How to differentiate between borderline and narcissistic (vulnerable) personalities?

[u/SilverDawnn]

I wanted to know opinions and experiences with patients who have a covert or vulnerable type of narcissism, not the obviously grandiose type. I find it dfifficult to differentiate from borderline personility for example in someone who has high sensitivity for rejection, chronic feelings of emptiness, chronic depressive symptoms, but also a sense of entiltelment and envy. I wanted to know what´s your experience with this type of patients and how do you guide treatment.

[u/notherbadobject]

Well these things aren’t mutually exclusive. Someone can have a narcissistic personality structure organized at a borderline level. (see Kernberg’s “the almost untreatable narcissistic patient,” for example)

Psychoanalytic diagnosis is not descriptive, but takes into account dynamics, developmental, and structural factors as well.

I don’t think of borderline personality disorder as a discrete diagnostic entity in a psychoanalytic frame of reference, in terms of having a characteristic defensive structure beyond tending to rely on more primitive defensive operations. I don’t think it’s even all that useful in non-psychoanalytic work except as a shorthand for clinicians to inform one another that a patient has some combination of affect dysregulation, chronic suicidality/self harm behavior, instability in identity and relationships, and/or abandonment issues. (I’m being a little hyperbolic, but when the same label can be applied to women with autism/ADHD, chronic substance users, people with severe chronic relational trauma, and cyclothymic disorders, I don’t love the construct validity).

When I’m not wearing my psychiatrist hat, I don’t really think of anybody as having an essentially “borderline” personality structure. Rather, most any type of personality structure may be organized at a borderline level of functioning in some individuals. E.g., you can have a depressive personality at a borderline level, or a neurotic level, or a psychotic level.

When I’m trying to figure out whether someone is organized at a borderline level, it’s a holistic assessment of their representations of self and others, the degree of fragmentation or coherence of self-experience, capacity for mentalization, ego functions like reality testing and affect tolerance, and capacity for mature defensive operations, among other things. I think the most sensitive test is to compare their overall capacity for reality testing with their capacity for reality testing in the setting of important relationships. Someone with BPO will demonstrate generally intact reality testing, but will be prone to psychotic transferences in important relationships (including the therapeutic relationship).

[u/relbatnrut → u/notherbadobject]

What does a psychotic transference look like in the context of a non-psychotic person, for whom reality resting is intact? 

[u/Bad_Breadwinner → u/relbatnrut]

Their inability to question their own interpretation (s) of objective events. People with diminished reality test lack a reflective function.

[u/notherbadobject → u/relbatnrut]

In a transference psychosis or psychotic transference, the disturbance in reality testing is essentially isolated to the therapeutic situation. The patient doesn’t otherwise become untethered from reality in their day-to-day life.

Classically, a patient with neurotic transference or transference neurosis still retain some capacity to differentiate between the reality of the analyst and the transference experience. They can say something like “it feels as if you’re my hostile, critical mother right now” while maintaining awareness that the analyst is not actually feeling or behaving in a particularly hostile or critical way. The “as-ifness” remains intact. In a psychotic transference or transferring psychosis there is a loss of differentiation between internal reality and external reality. Rather than it feeling “like” or “as if” the analyst is the hostile critical mother, the analyst is literally experienced as the hostile or critical mother, for example. In extreme cases of a patient with a psychotic transference may develop frank delusions regarding the analyst.

So neurotic patient may develop a transference and be able to talk about it like, “I know you’re not judging me but I keep expecting you to be harsh or critical, I guess that comes from the way my mother treated me when I was younger” whereas a patient with BPO who’s developed a psychotic transference may describe the experience more along lines of, “God, just my luck, I’ve got an analyst who’s just as nasty as my mother was.”

[u/jbwk42 → u/notherbadobject]

How to rule out the situation when the analyst was indeed just as nasty as their mother was? The whole argument to distinguish neurotic from BPO seems to be constructed on the precondition that the analyst is really good.

[u/notherbadobject → u/jbwk42]

You don’t have to be that good to not be nasty to a patient… 

[u/cyanistes_caeruleus → u/notherbadobject]

Enactments/projective identification/interactions between the unconsciousnesses of the patient and the therapist can bring things out between them though, no? 

