The term ‘borderline personality organisation’ was introduced by Otto Kernberg (1975) to refer to a consistent pattern of functioning and behaviour characterised by instability and reflecting a disturbed psychological self-organisation.
The understanding of borderline personality organization came from the analysis of the pathology of internalized object relation. Rapaport’s (1957) analysis of the level of cognitive structure focused on the degree to which primary process thinking predominates over secondary process thinking in borderline patients. That difference is still considered a distinctive clinical manifestation of borderline personality organization. Much of the thinking of Rapaport et al. (1945) with regards to structural differentiation was linked to their analysis of cognitive structures. They used a battery of psychological tests to evaluate the degree to which secondary process thinking or primary process thinking predominate.
The proposed classification explains clinical features of borderline patients on the basis of certain underlying structural characteristics that differentiate them from patients with neurotic and psychotic levels of personality structure.
The three structural characteristics are-
The degree of identity integration
The level of defensive operation
The capacity for reality testing
The degree of identity integration: Identity diffusion manifests itself in the patient’s inability to convey significant interaction with others and also in interaction with an interviewer, who as a consequence experience difficulty in empathizing with the patient, conception of patient himself and others. The patient with identity diffusion has a chronic feeling of emptiness, contradictory perception of self, contradictory behaviour that cannot integrate in an emotionally meaningful way and an impoverished perception of other. Neurotic personality organization presents a well-integrated ego identity. In contrast, borderline personality organization and psychotic personality organization present identity diffusion. Severely regressed psychotic patient may present a psychotic, delusional identity. Clinically identity diffusion is represented by a poorly integrated concept of the self and of significant other. It assumed that if there is lack of integration then-
a. In borderline personality organization, internal differentiation of self-representation from object representation is sufficient to permit a sharp differentiation between self and others, and in the psychotic structure they are poorly distinguished.
b. In borderline personality organization, contradictory aspect of self and of others has not been integrated into comprehensive conception, from that stem the clinical manifestation of identity diffusion.
c. The failure to integrate contradictory images of the self and of others is presumed to result from the predominance of severe early aggression activated in the patient and the rebated predominance of primitive defense.
The level of defensive operation: In neurotic personality organization there is a defensive organization which centers on repression and other advanced or high level defensive operation like- reaction formation, isolation, undoing, intellectualization, rationalization and protects the conscious ego from intra psychic conflicts by rejecting drive derivatives or their ideational representation. In contrast borderline and psychotic structures are reflected in the predominance of primitive defensive operation which centers on splitting and other mechanism related to it- primitive idealization, projective identification, denial, omnipotence and devaluation and protect the ego from conflict by means of dissociating contradictory experiences of the self and of significant others.
The capacity for reality testing: Reality testing is defined by the capacity to differentiate self from non-self and intra psychic from external origin of perceptions and stimuli and the capacity to evaluate realistically one’s own affect, behaviour and thought content in terms of ordinary social norms. Both neurotic personality organization and borderline personality organization present maintenance of reality testing, in contrast to the psychotic level of personality organization, so that reality testing permits the differentiation of borderline personality organization from major psychotic syndrome. Clinically reality testing is reflected in patient capacity. Reality testing thus defined needs to be differentiated from alteration in the subjective experiences of reality that may exist at the same time in any patient with psychological distress and from alteration of the relationship with reality that is present in all character pathologies and in more regressive, psychotic condition that is of diagnostic value by itself from only in extreme from. Reality testing may be evaluated by interpreting primitive defensive operation in the patient-interviewer interaction. An improvement in the patient’s immediate functioning as a consequence of such interpretation reflects maintenance of reality testing and an immediate deterioration in the functioning as a consequence of such intervention indicates a loss of reality testing.
Kernberg (1975) described additional structural criteria of borderline personality organization which are less essential in the differential diagnosis and include aspects of ego weakness such as lack of anxiety tolerance, lack of impulse control and lack of developed channels for sublimation. In addition, borderline patients usually suffer from severe pathology of object relation and a certain lack of integration of superego functioning.
To compare narcissism and ego impairment indicators among the three study groups, namely- neurotic, borderline and psychotic personality organization.
Study Design: It was a Cross-sectional study.
Sampling technique: Purposive sampling technique was used.
Sample size: Total Sample= 120 individuals; 30 participants in each study group (neurotic, borderline and psychotic personality organisation) and 30 healthy normal controls.
1. Socio-demographic and clinical datasheet
2. General Health Questionnaire-12 (Goldberg and Miller, 1979) (for screening of normal control group)
3. IPDE (International Personality Disorder Examination) (Loranger, Sartorius, Andreoli, Berger, Buchheim, Channabasavanna and Regier, 1994)
4. NPI (Narcissistic Personality Inventory) Narcissistic Personality Inventory (Raskin and Hall, 1979)
5. RIM (Rorschach Inkblot Method) (Exner, 1993)
Total sample, fulfilling the inclusion criteria, were selected from the inpatient/outpatient services. The diagnoses of the total sample were confirmed by administering IPDE and in consultation with senior psychiatrists who have experience (minimum 5 years) in the assessment and treatment of psychiatric patients and were blind about the study design. For the three study groups, comorbid neurological disorders and psychoactive substance dependence were ruled out. Informed consent was taken from the participants. After that sociodemographic and clinical information sheet and all other tools as mentioned above including Rorschach Inkblot Test were administered and the protocols were scored following Exner’s Comprehensive System. Two experienced clinical psychologists who were expert in RCS and were blind to the study checked the coding of the protocols for inter-coder agreement. Finally the data were scored and tabulated accordingly. The total data collected were 133 out of which 13 had to be dropped (7 due to R<14; 6 due to L>0.99).
