Antisco Psychopathy PEP

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Record: 1
Title: Passive Parasitic Psychopathy: Toward the Personality Structure and Psychogenesis of Idiopathic
Psychopathy (Anethopathy)
Authors: Karpman, Ben
Source: Psychoanalytic Review, 1947; v. 34 (2), p198, 25p
ISSN: 00332836
Document Type: Article
Language: English
Accession Number: PSAR.034.0198A
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Passive Parasitic Psychopathy: Toward the Personality Structure and Psychogenesis of Idiopathic
Psychopathy (Anethopathy)
Ben Karpman, MD, author; St. Elizabeths Hospital Washington, D. C.
(Continued from January issue)
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Part Two: Mechanisms, Processes, Psychogenesis

I. Emotional Life: 1—Emotional Organization. 2—Lack of Conditioned Affection. 3—Absence of CEdipus Reaction. 4—Lack of Guilt. 5—
Glimmerings of Conscience. 6—Absence of Mechanisms.
II. Intellectual Life: 1—Mental Organization. 2—Phantasy Life. 3—Watch Hobby. 4—Insight.
III. Sex Life: 1—Peculiarities of Sex Life. 2—Excessiveness.
IV. Personality Make-Up: 1—Infantilism. 2—Character Weakness. 3—Lack of Restraint. 4—Socialization.
V. Heredity, Environment, Constitution.
VI. Psychopathy (Anethopathy): A Specific Mental Disease. Finale.
Summary and Conclusions.

Only a little reflection is necessary to realize that we are not dealing here with a case of psychosis or neurosis. One of this man's central
characteristics is his crude selfishness and his utter lack of sympathetic emotion. Now, however selfish or egoistic neurotics or psychotics
may be, there is always someone in the environment to whom they are tenderly bound. Indeed, excess of tender emotions is their most
striking characteristic; it overflows all the channels of their personality, at the expense of the rational and normal. But that is certainly not the
case with the individual presented here.
There is little doubt that we are here concerned with a psychopathic personality. The only question which engages our attention is: What
particular type or variety of psychopathic personality does this patient represent?
I. Emotional Life
Emotional Organisation: Contrasted with the complex and varied emotional life of the neurotic or the psychotic, this man shows a
remarkably simple emotional organization. Although he may be momentarily suffused with intense emotion, especially hate, anger or
revenge, which, because it is uncontrolled, may lead to the most serious consequences, including murder, we observe that such emotional
reactions are largely lacking in anything resembling complexity.
When he stabbed another boy at the orphanage, it was merely because he couldn't get what he wanted. In the Reform School another
fellow beat him in a fight and he sharpened a knife with which he “intended to fix this fellow good.” Both reactions are essentially simple;
nothing of the least complicated nature enters into them. Presumably his stabbing of his common-law wife was equally simple in motivation.
He was drunk, he was mad, and he stabbed her with a knife. It is unlikely that there were any involved or intricate thoughts or feelings
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behind his action. When he defecated in his employer's bed, he thought of it “as a sort of punishment against these people for finding out
about my relations with the girl, causing her to give me all the presents back and also stopping her from coming to my room” and this action
gave him a feeling of satisfaction because he had done something to them “for their stinginess in depriving me of a little innocent fun.”
He has only one simple emotional reaction—to strike back at whoever crosses him or interferes with his pleasure.
Lack of Conditioned Affection: It seems as if our patient lived entirely by and for himself. If he ever showed kindness or affection toward
anyone else, the fact has not been recorded. Both his mother and his brother sacrified a good deal for him, but he never exhibited any
evidence of gratitude or showed any appreciation of their help. If he developed any feeling for them at all, there is no evidence of it. His
attitude toward his mother is not only significant, but in fact remarkable. To the new-born infant, the mother is universally the first source of
nourishment, comfort, protection and affection, thus providing the basis for the development of the œdipus reaction. Most human beings
pass through this in the course of their psychological development. Some do not pass through it but become fixated somewhere in the
course of their relationship to the mother, and thus develop any one of the varied neuroses or psychoses. Whatever the case may be, no
one misses it altogether; no one, that is to say, except that great human rarity, the Psychopath—he has missed the œdipus situation
completely.
Absence of œdipus Reaction: Our patient never speaks of his mother as “Mother” or “My Mother,” but invariably employs the expression
“the mother” as though she were merely the head of an institution. He never gives expression to any tender feeling for her, any more than
he does for anyone else. He simply has no tender feeling to express. Infant-like, he looks to her for his comforts, but she means no more to
him than anyone else who would provide him with what he wants. He says himself that when he was in the orphanage he only thought of
her as someone who brought him things. Presumably he saw very little of his father, who died when the patient was five years old and who
was probably away from home a great deal of the time. It is doubtful if the family life was ever such as to create in the patient any sense of
rivalry or competition where the father was concerned. This being the case, he was never called upon to share his mother. His numerous
attacks of sickness undoubtedly gave him preference over the two other children also, and thus circumstances conspired to foster the
impression that he was entitled to exclusive consideration. He took his mother for granted and regarded her from the beginning simply as
the source from which to obtain fulfillment of his wishes.
Lack of Guilt: Our patient's narrative leaves us with the suspicion that he has deliberately tried to make the expressions of remorse
retroactive. The psychotherapeutic treatment which he received at St. Elizabeths Hospital apparently caused him to look back and see
where he had been extremely selfish in the past; and the fact that this treatment bore some fruit is evidenced by our knowledge that for
some years after his discharge he did exhibit improved behavior and managed to keep out of trouble. (There is even a letter from his
mother which bears testimony to this fact); but there is certainly very little indication that he suffered any pangs of remorse in the days when
he was causing his mother so much worry and sorrow. However, he does seem to have experienced an occasional emotional reaction,
albeit one of questionable depth.
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He did confess his theft to the grocer for whom he had been working, although his motives were probably mixed, and it did not prevent him
from repeating the offense a short time afterwards. He also claims to have made a suicidal attempt following his desertion by a girl with
whom he had been having protracted sexual relations. The questionable sincerity of this suicide attempt has already been mentioned.
These actions, however, are departures from the pattern of the aggressive predatory psychopath. He does tell us, also, that when his
mother came to visit him in jail, “I was so full of drugs that I didn't want to go out and face her”; but whether this reaction may be attributed
to a sense of guilt or a fear of some unfavorable action on her part, is open to question. It did not prevent him from getting into the dope
racket the moment he was released, and he says, “It seems that I could not stay off the drugs long enough to go and see my mother.”
Whatever guilt he had was pretty superficial and short-lived. Following the episode with the ten-year-old girl his reaction was one of fear,
not guilt; and he certainly had no sense of guilt when he was turned away from the farm in Wisconsin and defecated in his employer's bed.
His only reaction on that occasion was anger because they had interrupted what he called “a little innocent fun.” He experienced no guilt
after stealing from his roommate, but rationalized the situation by saying that “the sight of the money made me feel that the money should
be mine because the fellow had a good job, while I was out of a job and nearly broke.” He experienced no guilt after helping the diseased
girls to escape from the hospital.
All in all, the evidences of the operation of a sense of guilt in his case are decidely few and far between.
Glimmerings of Conscience: As opposed to the hypertrophied and disturbing conscience which repeatedly plagues the so-called normal
individual, the neurotic and the psychotic, members of the group represented by our patient appear to have but little or no conscience at all.
Some of them may have an intellectual appreciation of conscience, but not an emotional one; at the verbal but not behavior level.
While it is altogether doubtful whether our patient ever felt sorry for any of his thefts, or for any of the discomfort and suffering that he
caused others, it appears that he did react to adverse public opinion;
for several times in his narrative he speaks of the “humiliation” of punishment because it was administered publicly or was known to others;
and he places more emphasis upon this feature of it than upon any physical pain which he suffered. In fact, he never describes any
punishment in detail. He speaks of being “beaten unmercifully” on several occasions by guards, etc., but never elaborates upon this
statement nor says just how the beating was administered or how he felt afterward. It is the element of publicity which rankles in his mind
and which causes his resentment.
He also speaks with some pride of his work as a printer, and one gains the impression that there were times when he became genuinely
interested in what he was doing. There is even one instance of his ability to resist temptation. A friend who worked in a chain store gave
him money to deposit in the bank, and he says that although “this money was a great temptation to me and I had a hard time to resist taking
it and running away, I finally overcame the temptation and took the money to the bank and deposited it for him and brought him back the
change he wanted.” At this time, however, he was working in a print shop, and it appears, therefore, that the element of privation which
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usually entered into his depredations, was absent. Had he been out of a job and in need of money himself, we question whether loyalty to
his friend would have kept him from using the money for himself. As it was, he tells us that “It was shortly after this that I cashed the checks
I had brought from the print shop,” and he says that he then thought of the money which he had previously deposited for his friend and
considered himself a fool for not taking it; so that this isolated instance of honesty appears to be only the exception which proves the rule.
With the proceeds of the cashed checks he promptly left for another city where he went “the rounds of the houses of prostitution.”
When he was stealing steadily from a department store where he was employed as a packer, he rationalized his behavior by saying with
respect to the things which he stole, “I could use them to better advantage than the ones to whom they were going.” He sold these stolen
articles in order to obtain drugs.
For the most part we can say that whatever conscience he had, he discovered after he had been committed to St. Elizabeths, and there is
considerable suspicion that it developed mainly for the benefit of the physician. The fact that he did remain out of trouble for some time after
his discharge, however, might argue that in developing a conscience for the benefit of others he somehow benefited by it himself.
Absence of Mechanisms: The variety of symptoms observed in neuroses and psychoses are universally found to be surface expressions of
unconscious mechanisms at work. Even the behavior of the mental defective within the limits of his mental and emotional organization,
brings into play a number of mechanisms. Though perhaps in a reduced form, sympathy is not uncommon to him, which means that he has
to bring into play the mechanism of identification. Within the limits of his intelligence, he can control his impulses, which means that he has
to employ the mechanism of repression. And so all along the line. But in our patient all this is strikingly absent. When a man cannot contact
others affectively there is little chance for the expression of sympathy and consequently for the working of identification. And when his
impulses are so strong as to demand immediate gratification, no opportunity is provided for repression.
Our patient exhibits no phobia, for there is nowhere any feeling of guilt to which one could be related. Nor is there any inner conflict which
he feels the need of projecting on to his environment. He is the child of nature, quite free of the curse of original sin. Even his hallucinations,
induced by drugs, are not projections of guilt. He does not hear condemnatory voices nor behold avenging angels or pursuing devils. His
hallucinations serve rather to entertain him. They are a pleasant sort of novelty. When they do frighten him, it is the rudimentary sort of
fright that one gets from riding on a roller coaster or shooting the chutes, a spine-tingling, pleasant sort of fear. Acrobatic men in black climb
through his transom or stand around his bed, even though he knows the bed is pushed against the wall. Symbolism is virtually unknown to
him, for he had no need of it. Everything is clear and simple because he has only one aim and that is to get something; and it is entirely
unobstructed by any inhibitory factor. As a child he saw no reason why he should not have what he asked for, and he has never seen any
since. There are no unconscious mechanisms because there is nothing to interfere with the operation of the unconsciousimpulse. In fact,
one might say that the unconsciousimpulse and the unconsciousdesire are, in his case, practically synonymous. The distance between
them is so short that they become almost indistinguishable one from the other.
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There is no ambivalence. The pendulum is stationary; it has no room in which to swing. The clock of his mind always registers mealtime,
the time to seek and obtain gratification of one sort or another. It is lust and greed. He cannot gravitate between love and hate, for he
doesn't know what it is to love, and for hate he substitutes a weak-willed vengeance which is speedily forgotten as soon as some external
change frees him from the particular pressure which created the revengeful mood.
II. Intellectual Life

Mental Organisation: To say that his mental organization is that of a savage is to be unfair to the savage; for the primitive man, crude as his
mental organization was, knew many inhibitions. Our patient is closer to the animals; indeed, he is little more than a human animal. In many
of his reactions he showed lack of stability and was seeming incapable of exercising any judgment which is the birthright of any normal
individual.
After his release from a reformatory, he went to another city where his brother was working in a hospital. His brother got him a job there,
too, but he promptly forfeited this, and at the same time incurred his brother's thorough disgust, by yielding to the pleas of female venereal
patients and facilitating their escape. Apparently he had no sexual motive where these women were concerned. Either he merely felt sorry
for them, in a superficial sort of way, realizing that they wanted their freedom; or else he was simply bent on mischief. He was incapable of
understanding that they were a social menace and should be exactly where they were. He used no more judgment here than he did in his
abortive relations with the little girl, for which he served a year in the House of Correction; in fact, he used less, for the child's prurient
curiosity did inflame his passion, and his behavior on that occasion had a definitely sexual side to it.
He is no paedophiliac, however, in the accepted sense of that term; rather, himself childlike, he failed to understand why he couldn't have
sexual congress with a child. Instead of belonging to paedophilia and being an instance of regression, this episode was more properly an
expression of psychosexual infantilism.
His phantasy life is primitive. While his material indicates that his phantasies may have been vivid, they embodied nothing but the idea of
sheer animal gratification. His indicated fondness for the hallucinations induced by drugs attests to the essential paucity of his phantasy life.
The few dreams which he has recorded during his sickness are almost exclusively related to the effects of external stimuli incident to
disease or its treatment. His mind seems to have been more or less of a vacuum in which simple desire was the only thing that moved. He
was much like a fish that is all mouth.
We do find that he became somewhat interested in his work as a printer, if his statements about this are not thrown in just to impress the
physician; if this was so, it may be that the very nature of his trade furnished a certain stimulus which his own mind lacked and gave him
something to think about which he never would have discovered on his own account. He mentions reading only in connection with
something which provided a stimulus for masturbation, and his most frequent source of entertainment seems to have been the amusement
park whose attractions, as we know, are designed to appeal neither to the intelligence nor the imagination.
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The only thing resembling a hobby in all of his material is concerned with his interest in watches which he “had the habit of buying and
trading” and which habit he says “seemed to be a mania with me.” He even pursued his practice of watch-trading after he was hospitalized,
and he says that the first thing he looks for in magazines is “advertisements showing different models of watches.” He also admits interest
in diamond displays in jewelry store windows concerning which he says that he “could stand there and look at them by the hour.” This
expressed fondness for watches and diamonds comes the nearest to an individual mental interest of anything in his narrative material.
What association it may have with some ungratified desire of childhood, or what symbolical significance it may have, if any, must remain a
matter of speculation.
Insight: Unlike the normal individual who has insight, and unlike many neurotics who have at least retrospective insight, our patient seems
to lackinsight of any sort. It is true that in prison he meditated upon what a fool he had been, just as he meditated upon the amount of worry
and suffering he had caused his mother; but this meditation bore so little fruit that it was practically wasted. Once released, he again
became the child of impulse, seeking momentary gratification, blowing with the first evil wind like an idle straw, glutting himself with
insatiable indulgence in sex or drugs, and inevitably winding up in jail, prison or hospital.
In the average neurotic insight is generally obscured by his emotional complexes. His obsession, fixation, compulsive activity, phobia or
anxiety makes him the slave of unconscious forces and creates certain blind spots which can be removed usually only by psychoanalytic
technique. The psychotic is similarly, but more hopelessly, the slave of his delusional formations or uncontrolled emotions. He is generally
without insight, or exhibits it only during periods of remission when from the bottom of his delusional sea he “comes up for air” as it were, or
has settled down to a more normal emotional level. Our psychopath under consideration here is the slave of eternal appetites. He travels on
a parasitic treadmill whose machinery forever echoes the motifs “gimme” and “get.” He might almost be termed congenitally parasitic or
congenitally predatory. He cannot see why he shouldn't have whatever he wants, and he cannot see that there must be something wrong
with him because he is forever wanting things. He sometimes has moods of self-pity when he feels that everything is wrong with him and
the world, but he has no actual notion of what is wrong. After his briefly contemplated suicide in the hospital where he was undergoing
treatment for pneumonia and drug addiction, he “had the feeling that I was no good to anyone and that it would have been better if I had
followed out my intentions”; but as soon as he was released he resumed the consumption of drugs. Actual insight is invariably followed by
some change for the better. When the neurotic learns to understand his complexes, he makes an altered adjustment to the problems of life.
When the psychotic is able to realize the nature of his delusions, he is on the way to recovery. But the psychopath seemingly cannot learn.
Experience teaches him nothing. He cannot gain freedom through a discharge of emotion because he is practically without any emotion
save one, which is the grasping and destructive will of an undisciplined child.
III. Sex Life

Peculiarities of Sex Life: Impulses are close to the instinctive. The cultured man is able to separate and move the instinct farther from the
deed that realizes or expresses it. In the normal individual, conscience controls the instinctive behavior, the compromise effected being the
Ego. We may suppose that in a normal individual the three are equidistant. In a highly cultured individual the Ego is closer to the Super-Ego
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and farther from the Id. In a true psychopath, however, the three almost merge, the distance between them being practically negligible, all
close to the Id.
There is nothing in the patient's material to indicate that he ever thought of a sexual partner as anything but a creature provided for his
gratification. He tells of one suicide attempt because a girl “went away without telling me anything about her going.” This seems inconsistent
with the rest of his narrative and we can only put it down to the anger of frustration.
He says, “I got to thinking about this girl and of the good times that we had.” It was clearly the loss of “the good times that we had” which
provoked his black mood, not the loss of the girl as a love object. It was a half-hearted attempt at best, for he tells us that “I had left the front
door open by an oversight.”
His behavior with the ten-year-old girl was completely devoid of any restraining factor. His only reaction to this episode was one of fear. He
ran away and went to a show. Concerning the episode itself, he tells us that “I was really horny by this time and in heat as the bitch dog,
and if she had been a little bigger and older I might have taken the chance and raped her, but as the case was, all I could do was to
masturbate with her looking on.” There is a complete absence of any of the inhibitions which we would see in an average normal man.
The same thing is true of his relations to the farmer's daughter in Wisconsin. They were both too young and inexperienced to know the
mechanics of sexual intercourse, but that is simply an accident in the girl's favor. He knew that she was his employer's daughter and that
she had no business in his bed. His only emotion, however, was anger when their discovery caused him to lose his pleasure and his job;
and he then revenged himself on the family by defecating in the bed before he left. Had the girl been older and more experienced, there is
no doubt that the farmer would have had a pregnant daughter on his hands. Nor would any consideration of such a possibility have
disturbed the patient in the least.
The excess with which he indulged in sexual relations with prostitutes bespeaks the lack of any restraint or inhibition. His ultimate reaction
was not one of remorse but of simple exhaustion.
When he talks about girls as “filthy creatures … all covered with the slime of their sins,” he is obviously striving for effect and trying to make
us believe that his feeling of disgust has a moral basis. He tells us of one period of two months’ steady sexual indulgence and says, “Then
all at once I got so I couldn't even look at a girl without being disgusted.” As stated elsewhere, his reaction was precisely that of a child who
overeats until he is sick. He tells us of relations with one girl in the reverse position, and says, “We would rest awhile and then go to it again,
keeping this up all during the afternoon, and sometimes we would indulge in it all during the morning.”
Not only does he lack the restraint based on morals, but he lacks all common sense. He is simply one big animated appetite.
In the state hospital he “would go to the sexual perverts they had on the ward who practiced fellatio … and let them do their work to satisfy
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the urge.” He makes no other mention of these people. Apparently they did not even excite his curiosity. They were there and they could
furnish him with a certain amount of gratification, and that was the extent of his concern. In reformatory and prison, where no partner was
available for sexual satisfaction, he would resort to masturbation, but this served the simple purpose of immediate relief and, while he may
or may not have phantasied a sexual setting with someone else, there is no indication that any guilt, conscious or unconscious, was ever a
concomitant of the practice.
There was seemingly no psychic side to his sex life at all; it was all physical. Nowhere do we get the impression that he ever hesitated in his
pursuit of sexual pleasure; and what he calls “disgust” after a long period of sexual indulgence was really no more than a form of anger
because he was incapable of continuing to enjoy sex indefinitely.
IV. Personality Make-Up

Infantilism: This patient's infantilism is altogether an example of arrested development; not one of regression. In order to regress, one must
first progress. This man did not progress to begin with, hence regression was out of the question. It has already been stated that he reacts
forever like a baby having a tantrum, and this truly seems to describe him as well as we can. He is essentially infantile in his desire to
possess things and secure gratification, and in his seemingly complete lack of understanding why these desires should meet with any
obstacle.
When an obstacle does present itself, he either ignores it completely—if it be cooperation with his mother, loyalty to his brother, a friend or
an employer—or becomes enraged and strikes out at it—as when he drew a knife on the boy who refused his homosexual advances,
defecated in his employer's bed after he had been turned away following the discovery of his immoral relations with said employer's
daughter, or manufactured a knife with which “to get even with” the fellow who had worsted him in a fight.
He is infantile in his inability to exercise any restraint or moderation. When he was working in a department store as a packer, he could not
content himself with the theft of an occasional article. He must keep on until he had accumulated so much stolen property that his detection
was a comparatively easy matter. Similarly, in his sex life he could not content himself with an occasional affair. Once started, he must
indulge in sexual intercourse until he reached the point of utter exhaustion and developed an actual antipathy for women. He reacted like a
child who overeats until he is sick.
The genesis of his drug addition was infantile. He took drugs to allay the least pain and whenever he had a headache; and later on willfully
persisted in taking drugs until he reached the point of hallucination. In fact, he writes as though these hallucinations were considered a
novelty which he actually sought. We have no doubt that his subsequent alcoholism was followed in much the same fashion, until it
culminated in the irresponsible murder for which he was sent to prison. His action in releasing the infected women in the hospital was
infantile. We do not know whether he sympathized with them in their imprisonment or whether he was simply up to deviltry, but his action
was typical of that of a child in either case. Whenever he stole money, he immediately squandered it in places of amusement or houses of
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prostitution, like a little boy who has been given some pennies and runs pell-mell to the corner store to buy candy. His whole personality
reaction is that of a bad child.
To neglect, denial, privation, or any form of thwarting of his wishes our patient reacts not by the commanding, bullying or fighting tactics of
an over-protected child, or by the behavior of an aggressive, predatory, psychopathic child; but by sullenness, explosive response, by
tantrums which demand and exact what he thinks is his due. This is quite unlike the aggressive, predatory psychopath.
Character Weakness: While in a large, perhaps even a complete sense, this man is soulless, conscienceless and predatory, he is not really
a cold-blooded schemer. His essential fundamental quality is weakness. He will do a foolhardy or dangerous or desperate thing upon a
sudden impulse, under the influence of leadership, or under the stimulus of alcohol or drugs; but he cannot coolly calculate a desperate or
dangerous act. Even the motive of revenge in him is weak and is exhausted in phantasies.
He phantasied revenge while in prison, but the moment he was free he forgot all about his imagined vengeance and turned his attention to
other matters of more immediate interest for he is forever moved by the needs of the moment and doesn't know the meaning of delayed
satisfaction or deferred pleasure.
He says in one place, “I took the easiest way I knew of to obtain money at the time”; and this is typical of practically all his attempts to
obtain money. He never plans anything himself. He “became acquainted with some fellows and they showed me something about breaking
into houses when the people were away.” He stole liquor under the direction of another fellow, and then stole from his mentor. He
attempted a safe-breaking job with “a fellow that I had met in the reformatory.” He met a couple of fellows who said they could dispose of a
car if they could steal one,” and with them he participated in the theft of a car. He never undertook anything the least bit daring unless he
was in company and was playing second fiddle to a more experienced law-breaker. His apartment house thefts were apparently his own
idea, but he was fortified by drugs when he attempted them; otherwise, it is unlikely that he would have had either the courage or the
initiative to experiment with this form of theft. “The drugs seem to make me feel fearless and unafraid of anyone,” he tells us. His alcoholism
and drug addition are, of course, in themselves evidence of his general weakness of character. Once when he was practically cured of the
drug habit he left the hospital and returned showing all the signs of having resorted to drugs again. His behavior in confessing to the grocer
whose money he had stolen, offering to pay him back out of his wages, and promptly stealing from him again at the first opportunity, is just
one more indication of his complete lack of anything resembling character.
Lack of Restraint: The patient's inability to exercise even moderate control when confronted by any sort of pleasure-producing stimulus has
been consistently characteristic of him and is directly responsible for his anti-social behavior. It attains its most obvious expression in his
drug addiction in which he so clearly shows that he lacks the power to resist almost any impulse.
After he became a slave to drugs, his development took on a more or less artificial character because it was then dependent upon and
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complicated by this particular form of slavery. In his drug addiction he showed the same lack of restraint that he had in his sexual
indulgence, and would persist in drugging himself until he reached a state of acute hallucinosis. In his narrative of the period preceding
hospitalization there is only a meager account of alcohol, but he and his companions were drunk when arrested and found to be carrying
concealed weapons, and referring to this same period he says, “I seemed to like the booze then better than the women, and did not seem
to care for them at all. He drank a good deal with the girl whom he married in St. Louis, and after she had left him he says “I also started
drinking heavily then in order to forget and nearly every Saturday afternoon would see me, after being paid, going to the saloon. I would
stay in the saloons until I had no more money and then I would come home.” (P. 78) The crime for which he was imprisoned several years
after his discharge from the hospital was committed, according to his own statement, under the influence of alcohol. We surmise that he
pursued the same pattern earlier exhibited with respect to sex and drugs, and that once started to drink, he simply kept on until he lost all
control over his behavior. His statement that he can remember nothing of the events preceding the stabbing of his common-law wife is
presumably true; probably he had then progressed as far in alcoholism as formerly he had in the consumption of drugs.
Lack of restraint is, of course, obvious in all of his sexual relations, and is also responsible for his attack on the boy in the orphanage who
would not respond to his homosexual advances.
There is only one mention of gambling in his entire narrative, and it does not appear that this was a frequent practice with him, but when he
did go in for it, he appears to have abandoned himself to it with the same unrestrained energy that characterized his adventures in alcohol
and drugs; for he says “I would feel the thrill of the thing creeping over me and it would seem that I would get hot all over,” and “the more I
lost the more I would risk in order to make up for what I had lost.”
Socialisation and Isolation; Interpersonal Relations: A striking feature of this man's personality is his almost complete lack of social feeling.
He is like an element with only very feeble, if any, valency. He has never had any friends, let alone intimates. He never shared, or felt the
need to share, his problems and confidences with anyone. He would associate with one or more men for the purpose of commiting a crime;
but this done, the loot secured and the need satisfied, he would leave them and go by himself. As he joined other men for the purpose of
committing crimes, so he would seek the company of a woman for the purpose of satisfying his sexual needs. That done, he had little use
for her; but he knew that the sexual need would soon reassert itself, and this knowledge frequently made him stick to one woman for a
considerable length of time. He is our supreme egoist, the original isolationist, more lonely than the lone wolf. One may even liken him to
the single-celled paramecium, surrounded by many others of her kind but swimming gracefully along in splendid isolation; only
exceptionally joining another paramecium for purposes of conjugation. Picture him, if you will, standing on a high mountain top, while below
is the great mass of humanity to minister to his needs. His is the primarynarcissism, unrelieved and unhindered. As he was at birth, so he is
today; and so he will be to the end of all his days. The world around him may change, and he perforce may change his method of approach,
but his basic personality will remain unchanged and unchangeable.
But he is entirely unlike the neurotic who shrinks from social contact because of a feeling of inferiority, or the psychotic who withdraws into
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the inner recesses of his dream world. He appears to have gotten along socially well enough. A couple at the orphanage wanted to adopt
him; the grocer from whom he had stolen money took him back (at least the first time); he frequented pool rooms, where he and others
planned a hold-up job which failed to materialize. He fraternized with other drug addicts in jail, and he got along well enough with a
roommate so that the latter was willing to steal for both of them (after which the patient stole from the roommate, who had served his
purpose, and departed with the money). But socialization was always motivated. He got along with people and made himself agreeable to
them until such time as he could get something out of them, or with their assistance. Then the party was over. Something of this reaction is
also in back of the “disgust” which he professes to have felt for women after he had reached the point of sexual satiation. When they no
longer represented anything that he wanted, he had no use for them. All social contact comes to an end the moment he gets what he wants
from the other person. He has no social need as such; it is always just a means to an end.
Passivity and Parasitism: While the man's instincts are strong, demanding immediate and continuous gratification, the energy resources of
his personality are decidedly weak. He seems to move along the line of least resistance to satisfy an immediate need rather than to put
forth any increased energy for the purpose of securing a greater, even though delayed, gratification. Relative passivity rather than
energetic, aggressive activity characterized his behavior. This personality trend is clearly shown by his lack of daring and courage in the
execution of anti-social and criminal acts. He lacks all the daring, originality and resourcefulness of the true aggressive psychopath.
Something of this has already been mentioned in connection with his character weakness.
He tells us that once in Denver, “I bought a gun with some of the money I had, intending to stick up someone before I left town,” but a little
later on he adds the information that “I soon got broke and not having the nerve to tackle the hold up work alone, I pawned the gun and with
the money left town and started back to Chicago.” An aggressive psychopath, determined to stage a hold up, would not have abandoned
the idea because of his lack of nerve to tackle the job alone. Either he would have tackled it alone or he would have found associates whom
he would have forced to participate in it with him. If our patient had found someone at this time who would have assumed leadership and
have provided him with the necessary stimulus, the hold up job might have materialized; but he could never have assumed the leadership
himself, nor could he, as we have seen, act independently. He could steal money from his roommate, who had already stolen it for both of
them from a liquor store; he could steal loose change from the stands of newsboys during their absence; he could pass worthless checks.
These things involved little risk and little courage. He could steal from his mother when he knew that there was little more than enough
money in the house for necessary food. The desire to get was always with him, but what he got must be obtained easily and the means for
getting it must be readily at hand now; he could never postpone his getting in order to devise more efficient means whereby to get more
tomorrow.
V. Heredity, Environment, Constitution

