Pragmatic Psychodynamic Psychotherapy—Bridging Contemporary Psychoanalytic Clinical Practice and Evidence-Based Psychodynamic Practice

Pragmatic psychodynamic psychotherapy (PPP; Summers & Barber, 2009) describes the therapeutic principles and approaches found in many forms of manualized psychodynamic psychotherapies, which are being used in research studies with the aim of building an evidence-based psychodynamic practice. This article focuses on one such treatment, Supportive-expressive psychotherapy (SEP; Luborsky 1984), which employs the Core Conflictual Relationship Theme (CCRT) method to formulate core interpersonal problems and treatment goals and identify therapeutic interventions. To illustrate SEP, we describe the 40-session treatment of a patient who met diagnostic criteria for several personality disorders. The case illustrates how complex ego-syntonic character pathology is expressed in CCRT terms and worked through in the transference, gradually becoming ego-dystonic and amenable to modification. In this case, the patient became more aware of his interpersonal wishes and vulnerability. Although his anxiety increased somewhat, he had an improvement in psychosocial functioning.

Biographer Explores Character, Pathology, and Achievement

Biographer Explores Character, Pathology, and Achievement

Key clinical processes in intensive short-term dynamic psychotherapy.

Davanloo's Intensive Short-term Dynamic Psychotherapy (ISTDP), while derived from traditional psychoanalytic theory, is a modified brief treatment with growing empirical support for its effectiveness with clients with psychoneurotic disorders and character pathology. This model describes key empirically derived processes that can bring ready access to unprocessed unconscious emotions that otherwise perpetuate widespread symptom and behavioral disorders. Herein we describe the metapsychological underpinnings, clinical application, and evidence for central interventions used in ISTDP through the use of a case example.

Testing theoretical models for future clinical practice in the treatment of psychopathy

The present study tests J.S. Wiggins and P.D. Trapnell's (1996. A dyadic-interactional perspective on the five-factor model. In J.S. Wiggins (Ed.), The five-factor model of personality: Theoretical perspectives (pp. 88–162). New York, NY: Guilford Press) meta-concepts of community and agency and H. Richards’ (1998. Evil intent: Violence and disorders of the will. In T. Millon, E. Simonsen, M. Birket-Smith, & R.D. Davis (Eds.), Psychopathy, antisocial, criminal, and violent behavior (pp. 69–94). New York, NY: Guilford Press) model of structural affective, relational, and defensive deviances in pathological extreme self-states in psychopathic high-security and detention prisoners, to identify areas where psychopaths may be influenced to change. Male inmates (n = 16) were compared to non-criminal and non-personality disordered controls (n = 35) on measures of parental bonding, symptom- and character pathology, and psychological defense. Results revealed a tendency toward parental overprotection or control. Attachment patterns characterized with neglect (lack of community) and affectionless control (lack of agency) were reported in more than half of the study's parental population. About 50% of the offenders were diagnosed with affective problems, and testing revealed high levels of immature defense. The possibility of a link between empirical findings and clinical theories provides therapists with knowledge that might be crucial for future treatment of psychopathy.

An Assessment of Psychopathology in Drug Addicted Victims: A Clinical Psychologist Perspective

There has long been an effort to develop a single unifying theory to explain the phenomenon of drug depend- ence. Some of these efforts have focused on psychoanalytic theory, various aspects of ego functioning, socio-economic factors, and physiological effects of drugs. Most investigators, however, have focused on character pathology in addicts and have considered addiction as representing one form of character disorder. There has been a lack of emphasis on various psychiatric conditions which could predispose and accompany drug dependence. This paper considers drug dependence as a multi-etiological phenomenon. This paper explores various psychiatric problems identified in drug dependent individuals and how they interact with the drug dependence. The use of psychotropic agents in the treatment of drug dependent persons is also explored.

Parallel Process and Projective Identification in Psychoanalytic Supervision

In the present paper I explore the notion of the parallel process, a controversial concept in psychoanalytic supervision. I suggest that the parallel process is essentially the operation of the defensive process of projective identification, which in some quarters is similarly viewed with skepticism and/or is mistakenly seen as primarily a malignant defense operating exclusively in severe character pathology (Kernberg, 1975; Mendelsohn, 2009). Further, I present several vignettes of psychoanalytic supervision where a series of parallel processes occurred, and I suggest that these parallel enactments are the result of the projective identifications which stimulated them. I agree with critical writers who say that simply suggesting the presence of a parallel process in the supervision adds no new information to the supervision, but I show how an exploration of the parallel enactments, which includes (1) exploring the patient-therapist dyadic dynamics, (2) a narrowly focused exploration of the dynamics of the therapist/presenter, and (3) and an exploration of the dynamics of the therapist-supervisor dyad, can enrich the treatment, as well as the supervision. Finally I suggest that while the projective identification that occurs in the supervisory dyad does not always lead to a parallel process, every parallel process is the result of projective identification(s). I further suggest that while every parallel process does not lead to an enactment via projective identification, enactments can only occur via the parallel process instigated by projective identification.

