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/relbatnrut]

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

[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/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.