In the interplay of environmental and hereditary influences, it is difficult if not impossible to determine with any degree of correct
approximation which one exerts the most influence; or more properly, how much of one and how much of the other has gone into the make-
up of the living organism. This is probably because organismal life is so complex and many-faceted that it is impossible to obtain adequate
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documentary evidence, without which scientific judgment is impossible. The difficulty may be better appreciated when one studies the
relative influence of hereditary and environmental factors in identical twins. For, though presumably such twins are of identical biologic
make-up, why do they differ in many ways, especially psychological, when brought up in the same environment?
Of recent years much emphasis has been laid on the influence specific parental attitudes have in the molding of the personality of the
growing child.1 A golden childhood, a wool-and-cotton environment, may be as harmful to the child as a childhood bereft of affection and
filled with antipathic emotions; an overprotective attitude often leads to as harmful consequences as one of rejection. Very trying indeed to a
child are those situations in which the parents become antagonistic to each other. The child becomes a buffer in the unresolved difficulties
of the parents and pays the price for it by the development of all sorts of unhealthy emotional attitudes that in totality can only lead to
neurosis. Nor can it be said with any correctness that personality reaction flowing out of one situation is the reverse of what may develop as
a result of the opposite situation. Indeed, rebelliousness or weakness may come as a result of over-protection as or rejection and privation.
It might be submitted that as a child our man was over-protected because of the unusual attention bestowed upon him in his frequent
periods of sickness; or that he experienced the feeling of rejection when his mother was obliged to consign him (along with his brother and
sister, however) to the care of an orphanage; and that, given proper training and a more than average amount of gratification, he could
have been taught to bring some order or balance into his life. But we are disposed to doubt this in the light of his subsequent consistently
antipathic reaction. He had no reason to feel rejected when his mother took him into her home repeatedly after he had been in one penal
institution after another. And certainly there have been many other children who were tenderly cared for during early periods of sickness
and who did not on that account develop any such persistent parasitic attitude as that manifested by our patient. Similarly, it may be argued
that much of his parasitic attitude is traceable to the vicious mental habits which he developed in that sickly childhood during which he was
pampered, waited on, and spoiled; but it appears far more likely that the illnesses only accentuated temporarily the basic trends which
seemed to have been an inseparable part of his make-up from the very beginning. We cannot blame his unsatisfactory development on the
fact that for several years he was an inmate of an orphan asylum, for so were his brother and sister, and it did neither of them any lasting
harm. Admittedly, the abrupt change from his mother's solicitous care to the environment of an orphanage must have created in him an
almost continuous state of rebellion and tantrum; and when his wants were not satisfied, and the things he demanded were not
forthcoming, he simply proceeded to gratify them himself and take whatever he could—but he also did this same thing during the earlier
period of his childhood preceding the orphanage days. At the same time we are compelled to concede that there must have been
something likable about him then, for he was considerably made over by women nurses or matrons in the orphanage, and one couple was
ready to adopt him if his mother would consent to such an arrangement. He was perhaps very much like a kitten which purrs and so
endears itself to you when you give it milk, but which is quite as likely to scratch when the milk is not forthcoming. Such a reaction is notably
characteristic of the parasitic type; by this very passivity they manage to ingratiate themselves with a responsive and often thoroughly
gullible host. Such apparent passivity makes an appeal to the tender-hearted, who fail to see the basic personality underneath.
Viewed from this angle, we see that, although he was subjected to a number of different environments, some of them very trying, our
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patient appears to have been influenced but little by any of them, but displayed everywhere his basic personality trends which were, as
already suggested, unconditioned and presumably unconditionable.
If then, environment appears to have played a minor part in the development of his personality, what part did heredity play? Constitutionally,
we are without much information beyond the fact that he was “sickly all the time” as a child, but the diseases recited by him are those which
are common to many children who thereafter developed normally. The more serious illnesses were associated with a later period of life,
and in type and duration were not unusual. There is a history of a severe burn at three and of a head injury at seven, but we have no further
details of that and therefore cannot appreciate the possible, if any, consequences of it, on his subsequent development. In all, there do not
appear to be any outstanding physical factors upon which to hand responsibility for his consistent “cussedness.” As concerns heredity
influence proper, we note that the children's mother was presumably of average mentality and probably sentimental, but she always seems
to have supported herself, and several times she maintained some sort of a home, which usually fell apart due to the anti-social behavior of
the patient. She appears to have been a good, average, normal, stable personality, with no particular assets but also without any special
limitations. The patient's older brother, who also inherited some of the father's traits, made a satisfactory adjustment, was generally
industrious, and died serving his country; and while we have no information concerning the life of his sister, we do know that she completed
a business education and became a stenographer in a New York banking institution. This does not argue conclusively against the
hereditary factor, but it does mitigate it considerably.
On the other hand, we still have to account for his father who-we know, was alcoholic and probably psychopathic. The mother spoke of him
as “half crazy.” It may well be that the brother and sister have escaped, genetically speaking, the father's influence, and have taken after the
mother; while the patient may have escaped the mother's hereditary influence, absorbing most, if not all, from the father. Nor need this
imply necessarily that the father supplied a heavy hereditary taint. It is sufficient that he had a definite, even if small, psychopathic trend, to
transmit the same to his son in a greatly increased dosage. Heredity often plays strange tricks. The writer has studied a family of ten
children where the mother was entirely normal. The father made a good adjustment throughout, except that at the age of about thirty-five he
went through a fleeting hallucinatory episode of a religious nature, lasting but two hours in all, and leaving no trace whatsoever. Yet this tiny
abnormality, wholy insignificant as compared with the rest of the man's life adjustment, was sufficient to endow one of his children—and
only one—with a deep-seated psychosis that has lasted for years, and is now entirely chronic and incurable.
All of the above considerations would therefore argue for the greater probability that more in our patient's psychopathic make-up is inherited
rather than acquired; that is to say, his make-up is constitutional. Yet with scientific and unbiased candor it must be admitted that the
argument is not entirely fault-proof and that conceivably further studies, more intimate than any attempted thus far, may yet reveal the
operation of more subtle environmental influences heretofore undiscovered. And there the case rests at present.
VI. Psychopathy (Anethopathy): A Specific Mental Disease

We recognize a mental abnormality by the failure of the individual to adjust adequately to the stream of social life around him, and ultimately
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to himself. Such a failure often necessitates the segragation of the individual in question and the placing of him in a lower-plane
environment more suitable to his adjusting powers. We know this to be true of the mental defective, the psychopath, and even some
neurotics. Viewed in this light, is psychopathy a mental disease sui generis, equally with those already mentioned and requiring, therefore,
hospitalization; or are these character trends to be viewed merely as peculiarities and oddities of a personality that otherwise does not differ
materially from the average and the normal? Anyone who has studied this type of individual in detail must recognize that we are dealing
here with something more than minor peculiarities of character, somethng more basic than mere capriciousness and slight deviation from
the accepted standard.
But in delimiting this reaction type nosologically, we are met with a number of pitfalls. These reactions look most deceptively like those
displayed by the other cardinal reactions and must therefore be carefully differentiated from the others, first by the totality of the reaction
pattern which is characteristically different from the others, and secondly, by the motivation back of the reactions which, too, differs from
others. It is the failure to take this into consideration that has been responsible for placing in this group a number of individuals who
outwardly present only a psychopathic facade but genetically have no relation to primary or true psychopathy.
Thus viewed we shall have no difficulty in placing our patient in the small but well denned group or primary or essential psychopathy
(anethopathy) and in proving that however he may resemble this or that reaction type by the display of this or that set of symptoms, he is
basically different from them.
In much of his behavior he resembles a mental defective, except that the same behavior in a mental defective is due to limitations that go
with deficient intelligence; whereas our man's intelligence, as measured by ordinary tests, is not defective, but is of a type that is not
allowed normal expression because the impulses demand automatic release, and intelligence has little chance to assert itself. This type
may sometimes have post factoinsight, really hindsight, and even be sorry for what he has done, but this is of little use to him when again
confronted with a like situation when primitive instincts take precedence over everything else. In common with the psychotic, he may show
a flurry of delusion-like reaction, and thus be regarded as a paranoid. But it is not difficult to see here that whereas paranoid reactions are
true delusions stemming from the deepest sources of the personality (e.g., unconscioushomosexuality), our patient's so-called delusions
are not delusions at all, but transitory fleeting projection reactions due entirely to some temporary frustration of an immediate need,
maintained only so long as the need remains unsatisfied, but disappearing promptly when the need has been relieved.
Here and there our patient displays reactions which seem to have some relation to the neuroses. His suicidal attempts are suggestive of
hysteria, but hysterical behavior is so universal that it is displayed even by animals under stress and tension. The display of one hysterical
reaction does not entitle one to be regarded as being a hysterical neurotic. Aside from that, our patient has not shown any behavior that
might be regarded as hysterical. His infantilism, too, differs from that of the neurotic, whose regressive tendencies are linked with
tremendous affectivity, whereas our patient exhibits such poverty of affect as to resemble a musical instrument with only one string. He
lacks the neurotic's capacity to develop insight because he has only one concept of himself in relation to his environment, the latter existing
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only as a potential reservoir for his needs. Where the judgment of the neurotic is obscured by emotion, this patient's judgment is limited by
absorption in his predatory aim. Where the neurotic is elastic, our man is entirely inflexible. Where the neurotic may be shown to have a
certain number of blind spots, this man has only one, and it is practically all-inclusive. In short, he constitutes a distinct disease entity with
its own typical pattern.
Finale
We have here, then, a socially worthless individual who has been in and out of reformatories, in and out of prisons, who has never
accomplished anything for himself and has never brought anything but sorrow and trouble to others, and whose death at any time would
have been a social good-riddance rather than a loss; but we are also compelled to recognize that this individual is not a predatory, criminal
type and that conceivably (with a question mark) something socially useful could have been made of him if the right psychological
influences, especially a protective environment, could have been brought into play at the right time. And then again, this might not have
been possible after all, for his progress reflects continuously the development of a being essentially untrainable, who has remained
throughout his life exactly as he appears to have been at birth—primitive, animalistic, unteachable, unconditionable, to whom the world
about him existed only for the purpose of feeding his ego and who could never be persuaded to view it any differently.
The environment did nothing more than bring out his original nature. If his problems and reactions cannot be directly charged to heredity,
they may yet stem from that aspect of it which, for lack of a better term, we are pleased to call constitutional. We don't know what this
constitution is, and we can only understand it in the same sense we understand electricity, through its manifestations, through its behavior.
At the same time, we cannot entirely ignore the possibility, however, remote, of psychogenetic influences, for under a more beneficent
environment he seemed to be more tractable, more docile, even though one had the feeling that basically he was unchanged. For some
inexplicable reason and against any hope that the writer entertained, the patient seems to have gotten something out of the analysis that
carried him along for a number of years, at least to the extent of keeping him out of conflicts with the law; whereas heretofore he had gotten
into trouble every few months. This is the one feeble ray of light in an otherwise complete darkness. One can only enter the plea that in
spite of discouraging results, the effort to understand this particular type of personality should be continued.
Summary and Conclusions

1. Behavior vs. Motivation. Conventionally, an individual is placed in the group of psychopathy, if judged by his behavior, he appears to
be utterly selfish and regardless of the welfare of those around him, always seemingly on the receiving rather than giving side: definitely
anti-social, continually getting into difficulties with others, living for himself and only for the immediate moment; possessing no
consciousness of obligation and sense of duty; unable to make any genuine sacrifices; an individual who cannot be changed from his
adopted pattern by any therapeutic method yet devised. Such definition is purely behavioral, however, made entirely on a descriptive level
on the basis of observable reactions and behavior, and fails to take into consideration the deeper motivational aspects of the situation, the
more basic structure of the personality. For it is obvious that since reactions superficially alike may come from different and divergent
sources, what is of paramount importance is the determination of such causation and with it the motivation and psychogenesis of the
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behavior. Thus, egoism, as a character trait may be found in many people, but it has a varied significance, depending upon its psychic
origin, the egoism of any hysteric being different from that of an epileptic, the two again being different from that of a schizoid personality
while all these are again different from the egoism of a primarypsychopath (anethopath).
2. Symptomatic vs. Primary Psychopathy.
a. When, therefore, this large group of psychopathy is studied in the light of motivation back of the behavior rather than
behaviorquabehavior, the group can be seen immediately to fall into two distinct divisions. Into the first division may be put all those cases
which even on superficial study (such as found in the routine state hospital histories) reveal the presence and operation of definite
psychogenic factors: that is, motivations. It is then seen that instead of being true psychopathies, they are merely psychopathic-like
reactions that belong nosologically to the various cardinal psychiatric groupings: neuroses, psychoses, epilepsies, etc. Accordingly, this
division may be designated as symptomatic or secondary psychopathy, which may yield to treatment when the underlying cause is treated.
This group comprises by far the greatest number of people commonly included into the group of psychopathy.
b. In the remaining group, even when considerable effort has been made to unravel the conditioning psychic factors, such do not appear
to be present. The reactions appear to be so deep-seated and ingrained as seemingly to be unreachable by the usual psychotherapeutic
approaches, and are as close to what is commonly called constitutional as a case could be. This group is designated here as primary
idiopathic, or essential psychopathy (anethopathy).
c. The delimitation of primary idiopathic or essential psychopathy is offered here as a distinct clinical entity in the same sense as it is in
the instance of pernicious idiopathic anemia or essential epilepsy; that is to say, it is such in the light of our present knowledge of the
subject, though this cannot be so regarded with any finality.
3. Primary Psychopathy: Sub-groups. Analyzing this group of primary, idiopathic or essential psychopathy (anethopathy) differentially,
two major sub-groups may be observed.
a. The aggressive-predatory type. Characteristic of this type is that their entire life is spent in active predatory aggression in which
there is a great energy output, though little that may be socially useful and for the most part harmful.
b. The passive parasitic type. Instead of being actively aggressive, this type of an individual has much less of energy output and feeds
himself by “sponging” on his environment for all his needs in a passive and entirely parasitic way. Its victims are willing, yet unwilling hosts.
Such aggression as there may be, is very minimal and no more than is absolutely necessary to satisfy immediate needs.
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c. The differentiation of psychopathy into two groups: symptomatic or secondary, and primary idiopathic, respectively, has important
psychotherapeutic implication for it has been accepted by common consent that psychopathic behavior is unmodifiable and cannot be
reached by any available psychotherapeutic method; whereas if psychopathy is traced to some other condition, it can be approached
psychotherapeutically through the basic condition of which it is symptomatic.
4. Passive Parasitic Psychopathy: Development. A survey of the extant literature discloses that psychoanalytic studies of primary or
essential psychopathy are lacking. For this reason, it seemed desirable to present for the first time an analytically studied case of primary
psychopathy of the passive parasitic type. A careful and detailed study of this case reveals the following finer features of his life.
a. Heredity appears to be somewhat tainted though not significantly so. We are without significant light on the constitutional angle of
the evil.
b. The patient has been, from the earliest, a very difficult child to handle. He couldn't stand the least privation to which he would react
violently. Nothing was brought out in the environment to show the operation of psychogenic factors—such as fixations, over-protection or
rejection.
c. Though many people, members of the family and strangers as well, have done a great deal for him, he has never shown the least
appreciation or gratitude.
d. He has been delinquent from as far back as he could remember, taking things from others without thought of consequences or feelings
of remorse, and apparently wholly unable to profit by experience or punishment. He never lived for more than the immediate moment,
taking no heed of the past nor reflecting on the future. In spite of all training given, it was impossible to inculcate in him conceptions of right
and wrong. He hardly knows it intellectually nor is he able to choose it emotionally. He was thus easily led into a life of crime and he spent
the major part of his life since the age of ten in reformatories, jails, prisons and hospitals.
e. His sex life parallels his life in general and suggests the same lack of organization and control, and obedience only to the law of self-
gratification. It was mainly on a heterosexual plane, but almost any female would do, and perversions readily resorted to in case of privation
or in prison. Here, as elsewhere, he would follow the instinct to the point of exhaustion.
f. Emotions, especialy antipathic emotions, were easily aroused in him but for all their strength were short lived and not deep seated. The
man shows a remarkably simple emotional organization. There is nothing in him of the complex and varied emotional life of the normal and
the neurotic.
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g. His phantasy and dream life is of exceedingly simple and primitive character concerned mainly with wants and needs, and lack the
complexsymbolic fabric found in neuroses and psychoses.
5. Personality Structure. The personalitystructure reveals the following important features:
a. Lack of conditioned affection. No evidence of any positive and generous human emotions, of sympathetic or tender affect, of
gratitude or appreciation for what has been done for him, no ability whatever to sacrifice himself for others. No evidence of any life goal
except only living for himself and for the moment.
b. The total absence of an œdipal reaction is one of the most striking features revealed by the study of the case. His mother, in spite of
all the sacrifices she made for him, was to him no more than another member of his environment—someone who would give or do things
for him. The brother was only useful in helping him out of trouble.
c. Another striking feature is a lack of guilt, remorse, or regret for things done. There is virtually a complete lack of conscience except that
he showed some, albeit minor, reaction to adverse public opinion, and this probably because it affected his security.
d. If such a thing is conceivable, the man is virtually without unconscious mechanisms. He is all instinct and impulse and there is virtually
no distance between stimulus and response; he doesn't know the meaning of deferred pleasure; there is no repression and no
unconsciousconflict. Conflict is experienced only at the conscious level, when meeting obstacles. As he cannot get into affective contact
with others, he knows not the meaning of identification, introjection, differentiation, transference or other mechanisms that are so
abundantly displayed in normal, neurotic and other people. In a life that is lived on a simple, primitive plane, there is little opportunity for
symbolization.
e. While the general level of intelligence is that of normal, or above, the details show a great many irregularities. Normal judgment and
other higher functions are interfered with by the continuous intrusion of primitive instinct that brooks no opposition. The mental organization
is not merely primitive and savage, but closer to the animal; indeed, individuals of this type are little more than animals in human form.
f. There is complete lack of insight. It is not merely the obscuring of insight by emotional drives as in the case of normal or neurotic
individuals.
g. In his sex life, he has the same parasitic attitude as in other life relations. The sexual partner never means to him more than only a
means to an end, someone to minister to his needs. The more a woman can satisfy his needs, the more he likes her; that over, he has no
further use of her. Like in everything else, he indulges in sex to excess, and to the point of exhaustion; there is complete lack of restraint.
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6. Specific Behavior Trails.
a. Essentially infantilistic in his desire to possess things and secure gratification.
b. As the energy resources of his personality are weak, while instincts are strong, he moves along the line of least resistance.
c. Because of continuous pressure of instincts, his fundamental character trait is weakness, rather than viciousness.
d. There is an inability to exercise even moderate control, when confronted with a pleasure producing stimulus—lack of restraint.
e. He is esentially an isolate with almost complete lack of social feeling. He may mix with people or a gang, but never does have friends,
let alone intimates. Interpersonal relations are at the lowest possible level.
7. Therapeutics. Against all expectation, the therapeutic efforts seemed not to have been entirely fruitless as the man appears to have
been able to maintain himself after leaving the hospital without getting into trouble for eight years, by many times the longest period in his
life. This provides the hope that such individuals may profit by treatment, even if to a limited degree, especially if they are put in a protected
and sheltered environment, that recognizes their basic traits.
Footnotes
1 Levy, David. Maternal Overprotection, 1943. Columbia University Press.
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Psychoanalytic Review, 1947; v.34 (2), p198 (25pp.)
PSAR.034.0198A
Record: 2
Title: Psychopathy. A Comparative Analysis of Clinical Pictures (Review of: Carl Frankenstein, Ph.D. New
York and London: Grune and Stratton Inc., 1959. 198 pp.)
Authors: Blau, Abram
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Source: Psychoanalytic Quarterly, 1960; v. 29, p421, 1p

ISSN: 00332828
Document Type: Review
Language: English
Accession Number: PAQ.029.0421A
(Permalink): direct=true&db=pph&AN=PAQ.029.0421A&site=ehost-live&scope=site
direct=true&db=pph&AN=PAQ.029.0421A&site=ehost-live&scope=site"></A>
Psychopathy. A Comparative Analysis of Clinical Pictures

Review by: Abram Blau, author; NEW YORK
Review of: Carl Frankenstein, Ph.D. New York and London: Grune and Stratton Inc., 1959. 198 pp.
The author resurrects the old nosological concept of psychopathy, which he proposes to clarify, as he states frankly in the first sentence of
the preface, by 'a study in clinical semantics'. The monograph bears this out. It is a discursive discussion with no clinical material, many
disagreements with other authors, and a synthesis of Jung's typological scheme, together with some unique psychological concepts of his
own designated as 'expansion', 'staticness', 'ego inflation', 'polarization'. Psychopathy, he postulates, is based on a constitutional weakness
for experiencing anxiety, which may be congenital or due to early trauma in the mother-child relationship. He makes a special point of the
difference between his structural theory and the psychodynamic psychoanalytic school, on the one hand, and the physiological hereditary
neuropsychiatric school, on the other. The principle of structuralization which he stresses accounts for the irreversibility of psychopathy.
This means, psychological function has its counterpart in cerebral structure, and that early patterns become structured organically.
This book is not easy to read or understand. I do not think it has much to offer psychoanalysts and since it presents no clinical material, I
question its value as a contribution to psychiatric nosology and theory.
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Psychoanalytic Quarterly, 1960; v.29, p421 (1pp.)

