International Journal of Mental Health & PsychiatryISSN: 2471-4372

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Research Article, Int J Ment Health Psychiatry Vol: 2 Issue: 6

Impulsiveness and Metarepresentative Functions of Borderline Patients with Psychopathic Conducts: An Experimental Study with the Rorschach Test

Maria Elena Cinti1, Mara Lastretti1, Antonella Pomilla1, Loredana Teresa Pedata2 and Franco Burla1*
1Neurology and Psychiatry Department, “Sapienza” Rome University – Rome, Italy
2“Tor Vergata” Rome University – Rome, Italy
Corresponding author : Franco Burla
Neurology and Psychiatry Department, “Sapienza” Rome University – Rome, Italy
Tel: +39 3382076780
E-mail:
[email protected]
Received: July 27, 2016 Accepted: September 06, 2016 Published: September 10, 2016
Citation: Cinti ME, Lastretti M, Pomilla A, Pedata LT, Burla F (2016) Impulsiveness and Meta-representative Functions of Borderline Patients with Psychopathic Conducts: An Experimental Study with the Rorschach Test. Int J Ment Health Psychiatry 2:6. doi: 10.4172/2471-4372.1000138

Abstract

The Borderline Personality Disorder (BDP) is defined as “a pervasive pattern of instability which affects regulation, impulse control, interpersonal relationships, and self-image”. Bateman model & Fonagy model, being a connection between the psychoanalytic tradition – especially the attachment theories and the cognitive approach, identifies the inability to mentalize as a fundamental problem of borderline patients, which is meant as “the capacity to make sense of ourselves and others, implicitly and explicitly, in terms of subjective states and mental processes”. Due to the considerable number of empirical evidence on the connection between mentalization and attachment, the authors defined the obstacles related to interpersonal relationships, which represent the distinctive feature of patients with BDP and which give rise to their typical impulsive behaviours. Such behaviours can be selfinflicted by means of self-destructive acts and attempted suicide and other-directed by means of aggressiveness and violence.This study aims to verify the differences related to impulsiveness and behavioural disorder, which can emerge from the comparison between an experimental group of borderline patients and a control group of non-patients. The experimental plan considered the administration of the Rorschach test and MMPI-2. The scoring of the Rorschach test, conducted according to the Comprehensive System has showed that patients with BDP proved to be clearly more impulsive than normal individuals and less capable to control their responsiveness on the personality level. Furthermore they have fewer abilities to plan and modulate the emotional response than the control group. In this study the Rorschach test had well identified the emotional dysregulation as a meta-representative distinguishing deficit, by pointing out the BDP patients who could more probably act impulsively by means of aggressive behaviours.

Keywords: Borderline personality disorder; Impulsivity; Aggressiveness;Rorschach test; Exner, mentalizing

Keywords

Borderline personality disorder; Impulsivity; Aggressiveness; Rorschach test; Exner, mentalizing

