Diagnosing borderline conditions in an outpatient setting.

Application of the Gunderson-Kolb Diagnostic Interview for Borderline to a population of psychiatric outpatients suggested two complicating factors in diagnosing borderline conditions in an ambulatory setting: the reduced level of borderline symptoms and the confounding presence of recompensated psychotic patients. Overlap between the Gunderson and Kernberg borderline constructs, which is relatively high in the inpatient setting, is diminished in the outpatient setting. Contrary to expectation, distinguishing borderline patients from patients with other personality disorders was not a source of difficulty.

The initial contract in the treatment of borderline patients.

The initial treatment contract with a borderline patient recognizes the patient's potential for destructiveness and builds in safeguards. The therapist's effort to protect the treatment mobilizes the patient's primitive defenses. The therapist must be prepared to respond to resistance to the contract by clarification, confrontation, and occasionally interpretation. Although countertransference reactions evoked by the patient's use of primitive defenses complicate the therapist's task of defining the necessary treatment frame, the therapist's recognition of countertransference responses can enable him to establish and enforce an appropriate contract.

Two reviews of the literature on borderlines: an assessment.

The author discusses Liebowitz's (1979) and Rieder's (1979) reviews of current issues regarding the diagnosis of borderline patients. He cites the need for further research examining the basic characteristics of the borderline syndrome. He also recommends that greater attention be directed toward defining subtypes of the syndrome. The author believes that a combination of the descriptive approach of Gunderson and Kolb (1978) and his own psychostructural approach (Kernberg 1977) would prove fruitful.

Aggression, trauma, and hatred in the treatment of borderline patients.

This article focuses on the etiology of aggressive affect, behavior, and fantasy in the treatment of patients with severe personality disorders in an effort to further our understanding of the psychopathology and treatment of these patients. In the process, the relationship between inborn disposition to aggressive behavior and the effect of severe trauma and psychosocial pathology in early childhood are examined. Various types of transferences marked by aggression and specific approaches to each of these are outlined. Particular reference is given to the management of intense hatred--as a derivative of aggression--in the transference, and of the unconscious identification with both victim and victimizer in patients who have experienced sexual or physical abuse.

Projective identification, countertransference, and hospital treatment.

The principal purpose of this article is to illustrate the pivotal function of projective identification within the therapeutic milieu of the hospital. A detailed description of crises in the treatment of two patients undergoing long-term inpatient psychiatric treatment is given. These patients suffered from very different psychiatric illnesses; hence, their cases illustrate some features of hospital treatment that cut across different types and degrees of severity of psychopathology.

The narcissistic personality disorder and the differential diagnosis of antisocial behavior.

This article describes a dimension of antisocial behavior that links the narcissistic personality disorder with the antisocial personality disorder, with the syndrome of malignant narcissism as intermediate between the two. Starting with a critique of the DSM-III-R description of the antisocial personality disorder, the author reviews some salient contributions to the concept of the antisocial personality disorder derived from descriptive, sociologic, and psychoanalytic viewpoints. Cleckley's classic description forms the historical background for an updated description of the key characteristics of the antisocial personality disorder. What follows is a summary of the differential diagnosis of antisocial behavior as found in the antisocial personality disorder, the syndrome of malignant narcissism, the narcissistic personality disorders with antisocial behaviors, other severe personality disorders with antisocial features, neurotic personality disorders with antisocial features, symptomatic neuroses, and, finally, dissocial reactions. Prognostic and therapeutic considerations regarding the treatment of antisocial behavior are briefly summarized in the light of this differential diagnosis. A final section describes the psychodynamics of the syndrome of malignant narcissism and of the antisocial personality disorder.

An ego psychology object relations theory of the structure and treatment of pathologic narcissism. An overview.

This article summarizes the author's contributions to the psychoanalytic understanding of narcissistic personality disorders and their application to a theory of psychoanalytic and psychotherapeutic techniques for the treatment of these patients. The treatment is described as primarily focused on the analysis of the pathologic grandiose self in the transference. The early stages of this transference analysis are differentiated from later stages in the treatment, when the gradual dissolution of the pathologic grandiose self brings to the surface the underlying, dissociated, primitive object relations reflecting unconscious conflicts. The final stage of the treatment is described as approaching the characteristics of the treatment of neurotic patients. Finally, expressive or exploratory psychotherapy and supportive psychotherapy for narcissistic patients are described as psychoanalytically derived alternative treatment methods, and their respective indications and techniques are briefly summarized.

The suicidal risk in severe personality disorders: differential diagnosis and treatment.