PAQ.029.0421A
Record: 3
Title: Some Characteristics of the Psychopathic Personality
Authors: Joseph, Betty
Source: International Journal of Psycho-Analysis, 1960; v. 41, p526, 6p
ISSN: 00207578
Language: English
Accession Number: IJP.041.0526A
(Permalink): direct=true&db=pph&AN=IJP.041.0526A&site=ehost-live&scope=site
direct=true&db=pph&AN=IJP.041.0526A&site=ehost-live&scope=site">Some Characteristics of the
Psychopathic Personality</A>
Some Characteristics of the Psychopathic Personality1

Betty Joseph, author; LONDON
In this paper I shall discuss some characteristics of the psychopathic personality. I use the term here in the sense in which it is generally
employed in psychiatric and psycho-analytic literature. I cannot, in a paper of this length, discuss the analytic literature on the subject, but
would refer particularly to Alexander (1), Bromberg (2), Deutsch (3), Fenichel (4), Greenacre (5), Reich (9), Wittels (10). It will be seen that
my approach to the problem is essentially dependent upon an understanding of the work of Melanie Klein(6), (7), (8).
I shall limit myself to describing and discussing one psychopathic patient whom I have had in treatment for about three years. I shall then
draw certain conclusions from this case which seem to me, both by comparison with other psychopathic patients and from a perusal of the
literature, to be relevant to the psychopathology of the non-criminal psychopath in general.
X was 16 when he came into treatment. His family is Jewish. His father is a somewhat weak and placating man; he works in a large
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industrial concern, but originally trained as a lawyer. The mother, of French origin, is an anxious and excitable woman who looks younger
than her age. She started running a small café a few months before treatment started. There is a daughter who is two years younger and is
more stable than X. There seems considerable tension between the parents, but both are concerned about X. X was referred for restless,
unhappy and unsettled behaviour. He could not stick to anything, had no real interests, and was doing badly at school. His mother was
anxious about his precocious sexual development and interests. and cross-question like a sadistic lawyer. At other times he was on the
whole co-operative, often very smooth to the point of being placating; but there was a shallow type of response to my interpretations, he
seemed consciously to pay little attention to them, would vaguely say 'Yes' and go on to something else, and would not from one session to
another show any continuity or refer back to insight he might have gained.
X was breast-fed for about two months; he was then put onto the bottle, as the mother had insufficient milk. He cried a lot between feeds.
He appeared to have become increasingly difficult with his mother since puberty, but was overtly fairly friendly with the father despite
frequent flare-ups. He went to boarding-school at 13 and in his holidays had one or two vacation jobs but could not stick to them. He
seemed interested only in earning a lot of money in the easiest possible way. At 16 he was moved from boarding school to a cramming
college in London in order to come to analysis. At this period he started to mix with a group of restless, near-delinquent teenagers who had
no regular careers, training, or jobs, and himself remained just on the outer fringe of delinquency. He and his friends went to endless parties
where there was a lot of petting with girls until all hours of the night, and they had virtually no other interests. At college he despised and
mocked his teachers, did almost no work, and cut his lectures. His two ideas for his future career were to be a lawyer or to go in for catering
(his parents' careers). Soon he added a third, that of being a psycho-analyst! He was extremely demanding and exploiting with his parents,
getting everything he could out of them, money, food, training, and then manifestly throwing away his opportunities. About all this he
showed no apparent sense of guilt, but was very bombastic, and maintained a picture of himself as being in some way special and unique.
He seemed emotionally very labile and impulsive and was apparently easily influenced by his group. He would often talk in a somewhat
maudlin and sentimental way. Although he considered himself universally popular, he had in fact no real friends. In appearance he was
slim, with a rather effeminate gait. and cross-question like a sadistic lawyer. At other times he was on the whole co-operative, often very
smooth to the point of being placating; but there was a shallow type of response to my interpretations, he seemed consciously to pay little
attention to them, would vaguely say 'Yes' and go on to something else, and would not from one session to another show any continuity or
refer back to insight he might have gained.
It seemed to me that X was in fact clearly a psychopathic personality. His difficulties did not seem to be just those of normal adolescence;
he lacked obvious neurotic symptons; he was not psychotic, and had a severely disturbed character formation. As I have suggested, he
was impulsive, had a weak ego, and was apparently lacking in a conscious sense of guilt. His object-relationships were primitive, he was
shallow in affect and very narcissistic. and cross-question like a sadistic lawyer. At other times he was on the whole co-operative, often very
smooth to the point of being placating; but there was a shallow type of response to my interpretations, he seemed consciously to pay little
attention to them, would vaguely say 'Yes' and go on to something else, and would not from one session to another show any continuity or
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refer back to insight he might have gained.
In analysis X attended regularly, but there were periods when he would become very aggressive, would twist my interpretations, throw
them back at me, verbally attack and mock at me, or would argue and cross-question like a sadistic lawyer. At other times he was on the
whole co-operative, often very smooth to the point of being placating; but there was a shallow type of response to my interpretations, he
seemed consciously to pay little attention to them, would vaguely say 'Yes' and go on to something else, and would not from one session to
another show any continuity or refer back to insight he might have gained.
I shall now discuss three interrelated characteristics which I believe to be fundamental to X's psychopathic state. First, his striking inability to
tolerate any tension; second, a particular type of attitude towards his objects; and third, a specific combination of defences with whose help
he maintains a precarious but significant balance.
X constantly shows his difficulty in tolerating any kind of tension. On a primarily physical level he tears at his skin and bites his nails when
he experiences any irritation; he was unable to establish proper bladder control until well into latency. He reacts to any anxiety by erecting
massive defences. He cannot stand frustration and tends to act out his impulses immediately with little inhibition. Nevertheless, as I shall
indicate later, a great deal that appears to be an uncontrolled acting out of impulses can be seen on further analysis to consist of
complicated mechanisms to avoid inner conflict and anxiety.
As to the second point—his particular type of attitude to his objects. X is, as I have described, extremely demanding and controlling, greedy
and exploiting. What he gets he spoils and wastes; then he feels frustrated and deprived and the greed and demands start again. I want to
show how this pattern is based on a specific inter-relationship between greed and envy. To give an example: he must have analysis, he
must have the sessions at the times he wants, it does not matter how difficult it is for his parents to afford the fees, but when he has it he
mocks, he disregards, and he twists the interpretations. As I see it, he knows that he wants something and will grab, almost to the point of
stealing, but then his envy of the giver—of the analyst, teacher, at depth the good parents—is so intense that he spoils and wastes it, but
the spoiling and wasting lead to more frustration and so augment the greed again, and the vicious circle continues. Melanie Klein in
discussing an aspect of this problem says, 'Greed, envy and persecutory anxiety, which are bound up with each other, inevitably increase
each other.'
As to my third point, I am suggesting that the nature of the anxieties aroused by this inter-relationship between greed and envy leads to the
establishment of a characteristic series of defence mechanisms. These I shall describe in more detail, and I shall suggest how they enable
X to maintain a particular type of balance. I shall show how X, despite his greed, exploitation, and impulsiveness, is not a criminal; despite
his envious, omnipotent incorporation of his objects, his cruelty towards them, his apparent lack of concern for them, and his resultant inner
persecution, he has not become psychotic. The balance that X achieves is, as I see it, the psychopathic state—a state in which profound
guilt and depression, profound persecution, and actual criminality are all constantly being evaded.
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The group of defence mechanisms mainly used by X to keep this precarious balance is centred round the maintenance and actual
dramatization of powerful omnipotent phantasies which are largely based on massive splitting and excessive projective and introjective
identification. So long as these mechanisms are effective, X's balance can be held and breakdown warded off. I have given some
instances, such as his inability to visualize any career for himself other than that of his parents or myself. Or, when he was attempting to
study economics for his General Certificate of Education, he immediately saw himself as a future writer of text-books or an economic
adviser to governments—not as a beginner student. I have also instanced how, when he was attending college, early on in the analysis, he
in fact did no work, cut lectures, and mocked at and derided his teachers as he did myself in the transference. But when faced with the
reality of exams he would firmly maintain that he could easily catch up in the two or three weeks that remained.
These defences depend upon a total introjection of, and magical identification with, the idealized, successful and desirable figures—the
parents, analyst, writers of text books. This type of introjection enables him to ward off the whole area of depressive feelings. He avoids any
dependence on his objects, any desire for or sense of loss of them. In addition, since he has swallowed up these idealized objects, and in
his feelings stolen their capacities, he avoids envy and all competitiveness, including his oedipal rivalry. He has all the cleverness—the
teachers and I are stupid, not worth his while attending to, we are the failures. Thus he splits off his wasting, failing self, his failure to make
good and use what is available, and projects it into the teachers and myself. He is also magically reparative, can put everything right, e.g.
the exams. In this way, failure, guilt, and depression are completely obviated.
Similar mechanisms are at work in his choice of friends. I have stated how, for a long time, he mixed only with a group of unsuccessful,
near-delinquent young people. It became clear that he projected into them his own criminal self—they stole, they lied, not he; thus he
avoids actual criminality and the guilt that could result. It is interesting to note, however, that on the one occasion when he did get arrested
by the police, along with a delinquent friend—mistakenly as it turned out—he lived in a state of near collapse for days, confirming that in
fact it is the intensity of his fear of persecution that prevents his being a criminal.
A similar method of avoiding actual criminality and persecution and yet living out his stealing impulses by projective identification can be
seen in the following type of behaviour. He would give a friend 10 s. to hand over to a storeman who would 'lift' a coat from a warehouse
and get it round to X. X is constantly having to evade his inner persecuting figures and superego. These he would project into the police
and parents, or, at college, his teachers, and then he allied himself with his delinquent friends against them. At other times he would identify
with his inner accusing figures and turn with violent accusations against his erstwhile friends, containing his criminal self. At yet other times
he would appear to do a great deal of wheedling, cajoling, and bribing of his internal figures as if constantly trying to prove that his criminal
impulses were not what they seemed, as is indicated in the example of the coat 'lifted' by the storeman.
Naturally the constant use of projective identification to rid himself of the bad parts of the self and inner objects leaves him feeling more
persecuted externally. This he deals with either by flight—for example he eventually could not face his college and teachers at all; or by a
manic, mocking, controlling attitude, as I have described in regard to his behaviour with myself and his teachers.
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The need to project these various internal figures into the external world to avoid both inner persecution and the possibility of guilt plays a
role of great importance in motivating psychopaths to manoeuvre rows, brawls, and fights in their outside environment to get themselves
noticed and punished and attacked for apparently petty reasons. X, when his environment did not persecute him and when he seemed to
be more settled and happy and to be getting more insight, became noticeably accident-prone. He poured boiling oil on his foot and cut off
the tip of his finger as if he now had to play out the role demanded by his slashing and burning internal figures. It was also obvious that he
unconsciously felt that such attacks were justified. He managed in a striking manner to neglect his scalded foot. I shall later indicate how
such unconscious guilt and inner persecution drove X into actual stealing and into actually beingrejected.
I have so far been trying to show some of the main mechanisms that X constantly used to avoid guilt, depression, inner and external
persecution, and actual criminality. I want now to mention a more extreme defensive process which may occur when these ordinary
mechanisms of omnipotence and projective identification fail him, and when he is momentarily faced with psychic reality. This process—a
massive fragmentation of the self and inner objects—could be seen at certain periods in the analysis when the nature and need for his
omnipotence were being interpreted; then one might get a sense of immediate chaos. X might become extremely angry and abusive with
me, shouting at me for being ridiculous, or he might appear to collapse, yelling 'All right, all right, all right', as if he were falling completely to
pieces. In these situations parts of the self and internal objects that had previously been split off and projected out and kept at bay by his
holding on to the idealized omnipotent phantasies, are, by virtue of the interpretations, brought back into contact with the self. At this
moment a new violent splitting and falling to pieces and projective identification takes place, since the patient feels overwhelmed by his
impulses and by his emerging guilt and his internal objects; at once the bad, for example 'ridiculous' parts, as well as his inner persecuting
figures, are projected into the analyst, who is attacked and abused, or is placated in a desperate masochistic manner—as with X crying, 'All
right, all right, all right'. This splitting is now of a diffuse fragmenting type, making one aware of his nearness to schizophrenic disintegration,
and his absolute need for the omnipotent defences that prevent it.
In the second part of this paper I shall bring more detailed material to illustrate some of the main points that I have been making—especially
the interconnexion between greed, envy, and frustration in X and the nature and functioning of his characteristic defences.
The material I am quoting occurred about a month before a Christmas holiday. My previous patient had in fact just left, but X arrived
early, and instead of going as usual to the waiting room, came straight to the consulting room, opened the door, looked in, realized his
error, shut the door and then went to the waiting room.
At the beginning of the session he told a dream, which was that he was in a place like a bar which also served food; his penis seemed to
have come through the zip opening of his trousers. He put it back, but then it was as if he pulled it out again; he thought that people would
realize that he was a homosexual, or a pervert. There were other men, perhaps sailors, in the bar. His associations were to a bar in a
village near a town D, where he stayed during the previous summer holidays. The bars there were closed on Sundays, but everyone went
to the bar in the nearby village which was really meant only for travellers passing through. The penis showing through the trouser opening
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refers to a party the previous weekend when X got a bit drunk and a boy had his trouser opening showing. X then described how he went
into a public lavatory a week or so before: the notice on the door said 'Vacant', but when he opened the door he saw a man's bag standing
on the floor inside, then realized that there was a man in the lavatory saying something to him as if inviting him to come in. X was alarmed
and fled. Briefly, I am suggesting that X was showing his feelings about the coming Christmas holidays, when I was felt to be the shut bar,
and he turned away to the open bar, the homosexual relationships with men, experienced as a drinking and feeding, which I connected with
fellatio phantasies. As I was speaking he said that he was just thinking about masturbation phantasies he had had about sucking his own
penis. He then seemed to trail off, saying that he had a heavy bag of school books with him, and wished he could leave it here in my flat. I
pointed out that he seemed to be turning my flat into the lavatory scene that he had experienced the previous week, for he had started the
session by pushing open the door as if maintaining that it said 'Vacant' and was proposing to push the bag in here too.
I shall now bring together the main points that I tried to convey to him and that I want to discuss here. First there is the dramatization of the
whole situation in the transference. There is also the avoidance of the frustration and anxiety about my being shut, as the mother,
unavailable over the Christmas holiday, by turning greedily to the ever-open bar. But the bar is run by men; he turns to the father inside the
mother, my room being a combined parent figure. There is a reference to his greed: last weekend he was a bit drunk; but the greed leads at
once to envy of the person who can feed, so he incorporates the feeding penis which is equated with the breast, and omnipotently sucks
from his own penis in his masturbation phantasies and will, apparently, feed the other men—the sailors. His trousers then become the ever-
open bar. Thus, all feelings of anxiety about loss and possible rejection by the mother are obviated; his need and desire for here are in the
men who are split-up aspects of the father. But now the fathercontaining these bits of himself becomes an object of terror, as is seen in the
association about the flight from the man in the lavatory. In the dream there is a breakthrough of persecutory fears; he puts his penis back
again, as if afraid of the greed of the sailors. X achieves his omnipotent solution by becoming homosexual, meaning that he now contains
the penis-breast. But the guilt and persecution about the stealing of the breast is evaded, since the actual homosexuality is projected into
myself as the father seducing him.
There are two further points I want to make. First, that the homosexual collusion with the men—there are no women in the dream—is
mirrored in his placating relationship with his actual father, in which both quietly denigrate the mother. Second, I am trying to show here the
depth of X's omnipotent phantasies. I have already stressed his need to have both his parents' careers, and he finally chose the one based
on his mother's, both her immediate one and her original maternal feeding one. In this material it becomes clear that at depth what X feels
he must have is the mother's breast stolen by the father and fused with the father's penis.
I shall now bring material to illustrate more fully an aspect of what I described earlier as X's particular type of attitude to his objects. I shall
show some of his ways of avoiding his deepest guilt towards his first object, especially his method of dramatizing a situation in which he is
thrown out, and thus punished, for a petty crime, rather than enduring the deeper underlying guilt which would lead him to experience the
depressive position.
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X decided to take up catering as a career and by now was able to start in a realistic way; he was accepted at a catering college and
found a job in the kitchen of a good hotel where he could get preliminary experience. He was good at the work, and, for the first time since
he had been in analysis, very happy in what he was doing. Suddenly, after being there just a month, he arrived saying that the chef had
given him the sack, but he did not know why, except that they were cutting down staff. This reason did not convince him. Throughout the
session he spoke very restrainedly, kept telling how very helpful and nice everyone had been, the work place, the employment agency,
adding frequently, 'I didn't fall to pieces, I didn't fall to pieces', and then went back to everyone's niceness. When I showed him both his
belief that the chef had now stolen his job and his potency, and his fear of facing his own despair, persecution, and hate, he suddenly said
that he thought that the chef was a crook. He had once overheard a conversation which seemed to indicate that in a previous job the chef
had stolen some hams. As he described this X became panicky, saying 'My anger's coming out', and went back to describing how nice and
helpful everyone had been. Right at the end of the session when speaking of his fear of his anger he said 'It's like when I went to the
cinema on Saturday, they showed the film of a plane crash, where fourteen people were killed. Tears came right up behind my eyes—
ordinarily you act as if you felt tearful, but this was real, it caught me by surprise, I stopped it, but in a way I was glad the feelings came.'
I want to stress three points here: first, his fear of falling to pieces if the hate, the persecution and despair were allowed to come through
and overwhelm him, just as he seemed to be liable to fall to pieces in the session that I instanced earlier when his omnipotence was being
analysed and he was momentarily facing psychic reality. Second, his attempt again to deal with the guilt by projecting the stealing parts of
the self (as will emerge later) and the oedipal impulses towards the mother, and the robbing, castrating internal figures into the chef
standing for the father, and at first even denying his fear about him. Third, the profound idealization of the self, being so quiet and
constructive, and of the whole outside world other than the chef. But this splitting and idealization is now aimed also at keeping his good
objects alive and safe. This can be seen by the emergence of depressive feelings; for example, the strikingly sincere way in which he spoke
of the plane crash, and his fear about the crashing of his constructive work, at depth his good internal objects. But he had in fact brought
about this partial crash, the loss of the good job. The reason for this emerged more clearly three days later when in response to
interpretations he said that he thought that he might have been given the sack for stealing food from the hotel. Three times he had taken
sandwiches home with him. So the criticism of the chef for stealing became clear. But as I shall now try to show, this petty stealing of the
sandwiches which almost certainly got him the sack was, as I suggested at the beginning of this paper, not just an acting out of greedy
impulses, but a more complex method of avoiding the deeper guilt and anxiety about stealing by the spoiling of his good object—at depth
the mother's breast. This was shown the following day, when he arrived complaining that although he had got a new job he had only been
paid one pound to keep him going. 'I can't manage, I have to pay rent, I can't manage, I shall have to borrow. At the hotel the menu is in
French and I can't understand it.' I suggested that what he could not properly understand was how he got into all these muddles with
money, and I should add that there was an important connexion here with the French menu, the French mother's food. He spoke of plans
for paying the money back, and went on to say he had had a bad night; his hot water bottle had leaked, the stopper wasn't in properly, and
the bed got damp. I suggested that the real problem was that he felt that the money, just like the analysis and his other opportunities,
seemed somehow to leak away and not get used properly. He spoke about a difficulty in plans for the day; how to manage about the
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suitcase he had with him. If he took it to work, the doorman would go through it when he left to make sure he wasn't stealing anything, and
he would be so embarrassed as it was full of soiled linen. I showed him his anxiety about taking in stuff from me, the hotel, in a stealing
way, that is, not to use it himself, for example, to have a good meal but to slip it out secretly and make it into a mess represented by the
soiled linen, as he did with the analysis, when the sessions again and again got lost and chaotic. He said that at the previous job it was true
he did get three good meals a day, but then went to the lavatory three times a day to defaecate.
Thus, the real nature of his guilt, his self-accusations, here projected on to the doorman, concern his turning his good meals at once into
faeces, my good interpretations into disregarded stuff, which are then just defaecated or leaked out.
There are two points that I want to stress here. First, I believe that it is this type of envious spoiling that is the really critical point of the guilt
in these patients, leading in X to a fear of loss and rejection. This guilt and anxiety he avoids by getting himself actively thrown out of his job
for apparently petty, greedy stealing. Second, it is this spoiling and wastage that leaves these patients always dissatisfied, feeling, as they
express it, that 'the world owes me something', and this stirs up greed again. Of course, this dissatisfaction is increased by their guilt, which
also prevents them from feeling able to use and enjoy what they do get.
Conclusion
I am suggesting in this paper that the psychopathology of X might be considered to be typical for a large group of non-criminal psychopaths.
It seems that he is particularly unable to tolerate frustration and anxiety: that he approaches his objects with an attitude of extreme greed
and stealing: that the greed and experience of desire lead immediately to feelings of intense envy of the object's capacity to satisfy him; he
attempts to obviate his envy both by spoiling and wasting what he gets from the object, thus making the object undesirable, and by
omnipotent incorporation of the idealized object. He is faced with profound anxieties on many levels. He cannot face and work through the
depressive position both because of the intensity of the persecution of his internal objects and his guilt; and because he is partially fixated in
the paranoid-schizoid position owing to the strength of his envious impulses and splitting. I have tried to show how, faced with these various
anxieties and impulses, he manages to keep a precarious balance, avoiding criminality on the one hand and a psychotic breakdown on the
other. I have discussed the nature of the defence mechanisms—based on omnipotence, splitting, and projective and introjective
identification which keeps this balance going—and am suggesting that this balance is the psychopathic state.
Footnotes
1 Read at the 21st Congress of the International Psycho-Analytical Association, Copenhagen, July 1960.
REFERENCES
1
ALEXANDER, F. 1930 'The Neurotic Character.' Int. J. Psychoanal. 11 (IJP.011.0292A)
2
BROMBERG, W. 1948 'Dynamic Aspects of the Psychopathic Personality.' Psychoanal. Q. 17 (PAQ.017.0058A)
3
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3 DEUTSCH, H. 1955 'The Impostor.' Psychoanal. Q. 24 (PAQ.024.0483A)
4 FENICHEL , O. The Psychoanalytic Theory of Neurosis (New York: Norton , 1945 .)
5 GREENACRE , P. 1945 ' Conscience in the Psychopath' Amer. J. Orthopsa. 15
6 KLEIN , MELANIE 1935 ' A Contribution to the Psychogenesis of Manic Depressive States' In: Contributions to Psycho-Analysis 1921-
1945
7
KLEIN , MELANIE 1946 ' Notes on some Schizoid Mechanisms' In: Developments in Psycho-Analysis
8
KLEIN, MELANIE 1957 Envy and Gratitude (London: Tavistock, 1957 .) (IPL.104.0001A)
9
REICH , W. Der Triebhafte Charakter (Leipzig: Int. Psychoanal. Verlag , 1925 .)
10 WITTELS, F. 1938 'The Position of the Psychopath in the Psycho-analytic System.' Int. J. Psychoanal. 19 (IJP.019.0471A)
International Journal of Psycho-Analysis, 1960; v.41, p526 (6pp.)
IJP.041.0526A
Record: 4
Title: Psychoanalytic Perspectives on Theories Regarding the Development of Antisocial Behavior
Authors: Bird, Hector, R.
Source: Journal of the American Academy of Psychoanalysis, 2001; v. 29 (1), p57, 15p
ISSN: 00903604
Language: English
Accession Number: JAA.029.0057A
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direct=true&db=pph&AN=JAA.029.0057A&site=ehost-live&scope=site">Psychoanalytic Perspectives
on Theories Regarding the Development of Antisocial Behavior</A>
Psychoanalytic Perspectives on Theories Regarding the Development of Antisocial Behavior

Hector R. Bird, MD, author, *
A great deal of concern currently exists over the increasing surge of crime and violence among young people, not only in the United States,
but also in many other countries in the industrialized world as well as in third world countries with emerging economies. The fear of violence
and crime has created climates of intimidation in many communities. Disruptive behavior disorders account for the highest rates of referral
to mental health services for adolescents. In their more severe and pervasive forms, these disorders include those adolescents who are
considered juvenile delinquents and those who exhibit criminal behavior. The care and management of these youngsters involve substantial
financial costs to society. We also know that a sizeable proportion of those children who exhibit antisocial behaviors become adults who are
antisocial personalities.
This article highlights issues relevant to classification and diagnosis of antisocial behaviors, the evolution of the diagnostic classification of
antisocial disorders, the psychoanalytic understanding of the syndrome, and how it relates to current developmental theories and to the
evolution of concepts about personalitydevelopment. The epidemiology of the disorder, including the importance of associated risk factors,
is also discussed.
Classification
The term antisocial behavior refers to any behavior that reflects violations of social norms and/or acts against others. Different from many
other psychiatric disorders, the behaviors generally cause distress and suffering to those who are victims of the negative, hostile, or
delinquent acts more than to the individuals who display them.
Antisocial behaviors may occur in many or most children as transient phenomena during the course of their development. When mild and
transient, the behaviors are considered to be normative and of little consequence. It is only when they become persistent, pervasive, and
more serious in their manifestations that their consequences impact upon the child and his/her social milieu. In their more extreme and
pervasive form, antisocial behaviors tend to vary by context, by level of severity, and by developmental periods (Loeber and Dishion, 1983),
and appear to predict antisocial disorders in later life (Robins, 1966).
The diagnostic systems, both in the United States and elsewhere, have been riddled with finding the best way to classify these disorders.
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Some have even questioned the appropriateness of classifying antisocial behaviors as psychiatric disturbances, and argue that so doing
provides delinquents with an excuse for their misbehaviors. Nevertheless, these disorders are included as psychiatric disorders in our
diagnostic systems. Since DSM-II (A.P.A., 1968), the nosology has become increasingly specific in its description of the syndrome and its
characteristics. Recent work that led to the formulations of DSM-IV (A.P.A., 1994), and the International Classification of Diseases (ICD-10)
has relied on empirical studies carried out by a number of investigations, including the DSM-IV field trials. In DSM-IV, the essential feature
of conduct disorder is a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal
norms or rules are violated. DSM-IV first institutes a subtyping that is based on age of onset, including a childhood onset subtype in which
the onset of the behaviors occurs before the age of 10 years, and an adolescent onset subtype, in which any of the characteristic behaviors
are absent before the age of 10.
The specific diagnostic criteria consist of behaviors that are typical of the antisocial individual, such as lying, stealing, vandalism, or cruelty
to others. But youngsters with conduct disorder are also qualitatively described as socially inept, lacking in empathy, and showing little or no
concern for the feelings or for the well being of others. They frequently have a hypersensitive, quasi-paranoid attitude and are prone to
misperceive the intentions of others as hostile and threatening, and are themselves likely to react with inappropriate hostility. These
individuals tend to be impulsive, intolerant of frustration, irritable, and reckless. They are accident prone and lack feelings of guilt and
remorse, although they may frequently express guilt and remorse as a way of manipulating others. Their self-esteem is usually poor,
although this may be covered up with an air of bravado and toughness.
A number of associated social features are also frequently present, including involvement in drugs or alcohol, early sexual behavior and
promiscuity, and reckless and risk-taking acts. As a consequence, these adolescents are likely to have frequent problems in school, both
academically and behaviorally. They may have difficulties with legal authorities, problems with school or work adjustment, proneness to
sexually transmitted diseases or unwanted pregnancies, and frequent accidents and physical injuries. Many of these characteristics render
such children difficult or impossible to treat through our more traditional psychoanalytic approach because their social ineptness, lack of
empathy, and difficulty in forming a deeper interpersonal bond makes the establishment of a therapeutic alliance virtually impossible. Their
suspiciousness and lack of guilt for their misdeeds reflect an almost absolute lack of insight. It is unfortunate that for these reasons
psychoanalysts very frequently dismiss these patients as untreatable.
The course of the disorder is variable. Those with earlier onset have a poorer prognosis, a finding that led to the DSM-IV subtyping.
Fortunately, in a majority of individuals the disorder remits by adulthood, with or without treatment, particularly among those with adolescent
onset and milder symptoms. However, a substantial proportion of these individuals continues to show deviant behaviors throughout
adolescence and becomes antisocial personalities in adulthood. These persistent types are at greater risk for drug abuse or dependence in
late adolescence and adulthood. Some investigators (e.g., Robins, 1981) have noted that conduct disordered children are at high risk, not
just for antisocial personality disorder, but for other psychiatric disorders later in life such as depression or anxiety disorders.
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Psychoanalytic Theory
Children manifesting behavior disorders have been a long-standing concern of the fields of psychiatry and psychoanalysis. Psychoanalytic
theory provides an in-depth understanding of the mental mechanisms through which antisocial behaviors develop, and supports the notion
that these in fact constitute psychiatric disturbances rather than entirely volitional misdeeds. From a psychoanalytic perspective, the
understanding of the development of antisocial behaviors must be grounded on those parts of the theory that deal with the development of
the superego and of conscience. Throughout the psychoanalytic literature the terms ego ideal, superego, and conscience are often used
interchangeably in the writings of different authors, and sometimes by the same author, including Freud himself, making the dimensions of
the concept unclear (see Nass, 1966).
Freud first used the term superego in his 1923 paper, “The Ego and the Id” (Freud, 1923), but it is in this paper that he himself initiates the
conceptual confusion by using the terms superego and ego ideal interchangeably. In his earlier paper “On Narcissim,” Freud (1914) had
first referred to the ego ideal as the mental agency that is intended to recapture the lost narcissism of early childhood. In Freud's view, the
narcissistic projection of the idealized parent becomes the ego ideal, and the ego ideal thus becomes the desired self to be strived for. As
described by Freud, the superego is an extension of the ego that generates a set of rules that ultimately become the individual's dictums of
conscience. A primary function of the superego therefore leads the individual to behave in such a way so as to promote the ego ideal. The
superego is constantly on guard, contrasting the actual perception of the self with the ego ideal and punishing the self through guilt when
the perceptions of the self and of the ego ideal do not match up. The ego ideal and the superego are not, therefore, interchangeable
concepts or mental agencies, as Freud often makes them to be. Freud speaks of the superego as developing as a result of identifications
with the values of the parents or of reaction formations against them. In his theory, this is the mechanism through which the ego ideal is set
up in the psyche.
Other theoreticians have contributed their own notions and refinements to these concepts, as well as to the conceptual confusion (Jones,
1926; Lampl de Groot, 1947; Reich, 1954). Ernest Jones(1926) saw the primary function of the superego as one of self-criticism. The
superego disparages the ego when it accepts or gives in to impulses that do not meet the standards set up by the ego ideal. In Jones's
view, guilt is generated because of this criticism. The psychic pain provoked by guilt thus leads the individual to punish himself and
ultimately to make amends and rectify his ways to avoid future guilt and punishment.
Most of psychoanalytic theory until the middle of this century viewed these developments as fairly static occurrences that took place at a
given stage of personalitydevelopment during which the mental structures were set up. Ego-psychology contributed immensely to revising
this static, cross-sectional view by proposing a more far-reaching developmental theory of ego and superegodevelopment. Freud had
postulated that the superego became established in latency after the resolution of the oedipal complex; Hartman and Lowenstein (1962)
see the establishment of the superego as an on-going developmental process that begins in latency but continues through adolescence
and early adulthood. In their view, what is involved is a constant readjustment between the ego, the ego ideal, and the superego to arrive at
a workable equilibrium. This position is supported by other psychoanalytic theoreticians (see Erikson, 1959; Jacobson, 1964).
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In terms of these basic psychoanalytic concepts, a child who manifests antisocial behavior is one in whom the process through which the
mental structures develop is astray. In such a child, the equilibrium that needs to exist between the mental structures is temporarily, or
sometimes permanently, unbalanced. We know, for example, that if the child identifies with the ethical distortions of unethical parents, the
result will be what Adelaide Johnson (1949) referred to as “superego lacunae.” The concept of superego lacunae applies to a child whose
behavior is antisocial in certain circumscribed areas because he is conforming with the requirements of a flawed ego ideal because of an
identification with flawed superegos in his parents or flawed parental values.
The child's superego lacunae correspond to similar defects of their parents' superego which in turn were derived from the conscious or
unconscious permissiveness of their own parents. (Johnson, 1949, p. 523).
The child guidance movement, which started in the earlier part of the past century, marked the beginnings of Child Psychiatry as a separate
field in both the United States and Europe. The child guidance movement was sparked by concern about antisocial behavior, and
constituted an effort to deal with the problems presented by juvenile delinquency. August Aichorn's (1935) seminal publication “Wayward
Youth” was first published in Austria and its English translation appeared in the United States in 1935. The ideas presented in this book
provided the earliest effort to understand and to deal with delinquency clinically and from a psychoanalytic perspective, rather than
exclusively through the legal system.
More Descriptive Developmental Perspectives