Background

The BDP represents a complex and debatable nosographic category in the clinical-therapeutic field and is one of the most complex and controversial diagnostic entities [1-5].
Different studies, aiming to identify its most adequate theoretical definition, agreed to consider its heterogeneous and polymorphous nature as a clinical picture “to the limit” among the psychosis, neurosis and psychopathy, because the BDP consists of an atypical variation for each of them and it include similarities from which it simultaneously distinguishes itself as it goes “beyond” them. As an example, the use of primitive defence is borrowed from the psychotic organisation, the modality of the object representation is borrowed from the neurotic one (the reality testing is preserved) and the behavioural impulsive, aggressive, self and other-destructive modalities are borrowed from the psychopathic one.
Borderline patients often oscillate between a functioning level of a neurotic kind with clear difficulties in the management of the emotional past and a functioning level of a psychotic kind, which is characterized by the loss of the touch with reality. That is why the term borderline refers to a personality that is set “on the border” and it is representative both of the emotional instability and of the ambivalence that is typical of interpersonal relationships of the subject: on the one hand he can appear seductive, friendly and manipulative, on the other hand he can simultaneously show an hostile behaviour, refusal and mistrust [6].
In order to give diagnostic legitimacy to BDP, by defining its typical “nucleus”, interesting etiopathological models can be found both in the psychodynamic field and in the cognitive-behavioural one [7].
Quotations concerning the first one are:
- Kernberg’s model [8,9] which postulates the existence of a conflict between two impulses of lustful nature (good) and aggressive nature (bad) that arises in the premature pre-Oedipal stage of the early two years of life. It is dealt with the primordial defensive mechanism of the splitting, so that it prevents from consciously comparing the contradictory positive and negative representations of the self or others. Mahler [10], focussing her attention on the psychodynamic elements, had already considered the difficulties of the mother-son relationship as a very important factor in the etiopathogenesis of the disturbance. The author especially believed that growing up in a parental hostile environment, which was not very coherent and reliable, not only emotionally but also physically and sexually abusing and also inadequate to provide support handling painful emotions, could interfere with the normal learning process of the emotional regulation of the child. Such environment could also interfere with the ability to tolerate frustrations and to integrate the different emotional past. The child will ultimately look for protection from these negative and painful elements through the mechanism of the splitting. For this reason, in the borderline subjects the splitting of the good parts of oneself and those of others from the copresent aggressive and dangerous parts allow to preserve the first ones from the destructive threat of the second ones, whose presence makes them feel confused and vulnerable.
- Adler’s model [11] which affirms the beginning of a serious deficit in the creation of a positive inner representation of the leading figure of caregiver (generally the mother), who is not adequately responding to the needs of care and protection of the child’s first moments of life. For this reason, the child, who is living very strong emotional stressful moments, is not able to recall reassuring images of the caregiver and becomes deeply vulnerable, feeling shame and fear of perceived refusal and abandonment. In fact, the borderline subject lives profound vulnerable moments in the self-perception and he does not feel to be worthy of an adequate care, with a correlated selfdeprecation and a feeling of inner emptiness.
- Fonagy’s model [12] which proposes the beginning of a deficit of the meta-cognitive abilities which allow “thinking about thinking” and to shape a “theory of mind”. Such deficit originates from the primary attachment relationships and, in particular, from the parent’s ability to give an adequate response to the child’s needs without “overwhelming” him with his own ones. In this regard, granting the child an adequate intentional ability in the expression of needs and desires will allow the development of the self-reflexive ability (metacognition on the self), which will be later generalized to include the future interpersonal relationships (metacognition on the other and on the experience in general). Instead, when the parent will not be able to fulfil his role by means of this modality, the child will find refuge in the splitting as a defensive modality and in the emotional and behavioural dyscontrol, with sudden and intense expression and actions. In conclusion, the metacognition attributes significance to the experience, thus enabling to distinguish between true and false, real and imaginary, right and wrong. The borderline subject is inevitably characterized by a lack of an adequate interpretation of the opposites.
As far as the cognitive-behavioural orientation models are concerned, the most well-known are:
Beck’s model [13] which is based on the co presence and interaction of three specific contents about the vision of the world and of the self, which are: 1) the firm belief that the world is malevolent and dangerous, 2) the firm belief to be weak and vulnerable, 3) the firm belief to be intrinsically unacceptable and therefore destined to be abandoned.
These assumptions originate the main pathological features of the disturbance: 1) the fear, the phobias and also the intense emotions of anger, 2) the intense emotional reactions when the abandonment of interpersonal relationships is perceived, 3) the feeling of emptiness and self-destructive behaviours.
Linehan’s model [14] that particularly specifies the serious deficit of the emotional past that afflicts the borderline patients and the correlated intense behavioural expressions. Such deficit derives from the interaction between temperamental aspects of a specific kind of emotional vulnerability and variables of “invalidation” of the value and significance of the emotions themselves, which derive from distorted social learning models (familiar devaluating, ambivalent, inappropriate and inadequate context, in terms of abusing and/or mistreating care).