This article describes the clinical approach to patients with severe personality disorders who present suicidal intention and behavior, developed at the Personality Disorders Institute of the Department of Psychiatry at Cornell University Medical College and the Westchester Division of the New York Presbyterian Hospital. It describes the diagnostic evaluation of patients' suicidal potential, personality disorder, and the presence or absence of a spectrum of regressive illness. The analysis of the combined features in these three symptomatic domains determines alternative strategies of psychotherapeutic and psychopharmacological interventions. Within these strategies, transference-focused psychotherapy is described as a specific psychodynamic psychotherapy geared to treat characterologically based suicidal and parasuicidal tendencies in the context of the treatment of the patient's personality disorder.

The development of a psychodynamic treatment for patients with borderline personality disorder: a preliminary study of behavioral change.

This study examines the effectiveness of a modified psychodynamic treatment called Transference Focused Psychotherapy (TFP) designed specifically for patients, with borderline personality disorder (BPD). Twenty-three female patients diagnosed with DSM-IV BPD began twice-weekly TFP. Patients were assessed at baseline and at the end of 12 months of treatment with diagnostic instruments, measures of suicidality, self-injurious behavior, and measures of medical and psychiatric service utilization. Compared to the year prior to treatment, the number of patients who made suicide attempts significantly decreased, as did the medical risk and severity of medical condition following self-injurious behavior. Compared to the year prior, study patients during the treatment year had significantly fewer hospitalizations as well as number and days of psychiatric hospitalization. The dropout rate was 19.1%. This uncontrolled study is highly suggestive that this structured and manualized psychodynamic treatment modified for borderline patients shows promise for the ambulatory treatment of these patients and warrants further study.

The Inventory of Personality Organization: psychometric properties, factorial composition, and criterion relations with affect, aggressive dyscontrol, psychosis proneness, and self-domains in a nonclinical sample.

This report describes 2 studies of the psychometric characteristics of the primary clinical scales of the Inventory of Personality Organization (IPO; O. F. Kernberg & J. F. Clarkin, 1995), which assess reality testing, primitive psychological defenses, and identity diffusion, in a nonclinical sample. The 3 IPO scales display adequate internal consistency and good test-retest reliability. Item-level confirmatory factor analysis supported a two-factor structure of the IPO consistent with O. F. Kernberg's (1984, 1996) model of borderline personality organization. Each of the 3 IPO scales was associated with increased negative affect, aggressive dyscontrol, and dysphoria as well as lower levels of positive affect consistent with Kernberg's model of borderline personality organization. The IPO Reality Testing scale is closely related to various measures of psychotic-like phenomena.

Regression in organizational leadership.

The choice of good leaders is a major task for all organizations. Inforamtion regarding the prospective administrator's personality should complement questions regarding his previous experience, his general conceptual skills, his technical knowledge, and the specific skills in the area for which he is being selected. The growing psychoanalytic knowledge about the crucial importance of internal, in contrast to external, object relations, and about the mutual relationships of regression in individuals and in groups, constitutes an important practical tool for the selection of leaders.

Suicidal behavior in borderline patients: diagnosis and psychotherapeutic considerations.

This paper summarizes the experiences with suicidal and parasuicidal behavior of the psychotherapy research project on borderline patients in progress at the Westchester Division of the New York Hospital-Cornell Medical Center. In the diagnostic evaluation of these patients, it is important to differentiate acute and chronic suicidal behavior with the presence or absence of depression. The dominant psychodynamic features of chronic characterological suicidal behavior are reviewed, with a particular emphasis on the psychopathology of self-directed and projected primitive hatred, and the defenses against its conscious awareness on the part of the patient. A general psychotherapeutic strategy to deal with suicidal and self-destructive behavior is mapped out, centered upon the transformation of self-destructiveness into specific transference constellations that must be diagnosed, interpreted, and gradually worked through in the transference in the course of the treatment. The treatment of chronic, characterologically anchored suicidal behavior without depression requires the setting up of specific structuring of the psychotherapy from the very beginning of treatment, embodied in the establishment of a treatment contract that contributes to the organizing frame for the entire psychotherapy. The precondition for this psychotherapeutic work and limiting factors affecting its effectiveness are spelled out.

Psychoanalytic perspectives on the religious experience.

This paper carries out an analysis of the nature of mature religiosity of the basis of psychoanalytic findings and concepts, rather than attempting a philosophical and theological approach to religion. It highlights a striking correspondence between the characteristics of mature religiosity, derived from the various sources of development of the ego-ideal and the superego, and reflecting a dominance of love over hatred, of libido over the death drive as an aspect of psychological health and maturity, on the one hand, and the characteristics of the Deity in Judeo-Christian religions, on the other. At a clinical level, one of the functions of the psychotherapist is to explore the extent to which religiosity as a mature desire for a transpersonal system of morality and ethical values is available to our patients. Psychotherapy also has to help certain patients to free themselves from the use of formal religious commitments as a rationalization of hatred and destructiveness directed against self or others.

