Practice for Psychiatry and Psychotherapy

Dr. med. Christian Iten,
Specialist for Psychiatry and Psychotherapy FMH

What are defense mechanisms?

Defense mechanisms usually occur unconsciously; they are behaviors that aim to reduce inner anxiety, tension and discomfort. They serve to maintain an emotional balance, usually by accepting a restriction of the ability to relate or in the state of feeling. Often affected persons see their defense mechanisms as something positive and meaningful, they describe them as “protection” and deny the resulting limitations.

An overview of the individual forms of defense mechanisms can be found under https://en.wikipedia.org/wiki/Defence_mechanism point 2.

Splitting, projection, projective anxiety and projective identification

– are the main defense mechanisms of early traumatized patients. Early traumatized patients develop massive archaic feelings of rage in their unconscious in response to an impairment in their desire for closeness to their primary caregivers, usually the mother, which are fused with feelings of guilt. According to the research results of H. Davanloo, “early” refers to a period of time from birth until age of 5. This early fusion of rage/guilt is enormously stressful and those affected fail to develop so-called “mature” defense mechanisms and healthy conflict resolution strategies. The defensive system remains primitve in structure.

Splitting:

• Function: separates ambivalent and ambiguous affects from each other, so that these can not be perceived at the same time. In one moment only one affect and also only one suitable perception is acceptable. The mechanism serves to reduce unconscious anxiety and creates by the division into good and bad clear conditions in the psyche and thus minimizes inner restlessness. Through this mechanism, the splitting ensures the person that he or she is not guilty.

• manifests itself in the alternation of idealization and devaluation

Example: A caregiver is perceived as loving and protective, although the relationship experience with this person also contains other qualities. At other times, the same person is perceived as scary, contemptuous and disturbing. The split is responsible for the “black and white painting”. A simultaneous integration of different feelings, cognitive evaluations, ideas, etc. is not possible.

Example 2: A patient who uses the mechanism of splitting can not recognize that someone can refuse a request and still remain a lovable person.

Projection and splitting are mutually dependent:

• in projection, conflicts, fears, problematic character traits and anxiety provoking feelings become denied with one’s own and representatively shifted to the outside (externalization), recognized within the others and there criticized, thematized and tried to fight.

• Function: aims at the reduction of suffering from one’s own conflicts. The image of oneself remains clear and free of contradictions. The projection “helps”, not to get into emotional distress through strong emotions. Mostly with assignment of blaming the other, it relieves the projecting person of the assumption of personal responsibility and «helps» to avoid own feelings of guilt.

• Projection is a form of insinuation !

  For example: I prefer to accuse the other person of being aggressive rather than to admit own aggression. “Childhood wisdom” from the sandpit age: “what you tell the other person is you yourself !

• Projection often leads to a distortion in the perception of the other person, which is perceived either as a feared aggressive or refusing person of the past or disqualified and devaluated as a formerly helpless person.

Projective anxiety: in projective anxiety, one’s own unconscious murderous feelings and impulses are repelled in such a way that the person affected by the projection is accused of wanting to destroy, murder or extinguish you. This form of anxiety is deeply entrenched in the unconscious in most of the cases and is becoming an unconscious conviction – without cross-check within the reality. Thus, projective anxiety is maintaining the mechanism of splitting and projection as a vicious circle.

Projective identification: Projective identification describes various phenomena that require projection:

1. While a mentally healthy person recognizes projection (insinuation) as such, rejects it and questions what renders the projection ineffective, a person (partner) who is burdened by unconscious feelings of guilt may under certain circumstances be persuaded to offer a false accommodation in order to avoid escalation, or to allow himself to be manipulated in the desired sense of the person projecting, to get a foreign will forced upon him.

   The projectee acts out aggressive feelings in such a way that the partner feels guilty and atone for a “crime he did not commit”, and that he has should apologize. (the projectee becomes an incarnation of the former aggressor and identifies with him). Under certain circumstances the partner is “maltreated” accordingly, until he admits what is desired and is ready for a gesture of humility. (The projectee/manipulator convinces himself in this way that he is by no means helpless - as he was as a child and forces his partner on behalf of the father/mother to apologize to him ;-). At the same time he is assuring himself his innocence and removes his aggressive feelings outside of his person in his partner.

