Character Pathology Research Articles

Standing in the spaces: Essays on clinical process, trauma, and dissociation.

This work recapitulates and extends a unique creative odyssey in modern clinical theory. Advancing no overarching theoretical system, Bromberg moves in ever widening exploratory circles as he works his way into the complexities of personality change. Early in these essays, the author contemplates how one might engage schizoid detachment within an interpersonal perspective. To his surprise, he finds that the road to the patient's disavowed experiences most frequently passes though the analyst's internal conversation, as multiple configurations of self-other interaction, previously dissociated, are set loose first in the analyst and then played out in the interpersonal field. This insight leads to other discoveries. Beneath the dissociative structures seen in schizoid patients and also in other personality disorders, Bromberg regularly finds traumatic experience - even in patients not otherwise viewed as traumatized. This discovery allows interpersonal notions of psychic structure to emerge in a new light, as Bromberg arrives at the view that all severe character pathology masks dissociative defenses erected to ward off the internal experience of trauma and to keep the external world at bay to avoid retraumatization. These insights, in turn, open to a new understanding of dissociative processes as intrinsic to the therapeutic process per se. For Bromberg, it is the unanticipated eruption of the patient's relational world, with its push-pull impact on the analyst's effort to maintain a therapeutic stance, that makes possible the deepest and most therapeutically fruitful type of analytic experience.

Psychological characteristics of candidates for liver transplantation: differences according to history of substance abuse and UNOS listing. United Network for Organ Sharing.

Liver transplantation for patients with a history of substance abuse remains controversial. Resumption of heavy alcohol use postoperatively is a threat to long-term survival, but recidivism among transplanted alcoholics is reportedly low. An argument against psychological evaluation prior to transplantation revolves around the speculation that candidates will attempt to portray themselves as more desirable prior to listing with UNOS (United Network for Organ Sharing). This study measured psychological distress, coping styles, optimism, selected personality features, and perception of family environment among 73 U.S. military veterans who were candidates for liver transplantation. Candidates with positive histories of substance abuse revealed significantly more distress, less adaptive coping styles, and more character pathology than their counterparts. The only significant difference according to UNOS listing was on one measure of family environment. Results support preoperative psychological assessment and intervention on a more extensive level for substance abusers and raise questions for future research.

Identification and classification of factitious disorders: an analysis of cases reported during a ten year period.

The current article offers a new conceptualization of factitious disorders based on cases reported in the literature. The current analysis examines twenty-nine cases of factitious disorder patients over the course of ten years (1986-1996). Cases were found through PSYCHLIT and MEDLINE searches. Patient variables examined include: demographics, occupational status, marital status, childhood history, extent of medical history, the presence of a borderline personality disorder, and presence of a psychosocial stressor prior to the onset of the factitious disorder. An examination of the cases found demographic patterns of illness presentation consistent with previous reviews of the disorder. From the examination emerged two distinct types of factitious presentations-one acute, one chronic. A two-dimensional approach is introduced in an attempt to understand various disease presentations. Cases were classified based on proposed Current Life Stress and Chronic Life Pattern dimensions. These dimensions are measures of the extent to which the patient's factitious presentation is in response to an immediate psychosocial stressor, or an action consistent with a long-term maladaptive behavior pattern resulting from an underlying character pathology. Three patient groups were identified based on estimated patient levels of each dimension. The three groups are: Stress Response, Life Response, and Mixed Response. Recommendations are made to increase the role of physicians in the detection of factitious patients, as well as to move toward a more uniform reporting of cases of factitious disorders in the literature.

A Closer Look at Sex Offender Character Pathology and Relapse Prevention: An Integrative Approach

Classical psychoanalysis has been unable to adequately address the underlying narcissistic character pathology in sex offenders and sufficiently reduce relapse. Recent theoretical constructs about the nature of attachments to others and the formation of self-esteem are discussed and applied to sexually exploitative behavior A new dimension of relapse prevention-the interpersonal dimension-is described, along with an enhanced explanation of the cycle of offending behavior and the nature of high-risk situations. Principles of change and recovery to follow in the treatment of the offender character pathology are also described This deeper theoretical understanding of the motivation of sex offenders has formed the basis for treatment developed by the Counseling and Psychotherapy Center (C.P.C.). Two cases serve to illustrate this theoretical approach.

