Introduction

Personality is defined as a person’s characteristic pattern of behaviors in the broad sense (including thoughts, feelings and motivation). It is the set of psychological traits and mechanisms within the individual that are organized and relatively enduring and that influence his or her interactions with and adaptations to, the intrapsychic, physical and social environments. There is a longstanding belief that personality is stable over time. Nevertheless, studies found that in patients with some psychiatric disorders, the rate of personality disorders using phenomenological system of conceptualizing personality in Diagnostic and Statistical Manual of Mental Disorders, DSM criteria decreased after treatment. This suggested that personality as assessed by this system is state-dependent. An alternative to this was the concept of character, that is, an enduring pattern of both adaptive and pathological defense mechanisms and of personality organization characterized by patterns of object relations, ego strengths and superego development [1].

Borderline personality organization is a term coined by Otto Kernberg by using combined psychological-object relations approach to describe a pathological personality organization. It encompassed a group of patients who are characterised by ego weakness, primitive defensive operations and problematic object relations. These patients usually maintain their capacity for reality testing with the tendency of primary-process functioning. Nevertheless, they may have transient psychotic episodes under special circumstances such as severe stress, regression under drug or alcohol influence or a transference psychosis. This case report illustrated a patient with major depressive disorder associated with borderline personal organization [2].

Case Report

Miss A was a young lady in her mid-20s, single and she was pursuing her Master’s degree. She was suffering from major depressive disorder, moderate to severe, with recurrent episodes, 3 episodes in the past 8 years (Table 1).

Table 1. Symptoms of depression.

She experienced multiple stressors such as unemployment, frequent arguments with parents and her conflict regarding her homosexual orientation and her religious belief, with fear of societal rejection. Miss A exhibited features with difficulty to maintain interpersonal relationships, frequent conflicts with family members, chronic emptiness, fear of abandonment by her friends, recurrent self-mutilating behaviour via cutting and mood instability with multiple anger outburst. Besides that, there were grandiose sense of self importance that she was gifted and more intelligent and she was envied of others who did better than her academically or in life. However, these symptoms were not pervasive and occurred when she was having depressive episodes. Miss A had functional deterioration in her social, academic and occupational aspects. She did not have symptom suggestive of psychosis, mania or hypomania. She did not smoke cigarette or consume any illicit substance [3].

Miss A had normal birth, growth and developmental history. She was brought up in a high emotional expressed family as her mother had high expectations on her and appeared hostile at times. Besides, Miss A had traumatic sexual experiences as a child whereby she was molested twice by her second degree relative. When Miss A was a teenager, she was a high achiever in a prestigious girls’ school. However, her academic performance when she pursued her tertiary education deteriorated due to her psychiatric conditions. She had multiple stressors as mentioned that perpetuated her illness. She has conflict with her gender preference and her religious and sociocultural background. Her parents had marital conflicts and always quarreled which upset Miss A. Miss A always wanted to be a perfect daughter but she disagreed with her father’s political views, always being very dominant in her family and felt pressured due to her mother high expectations on her. She had difficulty to communicate her thoughts and needs to her parents. Due to her past experience in her upbringing whereby her father is very dominant in important family decision, she disliked people who were of male figures of higher authority as she thought they were exploiting the minority and did not provide necessary help to them. Miss A had disagreement, anger and negative views towards them. She felt discriminated as she thought that the world was not fair to the minority, in terms of gender, race. Miss A experienced intense internalized stigma towards her gender orientation and mental illness with poor self-acceptance. She felt ashamed as well for being unemployed and unable to complete her Master’s degree on time [4].

During mental state examination, Miss A was depressed with tearfulness. She was coherent and relevant in speech. She was preoccupied with hopelessness and worthlessness associated with death wishes but she denied suicidal thought. There were multiple well healed scars over her left forearm and central abdomen. She was not psychotic. Miss A’s pharmacological treatment was optimised with Tablet Escitalopram 20 mg ON. Brief psychodynamic psychotherapy was commenced with the goals to promote insight, to promote self-acceptance, to promote change in maladaptive behaviours and to improve interpersonal relationships. She showed improvement after this combination intervention [5].

Discussion

Psychodynamic formulation was done prior to the commencement of brief psychodynamic psychotherapy for Miss A. Throughout the sessions, further exploration was done to understand her better and relevant reflections were given to her timely. Several psychodynamic concepts regarding her were worth discussed here, mainly about borderline personality organisation. We shall analyse the structural, descriptive and genetic-dynamic aspects of this organisation [6].