2. While the “success” of a projective identification in a relationship presupposes that the victim is reactive, the “projective identification with the victim” is the basis for the development or maintenance of psychosomatic complaints. In projective identification, the child who wants to murder the aggressor in his rage simultaneously identifies with the symptoms afflicted to the aggressor in such a desasterous way. This is due to feelings of guilt that oppose his love. In the end, the child remains trapped in himself and his feelings.

Example: A person has a shaky voice, has to clear his throat often under the effect of anxiety, etc. In the unconscious anger mobilized in the therapeutic work, this person feels that he wants to cut the vocal chords of the therapist. The therapist then becomes the person from the past (father, mother, etc.) originally connected with this rage. By total removal of anxiety and resistance in the therapeutic process, the person can experience his or her infantile feelings of guilt over this act and come inwardly at peace with the genetic person. After a series of such passages, the person is tremendously relieved of feelings of guilt and thus becomes more self-confident. He or she gets used to speak with a firm voice and clearly audible. Initially, or if anxiety remains in the experience of such feelings remains high, the patient may fall into a cough when the feelings of guilt want to pass, may suffer from pressure on the chest or may feel the sensation of swelling in the throat. Through these symptoms, the experience of guilt (pain) is jeopardized by the fact that the “perpetrator” now identifies with the symptoms of the “victim” to whom these injuries are inflicted, which hinders effective repentance and reconciliation and continues to sustain the neurotic suffering.

© Dr. med Christian Iten

What is a Borderline Personality Disorder (BPD)?

The term borderline personality was coined in 1938 by the American psychoanalyst Adolf Stern and later expanded by Otto F. Kernberg in 1967 with the term borderline personality organization.

Clinical picture: Essentially, people with BPD suffer from what is called “free-floating anxiety” This refers to a more or less constantly present anxiety that is not bound to an object. Concrete fears bound to an object are called phobias, e.g. spider phobia.

Furthermore, patients with BPD suffer from dysphoric affects (depressed, sad, joyless or discontented-irritated mood), they tend to impulsive actions (e.g. eating, buying, playing, nail biting, speeding in traffic, excessive masturbation, self-injury, etc.). They have difficulties in interpersonal relationships with adaptations in the social domain (fear of abandonment with clinging and rebellion through distance) and sometimes psychosis-like thoughts (on a spectrum from morbid distrust to paranoid persecutory ideas).

Incidence of BPD : Approximately 1.2% of the general population suffers from BPD.

In the majority, about 70%, women are affected, many patients have to be treated as inpatients in phases. Among the occupational titles, social professions (nurses, geriatric nurses and educators) are primarily found, working predominantly - due to the limited emotional resilience - in part-time stints.

Triggers and causes: The roots of BPD lie in adverse early experiences of the individuals concerned in the first 1 ½-2 years. Physical and sexual violence and extreme neglect by early caregivers are important risk factors for the later development of BPD.

Early caregivers often proved to be insensitive to the needs of the affected child, behaved extremely inconsistently, and were unable to meet the child with benevolent care. The child's original needs for love and life were not understood, childish boundaries were not respected and the experience of self-efficacy was prevented.

In addition, there is usually a lack of a second caregiver who offered protection and security and who would have taken the - with regard to injustice and assault - urgently needed counter-position. (innocent bystander).

In the metapsychological and diagnostic system of Davanloo's Intensive Short-Term Dynamic Psychotherapy, BPD represents an "early disorder" that floods the still immature infantile brain with primitive sadistic rage and guilt (hereafter called fusion); at a time when it cannot integrate such fear-producing feelings into its mental system. Early splitting, externalization, and projection are the result (as described under splitting, projection, projective anxiety, and projective identification). Without reappraisal, there is an intergenerational transmission of neuroses (transference neuroses) from one generation to the next.

