Normal and abnormal personality organization
The model of personality organization is based on Kernberg’s psychoanalytic object relations theory, supported by current research. Psychodynamic treatment presupposes that observable behaviors and subjective disturbances of patients with personality disorders reflect pathological features of underlying psychological structures.
Borderline pathology was described by Kernberg and Gunderson, who identified a pathological psychological structure, called Borderline Personality Organization (BPO), in patients with severe personality disorders. This group had poor impulse control, ego weakness, and pathological internalized object relations, which resulted in loss of reality testing and delusional ideas.
While Kernberg described these patients in terms of both descriptive pathology and structural characteristics, other researchers used a purely descriptive approach to identify patients with intense affect. Many of the descriptive characteristics of these patients were used to formulate the diagnosis of BPD for the first time in the diagnostic system.
Borderline pathology
The psychodynamic conceptualization and treatment of personality disorders presuppose that observable behaviors and subjective disturbances reflect underlying pathological features of psychological structures. The psychological structure is an enduring pattern of mental functions that organizes behavior, perceptions, and subjective experience. A central characteristic of severe personality disorders is the nature and degree of integration of the sense of self and others, which determines the spectrum of personality organization from normal, over neurotic to psychotic.
Object relations theory emphasizes that drives are always experienced in relation to a specific other, forming internalized object relations that serve as organizers of motivation and behavior. The drives described by Sigmund Freud— libido and aggression—are always experienced in relation to a specific other, an object of the drive. Internalized object relations are the building blocks of psychological structures and serve as the organizers of motivation and behavior. These building blocks are units composed of self and other representations linked by an affect related to a drive, called object relations dyads. It’s important to note that the self and object in the dyad aren’t accurate representations of the entirety of the self or other, but rather specific moments in time during early development processed by internal forces like primary affects and fantasies.
Normal personality development and its deviations
To understand personality pathology, it’s important to have a clear conception of normal personality functioning. Personality is a combination of behavior patterns rooted in temperament, cognitive capacities, character, and internalized values.
Temperament refers to an innate disposition to react to stimuli, and it’s linked to affective responses. The intensity, type, and range of affect exhibited in childhood are important in understanding Borderline Personality Organization (BPO).
Affective responses are also influenced by cognitive processes, which are crucial in transforming primitive affective states into complex emotional experiences.
Character is the behavioral manifestation of identity and is influenced by internalized relations with significant others. Identity is the integration of self-representations and significant other representations.
Finally, the internalization of significant object relations gives rise to an integrated system of ethical values known as the Super-Ego. Disturbances in this structure can have significant clinical implications for borderline pathology.
Normal personality organization
A person with normal personality organization has a well-integrated and coherent sense of self and others, which is reflected in their identity. This coherence enables them to have a positive self-esteem, enjoy relationships with others, and maintain a sense of continuity over time. It also allows them to make emotional commitments to others while maintaining autonomy. Their ability to establish stable and intimate relationships is a result of their coherent identity.
A second characteristic of normal personality organization is the presence of a wide range of affective experiences that are well-modulated without loss of impulse control. Defense mechanisms are crucial in managing anxiety related to conflicts within the self or between urges and external reality. A coherent identity associated with well-functioning psychological defences allows the individual to understand and absorb intense affects. In contrast, individuals with personality disorders often have difficulty containing intense affects and require therapy to help them to integrate these emotions.
A third characteristic of normal personality organization is the presence of an integrated system of internalized values that reflects a sense of personal responsibility, self-appraisal, and decision-making that is flexible and committed to standards, values, and ideals. This internal structure of values is rooted in parental values and prohibitions but becomes stable, individualized, and independent of external relations with others.
Overall, normal personality organization is characterized by a well-integrated and coherent sense of self and others, a broad spectrum of affective experiences that are well-modulated, and an integrated system of internalized values that reflects personal responsibility and commitment to standards, and ideals.
Developmental factors
Developmental factors play a critical role in shaping an individual’s psychological structure. Internalized object relations dyads, formed through affectively intense experiences in infancy, become prototypes of an individual’s experience of self and other. Object relations theory suggests that the combination of an infant’s temperament and experiences in interactions with caretakers is crucial to development. Optimal infant-caregiver interactions create a secure attachment that helps the infant deal with negative experiences on the developmental path.