Other theories that have been often juxtaposed to psychoanalytic theories, have also attempted to account for the phenomenon of
antisocial behavior. Cognitive theory first provided an alternative viewpoint about the development of morality in the individual that at face
value seemed antithetic to the psychoanalytic perspective. Contemporaneously with Aichorn, the Swiss psychologist Jean Piaget (1932)
proposed a theory about the development of morality to explain what leads children to behave in pro-social ways. For a brilliant exposition
integrating psychoanalytic and cognitive theory, the reader is referred to Martin Nass's (1966) classic article published in the Psychoanalytic
Study of the Child.
Piaget's seminal contribution, The Moral Judgment of the Child(1932), proposes that there are two types of morality that sequentially occur
in the child and that constitute distinct stages in the child's development. The first stage is the morality of constraint, or heteronomous
morality, characteristic of the child until the age of 7-8 years. This stage reflects the child's egocentrism, and its characteristic features
include unchangeableness of rules and absolutism of values. Transgression is defined by punishment, there is an absence of reciprocity,
and other characteristics of this period are all seemingly related to the cognitive stage of concrete operations defined by the same author.
Subsequent to this stage, Piaget describes a second, more mature stage of morality, which is less tied to egocentric influences. This is a
stage in which reciprocity with others develops through the give and take of social interaction rather than through the imposition of
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sanctions. It is characterized by cooperation, autonomy, and mutual respect. As Nass (1966) points out, despite differences in the
terminology, psychoanalytic theory and cognitive theory converge conceptually in many important ways.
Phenomena and objects of study overlap, are called by other names, are selected or ignored for further study, but generally are
concerned with similar basic issues, viz., the development of moral and ethical values from a more heteronomous position to a more
autonomous position (Nass, 1966, p. 63).
What is missing in Piaget's explanatory model is any consideration of the child's affect or any effort at integrating the cognitive
development's with the child's inner emotional life.
More recent developmental theories are highly descriptive of the observable phenomenology and tend to (albeit, not altogether) avoid
speculations about the possible mechanisms that can lead to these phenomena. These theories are grounded on empirical findings that
have led to two related theoretical perspectives. One distinguishes between two distinct groups of antisocial individuals: those who have
life-course persistent antisocial behaviors starting early in life and continuing throughout their development, and those whose antisocial
behavior arises in adolescence but subsists and is adolescent-limited (Moffit, Caspi, Dickson, et al., 1993). In the persistent individuals,
those that start behaving antisocially earlier in childhood, there are neuropsychological problems that interact with adverse environments to
generate heterotypic forms of anti-social behaviors at every life stage, culminating in a pathological antisocial personality in adulthood. This
group seems to be different etiologically from the adolescent-onset/adolescent-limited group whose antisocial behavior is considered to be
predominantly “social mimicry” of anti-social styles. In the adolescent-onset group antisocial behavior tends to de-escalate and to desist
once its developmental function of securing peer-acceptance, achieving a sense of belonging and a sense of autonomy, is realized.
A second but closely related theoretical perspective proposed by Loeber (Loeber, Green, Lahey, et al., 1992; Loeber, Wung, Keenan, et al.,
1993) views the development of serious and persistent antisocial behaviors and conduct disorder (CD) as intermediate steps in a
hierarchical unfolding of various levels of antisocial symptoms along a dimension of less to more serious or severe antisocial behaviors.
This theory posits that a relatively high proportion of CD children manifest oppositional defiant disorder (ODD) earlier in life, and of those,
decreasing proportions decrementally persist into different levels of CD in either childhood or adolescence and ultimately into Antisocial
Personality in adulthood. In this sense, the diagnosis of oppositional-defiant disorder can be seen as involving earlier and milder forms of
antisocial behaviors that move along a spectrum of severity in which the behaviors may either desist, persist, or escalate with the passage
of time. This developmental perspective highlights the importance of early intervention at both the individual and family level.
There are precursors of more serious oppositionalism and conduct problems that occur even earlier and are found in infancy and early
childhood. These include difficult temperament, over-activity, or impulsivity. When these characteristics persist they subsequently become
diagnosed as the syndrome of Attention Deficit Hyperactivity Disorder (ADHD) (Moffitt, 1990; Offord, Sullivan, Allen, et al., 1979). Specific
antisocial behaviors start early in childhood with symptoms of oppositionalism (spitefulness, defiance, disobedience). Less severe
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behaviors, such as lying, minor shoplifting, or physical fighting, tend to be the first manifestations of the disorder. A number of these
children persist in the behaviors through middle childhood and early adolescence, developing mild-to-moderate symptoms of conduct
disorder—truancy, more serious lying, staying out late without permission, or petty theft. Eventually, some of those may progress to the
more disturbing symptomatology of CD and delinquency in mid-to-late adolescence, including serious theft, fire setting, breaking and entry,
vandalism or physical cruelty, sexual assault, and even homicide.
When the escalation continues unabated, this developmental progression typically culminates in Antisocial or Psychopathic Personality
Disorders in adult life. Severity tends to increase with age, and frequency of the previous behavior predicts entry into levels of more serious
behavior (escalation). Unless something aborts this process, new problem symptoms are added to existing ones, eventually culminating in
greater diversification and pervasiveness of antisocial behaviors (Loeber, 1988).
Those with adolescent onset are less likely to exhibit aggressive behaviors and are more likely to have fairly good peer relations, although
they may tend to associate with the wrong crowd. They often manifest the deviant behaviors only in the company of others and are less
likely to have a persistent conduct disorder or to develop an antisocial personality disorder in adulthood than those with the childhood onset.
Persistence and escalation, as well as frequency and age of onset, seem to be the critical parameters of this model. They serve to
distinguish those who have the onset of the behaviors but desist, from those with a more serious, long-lasting and pervasive problem that
escalates and leads to a life-long pattern of serious antisocial behavior (Farrington, Loeber, Elliott, et al., 1990; Loeber, 1988). Thus the
notions of initiation, persistence, and desistance become important topics to assess clinically and to address in the study and the treatment
of antisocial behaviors.
Two important elements of this conceptualization must be kept in mind: frequency of occurrence and heterotypic continuity. Frequent
antisocial behavior predicts escalation to subsequent levels of severity and more adverse outcomes. Heterotypic continuity reflects the fact
that many problem behaviors change with maturation and developmental stage(Moffit, 1993). A recent report (Keenan, Shaw, Dellaquadri,
et al., 1998) provides good evidence for the hypothesis that antisocial children of the early onset variety may have an underlying biological
problem, be it neurophysiological, temperamental, or otherwise, that leads them to expand their behavioral repertoire, influenced by
physical and cognitive changes and changing parental demands that change as the child gets older and what seem to be new behaviors
emerge. Viewed this way, constant crying in infancy; temper tantrums, non-compliance and aggression in toddlerhood; externalizing
problems and hostility at schoolage; and actual delinquent behavior and criminality in adolescence and adulthood, may all be
manifestations of the same underlying disorder or dysregulation.
Most studies on continuity, the Keenan et al. (1998) study included, have been correlational and have not elucidated the mechanism by
which this developmental sequence operates, in other words, how changes in the patterns, escalation, and types of problem behavior occur
within individuals (Farrington, 1988). In most violent offenders, early physical aggression and less serious types of antisocial conduct are
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necessary, although not sufficient, for later, more serious violence to occur (Farrington, 1978; Magnusson, Stattin, and Duner, 1983). While
minor transgressions and sporadic antisocial acts may first be observed in adolescence, violence or serious aggression or delinquency do
not make an initial appearance in an adolescent who had been previously a well-behaved, normal child.
Epidemiology
That many of these behaviors in isolated and sporadic forms can be considered normative is supported by epidemiologic findings. Each of
the specific antisocial behaviors that constitute oppositional and conduct disorders are highly prevalent if one considers the rates at which
they occur in the population, in the full range from mild and sporadic to serious and pervasive. More than half of youths aged 13 to 18 years
admit to theft and close to half admit to property destruction of some sort (e.g., Feldman, Caplinger, and Woderski, 1983). Contrary to the
historical folklore surrounding our Founding Fathers, probably 100% of individuals have lied at one time or another during their childhood
and adolescence. Sporadic or isolated antisocial acts do not seem to have prognostic significance. Notwithstanding the high frequency of
specific antisocial behaviors, the proportion of children showing a persistent and more pervasive pattern who fulfill diagnostic criteria for CD
is relatively low. In studies carried out in different parts of the world, approximately 4-6% of children in the 8-16-year old age range meet
diagnostic criteria for CD, and around 6-8% of younger children meet criteria for ODD (Bauermeister, Canino, and Bird, 1994; Esser,
Schmidt, and Warner, 1990; Kashani, Beck, Hoeper, et al. 1987). The disorders are more common in children proceeding from
disadvantaged backgrounds (Institute of Medicine, 1989). Rates of the two disorders vary broadly depending on the age of the population
sampled and the methodologies used to assess and ascertain the disorders.
When the problem is pervasive during childhood and adolescence and persistent over time, its prognosis is poor (see Loeber, 1982, 1991).
Epidemiologic findings support the theories of Loeber and Moffit. The persistence of conduct disorder into adulthood (as adult Antisocial
Personality) has been estimated to be between 30% and 40% (Robins, 1978; Zoccolillo, Pickles, Quinton, et al., 1992). In other words, 30-
40% of adolescents exhibiting CD progress to become an antisocial adult.
Those who become antisocial adults are usually those that have been deviant since early childhood (the early onset variety). Moreover, the
occurrence of CD in childhood and adolescence foreshadows not only adult antisocial personality but also other serious problems in adult
life, including criminality and substance abuse, and other psychiatric conditions such as depression, anxiety disorders, and substance
abuse and dependence, as well as impaired social and occupational functioning (Kazdin, 1995; Robins, 1966, 1978; Wolfgang, Figlio, and
Sellin, 1972).
Risk Factors of Disruptive Disorders

So how can these empirical findings be integrated with psychoanalytic theory? The developmental sequencing of antisocial behaviors
proposed by current theory supports the notion, proposed by ego psychology, that superego formation is a gradual process that extends
from childhood through adolescence into early adulthood, rather than a phenomenon occurring at the point in which the oedipal conflict is
resolved. Nevertheless, it is the epidemiologic findings about the risk factors of these disorders that seems to have the greatest relevance
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to psychoanalytic theory.
The pattern of the disorders varies by age and gender. The male: female ratio has been reported to be anywhere between 5-11 males: 1
female. Although there is a male preponderance, the ratio of males to females is lower for the adolescent type of CD than for the childhood
type, and recent studies and official statistics suggest a trend toward increasing rates among females as they get older. There are also
gender differences in terms of the specific behavior problems that each sex manifests. Boys are more likely to exhibit fighting, stealing,
vandalism, and disciplinary problems in school, whereas girls are more likely to exhibit lying, truancy, running away, substance use, and
prostitution. The highest prevalence occurs in urban areas, the greatest risk being in urban poor from disadvantaged minorities (Robins,
1981).
Other Risk Factors and Familial Antecedents

Conduct disorder seems to have both familial and other environmental antecedents. The risk for conduct disorder is higher in a child who
has a parent or a sibling exhibiting antisocial behavior. This fits in well with the findings of Adelaide Johnson (previously discussed) in which
the child identifies with the faulty model provided by a parent with a faulty morality and develops the “superego lacunae” to which she
referred. Conduct disorder is also more common in children of parents with alcoholism, mood disorders, or schizophrenia, or parents with a
past history of ADHD or conduct disorder themselves.
It could be argued that a genetic factor is operating. Nevertheless, the literature related to the possibility of a genetic factor is equivocal. The
most compelling evidence comes from the Stockholm adoption study (Bohman, Cloniger, Sigvardsson, et al., 1982; Cloninger, Sigvardsson,
Bohman, et al., 1982), in which men born out of wedlock and adopted at an early age by a non-relative had 1.9 times greater risk for
criminality if either of their biological parents had a history of criminality. Although this finding is a good indication that a genetic factor is
operating, the genetic factor represented only 14% of the total variability in criminality, and it was evident that the effect of environmental
risk factors was of far greater importance, other such factors explaining 86% of the variance.
The effect of an adverse environment appears to be cumulative. Factors linked to disruptive behaviors generally include the child's own
vulnerabilities and social skills deficits (Werner and Smith, 1992), parenting deficits and inadequate child rearing practices, and family
stress and other environmental factors, such as poverty (Institute of Medicine, 1989).
Some patterns of early parent-child interaction that become perpetuated during development are said to set the stage for poor child
behavioral outcomes (Kendziora and O'Leary, 1993). These include uninvolvement and lack of stimulation, lack of warmth and emotional
support, overly harsh and controlling management of the child, inability to establish reasonable expectations and limits, reinforcement of
inappropriate behavior, and inconsistent, erratic, or inappropriate discipline (Patterson, 1982; Patterson, de Baryshe, and Ramsey, 1989;
Pettit, Bate, and Dodge, 1993).
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The aspects of psychoanalytic theory previously highlighted propose that the ego ideal is formed by an attempt to recapture the lost
narcissism of early childhood. We propose that the narcissistic projection of the idealized parent is shattered when the child is confronted by
neglectful parents who are unfair, erratic, and often physically or emotionally abusive. In such a situation, the ego ideal is unstable and can
never be well defined, and the internalization process is arrested, or at best, faulty. Through inadequate parental monitoring or poor and
inconsistent limit setting, parents fail to provide the modeling and the superego standards by which the self is defined and through which
behavior can become controlled. Escalating cycles of coercive and negative behavior towards the child promote the persistence of
antisocial behavior by reinforcing oppositionalism and non-compliance and by modeling hostile and punitive interpersonal styles with which
the child becomes identified and which become part of the ego ideal (Patterson, 1982; Patterson, et al., 1989).
Another factor that has become identified as a strong predictor in the development of antisocial behavior is the association with deviant
peers. Young adolescents who associate with antisocial peers tend to become antisocial themselves, even when antisocial behavior was
not a problem earlier in their lives. This empirical finding again ties in with the theoretical formulations of ego psychology, in which the
formation of the superego is not a single event but an on-going process that extends well into young adulthood. It is therefore possible that
as the young adolescent expands his social network, the exposure to the influence of deviant peers affects the equilibrium between the
ego, superego, and ego ideal by introducing modifications of what is expectable and socially acceptable behavior, even when the socially
accepting group is restricted to the adolescent's peers. We would hypothesize that a child with poor family models or with unconcerned
parents who are unable to set appropriate limits in a loving manner, would be the most vulnerable to such influences during adolescence.
Conclusion
Two things should become clear from what we know of these disorders. One is that both psychoanalytic theory and the results of empirical
research support the notion of an escalating process that is difficult to reverse once the process has set in, especially in situations of
greater adversity. It is therefore evident that the most effective way to deal with this condition is through prevention or early intervention.
The proposition from ego psychology that the process of superego formation extends into adolescence and early adulthood suggests that,
potentially, one can intervene and modify the mental structures and therefore modify behavior during the developmental period.
A related issue is that no matter how early the intervention, it cannot succeed if we dedicate ourselves exclusively to treating the individual
child. The impact of parental modeling and inadequate parenting on the genesis of the disorder is obvious. Parents must be guided in
providing sufficient monitoring and in safeguarding their children from the negative influences of deviant peers. Therefore, to break the
malignant cycles set off by faulty patterns of interaction and modeling, the entire family constellation must be involved in the therapy of
these children and adolescents. Traditional psychoanalytic models that emphasize insight and abreaction in the treatment of the individual
child are insufficient to be effective and are likely to drive these adolescents away from treatment. The educational component of the
treatment assumes much greater importance. Personal and family insight must be complemented by modern treatment approaches
involving parent training and cognitive and hehavioral methods of demonstrated efficacy.
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Footnotes
1 Professor of Clinical Psychiatry at Columbia University, College of Physicians and Surgeons, and Supervising Psychoanalyst at the
William Alanson White Institute, New York City.
Presented of the joint meetings of the American Academy of Psychoanalysis and the Organizzazione di Psicoanalisti Italiani-Federazione e
Registro (OPIFER) in Sestri Levante, Italy, June 25, 2000.
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Journal of the American Academy of Psychoanalysis, 2001; v.29 (1), p57 (15pp.)
JAA.029.0057A
Record: 5
Title: Developmental, Structural, and Clinical Approach to Narcissistic and Antisocial Personalities
Authors: Svrakic, Dragan, M.; McCallum, Kimberli; Milan, Popovic
Source: American Journal of Psychoanalysis, 1991; v. 51 (4), p413, 20p
ISSN: 0002953X
Language: English
Accession Number: AJP.051.0413A
(Permalink): direct=true&db=pph&AN=AJP.051.0413A&site=ehost-live&scope=site
direct=true&db=pph&AN=AJP.051.0413A&site=ehost-live&scope=site">Developmental, Structural,
and Clinical Approach to Narcissistic and Antisocial Personalities</A>
Developmental, Structural, and Clinical Approach to Narcissistic and Antisocial Personalities

Dragan M. Svrakic, MD, PHD, author, Fulbright scholar and visiting instructor in Psychiatry;
Kimberli McCallum, MD, author, Fellow, Child Psychiatry; both with Washington University Medical School.
Popovic Milan, author, Professor of Psychiatry, University of Belgrade, Yugoslavia. Address correspondence to: Dragan M. Svrakic, M.D.,
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Washington University Medical School, Department of Psychiatry, 4940 Audubon Ave., St. Louis, MO 63110.
The conception of personality disorders (hereafter referred to as PDs) as distinct units of mental disorders seems neither precise nor useful.
Many studies show a significant overlap of clinical features (Pfohl et al., 1986) and a generally unreliable diagnosis of PDs (Morey, 1988b).
One reason for the difficulty in separating individual PDs might be we do not appreciate data suggesting that PDs are more alike than
different (McGlashan and Heinssen, 1989).
It is reasonable to assume that at least some PDs, classified as separate units, represent different behavioral expression of the same
personality deviation. Some empirical studies (Lilienfeld, et al., 1986) have noted that PDs reflect co-occurring endpoints of the same
pathogenesis.
In this article we describe structural, developmental, and clinical continuum between more or less clinically distinct entities of antisocial PD
and narcissistic PD. We propose that the two disorders derive from the same deviant personalitystructure and reflect spectrum disorders.
We do not propose that the two disorders be classified as a single diagnostic entity. Despite clinical and structural similarities, narcissistic
and antisocial PD manifest predominant narcissistic or predominant antisocial features (McGlashan and Heinssen, 1989). The DSM MIR
(A.P.A., 1987) criteria, however, rely solely on narcissistic or unlawful behavior and establish an artificial gap that is likely to direct research
or treatment of the two disorders to distinct routes.
The scope of the present work is the following: After reviewing some previous work on the subject we (re) examine the (seemingly)
ambiguous relation between borderline personalitystructure, pathological narcissism, and deviant personalities in general. Then, we focus
on developmental, structural, and clinical aspects of narcissistic and antisocial PD and discuss the spectrum relation between the two
disorders.
Previous Work on the Subject

Numerous authors (e.g., Loeff, 1978; Modlin, 1983; Kemberg, 1989; Bürsten, 1989; McGlashan and Heinssen, 1989; Rinsley, 1989)
discuss the relationship between antisocial and narcissistic PD from either a theoretical or empirical perspective.
Bürsten (1989) suggests that each of the individual PDs derives from more or less severe narcissism and thus labels patients with
narcissistic PD as “grandiose narcissistic” and those with antisocial PD as “manipulative narcissistic.” If we were to follow this phrasing, we
too would have labeled narcissistic patients as “grandiose,” but would have labeled antisocial persons as “destructive” and histrionic
persons as “manipulative.” We discuss the continuum between histrionic PD, narcissistic PD, and antisocial PD elsewhere (Svrakic and
McCallum, in press). More importantly, Bürsten (1989) imprecisely defines narcissism as an increased interest in one's self and does not
distinguish normal narcissism (i.e., self-esteem) from pathological narcissism (i.e., the sense of one's own grandiosity that derives from the
borderline level of personality organization). The disregard for a primitive personalitystructure that antedates the development of severe
narcissism as well as the fact that most patients with PDs display an increased interest in themselves have led Bürsten to assume that
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narcissism represents the bottom line for the whole group of PDs.
Bürsten (1989) suggests that the relation between narcissistic PD and antisocial PD is analogous to the relation between a city and a state,
the former being a state and the latter a city (p. 579). We argue that narcissistic and antisocial PD represent two counties in the city of
pathological narcissism and in the state of borderline PD personalitystructure.
In contrast to Rinsley (1989) we do not regard antisocial PD and narcissistic PD as a “higher level” of borderline personality, but rather as a
“further deviance” and thus a lower level of this personality. In fact, narcissistic and antisocial patients must undo their deviant dominant self
concepts and progress to the less socially deviant borderline level if they are to form mature personality functions and relations.
In contrast to Loeff (1978) we do not consider antisocial PD as a severe form of narcissistic PD (p. 97). The issue of severity of PDs in
general is far from being clear (see Vaillant, 1985, for some examples). Instead of comparing the two disorders regarding the degree of
severity, it seems better to approach them as different endpoints sharing a primitive personalitystructure and pathological narcissism.
Borderline Personality, Pathological Narcissism, and Deviant Personalities

Borderline Personality Structure and PDs
The borderline level of personality organization is frequently observed and, in contrast to borderline PD, more reliably diagnosed in practice
(see Kernberg, 1984, pp. 3-51, for diagnostic details). The phrase denotes developmental ego and superego defects (Kernberg, 1967). The
former are observed as nonspecific ego weakness (poor anxiety tolerance, impulse control, and lack of sublimatory channels), partial object
relations (sharp division between “all good” and “all bad” experiences), splitting and related primitive defenses, impaired reality testing, and
identity diffusion. Inadequately developed superego is rigid in some areas but absent in other areas, permitting the conflict-free expression
of severely deviant behaviors.
Some studies have found that the concept of borderline level of personality organization is useful (Nelson et al., 1985), whereas others
have questioned its validity (Reich and Frances, 1984). The concept of borderline personality organization has its limitations (inclusiveness,
relatively low diagnostic specificity) and refinements are needed. Several lines of evidence (Nelson et al., 1985; Kernberg et al., 1981;
Kullgren, 1987), however, suggest that it is a reasonable construct that describes accurately what we frequently see in practical work. An
acceptable interrater reliability, some predictive validity, and some support for the concurrent validity of the concept have been shown
(Kullgren and Armelius, 1990, p. 204). Kullgren (1987) showed fairly reliable scorings on all subdimensions of Kernberg's interview
(identityintegration, maturity of defenses, capacity of reality testing) as well as an acceptable reliability for the final diagnosis of personality
organization.
Partial object relations and a fragmentary self concept, that is, the borderline personality level, are a normal early phase in the process of
personalitydevelopment(Kernberg, 1975). The attribute “borderline” has been widely used for this normal personalityphase/level (and we
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also use it in this work) even though the attribute “elementary” seems more appropriate.
In some pathological cases the borderline personality level persists in later periods. This seems to be determined both by biological factors
—that is, constitutional lack of anxiety tolerance, aggressiveness, genetic vulnerability to certain affects (Kernberg, 1975; Chetnik, 1986;
Bürsten, 1989)—and environmental factors such as excessive early frustrations (Kernberg, 1975).
The majority of individual PDs manifest the borderline level of personality organization. Kroll and colleagues (1981), using Interview for
Borderline PD (Gunderson et al., 1981), demonstrated that the discrimination between borderline PD and other PDs cannot be made at a
significant level. Next, patients with PDs are three to eight times more likely to use primitive defenses than those without PDs (Vaillant,
1985). Psycho-dynamic (Akhtar, 1983; Kernberg, 1975) and empirical data (Lerner and Peter, 1984) suggest that the predominance of
primitive defenses point to the background existence of partial object relations and borderline personalitystructure. Defense mechanisms
have been rated in neurotic, borderline, and psychotic patients (Lerner and Lerner, 1982): Borderline persons use primitive defenses
significantly more often than the other two groups(Lerner et al., 1981).
Reich and Frances (1984, p. 229) showed that the diagnosis of the borderline personality organization (as defined by Kemberg) is
equivalent to the clinical diagnosis of the presence of any PD. It is thus very likely that the borderline PD organization represents the bottom
line for the majority of PDs. Because of its low diagnostic specificity for individual PDs (Reich and Frances, 1984), the borderline level of
personality organization should be assessed in the light of other clinical, structural, inclusion, and exclusion criteria.
Specific intrapsychic dynamics supports the conservation of the borderline personality level. Primitive defenses interfere with the
neutralization and maturation of primary motives, mainly aggression and fear. These affectively charged primary (pregenital) impulses, or a
chaotic combination of pregenital and genital ones (Kernberg, 1975), monopolize personality by altering motivation, cognition, and behavior
in biased ways. In the course of adaptation, behaviors that are maladaptive but efficient in dealing with the borderline nucleus develop.
Different adaptive strategies, therefore, bring about specific symptoms of PDs.
Pathological Narcissism and PDs

