Bishop Gregory (hgr) wrote,
Bishop Gregory

antisocial personality disorder and related topics

просто конспект Borderline Patients: Extending The Limits Of Treatability (Basic Behavioral Science). By M.D., Harold W. Koenigsberg, M.D., Otto F. Kernberg, M.D., Michael H. Stone, M.D., Ann H. Appelbaum, M.D., Frank E. Yeomans (2000), чтоб под рукой было.

(p. 74) A basic question remains unanswered: Once a malignant intrapsychic
structure has evolved—that is, a pathological grandiose self infiltrated with
aggression dominates psychic functioning in the absence of the moderating
and maturing reliance on an integrated superego—can psychosocial influences,
and particularly psychotherapeutic treatment, be of any help?
One aspect
of this question relates to social influences that may facilitate antisocial
behavior; the Milgram (1963) experiments in the United States (это который с электрическим током и с артистами) and Zinoviev's (1984) analysis of socialized dishonesty as a major cultural characteristic
of the totalitarian system of the former Soviet Union have made us
dramatically aware of the power of these influences. Edith Jacobson (1971)
has pointed to the "paranoid urge to betray" that is a part of paranoid structures
in general, and Otto Kernberg (1998) has applied this analysis to the
psychopathic regression of leaders in organizations that present a very high
level of paranoiagenesis.

Are there healing influences that, either in early childhood or perhaps
even in later years, may alter the psychopathic structure? We do have good
evidence that the narcissistic personality with antisocial features may be effectively
treated, and that even the syndrome of malignant narcissism is
treatable. So far, to our knowledge, this has not yet been demonstrated for
the antisocial personality proper. What complicates the question of prognosis
is that, in many studies, the selection of individuals with antisocial behavior
does not differentiate sharply between the antisocial personality
proper and the less severe syndromes in which antisocial behavior dominates.
We believe that it is absolutely crucial that sharp diagnostic differentiations
in this field be reintroduced as a precondition for the evaluation of
the effectiveness of various treatment modalities.
p. 76
If the diagnosis is that of an antisocial personality disorder
in the restricted sense (that is, following the criteria proposed by us
and in harmony with Robert Hare's research, as contrasted to the looser set
of criteria of DSM-II1 and DSM-1V), it is crucial to take protective measures
involving the patient's family, social services, and, if circumstances warrant,
the law in order to protect human life.
The prognosis for psychotherapeutic treatment under such circumstances
is practically zero
, and the main therapeutic task is to protect the patient, the
family, and society from threatening aggressive behavior, including criminal
If the patient fulfills the criteria of an antisocial personality in a strict
sense, but with aggressive or exploitive behaviors that do not immediately
threaten physical harm to the patient or anybody else, the most urgent question
is to ascertain the reason for the consultation
. Is the family searching for
help? Is the patient seeking protection from impending legal actions brought (p. 77)
against him? Is the legal system trying to assess the patient's responsibility
for criminal action? Have the family or social agencies pressed for the consultation
as part of an effort to deal with the threats the patient represents
for his environment? Is the patient being seen during a period of genuine
psychotic regression? There does exist a small group of patients who constitute
what traditional German psychiatry denominated pseudo-psychopathic
schizophrenia, that is, patients who alternate between periods of
extended psychotic illness that conform to the criteria for chronic schizophrenia
and periods of either spontaneous development or medication-facilitated
recovery of reality testing, at which time the patient fulfills all the
criteria for an antisocial personality disorder. These patients constitute
prognostically the most ominous group within the category of antisocial
personality disorders and usually can be managed only under conditions of
practically permanent reclusion in specialized psychiatric hospitals or psychiatric
prison systems.
If a patient with an antisocial personality disorder presents with chronic
lying as a major symptom
, and the treatment conditions can be achieved—
for example, in the case of an adolescent patient still living with and potentially
under the control of the parents—the treatment arrangements should
also include educational contacts with the family that stress the fact that
nothing the patient says can be believed at face value and that the only reliable
source of information is the patient's behavior
<malignant narcissism:>
p. 80
In our experience, most of these patients require an initial period of hospital
treatment to set up these treatment arrangements
. When long-term inpatient
treatment is available, psychodynamic psychotherapy may start on
an inpatient basis, to be continued on an outpatient basis once the patient is
ready to take on the responsibility for fulfilling the preconditions for treatment
as part of her own treatment contract. Sometimes, however, outpatient
treatment may be attempted from the beginning and an ordinary psychotherapeutic
treatment contract may be set up.
As a general psychotherapeutic priority, the therapist should always first consider whether
interventions are urgently needed to forestall threats of danger to self and
others, disruption of the treatment, dishonesty in the communication, acting
out outside and inside the sessions, and trivialization of the communi(p.82)cation. Second, it is essential to focus on the material that affectively predominates
in the total patient material, including the patient's verbal communication,
his nonverbal behavior, and the countertransference. During
extended periods of time in the treatment of these patients, whose communication
of their subjective experience is such a relatively "weak channel,"
careful evaluation of the patient's behavior and the therapist's countertransference
usually provides the most important cues to what is affectively dominant
and needs to be explored.

