Molnos, A. (1998): A psychotherapist's harvest

Neurosis, psychosis, borderline and acting out

(31) Neurosis can be seen as one pole of a continuum of psychic disturbances with psychosis at the other end and borderline personality disorder between them. Originally neurosis meant some nervous illness, while nowadays it means just the opposite, a purely psychic disorder.

People suffering from any form of neurosis or psychic disorder persist in repeating their basic conflict which is generally rooted in early childhood. Usually these emotional and behavioural patterns were the child's healthy and reasonable response to some unhealthy and unreasonable situation, mostly in his relationship with his parents. As the child grows, he remains programmed, so to speak, to respond with the old patterns in any close relationship. In other words, the old patterns become inappropriate, maladaptive, neurotic.

The term "borderline" is used to indicate someone on the border between neurosis and psychosis, a person who has some psychotic features or mechanisms, but who is not psychotic nor about to become psychotic. The (32) borderline personality disorder is not a well-defined concept. It covers a number of characteristics such as a changing self-image, intense, manipulative relationships and instability of mood or behaviour with others. There might be poor impulse control and unpredictable behaviour, including physical self-damage. Mood shifts might be quite dramatic, including anger and rage unwarranted by the real situation. He might defend against intrapsychic conflict by repressing and denying any genuine feeling of guilt. There might be profound uncertainty about his own goals and values in life, feelings of emptiness or boredom and an incapacity to be alone. However, one or several of these features may be missing.

The borderline person's disturbance is fed by his fundamental belief that he has been or will be abandoned. He is afraid of total aloneness which he experiences as annihilation. The therapist who works with a borderline person has to modulate her distance and closeness constantly in such a way that the patient feels at a safe distance and not in any danger of being 'engulfed', yet still close enough to maintain a workable degree of relationship.

(33) Acting out can be looked upon as one of the defence mechanisms by which the unconscious protects itself against being uncovered by the conscious ego. It is one of the defences characteristic of borderline personalities.

Acting out is doing instead of feeling, that is to say it is making something happen, doing something instead of experiencing the corresponding feeling (AM). In the broadest sense we talk about acting out when a patient unconsciously uses action or any non-verbal communication instead of getting in touch with his true feelings, instead of acknowledging to himself and putting into words what he really feels and experiences inside himself. The patient might suffer from psychosomatic symptoms, become accident-prone, attempt suicide, or commit unconscious acts of self-sabotage or destruction in relationships, in his work, and so on.

Acting out can be a manifestation of destructive anger. Perhaps the most dangerous form of destructive anger is one that is not experienced as anger or any feeling at all, but is acted out instead. The repressed, unrecognized, destructive anger can also turn against the self and appear in many different guises.

As I said, at one extreme of the continuum of psychic disorders there is neurosis, at the other (34) psychosis. Some regard psychosis as being different from neurosis only in severity. The greatest difference between a neurotic and a psychotic person is that the latter is barely capable of insight into his illness or even of recognizing that he is ill. Consequently psychotics are on the whole inaccessible to psychoanalytic treatment, although some analysts and analytically trained psychotherapists attempt to treat psychotics as well. The degree of this inaccessibility is in a way more relevant for choosing the right treatment than the answer to the question whether the particular patient's psychotic illness is mainly of organic or psychological origin.

The main forms of psychosis are schizophrenia, paranoia and manic-depression psychoses.


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