Pathological narcissism is a defensive maneuver that helps a person to overcome his or her underlying borderline nucleus. Precisely,
pathological narcissism reflects an unrealistic sense of one's specialness that compensates for the fragile inner world (it seems that
pathological narcissism becomes a shelter whereby a person experiences himself as more valuable than others, thus preventing the
fragmentation and overcoming the inability to cope with the environment).
Thus, pathological narcissism in a nonspecific sign observed in a variety of disorders, not only in narcissistic PD. Ronningstam and
Gunderson (1989) showed that only half of fifteen items discriminative of pathological narcissism are classified as DSM IIIR criteria for
narcissistic PD. The other half of the items, typical of pathological narcissism but also present in other mental disorders, include
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aggressivity, promiscuity, self-centeredness, idealization and devaluation, haughtiness, arrogance, and grandiose fantasies (Ronningstam
and Gunderson, 1989, p. 589).
A clinical observation of pathological narcissism merely implies that, instead of a realistic relation toward one's self, an unrealistic sense of
specialness and a need for attention dominates. Pathological narcissism needs external support for its persistence in the internal
world(Kernberg, 1975). Repetitive behaviors deriving from one's sense of specialness can lead to the development of various PDs.
Antisocial, narcissistic, and histrionic PD are most likely to have been built on the borderline personalitystructure and pathological
narcissism. We focus on developmental, structural, and clinical aspects of antisocial PD and narcissistic PD below.
Developmental Aspects of Antisocial Pd and Narcissistic Pd

Empirical and psychodynamic data suggest that narcissistic and antisocial PD develop in two phases. Phase 1 refers to factors contributing
to the persistence of the borderline personality level and the emergence of pathological narcissism. Phase 2 refers to environmental factors
directing subsequent personalitydevelopment toward either antisocial PD or narcissistic PD.
Phase 1
Psychodynamic (Kernberg, 1975, 1989) and empirical (McGlashan and Heinssen, 1989) studies suggest that antisocial PD and narcissistic
PD share a borderline level of personality organization. For example, McGlashan and Heinssen (1989) found that the two disorders share
the same borderline baseline and differ only with respect to specific narcissistic or antisocial behavioral styles. Clinical studies show a great
similarity of prototypes for antisocial, narcissistic, and borderline PD (Blashfield et al., 1985), and a significant overlap between their clinical
features (Pfohl et al., 1986). Finally, all combinations of borderline, narcissistic, and antisocial features have been observed in a single
patient (Stone, 1989).
Vaillant (1985) empirically proved Reid's (1985)suggestion that both antisocial PD and narcissistic PD employ primitive defenses, mostly
splitting, projection, and acting out. Vaillant (1985, p. 177) uses the term “dissociation” for a primitive defense typical of most PDs. Such
phrasing corresponds to the concept of splitting as primitive dissociation (Kernberg, 1975). Vaillant's (1985) study is a valuable contribution
to the understanding of antisocial PD, narcissistic PD, and PDs in general, because the persistence and extensive use of primitive defenses
appears to be a significant indicator of the borderline personalitystructure standing in the background of the majority of PDs (see above).
Psychodynamic (Kernberg, 1975) and empirical data (Ronningstam and Gunderson, 1989) show that pathological narcissism determines
structural and behavioral organization of narcissistic PD. Additionally, both psychodynamic (Bürsten, 1989; Kernberg, 1989) and empirical
data (Harpur et al, 1989) suggest a close connection between pathological narcissism and antisocial PD. For example, Hart (1987), quoted
after Harpur et al. (1989), demonstrated elements of pathological narcissism in adult antisocial persons. Namely, Factor 1 (personality
deviation) in Hare's (1983) Psychopathy Checklist correlates best not with ratings of antisocial and criminal behavior, but with ratings of
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pathological narcissism.
Hare (1983) describes personality deviation in antisocial PD as grandiosity, pathological lying, lack of emotional depth and sincerity,
superficial charm, and irresponsibility for one's own actions. The features are also typical of pathological narcissism. Thus, psychodynamic,
clinical, and empirical data suggest that pathological narcissism underlies antisocial behavior in observed antisocial PD.
Phase 2
Even though no set of early experiences is highly predictive of PDs, it is likely that the exposure to the deviant environment plays a critical
role in the development of some PDs (Zanarini et al., 1989). A chronic exposure to antisocial parents, especially a father(Reid, 1986), or to
narcissistic parents (Kernberg, 1975) has been noted to contribute to the development of antisocial and narcissistic PD respectively.
Stone's (1989) vignettes of patients with narcissistic, borderline, and antisocial PD illustrate the importance of an antisocial father for the
development of antisocial personality style (pp. 631-639).
Kernberg (1975) observed that children who develop narcissistic PD are usually talented, intelligent, or physically attractive; parents focus
on these features which, in turn, become a nucleus for the development of the grandiose self and, ultimately, narcissistic PD.
We note here that antisocial persons manifest all levels of intelligence (Kernberg, 1989) and all degrees of giftedness or attractiveness. It
seems that some persons develop antisocial PD instead of narcissistic PD because they lack special qualities and talents.
The point is that specific pathology of the environment may shape typically antisocial style or typically narcissistic style of individual
adaptation to the external world and, ultimately, the development of antisocial PD and narcissistic PD. Empirical data seem to support this
point. Harpur and colleagues (1989) showed that family background, social class, and father are positively correlated with social deviation
(i.e., behavioral style) of antisocial persons (Hare's Factor 2 of Psychopathy Checklist). It has also been shown (see Cooper, 1984) that
environmental factors influence largely the incidence of crime and antisocial behaviors.
Heath and Martin (1990) have recently illuminated some important development aspects of antisocial behavior. The authors explored
environmental and genetic influences on the development of psychoticism (P), which has been proposed to reflect the genetic liability to
psychopathy and psychoses (Eysenck, 1981). Genetic factors determine what may be called a general disposition to psychopathology
(cautiousness, tender-mindedness, and suspiciousness), whereas family factors influence the development of hostility, tough-mindedness,
and antisocial behaviors (Heath and Martin, 1990).
Even though the period between six and ten years of age is quiet from the standpoint of stage-specific personalitydevelopment, cognitive
studies suggest that the internal fixation of morality and empathetic feelings occur at this age (Reid, 1985). The period seems to be very
important for the development of antisocial and narcissistic PD because “high-risk” children, exposed to specific environments, develop
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maladaptive self-concepts and behavioral styles determining specific behaviors with a common antisocial nuance. Accordingly, narcissistic
PD and conduct disorder can be more or less reliably diagnosed at the age of six to ten years (A.P.A., 1987; Kernberg, 1989).
Full-Blown Narcissistic PD and Antisocial PD

The features that reliably distinguish narcissistic PD from other PDs are the sense of grandiosity, intense reactions to other people's envy,
devaluation, and high accomplishments (Ronningstam and Gunderson, 1989). Indeed, narcissistic persons may achieve high professional
and/or social positions that are, as it were, a side effect of the admiration-seeking behaviors. Some of them are less efficient in reaching
high positions and enjoy their grandiosity mostly in fantasy(Svrakic, 1987). However, all patients with narcissistic PD attempt to support
their pathological narcissism by seeking admiration in the external world.
On the other hand, antisocial persons display numerous elements of pathological narcissism (such as egocentricity, omnipotence,
entitlement) but do not manifest what we usually regard as high achievements. Rather, they manifest frequent antisocial and criminal
behavior(A.P.A., 1987). Persons with antisocial PD support their pathological narcissism and develop specific personal and interpersonal
concepts by being exquisitely destructive.
Structural Aspects of Antisocial Pd and Narcissistic Pd

The Destructive Self and the Grandiose Self
Even though they start from the same start line, antisocial persons develop the destructive self, whereas narcissistic persons develop the
grandiose self. Structural and clinical features of the latter are discussed elsewhere (Kernberg, 1975; Svrakic, 1987).
The destructive self dominates in the inner world and shapes the clinical and social profile of antisocial PD (see next section). This newly
developed destructive self concept compensates for the borderline nucleus of the antisocial personality because it obtains precise
guidelines for personal and interpersonal relations. The term “destructive self” seems more appropriate than the term “antisocial self”
because an antisocial person is both socially and self-destructive (e.g., self-mutilations are frequently observed in antisocial PD). The
destructive self is organized around aggression and is oriented toward the destruction of internal or external problems. Antisocial persons
rarely enter the process of problem solving and negate the common rule that everyone who wants to reach certain goals must invest efforts
and, usually, must overcome a series of obstacles.
Structural Aspects of the Destructive Self
We conceptualize the destructive self as reflecting anomalous condensation of aggressive aspects of one's actual self with the ideal object
and the ideal self. The inclusion of the ideal object and the ideal self concepts into the structure of the destructive self seems puzzling
because the former are regarded as constructive rather than destructive personality “parts.”
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Kernberg (1989) noted that antisocial persons fail to achieve idealization of objects. Ronningstam and Gunderson (1989) showed that
idealization characterizes both narcissistic PD and antisocial PD (p. 591). We have also observed that the majority of antisocial patients
idealize their parents, usually an antisocial father or some more distant antisocial hero. Thus, antisocial persons both identify with and
idealize the antisocial environment that becomes their internalized ideal object. In fact, these persons convert “good” and “bad” ethical
criteria, and the wishful image of themselves (i.e., the ideal self concept) become connected with destructive and antisocial rather than
constructive and prosocial behavior. This may explain the fact that the identity of a “negative hero” supports and increases the self-esteem
of most A-S persons.
The Real Self of A-S and Narcissistic Personalities

Structural and clinical features of the real self in persons with narcissistic PD are discussed elsewhere (Svrakic, 1986). In brief, with every
narcissistic person one regularly observes the split of self concept existing side by side with the grandiose self and typically narcissistic
facade.
Numerous authors (Vaillant, 1975) have noted that underneath the antisocial facade there may exist a hidden self concept. Kernberg (1989)
noted that the core of antisocial persons consists of emptiness and aloneness, stimulus hunger, incapacity to learn, and a sense of
meaninglessness of life. Dysphoric affects in the background of antisocial PD, both in adults (Winokur, 1979) and in children and
adolescents (Kashani et al., 1982; Staton and Brumbach, 1981), have been noted. Dysphoric antisocial persons may represent 25% of all
hospitalized Antisocial PD (Weiss et al., 1983; Guze, 1976). Even though antisocial persons rarely commit suicide, they may represent 25
percent of all attempted suicides in hospital emergencies Games et al., 1963).
The above information suggests that underneath their destructive self, antisocial persons have a self concept generating behaviors and
feelings (see below) opposite to those observable on the clinical surface. We refer to this self concept as the “real self” because it consists
of the elementary self structure that remained split off in the inner world after the formation of the destructive self.
Structural Aspects of the Real Self of Antisocial PD
Antisocial persons are usually aware of the existence of some “tender” parts in themselves, but the awareness neither has emotional
significance nor brings about motivation for change. This suggests that the “two-leveled” structure (the dominant destructive and the hidden
real self) is supported by the splitting mechanism (Kernberg, 1975). The real self consists of nondestructive aspects of the self and the
environment that are actively kept apart from destructiveness. Reflecting the projective identification with its own real self experiences, an
antisocial person considers any pro-social behavior as an expression of “weakness” and views contemptuously the constructive efforts of
others.
Clinical expression of both the destructive and the real self of antisocial persons is discussed later in this article. It is sufficient to note that
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experiences associated with the destructive and the real self alternatingly emerge in the clinical picture of antisocial PD.
Superego Deficiencies
Practically all persons with antisocial PD display features typical of narcissistic PD plus a specific and substantially more severe pathology
of super-ego functions (Kernberg, 1980) observed as almost total absence of internalized moral values. Hence, antisocial persons manifest
both passive-parasitic (lying, exploitation) and active-aggressive (assaults, murders) types of antisocial behaviors, whereas patients with
narcissistic PD manifest mostly passive-parasitic behaviors (Svrakic, 1990).
Structural Aspects of the Superego of Antisocial and Narcissistic PD
As already noted, the ideal object concept (which normally becomes a part of the superego) is uniquely deformed in antisocial PD because
antisocial persons internalize idealized cruelty in significant others. Hence, an antisocial person's superego consists of idealized
destructivity and identifications with destructive significant persons and is therefore totally permissive for severe antisocial behaviors.
In contrast, sadistic superego forerunners represent the superegostructure in narcissistic PD (Kernberg, 1975). This explains several
clinical features of narcissistic PD, for example, nonpsychotic paranoidness (reflecting the reprojection of sadistic forerunners),
obsessiveness (reflecting punishing of the superego), remnants of moral behavior (in certain areas and more distant relationships), and
narcissistic persons' ability to feel guilt when confronted with major consequences of their antisocial acts.
The superego of an antisocial person has not been arrested at the stage of superego precursors, but is rather a fully developed organizer
that gratifies destructive behaviors and punishes positive behaviors. Such superego is best described as a “mirror” image of normal
superego. This may explain the fact that the identity of a “negative hero” supports and increases the self-esteem of most antisocial persons.
Clinical Aspects of Antisocial Pd and Narcissistic Pd

The overall clinical features of narcissistic PD are presented elsewhere (Svrakic, 1986, 1987). Narcissistic and antisocial PD are strikingly
clinically similar, especially in the domain of ethical and interpersonal features. Using cluster analysis of the DSM IIIR criteria for all PDs,
Morey (1988a) showed that antisocial and narcissistic PD regularly cluster together. In the sample of 200 subjects, the diagnosis of
narcissistic and antisocial PD was made in 22 percent and 6.2 percent of cases, but the distinction disappeared after analysis, as these
patients fell into one large cluster of “psychopathy.”
Ronningstam and Gunderson (1989) showed that the following features, regarded as typically narcissistic, also characterize antisocial PD:
disregard for rules, idealization, grandiose fantasies, self-centeredness, attention
ajp.051.0413a.fig001.jpg
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FIG. 1. Clinical features shared by antisocial and narcissistic PD.
Antisocial PD and Narcissistic PD: A Comparative Clinical Analysis

Figure 1 summarizes clinical features shared by antisocial PD and narcissistic PD. Clinical features of the dominant grandiose and the
hidden real self of narcissistic PD are presented elsewhere (Svrakic, 1986, 1987). In brief, the grandiose self shapes the the clinical profile
of narcissistic PD, but these patients regularly manifest symptoms entirely different from those dominating the clinical picture (“clinical
traces of the real self”).
Direct Clinical Expression of the Destructive Self
Several authors (e.g., Kernberg, 1989; Bürsten, 1989; Hare, 1983) described typical personality features of persons who are hostile and
frequently violate norms. Our data suggest that the following features derive directly from the destructive self: (1) hostility; (2) sense of
specialness; (3) omnipotence; (4) grandiose fantasies; (5) invulnerability; (6) entitlement; (7) destructivity; (8) psychoactive substance use.
The majority of the above features are also observable in narcissistic PD (Svrakic, 1987). In contrast to Kemberg (1989, p. 559), we have
not observed exhibitionism and overdependency on admiration in antisocial PD. Exhibitionism includes at least some respect for others who
are expected to mirror and admire one's behavior. Antisocial persons lack the grandiose self and related experiences and expectations from
others. This also explains the absence of shame in antisocial PD (Kernberg, 1989) and the proneness to shame in narcissistic PD (Kohut,
1971). Clinical features determined by the destructive self have been analyzed and emphasized in the literature as typical of antisocial PD.
Direct Clinical Expression of the Real Self of Antisocial Persons
The “two-leveled” personality of antisocial PD has not been analyzed in depth, and this seems to be the major deficiency of previous works
on this topic.
The overall clinical picture of antisocial PD includes not only behaviors determined by the destructive self, but also a spectrum of
experiences determined by the real self, such as: (1) inferiority; (2) insecurity; (3) black-and-white perspective of the world; (4)
somatizations; (5) psychoactive substance use. With the exception of somatizations and to a lesser extent alcoholism, these features of
antisocial PD closely correspond to those observed in narcissistic PD (Svrakic, 1986). Some differences are discussed below.
First, one rarely observes pursuit of metamorphosis (typical of narcissistic PD) with antisocial persons. A fantasy that a successful antisocial
act will bring about frame or wealth is more common among antisocial persons who commit crimes.
Second, instead of hypochondriasis (typical for narcissistic PD), persons with antisocial PD display somatizations (Cloninger and
Gottesman, 1987). Even though clinically similar to each other, the two symptoms are essentially different. Hypochondriasis derives from
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cognitive anxiety and is manifested as an apprehensive expectation of mental and/or physical malfunction. Somatizations reflect somatic
anxiety and bodily sensations that are not necessarily associated with health concerns.
Third, persons with antisocial PD (ab)use alcohol and drugs very frequently. Psychoactive substance (ab)use seems to be determined by
both the destructive and the real self of antisocial persons. The addiction not only helps these persons to become “etherized,” that is, to
avoid experiences connected with their real self, but also enables them to reach a state of disinhibition in which antisocial acts are more
easily performed (the latter being associated with the destructive self).
Indirect Clinical Manifestations of the Destructive and the Real Self of Antisocial PD
The destructive and the real self shape all ego functions, that is, emotions, cognition, and actions of the antisocial personality.
Emotional features. Emotional profile of antisocial PD is similar to that described in narcissistic PD (Svrakic, 1985). Antisocial persons
manifest positive emotions that are secondary to “successful” antisocial behaviors. Simply, their destructiveness supports the dominant self
concept, increases the self-esteem, and provides a triumphant image to antisocial persons.
In contrast, numerous authors (e.g., Reid, 1985) noted that antisocial persons regularly experience boredom, emptiness, and dysphoria,
which are likely to derive from their underlying borderline level of personality, that is, the real self. However, these persons are unable to
experience refined forms of depression, such as authentic sadness or remorse (Kern-berg, 1989) but rather “primitive” depression observed
as dissatisfaction, bitterness, and disappointment. This primitive depression of persons with antisocial PD is strikingly similar to the
pessimism of discouraged narcissistic patients (Svrakic, 1985).
Cognition. Cognitive features of antisocial PD are almost identical to those described in narcissistic PD (described by Akhtar and Thomson,
1982). The destructive self determines the “ego-centric perception of reality,” as antisocial persons perceive and accept only those aspects
of reality that fit their own experience of themselves and vice versa. On the other hand, these persons manifest superficiality, disinterest,
and lack of natural curiosity that derive from their real self concept.
The following points are relevant here: First, “proneness to adventures” does not necessarily imply the existence of curiosity and
exploratory behavior in antisocial PD. In fact, antisocial persons usually try to solve a problem by destroying it or, at the best, by a trial-and-
error strategy. “Adventure” seeking thus corresponds more to recklessness than to curiosity, and enables an antisocial person to avoid his
internal emptiness by searching for (physical) excitements in the external world.
Second, the inability to learn from punishment is frequently quoted as typical for antisocial PD. This feature can be observed in practically
all PDs. Patients with PDs relate unrealistically to both themselves and the external world, and are unable to identify real problems and to
center their self-esteem around this newly developed maturity.
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Activity. Most persons with antisocial PD do not manifest exhibitionistic motivation for work typical of narcissistic PD (Kernberg, 1975), but
rather general destructivity in their actions. Destructive approach to both internal and external reality is generically associated with the
dominant destructive self and is likely to be pathognomonic of the disorder.
The real self stands in the background of the lack of genuine commitment and lack of motivation for achievements that require continuous
work and long-term investments. This is quite similar to narcissistic persons' lack of endurance and dissatisfaction with professional identity
if their vocation does not provide quick success and fame (Svrakic, 1986).
Ethical Features of Antisocial PD

Ethical features of antisocial PD derive from the specific superego formation described earlier. Quite similar to narcissistic PD, a global mal-
development of the superego explains the absence of the internal system of ethical values, as well as the lack of mature goals and ideals.
We refer to the above as “global ethical poverty.” Other features of “narcissistic ethics” also observable in antisocial PD are corruptibility,
ethical unreliability, entitlement, egocentricity, and unscrupulousness.
Even though seemingly more consistent, superego functions of an antisocial person are more deviant than those observed in narcissistic
PD. The above described structural superego differences explain the absence of guilt feelings and frequent active-aggressive antisocial
acts in the clinical picture of antisocial PD. In contrast, narcissistic persons manifest “ethical herostratism” (Svrakic, 1986) because they
occasionally experience themselves as “ready to perform criminal acts if only it would help them to finally reach their grandiose goals.” Due
to the internal punishing functions, narcissistic persons substantiate such fantasies less frequently than persons with antisocial PD. In
contrast to narcissistic persons, antisocial persons rarely mask their immorality by an apparent zeal for ethics (“mock ethics”). This reflects
different styles of adaptation observable in narcissistic PD and antisocial PD. Narcissistic persons attempt to seduce the environment,
whereas antisocial persons tend to destroy the environment and problems deriving from it.
Instead of ethics shaped by the grandiose self (the achievement of grandiosity as the primary criterion of meaningful life), antisocial persons
manifest ethics shaped by the destructive self (frequent major and minor unlawful behavior and almost total lack of guilt feelings). Driven by
the destructive self and gratified by their converted superego, antisocial persons neglect the accepted social norms and violate them more
frequently than other deviant personality types.
Interpersonal Relations of Antisocial PD

In general, interpersonal relations observed in antisocial PD closely correspond to those described in narcissistic PD (Svrakic, 1986, 1987).
Lack of empathy, aggressivity, parasitism, interpersonal pragmatism, and distrust of others are features shared by the two disorders. Some
differences are discussed below.
Antisocial persons rarely display mirroring in external objects, addiction to flattering, and seductivity because antisocial style of adaptation
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does not include admiration-seeking behaviors. Destructiveness and hostility dominantly shape the interpersonal profile of antisocial PD.
Thus, both major and minor criminality against persons (i.e., violent crime) are substantially more frequent among antisocial than among
narcissistic persons.
Good, Less-Well, and Poorly Integrated Antisocial Personalities

Quite similar to narcissistic PD (Svrakic, 1987), persons with antisocial PD manifest different levels of integration. In some cases, the
destructive self poorly organizes behavior and the disorder is observed as destructiveness that does not benefit a person at all. Such
antisocial persons are in chronic conflicts both with themselves and with the environment. The inferior destructive self allows frequent
emergence of symptoms associated with their real self (see above) and the subgroup closely resembles either “pure” borderline or
borderline-narcissistic patients.
With other antisocial persons the better organized destructive self both supports and increases their self-esteem. Such persons frequently
benefit from their antisocial behavior. Because of the well-organized destructive self, the real self rarely emerges in the clinical picture and
persons appear ruthless and careless. This subgroup resembles the traditional concept of “psychopathy.”
With still other antisocial persons the destructive self is highly organized and such persons may obtain great material benefits or high
positions among criminals. Experiences associated with their real self do not appear on the surface, and such persons resemble what we
usually call “professional criminals.”
Conclusion
Curiously enough, most researchers neglect ambiguities in the classification of PDs, and continue to study heterogenous samples of
patients. For example, when DSM MIR criteria for antisocial PD are used, the sample is likely to include patients with narcissistic PD,
histrionic PD, borderline PD, paranoid PD, alcohol and drug abusers, and, finally, criminals without any apparent personality pathology. Still,
such studies conclude solely about antisocial PD. Instead of assuming a clear situation in the domain of PDs, we believe that it is more
useful to go “back to the future” and to revise the clinical and psychostructural conception of narcissistic PD and antisocial PD.
One of the most important goals of science is to show that seemingly different phenomena are essentially similar and vice versa. Clinically
(similar) different entities can be caused by (different) similar factors (see Cloninger et al., 1975). Narcissistic PD and antisocial PD share
important developmental, structural, and clinical features and are likely to derive from the same type of deviant personality.
We propose that narcissistic PD and antisocial PD should be conceptualized as “spectrum” disorders because (1) the disorders tend to
aggregate in the same family more frequently than can be expected by chance(Loranger et al., 1982) and (2) the disorders occur in the
same individual more often than can be expected by chance(Pope et al., 1983). Two phenotypically distinguishable disorders may be
referred to as spectrum disorders if they meet the above two conditions (Cloninger et al., 1975; Reich et al., 1975).
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Important clinical, empirical, and therapeutic implications emerge if the spectrum relation between antisocial PD and narcissistic PD proves
straightforward. First, the two disorders are regarded as distinct and are likely to receive different treatment. In fact, persons with antisocial
PD are deprived of psychiatric care offered to other patients (Lewis and Appleby, 1988). If antisocial behaviors reflect a deviant personality,
such persons, regardless of what they have done, should be treated in either classic or specially designed psychiatric institutions. If the
continuum between antisocial PD, narcissistic PD, and histrionic PD were established, both the acceptance and the treatment of antisocial
personalities may improve in the future.
Second, narcissistic PD has been extensively studied from both a psychodynamic and behavioral standpoint (Kernberg, 1975; Kohut,
1971). In contrast, antisocial PD has been and is currently studied and classified from the behavioral standpoint mostly. Relatively precise
guidelines for psychotherapy of narcissistic PD may prove useful for antisocial PD as well.
Finally, the spectrum relation of narcissistic PD and antisocial PD may have important implications for future research in this field (e.g.,
family and adoption studies or especially designed clinical and learning studies). One of the most important implications is that the two
disorders should not be studied as clearly separate nosologie units.
Summary
The conception of personality disorders (PDs) as distinct units of mental disorders is neither precise nor useful. At least some PDs,
classified as separate units, reflect different behavioral expression of the same personality deviation. In this article we describe structural,
developmental, and clinical continuum between relatively distinct entities of antisocial PD and narcissistic PD. The two disorders represent
different endpoints sharing a borderline level of personality organization and pathological narcissism. We propose a spectrum relation for
antisocial and narcissistic PD because the disorders tend to co-occur in the same individual and to run in the same family more often than
expected by chance.
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American Journal of Psychoanalysis, 1991; v.51 (4), p413 (20pp.)
AJP.051.0413A
Record: 6
Title: A Preliminary Report on Defenses and Conflicts Associated with Borderline Personality Disorder
Authors: Perry, J., Christopher; Cooper, Steven, H.
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Source: Journal of the American Psychoanalytic Association, 1986; v. 34, p863, 31p
ISSN: 00030651
Language: English
Abstract: The authors present preliminary psychodynamic findings from a naturalistic study of borderline
personality disorder compared to antisocial personality disorder and bipolar type II (depression with
hypomania) affective disorder. An independent psychodynamic interview of each subject was
videotaped from which ratings were made of the presence of 22 defense mechanisms and 11
psychodynamic conflicts. A factor analysis of ratings from 81 subjects supported the separation of
borderline (splitting, projective identification) from narcissistic defenses (devaluation, omnipotence,
idealization, mood-incongruent denial). While certain groups of defenses were associated with each
diagnosis, defense ratings did not significantly discriminate the three diagnostic groups, suggesting a
limit to their diagnostic value. Among 27 subjects rated, borderline personality was strongly
associated with two conflicts: separation-abandonment, and a global conflict over the experience and
expression of emotional needs and anger. Antisocial personality was psychodynamically distinct and
more heterogeneous. Bipolar type II was associated with two hypothesized depressive conflicts:
dominantother and dominant goal. Chronic depression, which was more common in both personality
disorder groups than in bipolar type II, was associated with a third depressive conflict, overall
gratification inhibition. Overall, conflicts were powerful discriminators of the three diagnostic groups.
The heuristic value of these findings is discussed.
Accession Number: APA.034.0863A
(Permalink): direct=true&db=pph&AN=APA.034.0863A&site=ehost-live&scope=site
direct=true&db=pph&AN=APA.034.0863A&site=ehost-live&scope=site">A Preliminary Report on
Defenses and Conflicts Associated with Borderline Personality Disorder</A>
A Preliminary Report on Defenses and Conflicts Associated with Borderline Personality Disorder
J. Christopher Perry, author; 1493 Cambridge Street Cambridge, Massachusetts 02/39,
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Steven H. Cooper, Ph.D., author