Treating Personality Disorder: Creating Robust Services for People With Complex Mental Health NeedsTreating Personality Disorder: Creating Robust Services for People With Complex Mental Health Needs MurphyNaomi and McVeyDes ; New York, Routledge, 2010, 320 pages, $55.95

Back to table of contents Previous article Next article Book ReviewsFull AccessTreating Personality Disorder: Creating Robust Services for People With Complex Mental Health NeedsBrian A. Palmer, M.D., M.P.H.Brian A. PalmerSearch for more papers by this author, M.D., M.P.H.Published Online:1 Apr 2012https://doi.org/10.1176/appi.ps.2012p400aAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Treating Personality Disorder: Creating Robust Services for People With Complex Mental Health NeedsMurphyNaomi and McVeyDes; New York, Routledge, 2010, 320 pages, $55.95Have you wished you could learn the condensed, practical wisdom of the most seasoned psychiatric nurse in your institution regarding the treatment of patients with personality disorders? Now you can.In Treating Personality Disorder, forensic psychologist Murphy and psychiatric nurse McVey bring considerable clinical experience and expertise to bear in this eminently readable and pragmatic volume. They draw from settings—prisons and hospitals—where “containment or management” has been the accepted strategy, and they challenge mental health professionals to do better. Plus they show us the path for doing so.Beginning with a description of character pathology that is hopeful but not sugarcoated, they outline how a number of systems issues collude to result in routinely poor patient care. They observe that training is inadequate and that nurses often resort to a medical model, even when faced with evidence of its ineffectiveness. Huge investments in brief cognitive-behavioral treatments are unlikely to be effective, yet they are emerging as the standard of psychotherapy. Because physician and nursing staff alike often lack a psychological understanding of personality, patients' bids to get needs met are sometimes interpreted with hostility.The authors take a sober look at the personal qualities required to be successful with this population, suggesting that many staff are likely ill suited for the work. Effective staff members bring a desire to work with patients with personality disorders, as well as good emotion-regulation skills, a capacity for self-reflection, robust self-esteem, the ability to set and hold limits, and the ability to perceive vulnerability of the patient, among other qualities.Chapter 4 meanders through questions of etiology, including trauma, and at one point suggests prioritization of an etiological focus, but by chapter 5, the book is fully back on track, presenting a number of very solid treatment strategies that could be useful for any mental health provider working with patients with personality disorders. Specifically, they advocate a primary relationship focus with appropriate emotional intimacy, built carefully by focusing on affect and identification of behavioral obstacles to tolerating emotions.A patient with a history of polysubstance dependence, eating-disordered behavior, self-injury, and angry outbursts once asked me, “Do all people have feelings?” These authors would answer yes to that question, and they advocate a stance of ongoing interest in the affective experience of the patient through systemically identifying and challenging barriers to emotional experiencing. One such barrier is the gap between the logical worlds of patient and clinician; for example, providers might assume that the kinds of relationships and ways of relating that make themselves feel safe and comfortable work as effectively with their patients.After two chapters on interdisciplinary work, the remainder of the book considers the roles of nursing, occupational therapy, prison officers, psychiatrists, and psychologists in working with patients with personality disorders. These chapters are worthwhile, although they contain less authentic wisdom than the chapters primarily written by Murphy and McVey.Despite its Britain-specific examples and occasional meandering, this volume is a welcome addition to the psychiatric services literature. It would be especially useful to treatment teams that provide care for patients with personality disorders.Dr. Palmer is a senior associate consultant in psychiatry at the Mayo Clinic, Rochester, Minnesota, and an assistant professor of psychiatry at the Mayo Clinic College of Medicine.The reviewer reports no competing interests. FiguresReferencesCited byDetailsCited ByNone Volume 63Issue 4 April 2012Pages 400-401 Metrics PDF download History Published online 1 April 2012 Published in print 1 April 2012

Overwhelming Patients and Overwhelmed Therapists

This article will address an aspect of many therapists’ practices that is often hidden from view. Therapists sometimes find themselves in impasses where they not only feel that progress is not being made but that they have had lapses in judgment. They report feeling both uncomfortable about their role and unable to extricate themselves from it. As members of a group that specializes in treating patients with personality disorders that have not responded to other approaches, we periodically get calls from therapists with regard to these overwhelming cases. 1 While this article will focus on the dynamics and management of these difficult situations rather than on an overall treatment approach, many of the concepts that we apply stem from the object relations–based model, called transference-focused psychotherapy or TFP (Clarkin, Yeomans, & Kernberg, 2006). The main ingredients of TFP can be described as follows: TFP is based on the clinical view that the symptoms of serious character pathology are manifestations of an underlying psychological structure that suffers from the lack of a coherent and consistent sense of self and others. The internal sense of self and others is built up of different pair