Structural aspect

Miss A was found to have non-specific manifestation of ego weakness, she failed to have the normal ego functioning of having the capacity to control or delay the discharge of impulses. She had difficulty in modulating affects such as anxiety or anger. Regression took place in her and she had predominant primary-process-thinking. According to Robert Holt, it is a drive-laden oral, aggressive and libidinal content and illogical thinking. Primitive affective content as such can be seen.

Miss A had difficulty sublimating powerful drives and using her conscience to guide behaviour. She was impulsive whereby she would post her inappropriate comments in social media to channel all her feelings and subsequently deleted them. She would also cut herself or perform masturbation impulsively when she was frustrated or in distress usually due to her conflicts regarding her gender orientation, interpersonal relationship issues, feeling ashamed due to her deferment in master’s degree and financial stress due to her unemployment [7]. Miss A viewed her life challenges as something to avoid as reality can seem too overwhelming to deal with. She used to actively avoid and delay her assignment and studies for her master’s degree. There was inability to tolerate her frustration, anxiety, disappointment or stress. Miss A also described her affective instability as a roller coaster type of mood swings. She could not regulate her emotion with difficulty in controlling her anger. There were frequent anger outbursts when she had arguments with family members.

The differentiation of self-images from object images which form the early introjections and identifications and the integration of the two are known as essential tasks for internalization of object relationships. Pathological, early internalized object relationships connected with primitive drive derivatives of a pathological kind was reactivated in borderline personal organization. There were reactivation of early defensive operations that affected the integration of cognitive process. Specific defensive operations such as splitting and dissociation are not uncommon [8].

Miss A had pathological internalised object relations which might be due to excessive frustration of early instinctual needs. She could not integrate good with objects images or self images. Miss A also could not view others with mixture of positive and negative qualities. Miss A could not integrate libidinal and aggressive aspects of others that inhibited her to appreciate internal experiences of other people. People are divided into polar extremes. Her perception also may alternate daily between idealization and devaluation.

Miss A utilised specific defensive operations such as splitting which is a primitive defence with an active process of keeping apart introjections and identifications of opposite quality, under the influence of aggressive drive derivatives (“good” and “bad” internal objects or “positive” and “negative” introjections ) [9]. The introjections and identifications of opposite quality is important for neutralization of aggression. If it doesn’t take place, it will be a fundamental cause of ego weakness. Miss A unconsciously compartmentalised experiences of self and others with lack of integrative capacity. This was to prevent anxiety in her by protecting the ego from intra psychic conflicts. She viewed female figures as all good and male figures as all bad whereby they took advantages on females [10]. They were rapists and abusive in terms of power. When Miss A was confronted with the contradictions in behaviour, thought or affect, she regards the differences with bland denial and indifference.

Her defence prevented conflicts stemming from the incompatibility of the two polarized aspects of others or self. There was coexistence of contradictory views and images of Miss A’s self representation that alternate in their dominance. Miss A viewed herself as good as she was helpful, responsible and intelligent. However, she sometimes thought that she was a bad person due to her emotional instability, homosexuality, unemployment and failure in a long term relationship.

Miss A practised extreme idealization and devaluation as her defence. With primitive idealization of protective fantasy structure, she had the tendency to see external objects as totally good to protect one against the bad objects. Her friends were idealized as kind, understanding, angel-like and individuals who were sent by God. Nevertheless, she devaluated her father and her brother. Another primitive defense which was projective identification could be seen in Miss A. It is an unconscious process whereby a phenomenon involves characteristics of an aspect of self or an internal object that is projected into that person. The person who is the target of the projection then begins to behave, think and feel in keeping with what has been projected. Miss A projected her dissatisfaction and dislike onto her friends bad internal object. Her friends unconsciously identified with what was projected and began to behave or feel like the projected self or object representation in response to interpersonal pressure exerted by her friends. Primitive defences like regression and acting out were present as well. Miss A enacted an unconscious wish of fantasy impulsively as a way of avoiding painful affect. She shouted and turned verbally abusive when she felt hurt and in anger [11]. She threw empty bottles to release her frustration. She had self-mutilation or masturbation to avoid her painful emotions.

Typical neurotic symptoms such as anxiety, polysymptomatic neurosis, perverse gender trends, prepsychotic personality structures (paranoid, schizoid or hypomanic personality), impulse neurosis and addictions and lastly “lower level” character disorders with chaotic and impulse-ridden character can be seen in patients suffering from borderline personality organization.

