Psychodynamic Diagnostic Manual (PDM) Views on Narcissistic and Borderline Personalities
1. Overview of Diagnostic Manuals and PDM Development
- Discussion on various diagnostic manuals: ICD-11, DSM, and PDM, emphasizing the differing approaches and the fractured landscape in psychology and psychiatry due to disagreements among scholars [00:00].
- The PDM started as a classical psychoanalytic manual and evolved into a neo-Kraepelinian approach, focusing more on biological, neurobiological, and genetic factors, reflecting a medicalized view of mental illness [02:00].
- Historical context mentioning Freud and Kraepelin’s contributions to psychiatry and mental illness classification [02:15].
- The shift in PDM from psychoanalytic dimensional model to a symptom-focused medical model, but reverting partially to psychoanalytic dimensions in its current form with three dimensions and three axes (P, M, S) addressing personality, mental functioning, and symptom patterns respectively [05:00].
2. PDM Structure and Classification
- Description of the three dimensions and axes of PDM: Personality syndromes (P axis), profiles of mental functioning (M axis), and symptom patterns (S axis) [05:30].
- The P axis provides a map of personality, distinguishing it from DSM and ICD which focus on lists or trait domains [05:45].
- S axis similarity to DSM and ICD with classification of psychotic, mood, anxiety, somatic, and addiction disorders [06:10].
3. Narcissistic Personality According to PDM
- PDM considers narcissistic individuals along a continuum from neurotic to psychotic levels, with varying severity recognized similar to ICD-11 [06:20].
- Neurotic narcissists may seem socially successful but have deficits in intimacy; pathological narcissists show identity diffusion, grandiose self-presentation, lack of morality, and destructive behavior [07:00].
- Introduction of “malignant narcissism,” a severe form blending narcissism and sadistic aggression, acting as a bridge between neurotic and psychotic narcissism [07:40].
- Characteristic inner emptiness is central to narcissistic personality, tying to psychoanalytic object relations theory; narcissistic supply is needed to mitigate this emptiness, leading to narcissistic elation or collapse [08:30].
- Covert and overt narcissistic phases are part of the same individual cycling through states; covert narcissists present with shame, avoidance, and grandiose fantasies internally [09:45].
- Critique of distinction between covert and overt types; all narcissists display grandiosity [10:30].
- Various subtype models are discussed but ultimately dismissed due to misrepresentation of the grandiosity core [10:50].
- Narcissists experience hypochondriacal preoccupations and have insecure attachment styles reflective of early confusing relationships [11:30].
- Narcissistic individuals use idealization and devaluation as defenses; therapists often experience idealization, devaluation, or invisibility when working with these patients [12:45].
- Therapeutic challenges include fear of progress due to narcissistic envy and self-sabotage; importance of empathic attunement and confrontation of defenses in treatment is highlighted [14:20].
- Narcissistic patients may respond better in therapy midlife once grandiosity is exhausted; treatment is difficult and slow but valuable [15:40].
- Summary of key narcissistic personality features: tension between inflated and deflated self-esteem, shame, envy, beliefs about perfectionism and others’ riches/power, and defenses of idealization/devaluation [16:10].
4. Borderline Personality According to PDM
- Initial use of ‘borderline’ in PDM refers to personality organization, with distinction between borderline personality organization and borderline personality disorder developed later, attempting a compromise between Kernberg’s and DSM’s models [17:00].
- Emotion dysregulation once seen as core to borderline pathology, but this view is outdated; ICD-11 offers a more updated framework [17:40].
- Borderline characterized by disorganized attachment style (Type D insecure attachment), involving confusion, fear, desperate clinging, hostility, and dissociation in relationships [18:15].
- Neuroscience shows early trauma impacts regulation and executive control but trauma types leading to borderline are mostly neglect and abandonment (the “dead mother” concept) [18:50].
- Borderline involves primitive defenses (splitting, projective identification), lack of mentalization, and problems with sense of self and others continuity [19:45].
- Genetic vulnerability present but limited to about 5% impact on disorder variability; environment and early attachment play larger roles [20:30].
- Borderline individuals are difficult patients: boundary challenges, emotional intensity, impulsivity, and tendency to catastrophize; highly sensitive to abandonment and engulfment anxiety, causing instability in relationships and work [21:15].
- They experience emotions intensely, may externalize aggression, use self-harm for regulation, and often present with suicidal gestures as calls for help [22:00].
- Cognitive and psychoanalytic therapies require adaptation with emphasis on working alliance and boundary setting; prognosis improves after age 35 and there’s hope for recovery with appropriate treatment [22:45].
- Key features of borderline personality per PDM: congenital difficulties in affect regulation, preoccupations with self-cohesion and attachment fears, central affects of rage/shame/fear, confusion about self-identity, reduced view of others, and primitive defenses [23:30].
5. Clinical and Therapeutic Implications
- Therapists encounter strong countertransference with narcissistic patients characterized by feelings of idealization, devaluation, or invisibility [12:45].
- Narcissistic therapy challenges include managing patient’s envy, grandiosity, and potential self-sabotage; progress requires support for vulnerability and empathic attunement [14:20].
- Borderline therapy demands clear boundaries, repair of ruptured alliances, and specialized approaches different from standard therapies (e.g., DBT) [22:45].
- Emphasis on integration of psychoanalytic, cognitive-behavioral, and other therapeutic models tailored specifically for personality disorders [22:45].