This brings us to the problems in the countertransference in the treatment
of patients with severely antisocial behavior. It is important, to begin with,
that the therapist find some potentially likable, human aspect of the patient,
an area of ego growth that could constitute the initially minimal yet essential
base for authentic communication from the therapist to the patient.
other words, the therapist's position of technical neutrality implies a genuine
commitment to finding what he expects, or hopes, will constitute a still
available core of object relation investment, of ordinary humanity, within the
within this core resides the capacity for authentic dependency and
the establishment of a therapeutic relationship.
The therapist's comments start from an implicit alliance between the therapist
in role and that preserved core aspect of the patient's personality, in
contrast to the therapist's consistent confrontation of those aspects of the patient's
internal life identified with the primitive, sadistic, corrupt, antisocial,
death-desiring parts of his personality. (а мультиплями аналогичный прием, наоборот, запрещен).
These patients' internal world of object
relations is populated by primitive, sadistic representations of self and
others and their interactions with masochistic, devalued, threatening, or corrupt
enemies. At the beginning, the therapist may only be able to assume the
existence of a somewhat normal self representation in the middle of this
nightmarish world
, but this assumption permits the therapist systematically
to confront the patient's imprisonment in this world without equating such
interpretations with an attack on the patient.
Paradoxically, a therapist's pseudo-investment—a friendly surface that denies the aggression
in the countertransference or reflects a basic indifference toward the
patient—may bring about an apparent "warming up" of the therapeutic relationship
without a resolution of the underlying dishonesty in the patient's
. More fundamentally, such pseudo-investment also makes
it impossible to resolve the severe denial and splitting processes defending
against the aggressive implication of the patient's antisocial behavior.
The protection of an honest investment on the therapist's part requires
the objective safety of the therapist.
Whenever the therapist feels threatened
by the patient's pathology or by the patient himself, the first step has to be
for the therapist to ensure his own physical, emotional, social, and legal
safety. That safety must take precedence over any other consideration, because
it is the very precondition for an authentic investment in the psychotherapeutic
, and therefore a basic guarantee for the survival of
the therapy.
The investment described here precludes the therapist's "going out of his
way" to try to help an impossible patient; it requires that he maintain at all
times a realistic boundary to his investment. In contrast, the therapist who,
with the messianic attitude that impossible cases can be helped and saved,
goes overboard to provide such patients with a "corrective emotional experience"
of total dedication in the face of their provocative behavior courts
the risk of his own denial of the negative aspects of the countertransference—
the gradual, unconscious, and eventually conscious accumulation
and sudden acting out of the negative countertransference that may precipitate
an end to the treatment.

Once the psychopathic transference has shifted into a predominantly
paranoid transference
—that is, the patient's dishonest and pseudofriendly
behavior has shifted into an honest suspiciousness and distrust of
the therapist—the patient may appear much more hostile and belligerent
in the sessions but, by the same token, more honestly engaged in the psy-(p. 84)chotherapeutic relationship. Now the main question is the extent to which the structure of the treatment protects the patient, the therapist, and the
treatment setting from the acting out of severe aggression. In other words,
to what extent cioes the patient have a sufficiently nondestroyed, noncorrupted
superego to be able to experience a minimum of guilt and concern
for the therapist and the therapeutic relationship in order not to threaten
the therapist or the treatment with total destruction? The task is now to examine
in great detail the nature of the patient's projections, the image of the
therapist that emerges throughout them as a sadistic persecutor, and, eventually,
the projective processes by which the patient is attributing to the
therapist that which he cannot tolerate in himself.

<narcissistic personalities>
p. 87
In severe cases, the incapacity to depend may present as the patient's
ongoing "self-analysis"; the therapist is treated as a "bystander," and an unrealistic
therapeutic atmosphere may arise within which the therapist feels
consciously (and sometimes, at first, unconsciously) excluded and frequently
experiences boredom, restlessness, or sleepiness.
At other times, a primitive, frail, and unstable idealization evolves in
which the patient apparently accepts the therapist's understanding or interpretations
with eagerness. Over the long run, however, the patient may find
these interpretations to be useless; he may also either devalue them or "extract"
them as magical comments to be used for his own purposes. These
patients tend to "outguess" the therapist in order to protect themselves
against attacks from the therapist, against unconscious envy, and, essentially,
against dependency on the therapist.
p. 90
The psychodynamic psychotherapy of narcissistic resistances may be frustrating
to the therapist because of the enormous time required to transform
the activation of the pathological grandiose self in the transference into its
component transference dispositions—the primitive object relations involved

and to gradually work them through. In its advanced stages, the
treatment of these patients resembles quite closely that of other patients
with borderline personality organization in whom narcissistic transferences
are not dominant, and the therapist may not be aware at that point that a
major breakthrough has been achieved. By the same token, the dissociation
between what often seems to be the patient's active life of engagement outside
the treatment situation and the monotonously narcissistic transference
(p. 91)
may prematurely discourage the therapist from gradually working through
these narcissistic resistances—an essential precondition for consolidating
the patient's apparent gains in the extratransferential field.
In conclusion, the most important complications in the treatment of patients
with borderline personality organization arising from the combination
of narcissistic, antisocial, and paranoid behaviors require that the
therapist carefully assess where the patient stands along the spectrum of
severity of this particular psychopathology; decide whether the patient, under
the present circumstances, is at all able to undergo psychodynamic psychotherapy;
set up realistic conditions and a frame for the treatment to
proceed; and finally, explore and work through systematically the particular
transference developments in these cases.

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