ABSTRACT
The authors present preliminary psychodynamic findings from a naturalistic study of borderline personality disorder compared to antisocial
personality disorder and bipolar type II (depression with hypomania) affective disorder. An independent psychodynamic interview of each
subject was videotaped from which ratings were made of the presence of 22 defense mechanisms and 11 psychodynamic conflicts.
A factor analysis of ratings from 81 subjects supported the separation of borderline (splitting, projective identification) from narcissistic
defenses (devaluation, omnipotence, idealization, mood-incongruent denial). While certain groups of defenses were associated with each
diagnosis, defense ratings did not significantly discriminate the three diagnostic groups, suggesting a limit to their diagnostic value.
Among 27 subjects rated, borderline personality was strongly associated with two conflicts: separation-abandonment, and a global conflict
over the experience and expression of emotional needs and anger. Antisocial personality was psychodynamically distinct and more
heterogeneous. Bipolar type II was associated with two hypothesized depressive conflicts: dominantother and dominant goal. Chronic
depression, which was more common in both personality disorder groups than in bipolar type II, was associated with a third depressive
conflict, overall gratification inhibition. Overall, conflicts were powerful discriminators of the three diagnostic groups. The heuristic value of
these findings is discussed.
FOR THE PAST SEVERAL YEARS we have been conducting a study of the psychopathology and course of borderline personality disorder
to determine whether this diagnosis is valid and can be discriminated from other disorders. We selected two near neighbor disorders for this
comparison on which there has been systematic research. We chose antisocial personality disorder because of a possible overlap in
impulse pathology, and bipolar type II affective disorder because recurrent depression and hypomania represent disturbances in affect
regulation which may overlap with borderline personality disorder. To determine the discriminate validity of borderline personality disorder
from these two comparison disorders, we have examined descriptive features, and the prevalence of accompanying syndromes such as
depression, alcohol, and drug abuse. We are following their course for patterns of impulse problems, social role dysfunction, and response
to life events (Perry 1985); (Perry and Cooper 1985). In addition to this descriptive work, we are systematically examining the
psychodynamics of these disorders using a framework of defense mechanisms and psychodynamic conflicts, ascertained outside of
psychoanalytic or other treatment contexts. This preliminary report addresses the question of whether the borderline personality disorder is
associated with psychodynamics that differentiate it from these two comparison disorders.
The psychodynamic literature has generally viewed the antisocial and borderline personality disorders as strongly related or even identical
regarding their underlying psychodynamics. Kernberg (1975) stated that most cases of antisocial personality disorder have an underlying
borderline personality organization. This concept is defined by the presence of intact reality testing, identity diffusion, and the use of certain
primitive defenses revolving around splitting, which defend against the activation of pathological internalized object relations(Kernberg,
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1981). Kernberg has suggested that the major deficit in borderline psychopathology is the inability to integrate positive and negative
identifications and introjects. The reliance on splitting differentiates borderline individuals from those with higher levels of character
pathology in which repression is the major defense. While Kernberg's contributions have emphasized the role of aggression and anger in
the treatment of antisocial patients, he has not specified the mechanism by which antisocial behavior results from borderline personality
organization. Given this view, there is a need to clarify why some borderline patients overtly express extreme dependency needs, object
hunger, and anaclitic depression, while others negotiate the same conflicts and deficits through enactment, stealing (Winnicott 1954), and
frank exploitativeness.
Other authors have related antisocial behavior to narcissistic and borderline personality disorders. From this viewpoint, the antisocial
individual suffers from a severe form of narcissistic personality in which the psychopathic behavior serves a reparative role. For example,
Adler (1982) noted that criminal offenders display many features characteristic of narcissistic and borderline personality disorders, such as
a sense of incompleteness, low self-esteem, and a predilection to experience rage following disappointment. Winnicott (1954) suggested
that some individuals engage in antisocial behavior in order to provoke institutions, such as the correctional system, into providing the
containment which they feel is woefully lacking from other sources. As Adler (1982) suggested, the containment and holding functions
offered by the correctional system may provide necessary controls for individuals who have ego deficits related to impulse control.
The psychodynamic literature generally has attributed the shared features among borderline and antisocial individuals—such as erratic
temper, impulsivity, unstable interpersonal relations—to an underlying psychodynamic constellation. This includes: (1) a weak ego with poor
affect tolerance and affect regulation that includes an ongoing lack of neutralized energy to support tolerating delays in gratification; (2) a
defensive constellation in which repression is conspicuously absent and splitting operations predominate, thus causing the individual to
view the world as sets of polarities; (3) conflicts centered around the need to fend off feelings of emptiness and fears of abandonment which
thereby influence how the individual relates to others.
In reviewing their series of cases, several authors have hypothesized that certain conflicts are common in affective disorders. Cohen et al.
(1954) examined 12 cases of bipolar manic depression and ascribed to them problems with conformity to an authoritarian ideal of being
special or outstanding, while lacking the ambition and autonomy to meet such expectations. The manic state is presumed to serve a
compensatory role for loss of self-esteem attendant to failing to perform up to expectations. Arieti and Bemporad (1980) described three
different conflicts that underlie depressive disorders: the dominantother, dominant goal, and overall gratification inhibition conflicts. These
are described more fully below.
This study begins with the assumption that the literature on the psychodynamics of the three disorders in question offers a rich collection of
clinically meaningful hypotheses. This study examines some of these within the context of systematic validation (Reichenbach, 1938),
outside of the context of psychoanalytic or other treatments. We test the following hypotheses.
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1. The borderline level defenses as defined by Kernberg represent two dimensions of defensive functioning that can respectively be
described as borderline and narcissistic.
2. Borderline defenses are closely associated with borderline psychopathology, while narcissistic defenses are better associated with
antisocial psychopathology. Neither set of defenses is highly associated with bipolar type II disorder.
3. Four conflicts associated with borderline psychopathology: separation-abandonment; global conflict over experiencing and expressing
emotional needs and anger; object hunger; fear of fusion. Two conflicts are associated with antisocial psychopathology: rejection of others;
resentment over being thwarted by others. Three conflicts are associated with the bipolar II diagnosis: dominantother; dominant goal;
overall gratification inhibition.
4. Our final hypothesis is that chronic depression will be associated with one conflict: overall gratification inhibition.
Methods
Sample Selection
We initially recruited 91 subjects from ambulatory mental health settings (49%), a series of advertisements for symptomatic volunteers for
each diagnostic group (45%), and from the Probation Department of the local District Court (7%). We then administered initial
semistructured diagnostic interviews lasting over two hours each to diagnose all three disorders and to fill out diagnostic scales.
Subject Diagnoses
Definite borderline personality disorder was diagnosed if the subject met the DSM-III requirement of five or more criteria and also had a
score above a preselected cutoff (150) on an earlier version of the Borderline Personality Disorder (BPD) Scale (Perry and Cooper 1985).
Borderline traits were diagnosed if the subject met at least four of the DSM-III criteria and met a lower cutoff score (130) on the early
version of the BPD Scale, but did not fulfill the criteria for definite BPD.
Because earlier examination of the diagnostic literature on borderline disorders revealed a heterogeneous group of descriptions (Perry and
Klerman, 1978), it is important to be explicit regarding the descriptive characteristics of this diagnosis as used in this study and the scale by
which we measure borderline psychopathology. Table 1 compares the nine subscales of the BPD Scale, used in subsequent analyses, with
the DSM-III criteria. While there is a significant overlap in features, there are several differences. First, unlike DSM-III, the BPD Scale
quantifies how much of a given characteristic an individual has. Second, the BPD Scale includes aspects of BPD which are not found in
DSM-III: subscale 3, a history of regressing in psychiatric treatment, subscales 6 and 7 (partly), the instability of how the individual
perceives others and himself, commonly described as splitting dynamics and identity diffusion, and subscale 9, the tendency to regress
during crises. While the BPD Scale and the DSM-III criteria have a high level of agreement, as shown by a kappa coefficient of .70 in this
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sample, the individuals who have definite BPD by the BPD Scale cutoff score are fewer and more disturbed than those who only meet
DSM-III criteria.
TABLE 1
OVERLAP BETWEEN THE BPD SUBSCALES AND THE DSM-III CRITERIA FOR BORDERLINE PERSONALITY DISORDER
BPD Subscale DSM-III Criterion

1. Anxiety Intolerance 5. Affective Instability
2. Self-destructive Impulses 1. Impulsivity
7. Self-damaging Acts
3. Regression in Treatment —
4. Dependent Relationships 6. Problems Tolerating Aloneness
5. Angry-Hostile Relationships 2. Unstable, Intense Relationships
3. Inappropriate Anger
6. Unstable Perception of Others —
7. Disturbances in Identity and Self- 4. Identity Disturbance
perception
8. Chronic Feelings of Emptiness 8. Chronic Feelings of Emptiness or
Boredom
9. Regression in Crises —
The other diagnoses were made as follows. Antisocial personality disorder was diagnosed according to DSM-III criteria requiring the onset
of conduct disorder before age 15, and a pattern of antisocial behavior after age 18 that includes significant antisocial behavior in the last
five years. Bipolar type II was diagnosed according to the Research Diagnostic Criteria (Spitzer et al., 1978), requiring a history of major,
minor, or intermittent depressive disorder and hypomania (i.e., periods of euphoric, expansive, or irritable moods lasting seven days or
longer with two or more accompanying symptoms), but no history of a manic episode (i.e., without severe impairment or hospitalization).
Psychodynamic and Descriptive Measures

After admission to the study, subjects received two other interviews relevant to this report. The first was the Diagnostic Interview Schedule
which yields information relevant to the subject's history of various DSM-III major psychiatric disorders (Robins et al., 1981). Next, an
experienced clinician blind to diagnosis conducted a psychodynamically oriented interview of the subject which was videotaped. This
served as the raw data from which ratings on defenses and conflicts were made. Both rating procedures are described below.
Defense Mechanisms
We selected 22 defense mechanisms representing immature, borderline, and neurotic categories. We defined each defense and
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constructed a respective scale to reflect whether a defense is absent, probably, or definitely present (Perry and Cooper, in press). Each
scale point is anchored with examples. The scales tap the use of defenses in the interview, as well as historical report of their use limited to
the past two years. While the scales do not provide an exhaustive catalogue of defensive functioning, they do codify evidence rules for
clinical judgment and offer clear examples. Three trained research assistants with some clinical background observed each videotape and
made individual ratings followed by a group consensus rating for each defense. This procedure yielded a median reliability of .57 for the
consensus ratings used in subsequent data analyses. For most of the analyses, however, we combined related defenses into summary
scales which had a median intraclass reliability of .74. Defense ratings were available on 73 study subjects and an additional 8 neurotic
subjects. The neurotic subjects were added specifically to increase the stability of the factor analysis of the borderline level defenses. Their
inclusion would in no way bias the results.
Psychodynamic Conflicts
Using the same videotaped interview, raters assessed conflicts on a separate occasion in a two-stage process. In the first stage, several
experienced dynamically trained clinicians observed the videotaped interview. They described the subject's intrapersonal (i.e., idiographic)
conflicts in a specified format. This format begins with the subject's psychodynamically relevant wishes and countervailing fears. They listed
evidence from the interview that supported each wish or fear. This requirement served to check the clinicians' more speculative tendencies,
while justifying those clinical inferences that were offered. Theoretical terms were not used because these would render ratings in the
second stage harder to make. Next, the clinicians described the resultant of the subject's conflicts in terms of symptomatic outcomes such
as depression, suicide attempts, rage outbursts, and so forth. The resultant was also described in terms of avoidant outcomes, that is, how
a subject minimizes or avoids experiencing the conflicts and concomitant affects and symptoms. Finally, the clinician raters described both
the specific stressors that activated the subject's conflicts and the subject's best available level of adaptation to his conflicts. In the present
sample of 32 idiographic conflict summaries, one of the clinicians was not fully blind to diagnosis in the majority of cases, although subject
diagnosis was never discussed throughout the procedure.
These idiographic conflict summaries were then rated in the second stage by two or three clinician raters on the Psychodynamic Conflict
Rating Scales we devised (Perry and Cooper, unpublished). These 11 scales reflect patterns of cognition, fantasy, affect, behavior, and
object relations that characterize certain conflicts. Two or three raters—variously Drs. Cooper, Holzman, and Perry—read each idiographic
conflict summary and rated whether each of the 11 conflicts was absent, probably present, definitely present, or present and central to the
individual's psychodynamics. Two of the three raters were blind to diagnosis, which was not discussed. The median intraclass reliability
coefficient for the individual raters was .53. A consensus rating was then made for each conflict (which should yield a more reliable rating)
and was used in all analyses. Ratings were available on 32 subjects, of whom 27 were in one of the three exclusive diagnostic groups.
We selected 11 focal conflicts for their potential relevance to the psychodynamics of borderline, antisocial, and affective disorders. We have
characterized these as conflicts because each contains elements of competing wishes and fears. However, some of the conflicts could also
be described as attitudes about oneself or others, or deficits in interpersonal relations and self-regulation. We do not construe these as
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exclusive, nor do we construe this study as a test of a conflict versus deficit model of borderline psychopathology. Abbreviated descriptions
of the conflicts follow.
Three conflicts were based on descriptions given by Arieti and Bemporad (1980).
1. The individual with a "dominantother" conflict requires a nurturing and supportive relationship with a particular dominant individual in
his life. He is overly sensitive to criticism and rejection from this individual since he depends on the person as a source of self-esteem.
abandonment feelings. Significant others are experienced as a necessary part of the subject's emotional life. This results in extreme
anxiety, bargaining, manipulation, and helplessness when rejection is threatened or occurs. We hypothesized that two of the final four
conflicts (9 and 10) would be common in antisocial personality disorder.
2. The "dominant goal" conflict is found in individuals who derive their self-esteem largely from areas of achievement with overriding
goals. These individuals shun other forms of satisfaction in pursuit of such goals and are particularly vulnerable to setbacks in the goal
areas of life. abandonment feelings. Significant others are experienced as a necessary part of the subject's emotional life. This results in
extreme anxiety, bargaining, manipulation, and helplessness when rejection is threatened or occurs. We hypothesized that two of the final
four conflicts (9 and 10) would be common in antisocial personality disorder.
3. The "overall gratification inhibition" conflict is found in individuals who believe it wrong to derive satisfaction from their life and are
inhibited from seeking out gratification by pursuit of goals, relationships, and everyday involvements. They often feel powerless and
dysphoric and see life as empty and futile. We hypothesized that the next four conflicts would be most relevant to borderline
psychopathology. abandonment feelings. Significant others are experienced as a necessary part of the subject's emotional life. This results
in extreme anxiety, bargaining, manipulation, and helplessness when rejection is threatened or occurs. We hypothesized that two of the
final four conflicts (9 and 10) would be common in antisocial personality disorder.
4. Individuals with "separation-abandonment" conflict become strongly attached and painfully prone to separation and abandonment
feelings. Significant others are experienced as a necessary part of the subject's emotional life. This results in extreme anxiety, bargaining,
manipulation, and helplessness when rejection is threatened or occurs. We hypothesized that two of the final four conflicts (9 and 10) would
be common in antisocial personality disorder.
5. The "global conflict over experiencing and expressing emotional needs and anger" characterizes individuals who are usually inhibited
from clearly experiencing their own needs and anger. They generally feel that both of these are unacceptable vis-à-vis significant others. A
pervasive sense of self-loathing, anxiety, and dysphoria commonly arises whenever they become aware of their own needs or anger. In
addition, they are generally blocked in expressing themselves except when desperate, in which case they may act in either very entitled or
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self-destructive ways.
6. Individuals with "object hunger" experience an emotional void in their lives and believe that their stability is endangered without
attachment to some person most of the time. However, this need is not specific to one individual and they fear that one object will never
suffice. The result is that they are often indiscriminate, so that many attachments are short-lived. The capacity to be alone is very
diminished.
7. "Fear of fusion" is a conflict in which the individual sees his wishes for contact with significant others as potentially engulfing and
overwhelming. While these individuals desire close relationships, they are overly sensitive to real or imagined threats of others'
intrusiveness and frequently misinterpret others' interest as an attempt to control them. As a result interpersonal closeness is often
accompanied by protestation and anxiety over the threat of loss of differentiation between the individual and others. We hypothesized that
two of the final four conflicts (9 and 10) would be common in antisocial personality disorder.
8. "Counterdependent" conflict characterizes individuals who feel the need to maintain autonomy by disavowing their own dependency
needs. Their vulnerabilities lie chiefly in fears of loss of control and autonomy at times when dependency or affection feelings and wishes
arise toward others.
9. "Rejection of others" is a conflict experienced by individuals with an underlying negative view of themselves who are unable to regulate
their mood or have lasting good feelings about themselves, both of which they desire. As a result they seek a sense of being valuable from
others' praise, or they may idealize selected others as if their positive attributes will somehow rub off. Conversely, they may devalue
themselves and others when their negative self-view nears awareness.
10. "Resentment over being thwarted by others" is a conflict in which individuals believe that others have no right to impose limits,
controls, or sanctions on them; rather, they believe they should be able to do whatever they want whenever they want. The subjects may
not be aware of their resentment and covert expression of it. Resentment may show itself in either or both active-aggressive or indirect and
passive-aggressive ways.
11. The final conflict in this group is "ingratiation-disappointment." Individuals experiencing this conflict feel they are less worthy than
others but desirerecognition and acceptance for being worthy. As a result, they try to please those around them. They seek approval by
making excessive promises, but frequently feel angry and resentful when their promises cost them more than they get back in return. They
frequently end up disappointing others and themselves as well when failures bring disapproval rather than the approval to which they feel
entitled.
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Statistical Analyses
All reliability coefficients were calculated using the intraclass correlation coefficient for multiple raters (Shrout and Fleiss, 1979). Factor
analysis of the borderline level defenses was carried out using a principal components factor analysis with a varimax rotation (SAS, 1979).1
Spearman rank order correlation coefficients (rs) were used for all correlations between ordered variables. This statistic minimizes the
distorting effects of subjects with extreme scores on the variables which might otherwise inflate the apparent degree of association. The
canonical discriminant function analysis (SAS, 1979) was used to determine whether the summary defense scales or the conflict scales
could discriminate the three major diagnostic groups at a significant level.
Results
Defense Mechanisms
The first question was whether the defenses attributed to borderline personality organization(Kernberg, 1975) covary as one or two
dimensions. We hypothesized that three defenses, splitting of self-images, splitting of others' images, and projective identification would
correlate highly reflecting a borderline dimension, while three other defenses, omnipotence, primitive idealization, and devaluation, would
intercorrelate representing a dimension having to do with the narcissistic regulation of self-esteem.
Table 2 shows the results of a factor analysis of the eight defenses described by Kernberg as characteristic of a borderline level of
personality organization. Two factors emerged as predicted. The borderline factor including the first three defenses accounted for 28% of
the variance. The second, narcissistic, factor, including mood-incongruent, or manic denial which we did not predict, accounted for almost
18% of the variance. This confirmed our hypothesis that these eight defenses do not represent a single underlying dimension but rather
two.
We examined the intercorrelation of all the defenses (correlation matrix not shown), with a special interest in the relation between
repression and splitting. Repression correlates nonsignificantly with splitting of self-images (-.08, n = 81) and splitting of others' images
(-.05, n = 81).
Table 3 displays the correlations between the defense mechanism summary scales and the borderline and antisocial diagnostic variables.
Correlations were calculated for both categorical and continuous diagnostic variables.
TABLE 2
FACTOR STRUCTURE OF EIGHT BORDERLINE-LEVEL DEFENSES (N = 81)
Defense Factor I
Loadings II
Splitting of Self-images .82 .22
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Splitting of Others' Images .82 .11

Projective Identification .63 -.12
Bland Denial .19 .18
Mood-incongruent Denial (Manic or Depressive -.05 .59
Denial)
Omnipotence -.06 .82
Primitive Idealization .31 .51
Devaluation .16 .60
% Total Variance Explained 28.1% 17.7%
1. The disavowal defenses—including denial, projection, bland denial, and rationalization—show a low positive correlation with the
number of antisocial symptoms (rs = .22, p < .10), but a negligible correlation with the BPD Scale or diagnosis. antisocial variables. There is
a moderate correlation with the bipolar II diagnosis (rs = .37, p < .001; data not shown in table).
2. Action defenses—including acting out, passiveaggression, and hypochondriasis—show a small significant correlation (p < .05) with
both the BPD Scale (rs = .26) and diagnosis (rs = .23). These did not correlate with antisocial symptoms or diagnosis. antisocial variables.
There is a moderate correlation with the bipolar II diagnosis (rs = .37, p < .001; data not shown in table).
3. The borderline summary defense scale correlates moderately (rs = .36, p < .01) with the BPD Scale and somewhat less with the BPD
diagnosis (rs = .19, p < .10). There is a slight nonsignificant negative correlation with antisociality. antisocial variables. There is a moderate
correlation with the bipolar II diagnosis (rs = .37, p < .001; data not shown in table).
4. The narcissistic defenses as a group do not correlate significantly with borderline psychopathology, whereas they do correlate with
both antisocial symptoms (rs = .23, p < .05) and the antisocial diagnosis (rs = .22, p < .10). antisocial variables. There is a moderate
correlation with the bipolar II diagnosis (rs = .37, p < .001; data not shown in table).
5. Obsessive defenses correlate with neither borderline nor antisocial variables. There is a moderate correlation with the bipolar II
diagnosis (rs = .37, p < .001; data not shown in table).
TABLE 3
CORRELATIONS BETWEEN DEFENSE MECHANISM SUMMARY SCALES AND THE BORDERLINE AND ANTISOCIAL DIAGNOSTIC
VARIABLES (N = 73)
Defense Summary Scale BPD Scale BPD Diagnosis
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ASP Score ASP

Diagnosis
Disavowal neurotic denial, projection, bland denial, -.06 -.07 .22 †.17
rationalization
Action acting out, hypochondriasis, passive aggression .26 * .23 *.05 -.03
Borderline splitting of self-images, splitting of others' images, .36 ** .19 †-.09 -.18
projective identification
Narcissistic omnipotence, idealization, devaluation -.10 -.06 .23 *.22 †
Obsessional undoing, isolation, intellectualization -.14 -.03 -.02 -.03
† p < .10;
*
p < .05;
** p < .01
BPD Scale = Borderline Personality Disorder Scale; BPD Diagnosis = borderline diagnosis rank ordered as follows: definite borderline,
borderline traits only, not borderline; ASP Score = the sum of all the subject's positive antisocial symptoms listed in DSM-III; ASP Diagnosis
= ASP versus not ASP.
Discriminant Function Analysis of Defenses

Taking all of the defense data together, we performed a canonical discriminant function analysis to determine whether the five summary
defense variables could discriminate the three diagnostic groups. Only nonsignificant trends emerged. This suggests that the association
between personality pathology and defenses, as measured by a single interview, is limited among these closely related disorders, making it
difficult to discriminate them clearly.
Conflicts
Table 4 displays the percentage of each diagnostic group rated so far that definitely has each of the 11 conflicts. Among the 10 subjects
with borderline personality disorder, the following five conflicts are common: the global conflict over the experience and expression of
emotional needs and anger (100%), separation-abandonment (80%), overall gratification inhibition (70%), object hunger (60%), and fear of
fusion (40%).
Among the eight subjects with antisocial personality disorder, three conflicts that are also found in borderline patients are prevalent: overall
gratification inhibition (75%), the global conflict over the experience and expression of emotional needs and anger (63%), and fear of fusion
(38%). However, unlike the borderline group, separation-abandonment and object hunger are absent, while three other conflicts are
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moderately common: resentment over being thwarted by others (50%), counterdependent (38%), and dominantother (38%) conflicts.
TABLE 4
PERCENTAGE OF EACH DIAGNOSTIC GROUP WITH DEFINITE CONFLICT RATING OF 2 OR 3 (NUMBER IN EACH DIAGNOSTIC
GROUP)
Borderline (10)
Antisocial (8)
Bipolar II (9)
1. Dominant Other 20% 38% 56%
2. Dominant Goal 0 13% 22%
3. Overall Gratification Inhibition 70% 75% 33%
4. Separation-Abandonment 80% 0 11%
5. Global Exper. & Express. Emotional Needs & Anger 100% 63% 33%
6. Object Hunger 60% 0 11%
7. Counterdependent 10% 38% 22%
8. Fear of Fusion 40% 38% 11%
9. Rejection of Others 20% 25% 22%
10. Resentment Over Being Thwarted by Others 20% 50% 0
11. Ingratiation-Disappointment 10% 0 11%
Two of the three conflicts Arieti and Bemporad described as underlying the psychological organization of depression are most common in
the bipolar type II group: dominantother (56%) and dominant goal (22%) conflicts. The third hypothesized depressive conflict, overall
gratification inhibition, is present (33%) but is less common than in either personality disorder group.
A number of conflicts are definitely present in more than one diagnostic group. In order to determine the magnitude and specificity of the
relation between each conflict and each diagnostic group, we examined their intercorrelations. Table 5 presents the correlations between
the psychodynamic conflict ratings and the continuous borderline and antisocial diagnostic variables on the 27 subjects who were members
of the three exclusive diagnostic groups. Bipolar type II is not included as a variable in this analysis because it is discrete, not continuous. In
order of magnitude, three conflicts are highly correlated with the BPD Scale and diagnosis: separation-abandonment, the global conflict
over the experience and expression of emotional needs of anger, and object hunger. Of these, separation-abandonment is also significantly
negatively correlated with the antisocial variables, indicating that it possesses a highly specific association with borderline psychopathology
in this sample. Fear of fusion demonstrates only a nonsignificant correlation with borderline psychopathology, thus failing to support our
hypothesis. Finally, dominant goal conflict is negatively correlated with borderline psychopathology.
The antisocial variables have modest correlations with two conflicts: resentment over being thwarted by others, and rejection of others. The
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antisocial variables correlate negatively with both the separation-abandonment and dominantother conflicts.
TABLE 5
CORRELATIONS BETWEEN PSYCHODYNAMIC CONFLICTS AND BORDERLINE AND ANTISOCIAL DIAGNOSTIC VARIABLES (N =
27)
Conflict BPD Scale BPD Diagnosis

