Reddit reviews Borderline Conditions and Pathological Narcissism (The Master Work Series)

Let me preface this with the disclaimer that I'm a fourth year psychiatry resident with a passion for psychoanalythic theory, so I've studied (and continue to) the topic extensively. This most likely is the reason why you'll find that I have very strong opinion on many of these matters. I don't know if you're from the field or not, but since you seem to at least have a very healthy curiosity and interest in these matters, be warned that I'm going to go balls deep with this comment and the defense of my claims.



Ok, I read the article. What stands out to me in the introduction is this paragraph:



>> Thus, it is important to clarify that this research does not address pathological narcissism [...]



after spending a while explaining or (or justifying, rather), why on earth it is that they refer to people who don't (as per their disclosure) qualify in any fashion in any classification of mental illness, as "narcissists". Now, I'm trying to reserve my personal opinion on this article in particular, but to be blunt, extensive "research" into what are essentially variations of normality have not much interest to clinical psychology (let alone psychiatry), but I'll grant that it's interesting research nonetheless, and certainly necessary to form comprehensive models or theories about the functioning of the human psyche. In this sense, since you provided a direct PDF link I can't where this paper was published, but I'd be surprised if it were published in a high-impact, well-respected, and peer-reviewed clinical or research journal of the field. I'll leave this at that, because later when I talk about narcissism again I'll go more in depth about the merits (or lack thereof) of using phenomenological measures (the NPI used in this article as the primary measure, for instance) and equating them with actual psychological or psychiatric pathology.



Now, let's get back to love. I think the matters we're discussing here, as I mentioned earlier, will boil down to definitions. Love is a concept that has existed for as long as humanity has existed, so I won't try to force down on you the idea that the psychoanalytic notion of "love" is the "correct" notion of love. So it's very much up for discussion. That's part of the reason I mentioned that the Christian idea of "love" is very similar to what I was defending, in that it stemms from pure altruism and selflessness, rather than being subject to the vicissitudes of hormones, general life events, convenience, or the homeostatic clash of 2 complementary neuroses. Now, if we were to agree that this is the definition of "love" that we want to work with, then I can support my claims with psychoanalytic texts, starting with Freud's classic "Three Essays on the Theory of Sexuality", and perhaps more specifically, "A Special Type of Choice of Object made by Men" (do take the time to read it if you're at all interested, it's pretty short). But Freud is dense and pedantic and nigh impossible to read if you're not familiar with psychodynamic terminology, so I'll instead (or in addition to) recommend a text by who's today probably the most influential psychoanalyst, and whose style of writing is much easier to grasp. the cited chapter of this book, talks very succintly and with examples about this matter, but if you're at all interested in the matter, that whole book is crazy interesting. I realise that psychoanalytic texts are probably not the best source to prove a point, but to anyone in the field what I say is very readily clear just by observing patients and the way they form relationships. If, by contrast, we were to take "love" to mean what is colloqually meant by the word (ie: the hollywood definition of love), then you'd be right, anyone has the capacity to fall in love.

edit: I just found this entry, worth a read as well.



And back to narcissism. Now, contrary to the term "love", "narcissism", or certainly the fact that is began to be used by people on the streets, derives directly from the psychoanalytic literature that started to become mainstream at the beginning of the XXth Century, so in this case I think it's fair to ask that we should use said theoretical works to define the term. I have to make this remark because even though the term originated in psychoanalysis, it's since been appropriated by general (medical) psychiatry and mainstream psychology, and that's how, more or less, it is understood colloqually. At some points both PoVs intersect, but for the most part they're referring to radically different things. I'll try to explain as best as I can (to provide a background in case you're not already familiar with this).



I'm sure that's you've heard of the controversies surrounding diagnostic manuals like the DSM, with rabid detractors fighting very publicly against very passinate defenders of such models. The crux of the issue is this: In order for psychiatry (and psychology in general) to become more in-line with the rest of medical specialties, and to be able to start to incorporate elements of Evidence Based Medicine into its practise, it needed a standarised way to classify mental illnesses, and that way simply could not be achieved with the (up until then, prevalent) psychoanalytic framework, because the matter of reliability and subjectivity was a huge one (2 well-respected psychoanalysts could very well disagree wildly on the diagnosis of a particular patient), because psychoanalysis seeks to understand mental illnesses according to their underlying mechanisms, rather than by symptoms. This is in theory great, but in practice, you can't expect a psychiatrist to a) undergo a full psychoanalytic formation (which takes longer than a goddamed psychiatry residency, and is crazy expensive), or b) have patients lie on the couch for months on end before reaching a diagnosis. It's just not practical. And that's not even taking into account the usual criticisms against psychoanalysis, which I think can boil down to it's "unscientificness" due to the fact that a great deal of its tenets are experimentally unfalsifiable (how can you prove the existence and universality of the oedipus complex?). So, a few decades ago the American Psychiatric Association sought to put and end to this mess by coming up with a classification system that required not much more than being able to accurately recognise and prioritise external symptoms; ie: a phenomenological classification of mental illness. This has the benefits of being universal, readily practical for its use in research, and all that, but the detractors (rightly), point out that for the vast majority of "illnesses", the syndromes in question might not accurately represent discreet clinical entities.



