Psychiatria Danubina, 2013; Vol. 25, No. 2, pp 179-181 Case report

© Medicinska naklada – Zagreb, Croatia

 

Snežana Samardžić

Psychiatric Clinic Sokolac, Sokolac, Bosnia & Herzegovina

 

Introduction

received: 19.11.2012;                       revised: 25.4.2013;                          accepted: 12.5.2013

Modern psychological examinations of early development of Borderline personality disorder point out that this pathological state is the consequence of fixation in development of the ego, which happened in early childhood, in the phase of separation- individualization. The greatest contribution in forming a scientific approach to pathology and to therapy of this disorder was made by O. Kernberg (Caran 1987, 1989). According to him, the pathology of the ego presents the basic problem of Borderline Disorder, in which dominant position is taken by an archaic defensive mechanism – splitting, and besides other more primitive defense mechanisms are used (primitive idealization, denying, etc.). Mahler (Ćeranić 1983, 2005) considers that there are some important clinical proofs, which speak in favor of the conclusion that ego-fixation happens during a sub-phase of re-approach that is in the period between the 16^th and 36^th month of life. The emotional moment which lays at the basis of this fixation is insufficient emotional availability of mother to her child during this period. The aim of this assignment was to show that, in spite of their thoughts, Borderline patients are »resistant« to psychotherapy and thus previously determined aims are hardly achieved,hence it is unusual that essential improvement happens by intensive and individual work with therapist for a longer period.

 

Case review

Patient J.D. is 34 years old. She is married and mother of one child. She comes for psychological exploration because of a problem in family functioning. In the consultation she is introspective, but she is especially fixated on personal problems, that she presents extensively and in detail. You get the impression that she played a role of a good, obedient, dependent and sickly child, who had the constant necessity to be loved and protected. Thus, she speaks about a primary family where there was not closeness on the parent-child level,and about a family where she felt abandoned and not loved, especially by her mother, with constant frustration at the necessity of belonging and fear of separation (Agrawal et al. 2004). This became more intense when her twin sisters were born, and when the mother’s attention and love definitely was transferred to the new born children. Then the patient felt unlimited jealousy, envy, deprivation and she reacted by regression (she started with urination) that was physically punishable (It is better to have any kind of attention than no attention?).

On becoming adolescent, the patient become shy, taciturn, and she did not show her feelings. Her conflict on the sexual level was solved by marriage (mother’s prohibitions of intimate closeness before the marriage), at the same time satisfying her personal »hunger« for love. After giving birth to her daughter it was as if the conflicts from the primary family were  activated: sibling rivalry for the parents’ love is replaced with rivalry between her and her daughter for her husband’s love. At the same time, we can notice ambivalent feelings about her daughter (love and jealousy), for which the patient compensates in an exaggerated way, cherishing her dependence, her helplessness and not allowing her to grow up. She began to feel that her husband had changed in relation to her, and this intensified her primary fear of separation and loss of love, so she reacted by developing a depressive clinical picture. So, we can say that the depressive affect is pre- genital in nature, and because of this it is followed by a feeling of dejection, indifference, emptiness, with a series of somatic problems, that is resulted from primary narcissism. Suddenly, she may even react auto- destructively, but as we were analyzing her presentation and the structure of her personality we came to the conclusion that she used depression and suicidal behavior as defense (it functions to call somebody’s attention to herself and to cause sympathy and attention of people close to her). (Soloff et al 1994, 2000). At the same time, manifesting depression is connected with projection (she blames her mother, her sisters and her husband for her state).