Statistical operations were done using Statistical Package for Social Sciences Version 22.0 (SPSS 22.0). Assumption of normality:For assessing the normality of the data Kolmogorov-Smirnov Test was used with exponential analysis which indicated that the distribution was normal. Comparison of groups:Categorical variables: For the comparison of the sociodemographic and clinical data (categorical) frequency, percentages and Chi Square tests were computed. Continuous variables: Inferential statistics were used to compare the 4 groups (psychotic, borderline, neurotic and normal). For the comparison of the sociodemographic and clinical data (continuous) mean, standard deviations and one way analysis of Variance (ANOVA) with post hoc analyses of Tukey were done.
Results revealed high EII-3 scores, indicative of increased pathology, in the psychotic group when compared against neurosis, borderline and normal groups. The EII increased in the pathological direction across the groups in a graduated fashion. This finding supports a previous result by Shenton et al., (1989) and Romney (1984) that first-degree relatives of psychotic patients demonstrate subtle disturbance in their thinking and yet appear considerably different from the clinical populations. The EII-3 variables represent different aspects of disturbance including impaired perception, disorganized language, impaired reasoning, and frank cognitive slippage, as well as the expression of contents that are normally censored and not expressed. Borderline patients demonstrated a moderately high degree of impaired formal reasoning and cognitive slippage problems and produced the greatest number of critical contents. In contrast, the psychotic patients had the highest scores compared to the other groups on the measures of perceptual inaccuracy, formal reasoning, and cognitive slippage. Disturbed thought and perception has long been regarded as a hallmark feature of schizophrenia spectrum disorders (Bleuler, 1950; Kraepelin, 1919). Kraepelin(1919) suggested that diagnostic subgroups could be established based on the type of thought disturbance the patient displayed. According to Bleuler (1950), the key to understanding psychosis lies in the pathological nature of the patient’s thinking. Current findings support the incremental validity of the EII-3 as a sensitive measure of thought and perceptual disturbance across the current study groups. The EII-3 have been shown to be effective in assessing qualitative changes in thought and perceptual disturbance while demonstrating a high degree of congruence with other scales of thought disorder.
DISCUSSION OF NARCISSISM AND ITS COMPONENTS
Results show that borderline, psychotic and the neurotic groups are significantly higher in terms of narcissism as compared to the normal group. Broadly defined, narcissism means a concentration of a psychological interest on the self. Pathological narcissism is a product of unempathetic parenting (Kernberg, 1975; Kohut, 1977). In case of borderline personalities the lack of attunement prevents the development of a basic sense of self or identity and leads to use of splitting (Kernberg, 1975). The grandiose sense of self acts as a defensive operation to hide the fragmented self-representations and also the painful childhood memories, and as adulthood prevails narcissistic grandiosity is typically manifested by heightened sense of authority, superiority, entitlement and exhibitionism (Kernberg, 1986) which is consistent with the current results. Moreover the higher narcissism in the psychotic group may be due to the presence of delusion grandiosity in their thought content (which is a cardinal feature for both paranoid schizophrenia and bipolar manic patients) which has been reflected in their self-report. As per researches the current tool used (NPI) to measure narcissism has a positive correlation with the hypomania scale of MMPI which is a measure of ego inflation(Morey et al., 1985; Novacek, 1989).
The concept of borderline states has not evolved with a proper evidence base. Most literature is primitive and there is a certain lack of recent studies. Other than borderline personality disorder, no aspect of the original concept has been. There is some clinical and research evidence to support that borderline patients may improve by psychotherapy, alongside with other studies suggesting the usefulness of psychopharmacological and other treatment approach to certain subgroup of borderline patient. Still there is much research should be needed to find out the etiological factor and other modality of treatment.
LIMITATIONS AND FUTURE DIRECTIONS
This study is exploratory, and as such, its results must be interpreted with great caution. Its limitations include the small sample size and the low statistical power to detect differences between the three groups, and to predict proper classification. Future studies will also need to evaluate the measurement of object representation complexity variable as it was applied here, as well as the relationship patterns. Nonetheless my preliminary findings are in general agreement with previous work on personality organization levels using the original CCRT method (Perry, 2004), and they are consistent with the general notion that patients with different disorders have different internal relationship patterns. I support the thesis that relationship patterns might be related to personality organization levels, and that object representation complexity might be a good predictor of psychological health – especially for distinguishing PPO and NPO from BPO. The empirical validation and clinical significance of the findings that we have derived now need to be further researched and verified to establish the contents findings as facts.
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Conflict of interest: None
Role of funding source: None