The current status of psychoanalysis.

Presented here is an overview of current challenges and controversies regarding psychoanalysis as a science, competing psychoanalytic theories, convergent and divergent trends in psychoanalytic technique, psychoanalytic education, psychoanalysis as a profession. Among other issues stressed are the importance of the relation of psychoanalysis to the University, the research implications of competing theoretical and technical orientations, the need to reexamine the structure of psychoanalytic education, and the importance of international cross-fertilization in expanding the application of psychoanalysis to other fields.

The couple's constructive and destructive superego functions.

Just as the couple becomes the repository of both partners' conscious and unconscious sexual fantasies and desires, and of their consciously and unconsciously activated internalized object relations, so does the couple activate both partners' conscious and unconscious superego functions. The interaction of the partners' superego over time results in the forging of a new system, which I am calling the couple's superego. The functions of the couple's joint superego structure is described, as are the symptoms of superego pathology in the couple's love life. The vicissitudes of gratitude and guilt, of stereotyping and conventionality, of deceptiveness and long-range destructive and self-destructive scenarios, are explored in the context of a spectrum reflecting the severity of joint superego pathology. A clinical case vignette illustrates some of these developments in a couple's life.

Love in the analytic setting.

In the context of viewing the analytic setting as a "clinical laboratory" to study the nature of love relations, this paper starts by outlining the relationships of transference love, "normal" love, neurotic love, and oedipal love. After a description of the vicissitudes of transference love when patient and analyst are of the same sex and of opposite sex, developments of transference love regarding homosexual and heterosexual longings in neurotic and narcissistic pathology are considered. Countertransference reactions in response to transference love are explored next, with emphasis on conditions under which erotic countertransference may become particularly intense. In describing the technical management of erotic countertransference, the analyst's ability to explore his own feelings and fantasies without constraint is stressed. The usefulness of understanding the erotic countertransference in arriving at transference interpretations is illustrated by a clinical case of a female patient with a neurotic personality structure and predominantly masochistic conflicts.

Sadomasochism, sexual excitement, and perversion.

Sadomasochism, an ingredient of infantile sexuality, is an essential part of normal sexual functioning and love relations, and of the very nature of sexual excitement. Sadomasochistic elements are also present in all sexual perversions. Sadomasochism starts out as the potential for erotic masochism in both sexes, and represents a very early capacity to link aggression with the libidinal elements of sexual excitement. Sexual excitement may be considered a basic affect that overcomes primitive splitting of love and hatred. Erotic desire is a more mature form of sexual excitement. Psychoanalytic exploration makes it possible to uncover the unconscious components of sexual excitement: wishes for symbiotic fusion and for aggressive penetration and intermingling; bisexual identifications; the desire to transgress oedipal prohibitions and the secretiveness of the primal scene, and to violate the boundaries of a teasing and withholding object. The relation between these wishes and the development of erotic idealization processes in both sexes is explored in the context of a critical review of the pertinent psychoanalytic literature.

Aggression and love in the relationship of the couple.

In this paper I examine the interplay of love and aggression in a couple's emotional relationship. I explore the activation of dominant repressed or dissociated object relations with the parental figures, and the unconscious collusion of both partners to enact these past relationships in the present. I then examine the couple's relationship as determined by differences in male and female development, as well as the counterpart of these differences--unconscious moves toward "twinship" and complementarity. Unresolved oedipal conflicts are explored as a major cause of invasion of the couple's sexual boundaries, and a vehicle for the expression of dissociated aggression from many sources. Perversity--the "recruitment of love at the service of aggression"--as a threat to the basic fabric of a couple's love life is one alternative to the normal channels for elaboration of aggression in their relationship. Protective functions of the couple's interaction with their social network are examined in the context of their elaborating and integrating aggression with love.

Some implications of object relations theory for psychoanalytic technique.

Whereas, traditionally, object relations theory--a refinement of structural theory that links structure more closely with genetic and dynamic aspects of mental functioning--has been applied mostly to the understanding and treatment of patients with severe regression in the transference, it also has application for technique in the standard psychoanalytic situation. This paper has focused on the object relations approach to the nature of conflicts to be interpreted in the transference; the varying relationships between transference, genetic history, and early development, revealed by an object relations focus; the technique used under conditions of regression in the communicative process in the transference; and the relation of empathy and regression in the transference. Two clinical cases are presented to illustrate the points made.

Self, ego, affects, and drives.

I have explored the concepts of self, ego, affects, and drives, with special emphasis on terminological confusions and Freud's use of Selbst and Ich. I have also proposed a modification of the dual instinct theory in the light of the relation between affect and drives. Finally, I have proposed a developmental model on the basis of all the above considerations, and stressed its relevance for the classification of nonorganic psychopathology.