ASP Score ASP
Diagnosis
1 Dominant Other -.22 -.20 -.34 -.25
2 Dominant Goal -.32 -.34 -.12 -.11
3 Overall Gratification Inhibition .21 .19 .20 0
4 Separation-Abandonment .70 .80 -.33 -.51
5 Global Exper. & Express. Emotional Needs & Anger .61 .51 -.17 -.19
6 Object Hunger .49 .59 -.13 -.29
7 Counterdependent -.05 -.13 .02 .11
8 Fear of Fusion .27 .25 -.17 -.07
9 Rejection of Others -.01 -.11 .41 .26
10 Resentment over Being Thwarted by Others .05 .10 .58 .45
11 Ingratiation-disappoint. -.04 -.13 -.33 -.31
rs > .29, p < .10; rs > .34, p < .05; rs > .45, p < .01; rs > .54, p < .001.
Overall gratification inhibitionconflict does not correlate significantly with either borderline or antisocial diagnostic variables, despite its
prevalence in both diagnostic groups. This indicates that it is not specific to either diagnosis.
Discriminant Function Analysis of Conflicts

Next, we performed a canonical discriminant function analysis in order to determine whether conflicts could discriminate the three major
diagnostic groups. Five conflicts (2, 4, 6, 7, 10) were selected by a priori judgment. Discrimination of all three diagnostic groups from one
another was highly significant using two canonical functions. The first canonical equation heavily reflects subjects' scores on separation-
abandonment and dominant goal conflicts, with ASP subjects scoring the lowest and BPD subjects scoring the highest. The second
canonical equation largely reflects resentment over being thwarted by others, counterdependent, and object hunger conflicts, with ASP and
BPD subjects scoring highest and bipolar II subjects scoring lowest. Visual inspection of the plot of subjects in Figure 1 indicates that only
four subjects appear to be misclassified: two antisocial subjects appear more closely aligned with the bipolar type II subjects, and two
bipolar II subjects appear more aligned with the borderline group.
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Chronic Depression
The final hypothesis addresses whether there is a relationship between chronic depression and the overall gratification inhibitionconflict.
Table 6 displays only the significant correlations between chronic depression and the diagnostic, defense, and conflict variables. Chronic
depression was defined as present when subjects were scored on the Diagnostic Interview Schedule as being depressed most of the time
for the previous two-year period.
Chronic depression is modestly associated with the BPD Scale and diagnosis. It is also associated with the individual defenses of
devaluation, passiveaggression, and hypochondriasis, and with the action defenses summary scale. Overall gratification inhibitionconflict
demonstrates the largest correlation with chronic depression (rs = .52, p < .001), while three other conflicts demonstrate lower correlations:
fear of fusion, object hunger, and ingratiation-disappointment (negative relationship). None of these three conflicts correlates significantly
with overall gratification inhibitionconflict, indicating that the latter conflict has a unique and powerful relation to chronic depression.
Case Example: Borderline Personality Disorder

Psychiatric History
Ms. A. is a twenty-seven-year-old single woman who was in outpatient psychotherapy at entry into the study. She was the youngest of three
children from an intact family. She described an early childhood and adolescence replete with feelings of isolation from both parents and
her considerably older siblings. She described her father as a very stern, quiet man who showed almost no affection toward any of the
children. She recalled that he never touched or hugged her, and she felt that he did not really care about her. She saw her father as a
punitive individual whose primaryconcern was to discipline the children, such as using a strap to punish her. Ms. A. described her mother as
histrionic, intrusive, and emotionally volatile, often screaming arbitrarily about seemingly unimportant events. Ms. A. was very nervous
around her mother, because her mother was only precariously in control of her emotions, at best.
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Figure 1; Discrimination of the Three Diagnostic Groups Using Two Statistically Derived Conflict Dimensions
TABLE 6
DIAGNOSTIC AND PSYCHODYNAMIC VARIABLES ASSOCIATED WITH CHRONIC DEPRESSION
Diagnostic (N = 82) Spearman r

BPD Scale .29 **
BPD Diagnosis .37 ***
Defenses (N = 72) .30 **
Hypochondriasis .47 ***
Passive aggression .40 ***
Devaluation .34 ***
Action Defense Summary Scale
Conflicts (N = 32) .52 ***
Overall Gratification Inhibition .31 †
Object-Hunger .37 *
Fear of Fusion -.32 †
Ingratiation-Disappointment
†
p < .10;
*
p < .05;
**
p < .01;
***
p < .001.
Before the age of fifteen, Ms. A. was generally very compliant at both home and school, with no history of conduct disorder. Following high
school, she lived at home until twenty-two, two, when she left abruptly. She lived briefly with two men who provided her a place to stay. At
twenty-three she worked as a prostitute for a three-month period, and since has worked at a series of other jobs without any career
development, apart from attending college part-time.
Ms. A. reported attaching herself very easily and steadfastly to others, stating "I'll attach myself to somebody out of necessity and I'll pick
someone who won't leave me alone." Her relationships had a superficial quality, and she conveyed no sense of the particular
characteristics or identities of her significant others. She would often spend the night with friends and sleep in the same room or bed just to
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avoid being alone. Ms. A. would feel frantic, depersonalized, and sometimes terrified of becoming crazy when alone. She reported several
"as-if" experiences when younger, in which she adopted the identities of her significant others. Her sense of identity diffusion was profound.
"When I look in the mirror," she said, "I often wonder, will I still see the same person; sometimes I seem to change completely, and I might
look like I did when I was a teenager."
Ms. A. recalled approximately 25 episodes of depression lasting two weeks or longer beginning about age sixteen. She also described
distinct periods of elevated mood with hypomanic symptoms, which usually terminated in depression, often of suicidal proportions. She has
no sense of control over her mood changes. Her limited psychotic episodes of several hours each usually occurred when she was alone
and had no overlap with affective disorder episodes. Her self-destructive acts and three suicide attempts were most often precipitated by
painful feelings of aloneness. Once she tried to cut off her breasts; another time she tried to cut off her fingers claiming, "I didn't deserve
them." Diagnostically, Ms. A. met all eight DSM-III criteria for borderline personality disorder, and her BPD Scale score was within the upper
half of those cases with definite borderline personality disorder. She also had bipolar type II affective disorder. An abbreviated idiographic
conflict summary follows.
Wish
The raters who viewed the videotaped inverview emphasized that Ms. A. had a central conflict revolving around the wish to have a
caretaking other complete her sense of self without incurring a dreaded fusion with that person. This is a predominant wish to be cared for
and nurtured by a need-satisfying person who is totally trustworthy. This wish leads her to attach herself to others while oblivious to their
actual characteristics. For instance, she stated, "I am dependent on people like a drug." Paradoxically, the dynamic interview included no
direct reference to her mother—a striking absence. Ms. A. assigns control for her life to other people and thereby maintains fantasies of
fulfilling her yearnings through passivity and powerlessness.
Fear
Ms. A. chronically fears being abandoned and losing fragments of herself if she invests emotionally in others. She seeks to fend off and
modulate these fears through her almost parasitic attachment to others. The casual manner in which she referred to events of major
importance, such as her suicide attempts, suggests that she is also frightened of her own rage. A primary way in which she handles this
rage is by projecting it onto others whom she eventually views as "devouring" or using her.
Symptomatic Outcome
As a result of her conflicts, Ms. A. often experiences confusion and impulsiveness when alone, and zestlessness and passivity when
around others. In response to separation experiences, she has been extraordinarily self-destructive, e.g., making suicide attempts after
breaking off a relationship or prior to moving, or becoming a prostitute upon leaving her family of origin. Repeated depersonalization
suggests that she finds awareness of her feelings, and her investments and considerable disappointment in others, to be dangerous.
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Avoidant Outcome
Ms. A. minimizes her dread of abandonment and feelings of loneliness by keeping her need for involvement with others generalized and
nonspecific, and focusing on passive nurturance. This passiveposition is maintained by viewing herself as a little girl. This became
symptomatic when she sought to cut off her breasts, which she equated with womanhood, and her fingers, which could make her
productive and creative. She also uses her mistrust of real people (i.e., those who do not satisfy her needs) as a mechanism to protect her
fantasy pursuit of idealized nurturing others. Finally, detachment from painful feelings, such as her suicide attempts or her disappointment
with her father, provides her with a way to avoid involvement with others who have needs of their own and who might separate from her.
Specific Stressors
Ms. A. is most vulnerable to the loss of people or situations that add structure to her life. Situations that demand adult independent action
are also stressful.
Best level of adaptation. Her best level of functioning probably occurred as a child when she was able to gratify some of her needs for
structure and a modicum of safety from those around her by acting in a compliant manner and maintaining the position of the little girl in the
household. Her attempts to cope as an adult have not been as successful.
Psychodynamic Conflict Rating Scale scores. On the PCRS, Ms. A. had two central conflicts: separation-abandonment, and object hunger.
Two other conflicts were rated definitely present: the global conflict over the experience and expression of emotional needs and anger, and
fear of fusion. The raters also noted that five other conflicts were probably but not definitely present: dominantother, overall gratification
inhibition, counterdependent, rejection of others, and resentment over being thwarted by others. Overall, more conflicts were scored
positive for Ms. A. than for most subjects with personality disorders.
Discussion
Our findings strongly suggest that psychodynamic data, including characteristic defense mechanisms and conflicts, provide a rich basis for
differentiating three disorders which otherwise share aspects of impulse and affect pathology. We found distinct clusters of defense
mechanisms and conflicts associated with the borderline and antisocial personality disorders, and with both bipolar II and chronic
depression.
The findings on defense mechanisms make several things clear. First, the separation of borderline from narcissistic defenses is supported
both by factor analysis and by the differential correlations with clinical borderline and antisocial diagnostic variables. These findings pose a
challenge to Kernberg's (1975) proposal that the above narcissistic and borderline defenses occur together, thus comprising a common
structural aspect to borderline personality organization. Our findings suggest that some antisocial individuals do not use the defenses of
splitting and projective identification, and conversely, some borderline patients do not use omnipotence, devaluation, and primitive
idealization. This is further supported by the finding that borderline and antisocial individuals have different patterns of using the immature
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defenses: borderline subjects use more action defenses, while antisocial subjects use more disavowal defenses.
There are two caveats to consider with the above findings. First, antisocial personality was defined by a history of the antisocial behaviors
that comprise the DSM-III criteria. This recent diagnostic concept is not necessarily the same as the psychopathic, sociopathic, or antisocial
personality disorder concepts that antedated DSM-III (Hare, 1985). It is therefore possible that some clinicians may have in mind a subset
of antisocial personality disorder, in which there are coexisting borderline traits. A second caveat is that it is possible that with repeated
measurement of defenses—such as in ongoing psychotherapy—borderline and antisocial subjects might demonstrate more similar
defensive functioning than in an initial interview. On the other hand, repeated measurement often has the opposite effect. Differences in
defensive functioning could become more distinct over time.
An interesting finding is that the defenses of repression and splitting of self- or others' images do not correlate with one another. The
independence of splitting and repression challenges the notion that these two defenses occur as two ends of a developmental continuum in
which the individual progresses from one to the other. This data supports the idea, noted by Robbins (1976), that repression and splitting
may occur together in some individuals.
We found that obsessional defenses correlated with the bipolar type II diagnostic variables and not with variables reflecting either
personality disorder. This strongly matches our clinical observation that the bipolar type II group is generally healthier than either impulsive
spectrum personality disorder.
It is important to stress the limits of our overall findings on defense mechanisms. The canonical discriminant function analysis failed to
demonstrate significant discrimination of the three diagnostic groups based on the five summary defense scales. However, we believe that
this differentiation can be increased. First, improved reliability of defense ratings should be attainable by using the same rating procedures
with trained clinicians rather than less experienced raters. Lower reliability tends to wash out potential findings. Second, supplementing the
present ratings with serial measures, such as ratings of subjects' life vignettes for defensive functioning, should also increase the
discrimination of the diagnostic groups. This procedure has been used by Vaillant (1976) to great effect. Third, comparing these findings
with those obtained by a Rorschach method of measuring defense mechanisms should further validate the differences between diagnostic
groups regarding defensive functioning (Cooper, Perry, and Annow, in press).
In our examination of conflicts we found many more differences among the three diagnostic groups than would occur by chance. Apart from
determining whether conflicts can discriminate the disorders, it is important to reflect on what our findings tell us about the psychopathology
of each disorder. Both the prevalence and the specificity of the association between each conflict and each disorder are important.
Separation-abandonment is the conflict with the strongest and most specific association with borderline personality disorder. Some
descriptive features of BPD clearly relate to this conflict: anxiety intolerance, overly dependent relationships, feelings of emptiness, and the
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tendency to regress in psychiatric treatment. We have reported elsewhere (Perry and Cooper, 1985) that borderline psychopathology
correlates with low venturesomeness and with high neuroticism, dependence, and emotional reliance on others. Prospectively, levels of
depressive and anxietysymptoms are high, although manic symptoms are not (Perry, 1985). These symptoms are consistent with a chronic
disturbance in separation and loss mechanisms, perhaps interacting with unstable relationships rather than a bipolar diathesis. One result
of this conflict is that borderline patients often transfer their dependence onto psychiatric health care facilities that include more total holding
environments than psychotherapy alone provides (Perry and Cooper, 1985).
The central importance of conflict over separation-abandonment is consistent with certain psychoanalytic hypotheses about the etiology of
borderline psychopathology. For instance, Adler and Buie ascribe a formative role to early abandonment experiences that are accompanied
by a painful sense of aloneness and reactive rage (Adler and Buie, 1979); (Buie and Adler, 1982). Because these patients fail to develop
the capacity for evocative memories, they are unable to mitigate the pain of various separation experiences and soothe themselves.
A second conflict, the global conflict over the experience and expression of emotional needs and anger, is highly prevalent in borderline
individuals, although less specific to borderline psychopathology. It is likely that borderline subjects are more prone to develop this conflict
because of the presence of separation-abandonment conflict. Descriptive aspects of borderline psychopathology that relate to this conflict
are: anger and hostility in close relationships, self-destructive dyscontrol of impulses, regression during treatment and during crises, and
unstable perceptions of self and others. The action defenses—hypochondriasis, passiveaggression, and acting out—help manage this
conflict by avoiding awareness of emotional needs and anger while expressing some of these in ways that maintain attachments by
entangling others. Splitting defenses also avoid awareness of contradictory feelings that, at least in fantasy, would result in punishment or
rejection if expressed. This conflict and these defenses suggest that borderline individuals frequently have strong underlying affective
reactions involving both longings and aggressive feelings that are often not evident on the surface.
Other conflicts were common in borderline personality disorder, but not as specific to it. They may be more ubiquitous among personality
disorders in general. Object hunger may reflect a history of relative emotional neglect with a subsequent fear that attachment to any one
person will bring a repetition of hurt and disappointment. Fear of fusion may be common in those who have experienced others' care and
concern as physically or psychologically threatening. Overall gratification inhibition may maintain the chronic depression prevalent in both
borderline and antisocial personality disorders, and to a lesser extent among our bipolar type II subjects. An unexpected finding is the
negative correlation between borderline psychopathology and dominant goal conflict. This is consistent with the finding of Grinker et al.
(1968) that borderline individuals have difficulty making commitments, something the dominant goal conflict entails.
Antisocial personality disorder demonstrates more heterogeneity in relation to conflicts than does borderline personality. This may result
from the diagnostic criteria which are based only on observable antisocial behaviors, excluding underlying personality traits or dynamics.
Two conflicts moderately common in antisocial personality disorder also correlate with the degree of antisocial symptoms. Resentment over
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being thwarted by others has the most specific relation to antisociality. Related to this are the disavowal defenses that project, deny, and
rationalize impulses and actions. The second conflict, rejection of others, relates to a problem in regulating self-esteem. Narcissistic
defenses characterize antisocial psychopathology as well. These results suggest that there is a subset of antisocial individuals in whom
narcissistic psychopathology has a role in producing antisocial behavior. Together, these findings challenge us to define psychodynamically
meaningful subtypes of antisocial personality disorder potentially responsive to different treatments.
The overall gratification inhibitionconflict has an intriguing association with chronic depression. Inhibitions against seeking out rewarding
experiences, activities, and relationships may initiate or sustain chronic depression. This conflict is common in both personality disorders
but does not correlate highly with the degree of either type of psychopathology. This suggests that the association between chronic
depression and both personality disorders is indirect, since it is mediated by the intervening high prevalence of overall gratification
inhibitionconflict among personality-disordered individuals.
Two conflicts, object hunger and fear of fusion, correlate to a lesser degree with chronic depression. Neither conflict correlates with overall
gratification inhibition. Both conflicts share the inability to sustain satisfying close relationships, a theme that chronic depression and
personality disorders share to some degree.
The present report has several limitations. First, the number of subjects is modest, especially for the data on conflicts. Second,
psychodynamics were assessed on the basis of only one interview without benefit of longitudinal assessment. Third, the reliability of our
measures, especially for defense mechanisms, is only moderate, which leaves the possibility that we might fail to detect a finding that is
present, given the number of subjects. Finally, not all of the raters were blind to diagnosis in the conflict rating procedures. While each of
these features is potentially important, nonetheless, we think that the present study offers a unique, preliminary test of several important
psychodynamic hypotheses. Our findings suggest certain new avenues. It is essential to examine the relation between descriptive
psychiatric diagnosis, such as represented in DSM-III, and psychodynamics. For example, our findings suggest it is valuable to investigate
psychodynamically meaningful subtypes of antisocial personality disorder and to define their relation to narcissistic psychopathology.
Further work should be carried out to determine whether overall gratification inhibitionconflict has relevance to psychoanalytic or other
treatments of chronic depression. Continued work is needed to replicate and extend our findings on the causal relation between the specific
conflicts and borderline psychopathology. For example, we believe that further development of research methodology may throw light on
the current theoretical debate concerning the relative importance of deficit versus conflict in the understanding of borderline and other
severe psychopathologies. It may also be possible to assess changes in defense and conflict as a result of psychoanalytic psychotherapy
to test Adler's (1981) proposal that borderline and narcissistic disorders lie on a continuum of psychopathology. Finally, it is important to
refine and apply methods such as ours to the study and testing of psychoanalytic hypotheses and treatment.
Footnotes
1
SAS Institute, Cary, North Carolina
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Journal of the American Psychoanalytic Association, 1986; v.34, p863 (31pp.)
APA.034.0863A
Record: 7
Title: Understanding Violent Behaviour within the Boundaries of a Locked Ward
Authors: O'Connor, Siobhán
Source: Psychoanalytic Psychotherapy, 1999; v. 13 (1), p3, 15p
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ISSN: 02668734
Language: English
Abstract: In the management of patients who are violent or antisocial in their behaviour, attention to safety is a
priority. Physical interventions which are required to provide safety have the effect of altering the
dynamics between patients and nurses, with forces towards regression in both. The nurses have to
stay alert to potential danger so that they can intervene quickly when necessary. This can alter their
responses to patients towards a parental approach, one which has been recognised as a problem in
institutions. In regression, the patients have the opportunity for affectionate relationships otherwise
denied. Unless a space for reflection is available, many patients who could otherwise benefit from
psychological intervention are trapped in regression. This space is provided by the work of the
multidisciplinary team. An interpretative intervention is described, one in which the patients were
alerted to a potential external reality of a concerned object. The patients’ responses showed a
capacity for psychological mindedness which had been obscured by behaviour. In a setting with
limited resources, a psychoanalytically informed approach proved to have major therapeutic impact.
Accession Number: PPTX.013.0003A
(Permalink): direct=true&db=pph&AN=PPTX.013.0003A&site=ehost-live&scope=site
direct=true&db=pph&AN=PPTX.013.0003A&site=ehost-live&scope=site">Understanding Violent
Behaviour within the Boundaries of a Locked Ward</A>
Understanding Violent Behaviour within the Boundaries of a Locked Ward

Siobhán O'Connor, author; 16 Newtownbreda Road Belfast BT8 6AS.
In the management of patients who are violent or antisocial in their behaviour, attention to safety is a priority. Physical interventions which
are required to provide safety have the effect of altering the dynamics between patients and nurses, with forces towards regression in both.
The nurses have to stay alert to potential danger so that they can intervene quickly when necessary. This can alter their responses to
patients towards a parental approach, one which has been recognised as a problem in institutions. In regression, the patients have the
opportunity for affectionate relationships otherwise denied. Unless a space for reflection is available, many patients who could otherwise
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benefit from psychological intervention are trapped in regression. This space is provided by the work of the multidisciplinary team. An
interpretative intervention is described, one in which the patients were alerted to a potential external reality of a concerned object. The
patients’ responses showed a capacity for psychological mindedness which had been obscured by behaviour. In a setting with limited
resources, a psychoanalytically informed approach proved to have major therapeutic impact.
Introduction
With the development of mental health services towards community care, there remains a group of severely ill patients in hospital who
require greater resources. In the acute phase of illness, some patients demonstrate violent behaviour which requires active intervention to
secure safety. Those patients who remain in continuing care also pose a risk because of violent or other antisocial behaviour. With tension
between hospital and community resources it appears to many that those with the more severe illnesses are suffering by relative neglect. A
psychoanalytic understanding can contribute in a therapeutic way in a setting with such limited resource.
The Setting
As Consultant Psychiatrist, I have responsibility for a twenty-bedded locked ward I took responsibility for the ward after renovations. A new
multidisciplinary team was formed as the patients moved into a spacious and modern ward. Most of the patients had been resident for five
years or more, some with failed attempts at rehabilitation. After tackling a few of the chronic problems, we could provide a secure facility for
the acute wards. Our policy is to accept on an emergency basis any patients who cannot be managed in any of the three admissions units
the ward serves, because of violent or seriously threatening behaviour, or because of attempts to abscond. At any one time we could have
eight to ten acute patients.
Many of the patients are detained under the Mental Health Order. In Northern Ireland, the Order stipulates that a person must have a
diagnosis of mental illness (specifically excluding personality disorder) and show evidence of risk, before he or she can be detained. A two-
week period of assessment is allowed before a firm diagnosis has to be made. The secure setting with intensive observation provides better
conditions to make a diagnosis.
The main physical boundary lies in the degree of freedom the patients have to leave the ward. This may be with a nurse-escort or on their
own for graded periods of what is called ‘ground pass’. There is a seclusion room which is used for severe agitation.
Recruitment is a difficulty in a retracting hospital. For a brief period, we had an occupational therapist, who left for better career
opportunities. We now have an occupational therapy assistant, and an art therapist for one session a week. The nurses arrange most
activities in and out of the ward. Weekly group sessions for some of the patients are provided by therapists from my separate
psychotherapy service. With only one psychologist in the Trust, there is no input to the ward, unless by specific request. Staff shortages or
emergency situations interrupt any attempts to do psychotherapeutic work. The policy is for each patient to have a key nurse, but the time
devoted to discussion of their input is limited by the demands of managing disturbed behaviour.
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Boundaries between internal and external reality

A medical model of illness allows attention to be given to a variety of illnesses which may respond to medication or treatment of organic
pathology. This does not help when there is a persistence of disturbed behaviour. A model of mental structure must take into account
biological and psychological factors. Using the concept of regression, one can think along different lines of development within each
individual.
In the psychoanalytic approach to functional and organic psychosis, I work within a theoretical model, using the concept of dissolution of
mental processes (Ey 1962, Stengel 1963, Freeman 1988). This model envisages dissolution of the structures which organise higher
mental processes and regression along biological developmental lines. With dissolution of more advanced structures, the most primitive
processes emerge, ie regression towards primary mental processes. In the acute phase, impulses may be expressed physically in
response to hallucinations and fluctuating paranoid beliefs. In the more chronic phase, systematised delusions may betray a coherent
phantasy around a core theme. Conflicts with preoedipal and oedipal themes may be discernible in the delusional system. Speech may be
interrupted by thought disorder, the form of which is just as important as the content. In order to understand the meaning of behaviour, the
level of disorganisation has to be taken into account. At any stage of the illness, different forms of regression may be observed in the same
person: for example, regression to instinctual (oral, anal or phallic) defences, at the same time as topographical regression towards auditory
and other sensory hallucinations. Regression leads to loss of differentiation between self and other, ie loss of an ego-boundary (Federn
1953). For example, a schizophrenic patient may believe that his thoughts are not his own, or that others are controlling his feelings and
actions.
In the interventions which I describe, I outline to the patient a potential emotional response to his or her behaviour. I assume the possibility
that the patient has the capacity to understand that others may have different thoughts and feelings about the same external reality. This
presupposes achievement of an oedipal stage of development described in the concept of ‘theory of mind’ (Fonagy & Target 1996). I
assume that awareness of a different external reality has been lost, either by psychological regression with introversion and egocentrism, or
by dissolution of structure and resultant disturbance of ego-boundary.
Using the concept of psychological regression, one may understand the early influences which have given rise to fixation or arrest in the
development of personality. Early experience of chaotic relationships or insecure attachments may become revived as a result of a
perceived loss or trauma. With regression and introversion, the patient may experience feelings of abandonment and of being left alone to
cope with intolerable impulses. Although the patient has developed a ‘theory of mind’, the presence of any ‘other’ has been lost in phantasy.
Precocious sexual stimulation may have led to sensitivity to arousal, or physical abuse may later arouse an automatic physical response
accompanying painful affect. Thus, with the egocentrism of regression, the patient is so preoccupied in seeking relief from bodily tension,
that the behaviour of others is experienced, by projection, as if motivated by the patient's hostile impulses. In the schizophrenic or organic
psychoses, an experience of hostility from others may arise from similar dynamics (temporal regression). At times, for example, it seems
that an early experience of violence within the family has had the predominant aetiological influence on behaviour. In other cases, the
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illness appears to have a more organic basis, with greater dissolution of higher processes. The patient whose delusion is of having his body
altered or having been assaulted (formal regression), or who hears voices denigrating him or giving him commands (topographical
regression), may be more likely to react in a physical way.
The concept of a psychic boundary can help the professional. The boundary allows for the unknown, a freedom of thought in which the
patient is seen as having his or her own biological and psychological history, a history which can never be fully known. The nature of
attentive listening to the patient is different from what is possible in the consulting-room. Emotional sensitivity to the patient must take into
account the physical presence of a third person, or the psychical representation of the physically secure environment, without which the
professional would be at personal risk.
In a multidisciplinary approach, each professional relies on others from different disciplines, giving information or taking action as deemed
appropriate. A confident and effective team may be understood as operating at an oedipal level of development, working throughconflict
together. Mutual cooperation leads to a more productive therapeutic approach. Within the structure of a team approach, there are
professional guidelines and limits in responsibilities. Such limits can alert the professional to countertransference reactions.
The nurses working with the severely disturbed are given training in methods of control and restraint. Their first responsibility in any
situation is to ensure physical safety. This affects the nurse's role. While doing my own training in ‘breakaway’ techniques, I was alerted to
the intrusion of physical space by patients whose behaviour is the problem. In close physical contact, violence is more likely to occur.
During my training, I was reminded of the time I was attacked by a patient. She had moved too close to me, lifted her hands to encircle my
throat, and then changed her approach to grabbing me by the hair. Despite my observation of her movements, I was too slow to respond
appropriately. In conversation with a patient, I may neglect my own safety in my attempt to understand the patient. This is where I rely on
the nurses, who do focus on that aspect when accompanying me. Such a focus on behaviour is relatively neglected in the psychoanalytic
literature. There may be hypotheses on acting-out behaviour, and some examples of violence towards the analyst. However, because of
the setting of the consulting-room, there can be no such experience of persistent violent behaviour available for observation.
Pre-oedipal dynamics actualised in the ward

