Neuroses Psychoses and Personality Disorders

Freud called his earliest conception of neurosis neurasthenia, and he saw all neurasthenias as rooted in sexual difficulties. Later, he differentiated the neurasthenias into different types, such as anxiety, hysteria, melancholia, narcissistic, obsessional, sexual, and war neuroses. He maintained that neuroses had no specific etiologic factor but that their nucleus, regardless of neurotic type, was the Oedipal conflict (or presumably Electra conflict for women) during the phallic stage. Neurotics, in general, had the common symptom of anxiety, either manifest or latent. When DSM-III adopted a more behavioral approach than the formerly psychoanalytically based DSM-II, it dropped the specific term neurosis but not the essential idea that a group of disorders had at their core the symptom of anxiety. Notably, some of Freud's other neuroses were later categorized by the DSM as personality disorders, such as narcissistic (Narcissistic Personality Disorder), obsessional (Obsessive-Compulsive Personality Disorder), and melancholia (Depressive Personality Disorder). In summary, many of Freud's neurotic types serve as clear prototypes for modern personality disorders.

Freud's conception of psychosis also plays a fundamental role in modern psychoanalytic interpretations of the more severe personality disorders: Schizoid, Schizotypal, Borderline, and Paranoid Personality Disorders. Contemporary psychoanalysts (e.g., Kernberg, 1996) view psychoses as a crisis in identity fusion and diffusion in the integration of self and others. There is a prominence of primitive ego defenses such as projection, denial, and omnipotence. In high affective states, there is a severe loss of reality testing often resulting in a lack of differentiation between self and object representations. A splitting often occurs under these conditions to protect psychotic persons from their perceived chaotic and aggressive conditions. According to Kernberg, the current cluster of symptoms of the Borderline Personality Disorder typifies the psychotic personality organization.

Kernberg (1996) has attempted to classify modern personality disorders into psychoanalytic schema. He views the interrelationships among personality disorders as varying along several continua. First, personality disorders may vary from mild to extreme severity. He considered Obsessive-Compulsive and Depressive Personality Disorders in the mildest category and characteristic of the neurotic personality organization. The Dependent, Histrionic, and Narcissistic (some of the better functioning narcissists) Personality Disorders were considered by Kernberg to be more severe than mild but less severe than extreme, and he considered them to be in the "high" borderline personality organization. Kernberg viewed the Paranoid, Schizoid, Schizotypal, Borderline, Antisocial, and Narcissistic (some of the more malignant narcissists) Personality Disorders in the "low" borderline personality organization. By high personality organization he meant that these people could achieve some satisfactory social and occupational adaptational levels, whereas people in the low category more often could not.

Kernberg (1996) views one of the benefits of psychoanalytic conceptions of personality disorders as allowing a combination of both the categorical and dimensional criteria, such as viewing modern personality disorders as groups of categories along a severity dimension. Kernberg also argues that psychoanalytic theory also has the advantage of viewing personality disorders from a developmental perspective in that varying levels of temperamental affective and aggressive states interact with parents and culture to shape the ultimate expressive symptomatology of personality disorders.

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