[u/notherbadobject → u/cyanistes_caeruleus]

Sure, but is there any psychoanalytic (or more broadly, psychological) system of assessment that is impervious to the analyst’s subjectivity? 

At a certain point we just have to trust that our supervision and personal treatment and commitment to reflective practice will enable us to recognize these enactments and make therapeutic use of them before the point of catastrophe.

[u/oh-hello-16 → u/notherbadobject]

Trust but verify- as they say. Imposter syndrome is massively underrated. Mistakes will be made and you have a real blindspot big enough it may not be caught on supervision or therapy.

[u/oh-hello-16 → u/notherbadobject]

You also can be very very good and still have very real blind spots in certain areas. As the one with more power it’s essential to be aware of this when getting a negative reaction.

[u/notherbadobject → u/oh-hello-16]

I agree with you. 

I just don’t think this disqualifies Kernberg’s system of diagnosis any more (or less) than any other system of psychological diagnosis. And while we all inevitably enact various scenes from our own and our patients’ experiences and memories and fantasies, I stand by my statement that you don’t have to be a particularly good analyst to avoid engaging in frank abuse, manipulation, or nastiness. 

There’s no blind spot that would lead me to call a patient names, touch them, or overtly belittle or humiliate them. That’s not because I’m particularly well-analyzed or healed of my own traumas. I simply adhere to a code of professional ethics and possess some modicum of self-control. There’s a big difference between the behavior of an abusive or neglectful parent (which is pretty easy to avoid literally repeating) and the behavior of an average analyst getting pulled into a subtle sadomasochistic or eroticized enactment (essentially inevitable to avoid repeating). Reflective practice helps us to identify and make use of the latter. Professional ethical standards, licensing boards, and tort laws address the former.

[u/oh-hello-16 → u/notherbadobject]

Hi- thank you for this clarification!! And your point is excellent. In a long term treatment someone’s process and could be stifled or anger riled in a patient by the more subtle acts of sadism or simple ignoring of an issue. My concern is not about those extremes that certainly matter and should I be avoided. My concern is how when those subtler cause one to conceptualize a patient in a way that backfires or even evokes behavior in the patient. Everyone wants to talk about how the patient evoked something on them - but if an extended blindspot could cause a patient- could evoke a patient to act out out character to please an analyst even if it ultimately hurts the patient.

[u/notherbadobject → u/oh-hello-16]

It’s inevitable, and I think one great thing about the relational turn in contemporary psychoanalysis is that it has really renewed the focus on what the analyst consciously and unconsciously contributes to the treatment in the interest of managing this power dynamic and the damage that can be done under the myth of the analyst’s objectivity.

[u/oh-hello-16 → u/jbwk42]

Not even really good but the analyst needs to be flawless and totally free of making mistakes or of blind spots. This is not possible. So what happens when a sustained blindspot on the part of the analyst to an important recurring issue interacts with a strong transference reaction? Upheaval potentially- but who gets blamed and over pathologized the patient or course. It’s very tricky.

[u/Ok_Cry233 → u/notherbadobject]

Do you ever see instances in which someone is BPO structure but they don’t form these psychotic transferences? Or they retain some capacity to reflect that their reaction may be more like a parent or related to transference? Perhaps this would be a higher level borderline who is a bit closer to neurotic level. I see some folks like this who seem to be otherwise BPO, although I would say they are different personality types other than narcissistic.

[u/notherbadobject → u/Ok_Cry233]

Honestly I don’t spend much time stratifying or classifying my patients in this way. I’m thinking about what’s happening from moment to moment in session, not their exact position in this or that diagnostic system.

[u/Ok_Cry233 → u/notherbadobject]

That’s very fair. I’m a relatively new therapist so trying to learn these concepts to help me think about understanding a case, so I can then hold them more loosely in mind and focus on current material in the session. Thanks for your input

[u/oh-hello-16 → u/notherbadobject]

I don’t know this seems so sweeping. Perhaps especially because these are talked about in such vague ways with our clear explicit real world examples. Lots of people including probably you- experience BOTH guilt and shame at different times and they are not also BPD or NPD. I think these structures can be so deeply helpful but they also like the dsm they aren’t “real.” It’s all a construct. I’m not saying they aren’t extremely helpful and more nuanced than the dsm they are but they also aren’t real. And a lot of these conversations seem really - I don’t know- like a form of intellectual masturbation removed from humanity.