Ferenczi's trauma theory.

Ferenczi's Trauma Theory Jay B. Frankel, Ph.D. Trauma was at the heart of Sandor Ferenczi's clinical concerns. Toward the end of his life, he became convinced that trauma was an important cause of much neurotic and character pathology, despite the fact that traumatic factors were generally neglected by other analysts (1933, p. 156).’ Ferenczi's final ideas about trauma were presented in very brief form—“a short extract” (1933, p. 156), as he said—in his final paper, “Confusion of Tongues Between Adults and the Child.” He intended to expand, develop, and reevaluate these ideas (Balint, 1958), but soon after he wrote this paper he became too ill to do so, and after several months he died. However, Ferenczi had published other papers that dealt with trauma, notably during the First World War on “war neurosis” (1916/17), and much later in his papers on relaxation technique (1929, 1930, 1931). In his last years, he also made many notes to himself on his ideas about trauma, among other topics, which were posthumously gathered together and published in the third volume of his collected papers (1955) under the title, “Notes and Fragments” (1920 and 1930-1932). These “Notes and Fragments” flank his Clinical Diary (1932), which was written between January and October 1932 but not published until 1985 (and not until 1988 in English), and which contains many additional clinical observations and ideas about trauma. The present paper will attempt to bring together all of Ferenczi's writings about trauma and to present them in a concise, integrated, and organized way.

Boundary violations and personality traits among psychiatrists.

To demonstrate that sexual abuse of patients by psychiatrists can be due to a variety of contributors, which may include therapists' psychopathic and narcissistic personality styles. Data from a prospective cohort of residents training in psychiatry were examined to evaluate the personality traits of 2 psychiatrists subsequently convicted of boundary violations. The 2 psychiatrists who lost their licenses were identifiable at the beginning of their residency training as individuals with significant character pathology. For some psychiatrists, repetitive sexual abuse of patients represents one aspect of an ongoing pattern of exploitative relationships. The professional and ethical implications of these findings as they relate to early identification for those at risk are considered.

Clinical psychologists' judgments of older adult patients with character pathology: Implications for practice.

Clinical psychologists' judgments of older adult patients with character pathology: Implications for practice.

Transference and Regression in and Beyond Analytic Group Psychotherapy: Revisiting Some Timeless Thoughts

ABSTRACTIn this article the author reconsiders the ideas of Durkin and Glatzer (1973/1997) on the process of transference and the function of regression in dyadic and group treatment in light of developments in contemporary analytic theory and practice. Transference is reexamined theoretically as a function of internal psychological processes. Transference and regression are also considered in relation to the nature and treatment of character pathology.

Clinical psychologists' judgments of older adult patients with character pathology: Implications for practice.

Clinical psychologists' judgments of older adult patients with character pathology: Implications for practice.

Technique and Metapsychology of the Early Working Through Phase of Davanloo's Intensive Short-Term Dynamic Psychotherapy

This article discusses the metapsychology and technique of the early working through phase of Davanloo's Intensive Short-Term Dynamic Psychotherapy. This is done by presenting a transcript of such a session with a highly resistant patient with complex character pathology with detailed description of nonverbal aspects of the patients behavior and analyzing the process in detail. Dr. Davanloo's continuing refinement of technique and metapsychology are included. © 1996 by John Wiley & Sons, Ltd.

The Sexually Sadistic Serial Killer

This article explores characteristics and crime scene behavior of 20 sexually sadistic serial murderers. The pairing of character pathology with paraphilic arousal to the control and degradation of others is examined as it manifests itself in their murders. Commonalities across murders and across murderers are highlighted, i.e., the execution of murders that are well-planned, the use of preselected locations, captivity, a variety of painful sexual acts, sexual bondage, intentional torture, and death by means of strangulation and stabbing.