I would suggest that the personal interaction the patients have with nurses recapitulates a pre-oedipal situation. The nurses must remain
attentive to the possibility of violence in the chronically ill patient. It can be likened to that of a vigilant mother with her child. The mother
ensures that the environment is safe, and apparently allows freedom of movement until she is alerted to danger. She then intervenes to
neutralise, taking the child away from the danger, or stopping its activity. It is a dynamic of dependence in which the mother is experienced
as omnipotent. With development and internalisation of the mother's response, the child becomes aware of his own power to act, and can
take responsibility for safe behaviour. It is necessary for the nurse to adopt a mental attitude similar to that of the vigilant mother. The
locked door and restrictions on independent movement are constant reminders to all that the patients are perceived not to be fully
responsible. Furthermore, active responses by the nurses may reinforce regressive behaviour. The nurses are alert to increased agitation,
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intervening verbally to resolve disputes, or physically removing patients from situations which threaten safety. The dynamic may be
perceived in a more subtle way in the verbal interaction between nurses and patients.
It is important to appreciate first how severe the disturbance can be. At any time we may have one or more patients who are persistently
agitated. Even the most judicious use of medication does not help to settle some manic patients, who can be active all through the night,
violent at times. One may require two male nurses at his or her side, keeping the patient in an area of the ward that is relatively quiet, so as
not to agitate the others. A balance has to be struck between allowing the patients relative freedom to interact with each other, and
removing those who are creating greater disturbance.
Godfrey
To illustrate a regressed interaction, Godfrey is a patient with a severe and chronic schizophrenic illness. He will rarely eat solid food,
believing that it is poisoned. When he interrupts the nurses at their tea-break, they let him take the toast from their table, pleased that he
has at least taken some solid food. He paces the ward, with persistent thought disorder based on themes of physical health and illness. He
repeatedly greets staff with requests to take him to the river or swimming-pool so that he can drown himself. At times, the interaction is
teasing. A nurse told me as she came into the office one day that when Godfrey had made his usual suicidal request to go to the pool she
had responded by cheerfully asking him to get his swimming trunks, saying they could take the hospital car. When I first worked in the ward,
I was surprised to hear some of the teasing comments made to patients. On the other hand, it is difficult to illustrate just how persistently
demanding these patients can be. In time, I have come to appreciate that a little sadistic humour is essential for the mental health staff in
such a setting. Sometimes the patients taunt the nurses. Teasing in response may be playful in an overall affectionate relationship,
neutralising some of the destructiveness. The dynamic can be differentiated from more overt sadomasochistic relationships, which can
happen in institutions.
Within this approach I become identified as a person with great power. Although decisions are made after discussion with the team, the
patients perceive them as mine. This fantasy is symbolised by a hierarchy which becomes reinforced in the daily work. I am protected by
the interventions of the nurses. For example, on one occasion I was interviewing a patient in the seclusion room, trying to understand his
psychic reality. When he gave bland answers to my questions, a nurse intervened to reprimand him for not telling me everything, reminding
him that I was the doctor, there to help him. He looked beseechingly at the nurse, and then responded by outlining his delusions to me. If a
disturbed patient will not leave when I have finished the interview, the nurses, at a cue from me, will manage the situation. Standing
between me and the patient, excluding his view of me, the nurses persuade him by telling him that the doctor has finished, and distract his
attention towards the ward.
In this setting, the team approach is necessary to allow a space for reflection. The nurses manage by thinking of the patient as ill, and not
responsible for impulse-driven behaviour. It is a major theoretical shift to see the patients as responsible, although ill. If the nurses make
that mental adjustment, their reactions will be slower and they will miss signals of danger. When interviewing potentially violent patients, I
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now feel much safer in the presence of such nurses. They intervene when I am concentrating on a verbal exchange and missing important
cues of agitation.
As Consultant, my responsibilities alter the nature of my psychotherapeutic contribution. I discovered that giving more attention to some
patients roused expectations and disappointment in others. After finding that this increased the disturbance in the ward, I reverted to the
traditional style of Consultant. I now seldom see patients without a nurse present. Most of my interaction with the patients is at the team
meeting.
It is as if I represent a father figure, responsible for enforcing structure and rules of behaviour. The nurses adopt a maternal role, empathic
and tolerant, reporting to me their observations. At times they describe the patients’ delusions as if intrigued by the bizarre content. At other
times, they report on the patients’ behaviour, using the delusional explanation as if they believe them:
“Patient A is upset because so many people have been hitting him.” There are times when I have to check, for example, that they are
referring to Patient A's delusions. The maternal analogy can be used further to describe the way they report to me. It is as if they listen like
a mother does to a child: at times intrigued by childish utterances; and at other times using the same explanation as the child in a fleeting
identification with the child's feelings. Initially, I felt uncomfortable with the role assigned to me, and tried to encourage the nurses to think
about the meaning of the delusions. Although they seemed to understand, it did not change their approach. I then discovered a more
productive use of the paternal role, in which I worked with the nurses to introduce a more thoughtful communication to the patient.
In two case examples, I will show how I used my dynamic understanding to encourage the patients to reflect upon their behaviour in a
different way. The examples may also illustrate some of the problems in institutional care. Occupational therapists, for example, introduce a
different perspective, recognised as essential in rehabilitation. When resources are limited, there is too much reliance on the nursing
response alone, which can exacerbate the regressive forces.
Brian
Brian is a 34-year-old man with a diagnosis of paranoid schizophrenia. In his first presentation in 1984, at the age of 21, he was withdrawn,
spending hours sitting with the curtains closed. He had been violent towards his mother. He had auditory hallucinations and believed that
others could read, and were interfering with his thoughts. He had been in the locked ward since 1988. He was considered one of the most
violent, and could not be allowed out without nurse-escort. Outings from the ward were severely limited. To manage his more disturbed
behaviour, he had usually been given intramuscular injections of a tranquilliser, or time in the seclusion room.
The first time I interviewed him, it was in the presence of nurses. His speech was almost incomprehensible to me, partly because of high-
dose medication — but also because of muttering. At one point he obviously withdrew from the interview with me and moved towards a
nurse, touching her ear, smelling her hair, and making humorous remarks. I was told that this was not unusual, and the nurses were used to
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this touching and smelling behaviour. I saw it also with other patients, notably on occasion with another male patient, openly in the sitting-
room.
At interview, he presented an imposing figure, looking darkly out from under his eyelids. During one session, I asked him about his sleep.
He told me that it was all right, and then went on to say he was the only one sleeping in the ward, that all the other patients were having sex
with the nurses, that they were at it all night. I said:
“I think the problem is that you feel lonely and frustrated here in the ward, and it is particularly bad when you are in bed at night.” His
response was an angry retort:
“Talk ordinary, will you! I am telling you the others are having sex all night,”
and he became very agitated, muttering obscenities. As soon as I thought he could hear me, I said:
“Well, I think it must be lonely and frustrating for you.”
He calmed down. I began to realise that he experienced such conversation as a pressure for him to think before responding. His response
of telling me to talk ordinary, suggested to me that he felt that I was talking on a higher plane, to which he could not manage a response.
When I changed it to emphasising it as my thought, with no pressure on him to respond, he could relax.
On another occasion, I asked him what led him to become so agitated when he was watching television. He started to tell me in mumbled
fashion that there was a woman, and they were all having sex except him, and the woman on television was laughing at him. I urged him to
tell me this in more detail. We had to go over it many times, because he reverted to mumbling. He fluctuated from becoming increasingly
enraged with me, to one point when he paused as if to think, but became stuck in a frozen pose. After a silence, I said “What is
happening?” He said, “I can't think.” In the course of this conversation he also complained that the medication made him impotent. But then
said that he had never had a girlfriend anyway, and never would.
My understanding of this is that he was trying to verbalise his frustration. He felt impotent, not only sexually, but generally. This was evident
in conversation, when he became distracted. He regressed in thought and behaviour. The nurses responded affectionately to his regressed
behaviour. When he tried to progress, and could not, he met his frustration with rage. He showed awareness of his difficulty in
communicating, in that he was able to tell me that he could not think. He tried to rationalise that the medication was making him impotent;
but, showing that he was still in touch with reality, he could tell me that he was sexually impotent anyway.
I hypothesised that in his attempt to retain contact he was over-stimulated and overwhelmed. He used behaviour to remain in contact,
expressing affection physically in a childlike manner. At the same time, he denied and projected his sexuality with concrete representations.
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Much of his violent behaviour could be understood as arising out of frustration. I tried various approaches. His agitation was so frequent
throughout the day that the first step was to encourage a physical space from others. Initially I got the nurses to take him away to a quiet
area periodically, on a daily basis. Gradually we moved to encourage him to take himself to a quiet room when he was enraged, until he
calmed down.
I started then to draw attention to his behaviour in a different way. He was preoccupied with persecutory ideas, believing that others were
laughing at him. I pointed out how threatening his behaviour appeared, and described to him how frightened others became when he was
agitated. He expressed shock and disbelief, but over time I elaborated on the theme. While he protested that he was the victim, he clearly
listened and would ask me further questions. I gave detailed descriptions of the potential emotional response of others to specific
behaviours of his. Gradually, his behaviour became much more appropriate, and this was remarked upon by many staff around the hospital
with whom he would stop to converse socially. It was possible to regrade him to voluntary status and move him to an open ward, allowing
him to take the bus on his own to go home for weekend leave.
Brian's appearance was another problem we needed to address. Periodically he dressed in a most ridiculous manner. On one occasion, he
started wearing dangling earrings, despite the usual efforts by staff to dissuade him. These were excessively exhibitionist, like those only a
child might wear — large hearts with pink stones. At the meeting, the nurse in charge again tried to persuade him out of wearing them. The
next day, I brought him in to discuss the earrings. I referred to his frequent belief that other people were laughing at him. I told him that the
earrings were very obvious and feminine-looking. I suggested that in all likelihood he would draw attention to himself and that people might
laugh. I said that he would probably confuse this with his other ideas of people laughing at him, not realising that it was the earrings. The
next day, he passed me in the corridor and remarked that he had decided not to wear the earrings any more because they were too heavy
and a strain on his lobes, and they might tear his skin.
He appeared to be able to generalise this to other aspects of his appearance, and now dresses more appropriately. I would suggest that he
had responded to the nurses’ parental approach in a masochistic way, at times exhibitionist, and delighting in their reaction.
Brian now shows a better ability to reflect upon himself. Recently I asked him about his belief that people were laughing at him. He paused,
as if in surprise, and said that it did not seem to be happening much lately. He went on:
“I may have got it the wrong way round. I do enjoy laughing at other people myself, you know.”
In the second case, I will give another example of the same approach in a completely different situation. This is one in which psychotherapy
had focused on a history of abuse.
Patricia
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Patricia was an 18-year-old girl who had been under the care of the Social Services Department since the age of 13. The problems of a
deprived background led to admission into care two years later. Following this, Patricia disclosed a history of sexual abuse. Episodes of
self-harm led to her admission to an inpatient unit.
Among her disclosures, I was told, she had accused relatives, staff in care, and up to twenty police as having been involved in sexual
abuse. Furthermore, I was told that she had confessed to having actively abused others. During a six-months period, while having
psychotherapy, she had taken eight overdoses of drugs. The self-harm increased: with wrist-cutting and eventually trying to set fire to
herself. The transfer to my ward came about because she had originated from our catchment population. She was not detained; the
diagnosis was uncertain but she was considered not to be psychotic. However, she had been treated with large doses of Chlorpromazine.
Patricia was severely overweight, sullen in her manner and appearing immature for her age. Her history of self-harm suggested that she
was on a spiralling course. It appeared inevitable that she would kill herself, or cause serious damage, unless we could engage her in a
therapeutic alliance.
I suggested to the nurses that they should not actively seek information about the past, something which might have encouraged
regression. If she had made accusations which were false, it would be difficult for her to retract them. A more passive approach to the
details of abuse would remove the exciting or stimulating effects of the transference.
With Patricia, I outlined a treatment plan whereby we would help her to take control of her behaviour. I told her that I believed that only she
could be responsible for her behaviour, and we would do all we could to help her. I made it clear that I would not detain her against her will,
although I considered that she was at great risk of successful suicide. I outlined the relevant features of the Mental Health Order, which
would support me if such a tragedy should occur. Her first response when I stopped her medication, was to make superficial cuts to her
wrist. She protested that she must have schizophrenia, because she had hallucinations. I outlined a borderline state to her, and said that
people with this had hallucinations. She appeared to accept this as an empathic understanding of her psychic reality.
Patricia settled very quickly into the ward. She had been completely rejected by her family because of her ‘disclosures’. Her only visitors
were staff from other units. There was limited opportunity for her to have contact with any peers. Using the more restricted setting as a
psychic boundary, we attempted to encourage outside relationships and gradual freedom.
I want to describe an episode which occurred after she had been an inpatient for five months. It was during a very disturbed period in the
ward. One evening, she did not return from a period of leave from the ward. She was discovered, many hours later, by a member of staff
who was taking a shortcut across a field at the back of the hospital. He found her lying in the cold — withdrawn into a foetal position, having
cut herself with glass. She had made so many superficial wounds to her arms so that they appeared macerated. On return to the ward her
communication was withdrawn, with very little verbal interaction.
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I hypothesised that she would have felt totally forgotten as she lay for hours in the field. I considered the potential response of staff, and
how she might interpret this. The danger was of her expecting staff to be disappointed and angry. Confronting such behaviour as violent
was potentially arousing. However, I knew that an emotional response could be managed by staff. In my intervention, I relied on her
relationship with staff as potentially affectionate.
At the team meeting she was still withdrawn, but was beginning to respond slightly. I told her of how shocked everyone was about what had
happened. I told her that the nurses had spoken to me often of how helpful she was on the ward, how they had described her work in
helping with daily tasks. I then outlined the details of what had happened in her absence in order to give her some idea of another
emotional response. I described the telephone calls to me and to the police. I told her how worrying it was for the nurses, and how they had
told me that they thought it had happened because of how busy they were with other patients. Then I told her of the description the doctor
had given me of her arm, and how alarmed he was by the extent of it. As I spoke, she showed interest and shock. She said ‘I didn't know
you cared so much.’ She went on to talk a little of how bad she had felt, but still showing visible surprise at what I had said. I concluded the
interview, saying that I hoped she might not do this again, although I knew that situations like this would arise when the nurses were busy.
She left the meeting. Half-an-hour later, a nurse came into to tell me that she had gone into the seclusion room in an agitated state, kicking
the walls, and throwing furniture around, saying she wanted to discharge herself. I went to assess the situation and speak to her. I told her
that I realised this was a difficult time, but I wanted to make one request. I said she knew the position with regard to her voluntary status. I
asked her not to threaten to discharge herself because it placed us in a difficult position. If she insisted upon it we would have to allow her
to do it. We hoped we could help her, but this would make it impossible for us to do so. After listening, she stormed out of the room in a
rage, and continued her sulky behaviour, but without the threat of discharging herself.
Before her eventual discharge from the ward, she described how she had been tempted often to become self-destructive, and elaborated
on times when she had become quite preoccupied with an impulse to do herself harm. She had overcome this by trying to keep in mind that
others did care about her. She was determined not to give in to these impulses. She said that she did not want to let us down.
After a year as an inpatient, Patricia moved on to a group home in our rehabilitation service, under the care of another psychiatrist. There is
an obvious change in her appearance. While with us, she lost six stones in weight, and since discharge has maintained an appropriate
weight of about 8st (112 pounds, 50 kg). At the time of writing, it is over a year since Patricia's discharge, and there has been no further
destructive behaviour. She has reestablished contact with her mother and sisters, and is in a relationship.
Engaging the patient in verbal communication

In the interventions described, I have tried to convey to the patients an alternative perspective on their behaviour, one which they may not
have considered. Frequently, when I have heard others try to follow this approach, I find that they have not grasped an essential feature.
They almost invariably include a remonstration or instruction. They betray a therapeutic zeal which distracts from simple communication. I
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present a ‘simple fact of life’ from my point of view. I urge the patient to consider a different fantasy, and suggest that this might help in the
control of behaviour. In my view, nobody, but the patient can be responsible for his or her behaviour. We can take responsibility for the
consequences. I acknowledge the possibility of failure. This is quite different from the remonstration or instruction which implies that we will
be annoyed or disappointed if the patient fails. I convey the strength we do have to contain, in an attempt to reduce anxiety. With Patricia,
for example, when proposing a treatment alliance, I outlined the hostility of her suicidal behaviour. At the same time, I told her that we would
be protected by the Mental Health Order, to make it clear that her destructiveness was not overwhelming for us. When I asked her not to
threaten to discharge herself, it was meant as a reminder of our previous conversation about the Order. I understood that her threats were
only an expression of anger, and she had forgotten the full legal implications of them. Reminding her in the form of a request also held
meaning. I clearly stated that she had the power to decide, and expressed a wish, rather than a threat, in return. This is in contrast to what
often happens when dealing with difficult patients. The patients may be described as manipulative, but it is the professionals who get
frustrated when their own interventions have failed, such frustration can lead to hostility, which is expressed in coercion or subtle threats, a
manipulative countertransference reaction.
The multidisciplinary approach

Within the secure setting of a locked ward, the nurses are tolerant of the patients, providing empathic warmth and humour. Selective
attention towards safety, however, must play a large part in their daily interaction. A therapist has to be able to think freely about a patient's
behaviour in order to help reflective processes. There is a contradiction between the processes of free reflective thought and that of the
selective attention required in order to stay alert and intervene actively.
The space for reflection occurs in the multidisciplinary approach. However, there are still powerful forces towards regression. Persistent
demands by patients or their relatives are often dealt with by reinforcing the fantasy of a hierarchy in which I am supposed to have ultimate
power and responsibility. Patients are asked to wait for an answer from the team meeting. My name may be used in explanation, as if it is
only I who will make a decision. At times, I can feel that I am expected to provide an answer, particularly when the ward is over-stimulating,
and the nurses seem to me to be feeling relativley pwoerless. Before I make an intervention, I sometimes describe it to the nurses for their
opinion. Empathically tuned to the patients, they can assess potential response to the thoughts I am introducing. Their empathy extends to
their experience of me and anticipation of my interventions. I sometimes find that they give me further details as I am about to act, to
influence a different course of action.
Other professionals in the multidisciplinary team have a degree of freedom from attention to safety. Their contributions of novel
observations and suggestions often rouse the team out of a preoccupation with an illnessmodel, or of excessive concern about safety. I
marvelled one day to hear the Occupational Therapy assistant describe an evening when she and the nurses took some of the most
disturbed patients to the cinema. After watching the sinking of the Titanic, they proceeded to a café, where Godfrey ordered and ate his full
portion of fish and chips. I still find it hard to imagine managing such an outing, or sitting with Godfrey and many of the others through a
whole movie!
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With such powerful dynamics, there is a danger of splitting into rigid roles of nurse as empathic mother and doctor as thinkingfather having
the power and responsibility for decisions. It is important for me to retain an empathic approach, sensitive to all the dynamics. At the same
time, the nurses must feel confident and supported in the team in order to make decisions. In reality, their responsibilities lie not only in their
daily work, but in their involvement in what can be perceived as my decisions. They introduce their own thoughtfulness, the paternal side,
when they intervene to persuade me towards a different approach. Without freedom, and awareness of the dynamics, the hierarchy can
become rigid, dominated by the father figure. Nurses often adopt the maternal role in the institution, reporting their observations to doctors.
They restrict their own freedom to think, with rigid guidelines and policies. Doctors become the ‘thinkers’, supported by the nurses who
welcome the father figure who will take responsibility for decisions.
Discussion of the case examples

In Brian's case there was evidence of some developmental arrest but with regression. The physical intervention of a locked ward provided
empathic warmth, but also exacerbated his regressed behaviour. He had been trapped in a vicious circle. His verbal communication was
almost incomprehensible because of muttering interspersed with fantasy and concrete representations of sexuality and hostility.
Occupational therapy, or any outside intervention, was unavailable because of his behaviour. All that was required was a more thoughtful
approach, albeit one based in psychoanalytical theory, and requiring cooperation with the team.
In Patricia's case, the therapeutic milieu afforded her the opportunity for affection within regressed relationships. However her frustrated
hostility was expressed in introversion, with self-destructive behaviour. The setting in which outward aggression was easily managed
allowed her a space to work through her emotional response to intervention. In phantasy, she was no longer powerless, and not so severely
destructive in her hostile impulses as she may have imagined. She became aware that she could contribute to our well-being.
Patricia's case further illustrates the difficulties in containing the violence of para-suicidal behaviour. I have tried to illustrate some of my
thinking in each step, to show how I resolved some of my doubts. When I made the first decision that I would not detain her, it was because
I believed that she would eventually kill herself. It was difficult to make a decision to remain inactive, hoping that it might prove therapeutic,
containing a fantasy that I might have to answer for my decision at a Coroner's court. Later, during the outburst after my intervention, I was
again faced with a critical decision. Even as I reminded her that she was voluntary, and asked her not to discharge herself, I knew from
experience that the team would alert me if they were still concerned about her behaviour. Thus, knowledge of the team helped me to
contain my own doubts and fears.
The Mental Health Order provides a further psychic boundary which can be used to good effect. Unless a patient is detained, nurses do not
feel free to take appropriate physical action when a patient's behaviour is threatening or violent. Discussion of the law with the patients can
be used in clarification of boundaries. As illustrated in Patricia's case, the Order can be used to help a patient focus on behaviour as the
problem which is leading to restriction of autonomy. Those who can benefit can feel less hopeless about having an illness or problem which
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is global, affecting personality.
Conclusion
In the therapeutic approach to violent behaviour, priority must be given to physical safety. The locked ward can provide the warmth and
affection of a regressed relationship. While empathically engaging in a regressed relationship, the nurses have to give selective attention
towards the potential for violence. Their responses can, however, reinforce the antisocial behaviour. A psychoanalytic understanding of the
multidisciplinary team can contribute to greater effectiveness. A different focus on violent behaviour may help in the understanding of the
problems of the institution.
References
1 Ey , H. (1962) Hughlings Jackson's principles and the organo-dynamic concept of psychiatry. Amer J. Psychiat. 118 , 673-82.
2
Fonagy , P. & Target , M. (1996). Playing with Reality, II. Int. J. Psycho-Anal., 77 459-480. (IJP.077.0459A)
3 Federn , P. (1953). Ego Psychology and the Psychoses. London: Maresfield Reprints.
4
Freeman , T. , Cameron , J. L. & McGhie , A. (1958) Chronic Schizophrenia. London: Tavistock .
5 Freeman , T. (1988). The Psychoanalyst in Psychiatry. London: Karnac .
6
Mental Health (Northern Ireland) Order (1986). London: HMSO.
7 Sandler , J. (1976). Countertransference and role-responsiveness. Int. Rev. Psycho-Anal., 3 43-47. (IRP.003.0043A)
8
Stengel , E. (1963). Hughlings Jackson's influence in psychiatry. Brit. J. Psychiat., 109 348-355.
Psychoanalytic Psychotherapy, 1999; v.13 (1), p3 (15pp.)
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Part Two: Mechanisms, Processes, Psychogenesis

III. Sex Life: 1—Peculiarities of Sex Life. 2—Excessiveness.

IV. Personality Make-Up: 1—Infantilism. 2—Character Weakness. 3—Lack of Restraint. 4—Socialization.

V. Heredity, Environment, Constitution.

VI. Psychopathy (Anethopathy): A Specific Mental Disease. Finale.

Summary and Conclusions.

II. Intellectual Life

III. Sex Life

IV. Personality Make-Up

V. Heredity, Environment, Constitution

VI. Psychopathy (Anethopathy): A Specific Mental Disease

Summary and Conclusions

2. Symptomatic vs. Primary Psychopathy.

6. Specific Behavior Trails.

Source: Psychoanalytic Quarterly, 1960; v. 29, p421, 1p

Psychopathy. A Comparative Analysis of Clinical Pictures

Psychoanalytic Quarterly, 1960; v.29, p421 (1pp.)

Some Characteristics of the Psychopathic Personality1

refer back to insight he might have gained.

4 FENICHEL , O. The Psychoanalytic Theory of Neurosis (New York: Norton , 1945 .)

5 GREENACRE , P. 1945 ' Conscience in the Psychopath' Amer. J. Orthopsa. 15

Psychoanalytic Perspectives on Theories Regarding the Development of Antisocial Behavior

More Descriptive Developmental Perspectives

Risk Factors of Disruptive Disorders

Other Risk Factors and Familial Antecedents

William Alanson White Institute, New York City.

Developmental, Structural, and Clinical Approach to Narcissistic and Antisocial Personalities

Previous Work on the Subject

Borderline Personality, Pathological Narcissism, and Deviant Personalities

Pathological Narcissism and PDs

Developmental Aspects of Antisocial Pd and Narcissistic Pd

Full-Blown Narcissistic PD and Antisocial PD

Structural Aspects of Antisocial Pd and Narcissistic Pd

Structural Aspects of the Destructive Self

The Real Self of A-S and Narcissistic Personalities

Structural Aspects of the Real Self of Antisocial PD

Structural Aspects of the Superego of Antisocial and Narcissistic PD

Clinical Aspects of Antisocial Pd and Narcissistic Pd

FIG. 1. Clinical features shared by antisocial and narcissistic PD.

Antisocial PD and Narcissistic PD: A Comparative Clinical Analysis

Direct Clinical Expression of the Destructive Self

Direct Clinical Expression of the Real Self of Antisocial Persons

Ethical Features of Antisocial PD

Interpersonal Relations of Antisocial PD

Good, Less-Well, and Poorly Integrated Antisocial Personalities

Steven H. Cooper, Ph.D., author

BPD Subscale DSM-III Criterion

Psychodynamic and Descriptive Measures

Splitting of Others' Images .82 .11

Defense Summary Scale BPD Scale BPD Diagnosis

ASP Score ASP

** p < .01

Discriminant Function Analysis of Defenses

Conflict BPD Scale BPD Diagnosis

Discriminant Function Analysis of Conflicts

Case Example: Borderline Personality Disorder

Diagnostic (N = 82) Spearman r

11 KERNBERG , O. F. 1981 Structural interviewing Psychiat. Clin. N. America 4 169-195

Mechanisms of Defense Washington, D.C.: Amer. Psychiat. Press.

Understanding Violent Behaviour within the Boundaries of a Locked Ward

Boundaries between internal and external reality

Pre-oedipal dynamics actualised in the ward

“Well, I think it must be lonely and frustrating for you.”