Miss A experienced chronic and diffuse anxiety and she used it as a resistance in our psychodynamic sessions with explorative nature. She complained of having emotional pain when her conflicts were uncovered. She demonstrated her resistance by coming late for the therapy session. Besides, Miss A’s paranoia towards males with higher authorities could be seen throughout the psychodynamic sessions [12].

Narcissitic personality structure was also seen when Miss A was in acute depressive episode. She viewed herself as special, unique, gifted fast learner with high Intelligence Quotient and Emotional Intelligence but she had no chance to show it to others. She had unusual degree of self-reference in her social interactions with a great need to be admired by others. There is the presence of pathological grandiose self with a fusion of the ideal self, the ideal object and the real self. Miss A denied dependency on others. The unacceptable features of her own self-images were also denied and projected onto others.

Miss A felt envy with people who did better than her in academic, occupation and life. There was chronic intense envy and she constantly comparing herself with her school mates, friends and elder sister. She devaluated others especially male figures. Miss A loved to be admired and enjoyed receiving compliments. Her emptiness could only be compensated by constant admiration from others and an omnipotent control over others [13]. Besides, Miss A has vulnerable self-esteem that was highly sensitive to slights from others. This feeling of inferiority frequentlty represent the secondary surface layer hiding the narcissistic character traints. Miss A’s attention was continually directed toward others and she listened to others carefully for evidence of any critical reaction. Miss A was shy and inhibited in making new friends to the point of being self –effacing. At the core of her inner world is a deep sense of shame related to her secret wish to exhibit herself in a grandiose manner.

Miss A also demonstrated primitive self- destructiveness as a feature of “low-level” masochistic characters. Via self-cutting, there was nonspecific relief of anxiety. Preoedipal conflicts predominate in these patients with primitive fusion and defusion of aggressive and gender impulses [14].

Genetic-dynamic analysis

Melanie Klein and her co-workers described the intimate relationship between pregenital aggression (especially oral conflicts) and oedipal conflicts. Nevertheless, suggested the characteristic of borderline personality organization as a specific condensation between pregenital and genital conflicts and a premature development of oedipal conflicts. It was associated with history of extreme frustrations and intense aggression especially during the first few years of life. In the oedipal phase of development, it is associated with a more intense focus on the genitals as the source of pleasure and also with the longing to be exclusive love object of the parent of the opposite gender. When a girl discovers the existence of penis, she feels inferior and develops penis envy. She blames her mother for her inferiority so she turns to her father as her love object and there is a wish for a child from her father. Excessive pregenital oral aggression was projected resulted in paranoid distortion of Miss A’s mother. She was not in good terms with her mother since young. She was frustrated by her “dangerous” mother. A search for the gratification of oral needs from an idealized mother image, which was completely split off from the dangerous, threatening mother image, is an important source of female homosexuality. This could explain the hypermasculinity and homosexual orientation seen in Miss A. Masterson and Rinsley view borderline pathology as emerging from difficulties occurring within the rapprochement subphase [15]. They propose that the actual failure of the mother to be adequately available on an emotional basis at this time (beginning around 16 to 18 months) is the key etiological feature of borderline problems.

Conclusion

Miss A manifested features suggestive of borderline personality organization during her acute presentation of major depressive disorder as discussed. Nonetheless, these features including their specific defense operations were resolving after her condition was stabilized with treatment and she did not meet the criteria of borderline or narcissistic personality disorder. This finding was in consistent to previous studies whereby patients with major depressive disorder revealed a significant decrease in “maladaptive” defenses after receiving antidepressant. This suggested that there may be some aspects of personality which are state-dependent. Further studies are needed to investigate the concept of personality especially in those with primary psychiatric disorder such as major depressive disorder and the practicability of phenomenological system of conceptualizing personality in our main reference of personality disorder diagnostic criteria, DSM.

Ethical Statement

A written informed consent was obtained from the patient and her details were kept anonymous. This report had met the ethical guideline and legal requirements in Malaysia.

Declaration of Competing Interests

There is no conflict of interest.

Acknowledgement

The authors are grateful to the patient for his written informed consent. They are also thankful to Director General of Health Malaysia for his permission to publish this case report.

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Citation: Psychodynamic View in a Case Of Major Depressive Disorder with Self Harm Behaviour. ASEAN Journal of Psychiatry, Vol. 23(8) December, 2022; 1-6.