The analysis of the results obtained shows that the patient’s structure is neither neurotic nor psychotic, but it is somewhere between these fields, due to cessation in libidinous development that was caused by some disorganized trauma from oral period (Becker et al 2000, Benedik 2008, Bleiberg 1995). The Rorschach- technique is particularly interesting for analysis (Berger 1989). Thus an accumulation of responses from osseousanatomy suggests fear of loss of control, indicating suppression of hostile impulses and inhibition of their expression. This makes here rigid and anxious in her interpersonal relation s. On the other hand she actually wants to experience loss of control of personal  impulses. The test also offers answers which imply cessation in the oral phase of psychosexual development. Her parents’ cards are especially interesting: observing her father’s card we can notice alienation, blockade in expressing feelings and the necessity to struggle against it. Furthermore, the mother induces fear, negative feelings, expectation – if she becomes closer to her – then she will release all evils of the world (complex-answer: »…..an object with a door… if I open the door the storm, thunder and rain are going to start there… as if Pandora’s box is going to be opened… inducing fear.«). Apparently, the patient is not ready for closeness with her mother. Essentially, psychological exploration discovered a series of psychopathological indicators of neurotic, psychopathic, schizoid and paranoid type, which suggests that in this case was a case of Borderline disorder. The patient was recommended for psychotherapy.

The patient came to the new psychological exploration apparently satisfied. In the contact we could notice a lower level of anxiety. Now, the patient gave the impression of good controlled impulses. The relationship with her parents, towards whom there was a feeling of disapproval, prohibition and rejection, even now causes a certain anxiety, but better treatment and acceptance of reality are evident. The patient says that she is able to accept her mother as she is and she does not reject her any more. Since her father died, she had also created a rather different attitude towards him, and in the psychotherapeutic procedure she succeeded in »awakening« his feelings to pronounce them and react, so in this way she reduced the level of negative evaluation.

The patient’s personality, indeed, it still can be described as a weaker ego, but compared to the time before psychotherapy her ego has become rather stronger (Mitić et al. 2011). Now, the patient experiences herself as strong and capable for recovery and regeneration. In the Rorschach-test, there are no indicators to show the presence of aggressive impulses; a certain level of disorganizing affects is recognized and is felt as disturbing.

 

Discussion

As far as this case is concerned, the therapist had immediately established a stable working frame at the beginning of his work with the patient: the exact beginning and end of the session, the exact interval of holding of the session, etc. The aim of this was to induce a certain stability into her life. She was confronted with her self-destructive behavior. Furthermore, work was carried out on the connection

between feelings and actions (Roepke et al. 2011). In connection with this, as the patient had a strong affective blockade towards her father (who had died in the meanwhile) one of the ways to partly get rid of this negative load was to express her own objections and confusion on his grave; to expose herself to the powerful affective state of fury and alienation and to achieve relief by expressing these feelings freely. As far as the mother was concerned, with whom the relationship was quite bad (because of developing difficulties which happened not only in the first years of life, but that also extended during the whole adolescent period) the interpretation of these problems and the clearing up the origin of her own ambivalence, gave an idea to the patient of the size and intensity of her aggression, on its origin and bad influence, on the perception of realty and relationships with other people. At the same time it helped her to feel and understand  her feelings. Through experiencing the mother-child interaction in the therapeutic situation, she developed a better integration of the ego and an intensive focus towards reality. The relationship with her mother also improved (Clarkin et al. 2006, Tölk 2007).

 

Conclusion

Although the result of Borderline psychotherapy is often unexpected and modest, from the case that is shown here it can be shown that those patients who get the strength to finish the treatment can permanently improve the picture about themselves and about others. The patient succeeded in integrating the aspect of love and hatred much better, by which the »splitting« as the defense mechanism was considerably neutralized (she accepted the feeling that she was very fond of people who frustrate- the parents). This led to a decrease of the level of ambivalence, but furthermore the level of integration of impulse and affect was increased. She apparently better accepts and asesses reality. By increasing her level of self-respect and self-confidence, the patient strengthened her ego; she attained better tolerance of anxiety and decreased her dependence on her husband, as an object of love.

 

Acknowledgements: None.

Conflict of interest : None to declare.

 

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Correspondence:

Snežana Samardžić, MD

Psychiatric Clinic Sokolac

Sokolac, 71350 Sokolac, Bosnia & Herzegovina E-mail: zokasam@teol.net