The cognitive-behavioural explanation of the borderline patient’s, cognitive functioning focuses on the predominance of the so-called “dichotomous thinking”, that is an extreme interpretation (“to the limit”) of the self, of the others and of the events, thus making the integration between opposites within intermediate categories impossible (good/bad, white/black, everything/nothing), so that behavioural drastic, dramatic and impulsive responses are originated. According to Freeman and his colleagues [15] the training of the impulse control is fundamental in the cognitive-behavioural therapy of BDP, in order to help the patient to focus on his real objectives and to choose “step by step” well-thought-out and appropriate responses for difficult situations, rather than behaving in an impulsive and dangerous way.
As can be seen, the two positions (the psychodynamic one and the cognitive-behavioural one) do not seem to be so different [7]. In fact, taking into account the models above, the nucleus of the borderline personality is composed of three elements:
1) The incomplete, split and contradictory representation of the vision of the self and of the others/the world;
2) The profound past of fear for separation and abandonment and the consequent emotional abnormal reactions with respect to real or perceived events, which represents such danger;
3) The difficulty of modulating emotional reactions, which derives from greater mental processes with this function (the previously mentioned deficit of mentalization).
The experimental in-depth analysis of this study particularly refers to the Bateman model [2] and Fonagy model [3], which seems to be a connection between the psychoanalytic tradition and the cognitive approach. The authors identify as a fundamental problem of borderline patients the inability to mentalize, which is meant as “the capacity to make sense of ourselves and others, implicitly and explicitly, in terms of subjective states and mental processes”.
The development of the child’s ability to mentalize takes place within the relationship of certain attachment in the early childhood [12]. The caregiver, through an adequate and contingent (precise and responsive) mirroring of the child’s inner conditions, helps him to convert a physical experience (for example crying) into a mental one with conscious contents. Such process enables the child to begin to mentalize, who think about his own thoughts and his own inner experience, which is a necessary function for the emotional regulation connected to such process and for the formation of a stable conception of the self [16,17].
When the caregiver’s responsibility becomes unstable, his mentalization level of the child’s needs appear to be inadequate and the mirroring turns into unsatisfactory and/or discontinuous, a disorganized attachment modality which will be originated. In this sense, authors talk about Alien Self to specify this disorganization, fragmentation and incoherence of the child’s self, which will endure in the advanced age and which will be the origin of the typical random failure of mentalization: the failure of such ability causes the reappearance of pre-mentalistic modalities of subjectivity, which in fact are typical of the Borderline Personality Disorder (BDP).
In conclusion, according to Fonagy and his co-workers [17] the inadequate structure of the mentalization ability, which is caused by the failure in the attachment with the caregiver, together with the alteration of the ability of self-awareness and self-regulation are the elements which define the psychopathologic picture of the BDP.
In the light of the above, it has to be said that:
- The modulation which is a particular structure of the borderline personality has in connection with the reality in the different sentimental and connective aspects (where he oscillates between interpretative integrity and the possibility of temporary experience of a dissociative kind, which, however, do not result in a schizophrenic destructuration);
- The cyclic nature of emotional conditions and of the state of mind (with serious anxiety, depression and maniacal episodes);
- The behavioural dyscontrol in a self and other-destructive way, incurring in sudden “acting out” (which, however, do not worsen neither in the antisocial behaviour of the psychopath nor in the in the antisocial behaviour of the schizophrenic),
are the elements that make the borderline psychopathologic picture so fascinating and complex in terms of treatment as well as in the eventuality of a psychiatric forensic judgement, in terms of criminal liability. The topic of the personality test in the judicial field has always represented a subject matter for discussion and debate.
However, the present research particularly focuses on the close examination of the impulsiveness aspects and of the emotionalbehavioural dyscontrol, which characterizes the BDP patients.
As for impulsiveness, as described in the DSM-5 and in the whole specialist literature [18,19], it concerns the predisposition to act rapidly under the impulse of the moment in response to immediate stimulus, without planning one’s own conduct and especially without making an adequate evaluation of the possible consequences of the conduct itself, even if it has a negative nature.
The literature has also outlined different forms of impulsiveness: the “motor” one, characterized by the impetus of the moment, very similar to the concept of “impulsiveness in the strict sense”, described by Eysenk [20], the “unplanned” one, defined as the tendency to choose an immediate advantage, even a scarce one, instead of a greater but procrastinated reward; the “cognitive” or “attentional” one characterized by an inclination toward sudden decisions and a rapid processing of the contextual information [21], with scarce or inadequate reflection with respect to the situation [22].
The above-mentioned forms of impulsiveness are variably present among the BDP features. Moreover, the intervention of the emotional and cognitive requests in the borderline subjects is limited to the modulation of the fulfilment of such instinctive behaviour. Impulsive behaviour (excessive expenses, promiscuous sexual relationships, substance abuse, reckless driving, food feasts) recurs, in order to relieve emotional unbearable conditions or to show emotions of anger and intense frustration, deriving from emotional confusion and/or from the fear of abandonment.
Although such conducts take place in order to achieve one’s own immediate satisfaction and not to damage the self or the other, outcomes are often negative for the subject or for those who surrounds him [23]. In fact, in the BDP there are some symptoms that express aggressiveness, which is meant as fit of anger resulting in violent and destructive behaviours, which can be sometimes relevant from a criminal law point of view.