"Someday ..." and "if only ..." fantasies: pathological optimism and inordinate nostalgia as related forms of idealization.

Fantasies whose core is constituted by the notions of "someday" and "if only" are ubiquitous in human psyche. In severe character pathology, however, these fantasies have a particularly tenacious, defensive, and ego-depleting quality. The "someday" fantasy idealizes the future and fosters optimism, and the "if only" fantasy idealizes the past and lays the groundwork for nostalgia. The two fantasies originate in the narcissistic disequilibrium consequent upon the early mother-child separation experiences, though the oedipal conflict also contributes to them. Both can be employed as defenses against defective self and object constancy as well as later narclssistic and oedipal traumas. This paper attempts to highlight the metapsychology and behavioral consequences of these fantasies as well as their unfolding in the treatment situation. It suggests six tasks to be especially important for analytic work with such patients: (1) providing and sustaining a meaningful "holding environment"; (2) employing "affirmative interventions"; (3) helping the patient unmask these fantasies and interpreting their defensive, narcissistic and sadomasochistic aspects; (4) rupturing the patient's excessive hope, analyzing the effects of such rupture, and facilitating the resultant mourning; (5) reconstructing the early scenarios underlying the need for excessive hope; and (6) paying careful attention to countertransference feelings throughout such work.

The characterological basis of multiple personality.

This review has focused on the characterological features of dissociative identity disorder (DID), extending the "state versus trait" debate to the realm of the dissociative disorders. A number of different theories are presented describing DID as a variant of, on a continuum with, or being comorbid with the narcissistic and the borderline personality disorders. It is then hypothesized that DID is best considered a distinct characterological entity. Two theories are put forth, which describe a personality disorder whose predominant defense is dissociation. The more developed model which possibly has more explanatory value is the "dissociative character." In this schema, DID would be considered a lower-level dissociative character, utilizing primitive forms of dissociation in which splitting is enhanced by an autohypnotic defensive altered state of consciousness. These altered states originate in response to the overstimulation of external trauma, but get reactivated in the service of here-and-now intrapsychic conflicts. Recognition of this dual quality of dissociation seems helpful in psychodynamic treatment, which allows for analysis of the defense and analysis of the content of these states. The nature of the content of what is "in dissociation" appears to have a dreamlike quality to it that may correspond to previous trauma but also be subject to some secondary revision. There is clinical evidence to suggest that "dream work" of the ego is operative in both the representation of a separate self in dreams and in alter personalities. Another organizing influence which contributes to seemingly separate identities is that of perverse sexuality. It appears that a number of dissociated sexual pathways may be followed in the same individual, which encapsulate aggression, childhood trauma, anxiety, and a sense of self. When this exceedingly complex psychic structure is successful, it may then free up some ego to proceed with aspects of healthy development.

Character and psychotherapy.

Psychoanalytic theory of psychopathology began as a theory of particular pathogenic agents in the form of repressed memories or drive-generated fantasies. It has developed in the direction of a theory of the mind's organization; that is, a theory of character pathology. A characterological understanding of psychopathology enlarges therapeutic attention beyond the patient's verbal references and toward the patient himself in the "here and now."

Long-term psychotherapy in borderline and narcissistic disorders: when is it necessary?

This paper explores the barriers and impediments to psychological change in those patients with borderline and narcissistic character pathology requiring long-term psychotherapeutic treatment. Examination of the relevant literature was made and the author's clinical experience included. Those patients with borderline and narcissistic character pathology requiring long-term psychotherapeutic treatment to achieve lasting psychological change are characterised by their experience of severe early developmental trauma. This has resulted in the formation of entrenched adverse relational patterns which are unconscious, difficult to bring into consciousness and slow to change. These patients have failed to establish security of attachment patterns in the course of a depriving and/or traumatic childhood, often in the care of parents with similar character pathology. Such patients will often require a therapeutic relationship with an emotionally responsive therapist sustained over time within a secure therapy frame to achieve lasting psychological change. Patients with borderline and narcissistic pathology who have sustained severe early developmental trauma will often require long-term psychotherapeutic treatment to achieve lasting psychological change. Such treatment is necessary for the relief of suffering in the patients, and may contribute to the alleviation or prevention of the intergenerational transmission of these disorders.