Infants experience periods of high affective intensity, usually related to needs or wishes for pleasure or fears or wishes to get away from pain. These intense affects help immature mammals survive through pleasure/nurturance seeking and harm avoidance and signal needs via affect expression to the caregiver. Peak-affect experiences may facilitate the internalization of primitive object relations, which influence the developing individual’s motivational system. The infant’s satisfying experiences involve an ideal image of a perfect nurturing other and a content, satisfied self, whereas the frustrating experiences involve a totally negative image of a depriving or even sadistic other and a needy, helpless, anxious self.
Disruptions in the infant-caregiver interaction
Disruptions in the infant-caregiver interaction can lead to deviations in the optimal developmental path and cause negative experiences to take on a more dominant role in the developing mind. The conception of self and others develops from an early age and depends on the emergence of language and the encoding of semantic and episodic memories. Disruptions in the relationship between the child and caregivers and/or the presence of trauma have a profound effect on the developing conception of self and others.
Early sexual abuse
Early sexual abuse, caregiver neglect, indifference, and empathic failures have been identified as additional factors with profound, deleterious effects. Children reared in disturbed environments form insecure attachments with their primary caregivers that interfere with the development of capacities for effortful control and self-regulation, and the internalization of conceptions of self and other are compromised by intense negative affect and defensive operations that distort the information system in an attempt to avoid pain.
Developmental factors
Developmental factors play a critical role in an individual’s psychological structure, with internalized object relations dyads becoming prototypes of an individual’s experience of self and other. Optimal infant-caregiver interactions create a secure attachment that helps infants deal with negative experiences, whereas disruptions in the interaction can lead to deviations in the optimal developmental path. The presence of trauma, sexual abuse, caregiver neglect, indifference, and empathic failures can have profound and deleterious effects on the developing conception of self and others.
Affects and internal objects relations
To engage in healthy self-reflection, several mechanisms are necessary. These include internalizing dyadic relationships, integrating concepts of self and significant others, and acquiring a comprehensive understanding of others. Understanding others in-depth is essential to evaluate their behavior in context and beyond a single moment. When our evaluation of others is distorted by internal images, we cannot accurately reflect on them. We become limited to the narrow representation of the person that is immediately triggered in our interactions. This limits our ability to judge others beyond their current emotional state and actions. Instead, we should strive to understand the complexity of others and avoid defining them solely by their current behavior.
Diagnosing pathological personality
Personality pathology is visible in behavior as well as at a structural level. At the behavioral level, personality disorders can cause inhibition of normal behaviors or exaggeration of certain behaviors. Contradictory behaviors and oscillation between them are also common. At the structural level, personality can be organized with or without a coherent sense of identity. Identity diffusion refers to the lack of a coherent sense of self and others. Considering concepts like defense mechanisms, reality testing, object relations, aggression, and moral values can help conceptualize different degrees of personality organization. As one moves from normal to neurotic to borderline to psychotic personality organization, the levels of pathology can range from healthy to increasingly dysfunctional. Thus, understanding the levels of pathology can aid in developing a more comprehensive understanding of personality disorders.
Neurotic Personality Organization
Patients with neurotic personality organization (NPO) differ from those with borderline personality organization (BPO). NPO patients have an integrated identity with a mature defensive strategy that revolves around repression rather than splitting. Repression helps them keep their disturbing thoughts and emotions under control without acute effects on their lives or interpersonal interactions. Neurotic defenses involve an integrated self-concept and object representations that provide stability, unlike BPO. For example, a neurotic individual might use reaction formation as a defense mechanism to deal with aggression. They might behave politely and submissively with authority figures but repress any rebellious or aggressive tendencies that don’t fit their coherent sense of self. This allows them to maintain a consistent self-concept while keeping conflicting emotions at bay. In contrast, BPO patients experience abrupt changes in affect states and manifest behavioral characteristics that distort their lives and interactions with others. By understanding the differences between NPO and BPO, clinicians can better identify and treat personality disorders.