On the Neurotic and More Primitive Aspects of Personality

The pathology that seemed to be predominant during the first decades of the century (until the Second World War) was considered by psychoanalysts primarily as neurotic, i.e., as symptom or character neuroses. The clinical material indeed favored the adherence of psychoanalysts of the time to the study of so called "high level" psychopathology arising from intrapsychic conflict, especially the structural conflicts of the oedipal phase of development. However, the "range of possible diagnoses was greatly limited by the contemporary state of psychoanalytic knowledge" (Gaddini 1984/1992,187). The shift of interest from neurosis to psychosis or near-psychotic (borderline or narcissistic) conditions, in spite of some brilliant publications (for example, Freud 1914, 1924, etc.) has not yet taken place.

In recent decades psychoanalysts and mental health professionals have been increasingly confronted with a variety of severely regressed (prone to psychotic decompensation) patients whose core-psychopathology is indebted to earliest preoedipal (in classical terms) trauma. They reveal ego-weakness, poor identity integration, primitive defenses of splitting and projective identification, fragility of ego-boundaries and of reality testing. After an impressive outpouring of the literature over the last forty years (Klein 1946; Sullivan 1947; Fromm-Reichman 1952; Bion 1957/1988; Segal 1950/1988; Searls 1956; Rosenfeld 1947; Steiner 1987/1988; Little 1981/1986; McDougall 1991, etc.), primitive dimensions of experience have become commonplace. Some analysts not only treat severely disturbed patients, but find psychotic-like phenomena even in our "most solid citizens" (Milner 1987).

In fact, we now know much more about the earliest traces of mental life, about the "primitive edge of human experiences" (Ogden 1989)--up to the most sensory dominated, pre-structural and pre-symbolic (Gaddini 1984/1992) psychological organization, namely, the autistic-contiguous position (Ogden 1989) that lies even beyond the states "addressed by Klein's concept of the paranoid-schizoid and depressive positions" (Ogden 1989). In this position, the infant attempts to organize and structure different sensory impressions, particularly tactile sensations of the skin "that come to constitute bounded surfaces" (Ogden, 49). As Ogden suggests, these tactile impressions primarily at the skin surface constitute the earliest experience of the self and are forerunners of later internalized self- and object-representations. Failure to establish a secure, lasting sense of a bounded sensory contiguity leads in turn to pre-symbolic anxiety involving the terror of "impending disintegration of one's sensory surface or one's 'rhythm of safety' resulting in the feeling of leaking, dissolving, disappearing, or falling into shapeless unbounded space" (68).

Whether psychopathology has changed or analysts have changed, the once ruling "pure" neurosis has been dethroned, though not banished outright from the pantheon of psychoanalytic diagnoses. Oedipus (or Guilty Man) has been replaced by Hamlet (or Tragic Man) as the prototype of our period (Green 1977; Kohut 1977). Psychoanalysts have gradually refined their diagnostic and technical capacity and turned to the "frontiers of consciousness beyond which words fail though meanings still exist" (as Ogden 1989, cites T.S.Eliot). Now, in the psychoanalytic diagnostic lexicon, besides neurotic, the "magic words" are borderline, narcissistic, psychotic.

As Nancy McWilliams (1994) wrote recently, "it is one of the ironies of contemporary psychoanalytic parlance that the term 'neurotic' is now reserved for people so emotionally healthy that they are considered rare and usually gratifying clients" (53). But in fact, many of the patients Freud diagnosed as having neuroses had underlying near-psychotic (or borderline) personality organization, and some had periods of psychotic decompensation (for example, hallucinations that clearly crossed the border of reality testing). The realization of this fact raises some questions: Should we reserve the term "neurotic" exclusively to denote a very high level of capacity to function despite some emotional suffering which centers predominantly around oedipal problems? Should we apply the structural theory alone ("monocular vision") to understand neuroses and high-level character disturbances? Or may we adopt "binocular vision" and apply simultaneously (or successively) different models (structural, object relational, self psychological...