On Those Wrecked By Success: A Clinical Inquiry

Freud's description of those wrecked by success outlines conflicted oedipal triumph as the central underlying dynamic in this character type. It does not distinguish those patients who avoid success from those driven to achieve and then wreck their success. We present a complex picture that we believe is prototypic of patients who destroy their success. A clinical case illustrates our point of view. We emphasize the developmental problems we believe typical of patients who dramatically wreck the success they achieve. We hope to extend rather than replace Freud's landmark contribution to our understanding of this type of character pathology.

The Nature and Function of a Pathological Oedipal Constellation in a Female Patient

The first analysis of a female patient dealt essentially with separation-individuation and narcissistic issues. During the second analysis a dynamic constellation of narcissistic character pathology, some psychopathic tendencies, perverse fantasies, and enactments emerged. Prominent was an unconscious fantasy of stealing the sexual organs of one parent to sexually satisfy the other parent. The etiology of this constellation and its transmutations in analysis are described.

Therapeutic action and procedural knowledge a case study

Abstract Two types of memory processes, declarative and non-declarative have been identified by cognitive scientists. Cognitive science is currently making a distinction between 1) declarative memory and non-declarative memory. This paper is concerned with one type of non-declarative memory, procedural memory. Declarative knowledge refers to the things we know such as names, places, dates. Procedural knowledge is information associated with a highly practiced schema or action which is usually not conscious when the sequence is activated. The implications of procedural knowledge for psychoanalytic treatment are now beginning to be explored. This paper is a further step in this exploration. It has been hypothesized that because of the automaticity of learned procedures underlying character pathology, character change can best be accomplished by intervening at the procedural level. This paper suggests that such interventions are optimal when they are noninterpretive and occur within the context of an interactive, mutually regulated, dyadic system. Procedures, when they become accessible to the analyst through empathy and introspection, can be, and in the case discussed below, were addressed within the context of the dyad. The psychotherapy of an adult man with difficulties at the procedural level is utilized to illustrate the importance of noninterpretive interventions that address the procedure in order to engage it in the dyad where it can begin to undergo therapeutic transformation. This paper illustrates the importance of understanding procedural knowledge and how this can provide a valuable additional tool to shape the modes of therapeutic action utilized in psychoanalytic treatment.

Bipolar II: Not so different when co‐morbidity excluded

AbstractSubjects with unipolar depression and bipolar disorder types I and II who had been selected to be free of recent substance abuse and severe character pathology as part of their participation in two research studies, were compared on a number of clinical features. No significant differences were observed between bipolar I and II subjects on any of these measures. These results are consistent with the suggestion that previously reported differences between bipolar I and II might be attributable in part to the presence of character pathology and substance abuse in unselected bipolar II populations. Depression 3:154–156 (1995). © 1995 Wiley‐Liss, Inc.

Dimensions of self-concept: a comparison of heroin and cocaine addicts.

Two groups of drug users on an inner-city inpatient drug detoxification unit were studied: 42 heroin addicts and 47 cocaine addicts. The two groups were compared on personality disorder diagnoses, personality traits, and demographic variables. Cocaine and heroin addicts scored similarly on: 1) number and kind of personality disorder diagnoses, with the exception of antisocial personality; 2) all personality traits measured; 3) positive and negative temperament; 4) description of self-concepts; and 5) positivity and negativity of self-concepts. It was also found that heroin addicts showed significantly higher levels of social deviance than the cocaine group, with significantly more antisocial personality disorder diagnoses, higher levels of social deviance, and lower scores on a Propriety Scale. Character pathology was more heterogeneous among cocaine users. Heroin addicts had used significantly longer and showed less educational and occupational achievement than the cocaine group. Our results also suggest that personality psychopathology in drug addicts is associated with lower self-esteem, more negative self-valuation, and longer duration of use.