Symptoms of BPD : Gundersohn and Singer (1975) describe six characteristics in five dimensions in which sufferers show deficits. These are found in the area of

• affect regulation
• self-image
• Psychosocial integration
• Cognitive functioning
• Behavioral level

In the area of affect regulation, people with BPD have great difficulty regulating their mood states. They have a low stimulus threshold and, due to all kinds of causes, can reach a very high level of inner arousal several times a day, from which they only gradually "come down" again. This is experienced by those affected as torturous, and self-injury, such as scratching the arms and legs, is often used to regain inner calm. These states of high inner agitation alternate with episodes of sudden onset of emotional numbness, lifelessness, deadness; a state of complete lack of emotional perception, which is also described as agonizing and unpleasant.

In the area of self-image, most patients with BPD are severely insecure about their own identity (often including sexual) and bodily integrity/completeness/integrity, with more than half describing having no secure sense of "who they really are." They experience being cut off from themselves and find it uncomfortable to be left to their own devices. Many also reject their bodies and do not feel comfortable in them.

Deficits in the area of psychosocial integration: presumably due to the early onset of free-floating anxiety and insecurity in self-image due to fusion, these patients report feeling "different from everyone else; isolated and cut off, lonely, abandoned, and untouched among everyone else" as a basic perception of life. In the interpersonal sphere, difficulties with closeness and distance are characteristic, with a pronounced fear of being abandoned. Due to the poor object constancy, the absence of an important reference person (partner) is synonymous with actual abandonment. Affected persons try to permanently bind their partner to them and to merge symbiotically with them and to be one. On the other hand, actual closeness and security mobilizes all the unresolved feelings in the unconscious of the affected person, so that above all the unresolved feelings of guilt from the merger drive the patient to reduce the inner tension by breaking off the relationship or otherwise destroying the relationship (entering into extraneous relationships). Internally trapped in these patterns, many oscillate between frequent separation and reapproach processes.

Deficits in cognitive functioning: Although there are no general cognitive performance deficits in borderline patients, a breakdown of cognitive and perceptual functions in the form of blackouts to syncope or fainting-like states of weakness often occurs due to free-floating anxiety and poorly developed capacity to withstand internal tension.

The early traumatizations lead to a distorted perception on the relational level, in which one's own ambivalent feelings (love, hate, guilt) cannot be seen as threatening and as the cause of one's own problems, but are shifted outward (externalized) and projected into the reference persons on whom one is dependent. This distorted perception with the associated defense mechanisms of idealization, devaluation and avoidance remain as a deficient affect regulation throughout life, if no restructuring through treatment takes place.

As a result of the unprocessed traumatizations, later negative experiences in reality (frustrations in interpersonal relationships) are always experienced as a repetition of the original injuries, and thus have a real character for the affected person. The separation between past and present succeeds at most cognitively, but not emotionally.

Exaggerated mistrust as well as magical and paranoid thinking are found in almost all patients with BPD as further disorders in the cognitive domain.

Behavioral level disorders: the vast majority of patients with BPD exhibit current or past history of self-injurious behavioral patterns. Known are the addition of cuts, burns with cigarettes, scalds, burns or the infliction of stab wounds.

In eating behavior, bulimic attacks or anorexic behavior, as well as the self-injuries mentioned above, serve to reduce or overcome aversive (negative) states of tension or feelings of emptiness. Feelings of paralysis, lifelessness, being dead, in turn, serve to keep even worse sensations of dissociation, of dis-identification, at bay.

Other common behaviors of sufferers include substance abuse, pathological buying behavior, compulsive acts, or aggressive breakthroughs.

Literature references:

Summary on Borderline Disorder: https://www.wicker.de/kliniken/wicker-klinik/behandlungsschwerpunkte/erkrankungen-a-z/borderlinestoerung/ last accessed on December 26th, 2021

Adolf Stern: Psychoanalytic investigation of and therapy in the borderline group of neuroses, The psychoanalytic quaterly 7, 1938, pp 467-489.

J.G. Gundersohn and M.T. Singer: Defining borderline patients: an overview, Am. J Psychiatry, 1975, Jan; 132(1): 1-10.

M. Bohus: Borderline disorder, reference book, Hogrefe-Verlag, first edition 2002, 2nd edition 2019.

Birger Dulz, "Anger or fear - which affect is the central one in borderline disorders ?", Personality Disorders 1999; 3: 30-35, Schattauer Verlag.