Personality disorders from a psychoanalytic point of view

Personality disorders.

Psychoanalysis has made fundamental contributions to the understanding of personality disorders, interpreting them as outcomes of deep psychic conflicts and difficulties in identity development. Compared with cognitive and behavioral approaches, psychoanalysis investigates the unconscious roots of disorders, seeking to understand how childhood experiences and intrapsychic dynamics have shaped personality structure.

Personality structure and psychoanalytic disorders

According to Sigmund Freud, personality is composed of three basic instances: the id, superego and ego. Personality disorders can be interpreted as outcomes of an imbalance between these components. Otto Kernberg, among the leading contemporary psychoanalysts, developed a structural theory based on three levels of personality organization:

• Neurotic organization: characterized by a well-integrated ego and a clear distinction between self and other.
• Borderline organization: characterized by a fragmented identity, primitive defense mechanisms (such as splitting) and difficulty regulating emotions.
• Psychotic organization: characterized by severe reality impairment and a very weak ego.

Personality disorders can affect people with different types of personality organization, and the related characteristics will vary slightly according to the type of organization.

Defense mechanisms and personality disorders

Defense mechanisms are automatic psychological processes that individuals use to manage painful emotions or intrapsychic conflicts. They may be more or less mature and profoundly affect personality functioning. In general, defense mechanisms are divided into:

• More evolved defense mechanisms: contribute to effective adaptation and emotional regulation. Some examples are:
• Removal: excludes painful thoughts or memories from consciousness.
• Sublimation: transforms undesirable impulses into socially acceptable activities.
• Rationalization: justifying a behavior or emotion logically to reduce its emotional impact.
• Affective isolation: separates the emotion from the event that provoked it, allowing it to be dealt with in a detached way.
• More primitive defense mechanisms: these are less adaptive and often associated with more severe personality disorders. Some examples are:
• Splitting: rigidly separates the positive and negative aspects of self and others, preventing integration.
• Projection: ascribes to others own impulses or feelings that are unacceptable.
• Projective identification: projects parts of oneself onto another person and tries to influence them to live and act them out in the relationship.
• Denial: refuses to acknowledge a painful reality.
• Acting out: expressing emotions through impulsive actions, without cognitively processing them.

List of personality disorders according to the PDM and related defense mechanisms

The Psychodynamic Diagnostic Manual (PDM) classifies personality disorders from a psychoanalytic perspective. Personality disorders are of different types and differ according to the defense mechanisms predominantly used by the person:

• Paranoid personality disorder: characterized by extreme suspiciousness and distrust of others. Defense mechanisms: projection, denial, rationalization.
• Schizoid personality disorder: marked detachment from social relationships and reduced emotional expression. Defense mechanisms: isolation, retroactive avoidance, idealization of an internal world.
• Schizotypal personality disorder: eccentric behavior, magical thinking, and difficulties in relationships. Defense mechanisms: dissociation, magical thinking, splitting.
• Borderline personality disorder: emotional, relational and identity instability, with intense fear of abandonment. Defense mechanisms: splitting, projective identification, acting out.
• Narcissistic personality disorder: grandiosity, need for admiration and lack of empathy. Defense mechanisms: idealization, devaluation, denial, projection.
• Antisocial personality disorder: disregard and violation of others’ rights, impulsivity and lack of remorse. Defense mechanisms: rationalization, acting out, denial.
• Histrionic personality disorder: constant attention-seeking, excessive emotionality and theatricality. Defense mechanisms: dissociation, repression, dramatization.
• Obsessive-compulsive personality disorder: perfectionism, mental rigidity and excessive control. Defense mechanisms: affective isolation, retroactive avoidance, rationalization.
• Avoidant personality disorder: strong fear of judgment and tendency to avoid relationships for fear of rejection. Defense mechanisms: avoidance, projection, isolation.
• Dependent personality disorder: excessive need to be cared for, difficulty making decisions independently. Defense mechanisms: introjection, identification, denial of autonomy.
• Depressive personality disorder: persistent sense of inadequacy and pessimism. Defense mechanisms: introjection, repression, idealization of the other.
• Masochistic personality disorder: tendency to seek suffering and self-sabotage. Defense mechanisms: identification with the aggressor, introjection, denial of the need for pleasure.

The role of childhood experiences

In the psychoanalytic perspective, personality disorders often stem from traumatic childhood experiences, particularly related to relationships with attachment figures. These experiences shape the way the person perceives himself and others (without his awareness of it) and the way the person relates to the world. Each personality disorder can be thought of as a particular type of adaptation that a person has found to cope in the best possible-but in the long run dysfunctional- way with his or her inner conflicts and the resulting anguish.

Psychoanalytic treatment

Psychoanalytic therapy of personality disorders focuses on exploring the particular beliefs (about oneself, others, the world), attitudes and unconscious strategies that the individual has built up over the course of his or her life -which, by hardening, have created the personality disorder-, in an attempt to modify them, making them more functional for a satisfying life. Techniques such as dream interpretation, free association listening, transference and defense analysis enable the patient to gain a greater awareness of his or her own internal dynamics that can lead to malaise and suffering.

Bibliography

• Freud, S. (1923). The ego and the id.
• Kernberg, O. (1975). Borderline Conditions and Pathological Narcissism.
• PDM Task Force (2006). Psychodynamic Diagnostic Manual.

Lo Studio of Psychology, Psychotherapy Dr. Pedrazin is located in Milan, via Procaccini 11; the doctor receives in the office and online.