Taking all of that into account, now we can see the differences between the psychoanalytic concepts of "narcissism" and the DSM concept of the same "pathology". For the DSM, narcissism is indeed an outward (phenomenological, remember?) manifestation of self love, while for psychoanalysis, it's a crucial development stage, on whose appropriate and satisfactory traversal depends the person's adult ability and way to interact in his relationships (Kernberg also has a book on the matter as well, which I haven't read, but surely is as good as the rest). The only place in which the two worlds coincide in regards to narcissism, is in the grave phases, which the DSM calls "narcissistic personality disorder". But that's where the similarities end. What your article proposed, which by DSM standards would be "a lesser grade grade of narcissism", in psychoanalytic terms would be radically different, in that it would mean a person with a perfectly adequate traversal through the narcissistic phase, but who as a percularity of personality traits has high self-esteem and such, except for the whole "exploitative" measure they did, which is something I wouldn't consider healthy, but w/e.



Hopefully I've been able to express myself in a clear enough manner.

I think the best way to understand BPD, beyond the reductionist biological imperative that posits understanding of the brain and not necessarily of the mind and its experience, seeing that you're neuroscience-inclined, I would first delve into psychoanalytic literature describing the subjectivity-phenomena of BPD, then delve into attachment theory and the therein neuroscience that follows it. Basically, I am suggesting that you take a few decades back in time, before today's popularized neuroscience and brain research, and into the journey of the psychoanalysis heyday to cultivate an understanding from master clinicians with psychoanalytic analytic-observation-heavy theory-building.

I would start off with James F. Masterson's work whom was the quintessential clinician to tie psychoanalytic theory into an applied treatment for BPD clients: I would begin with his Search for The Real Self: Unmasking Personality Disorders of our time. After this, I'll read his other work to build upon his psychoanalytic framework to provide you with a structural understanding the subjective matrix of the psychic mind of a BPD person. You'll get a theoretical psychoanalytic framework to base the underlying positing phenomenological psychic structures that manifests into the DSM-5 criterion for BPD. With this beginning, you'll also assume an overlap understanding into the other potential trajectories of Schizoid, Anti-Social, and Narcissistic personalities, which, in summation, originates from an arrested and inhibited core self.

After that, if you breezed through Masterson's work, and have amassed a precursory understanding of object relations theory, if you are intellectually-able, Borderline Conditions and Pathological Narcissism by psychoanalyst Otto Kernberg, is the definitive clinical psychoanalytic text for BPD. It will provide you a greater depth into the subjective sphere of theory-building the psychic apparatus of folks with BPD. You may need to do supplemental research with Donald Winnicot, Heinz Khout, a bit of Erik Erricson, and especially Melanie Klein and Margret Mahler (which Masterson's work will greatly assist here) to understand Kernberg's use to re-conceptualize of their respective theories in the application toward his own conceptual work.

From there, I would move onto to Peter Fonagy's Affect Regulation, Mentalization, and the Development of Self, which he transitions psychoanalytic theory with attachment theory/Theory of the Mind (ToM) imbuing it with infant-neuroscience. He focuses analytically on whilst practicing MBT with infants/toddlers/children, concurrent with theory-building/researching on the adolescent/adult+ BPD population that carry developmental trajectories of his predominately child-specific research that is applicable to the wider gamut of age-prevalent disorders/deficiencies and to the general disciplines and subspecialties within mental health.

I believe in this chronological order of ideal cross-disciplinary studies will provide the best solid-base for core-conceptualizing the clinical understanding of BPD beyond the reductionistic imperatives of neuroscience. Once this is understood, you can pick-and-plop any other neuroscience, psychoanalytic, attachment theory – including behaviorism (which is really quite oversimplified, inconclusive, and sometimes counterintuitive) research-book out there!