Objectives

In the light of the above numerous impulsive behaviours typical of BDP patients, this research aims to:
1. Evaluate if the dimension of the impulsiveness is superior in borderline subjects rather than non-patients;
2. Evaluate if the borderline subjects, who show greater behavioural disturbances of a psychopathic kind, reveal differences from those who do not present such disturbances with regard to the impulsiveness feature;
3. Improve the clinical knowledge regarding the relationship between impulsiveness, as a personality trait and the actual development of psychopathic behaviours.

Methods

A sample of patients has been selected to this end. They were examined in outpatient services of the Clinical Psychology of the Neurology and Psychiatry Department in the “Sapienza” University in Rome. The subjects have been selected by means of a psychological assessment, aiming to make diagnosis of BDP and through the administration of the Diagnostic Interview of Borderline patients (DIB), considered by the literature as a valid screening instrument [24].
50 subjects, who had received a score ≥ 7 in the DIB, have been included in the study; they met at least 5 out of 9 criteria for the BDP according to the DSM IV-TR (2000), pointed out by the case history.
The control group is made up of 50 subjects. They were employed in the administration of the State Police and tested in the Applied Psychology service of the State Police: the DIB has been administered as a screening instrument to these subjects too.
Taking into account the identity records of the two samples, there are:
• An experimental group of borderline subjects made up of 25 males and 25 females, with an average age of 33,68 years (SD=10,78) and an average education level of 11,16 years (SD=3,67);
• A control group of non-patients made up of 25 males and 25 females, with an average age of 32,53 years (SD=9,90) and an average education level of 12,13 years (SD=3,99).
The Rorschach test has been administered to both sub-samples, then scored according to the Comprehensive System by J. E. Exner [4]. Besides DIB, the MMPI-2 has also been administered to the group of borderline subjects [25].
The experimental group of BDP patients has been divided into two subgroups according to the weighted scores of the Pd Scale (Psychopathic Deviate) of the MMPI-2, related to the control deficiency of emotional and behavioural responses, with a lacking internalization of the social rules and antisocial actions: a subgroup of 30 subjects, who received a score <75 T, and a subgroup of 20 subjects, who received a score ≥ 75 T, have been obtained.
The most representative Rorschach variables out of the different variables, which according to the Exner scoring and to the literature are the most connected ones to impulsiveness, have been selected.
From a quantitative point of view, the following ones are involved:
- D score that provides some information on the comparison between EA and ES and it refers to tolerance towards stress and control elements;
- D score Adjusted that allows to identify if the D indicator has been influenced by situational elements;
- X+% that provides some information on the perceptual efficiency and the ability to modulate and control the sentimental experience;
- Xu% that identifies an unconventional response modality;
- EA that identifies the available resources of personality and the psychological behaviours, which were intentionally undertaken;
- M% indicator that is associated with good mentalization abilities and which allows a high level of emotional integration;
- C+T+C’ whose presence is associated with a scarce ability to direct the sentimental experience;
- Afr, indicator of interest in the response to the emotional stimulation;
- Lambda (L), whose value increases in the impulsive subjects and/or with antisocial behaviours;
- FC% that gives some information related to a socially accepted and well-adapted affectivity;
- CF% that identifies a scarcely controlled and not welladapted sensitivity instead, and also sentimental liability, instability, inconstancy of emotions and suggestibility;
- C% related to emotional behaviours, with a lack of control.
• From a qualitative point of view, there are:
- FC<CF+C (E1) in which if the Cf+C prevails in a context of inadequate emotional control, they are expression of impulsiveness and inadequate responsiveness;
- X+%<.70 and FQu≠0 and P ≤ 4 and L>1 (E2), which identifies the presence of elements of scarce modulation, together with a thought which is not very conventional;
- X+%<70 and C+T+C’≠0 (E3), which identifies the inability or the unavailability to insert some aspects of control and of orientation of the sentimental experience;
- X+% <70 and D<0 (E4), which identifies a scarce control in a subject that is overwhelmed by feelings;
- X+%<70 and D ≥ 0 and C+T+C’≠0 (E5) that represents the inclination to give emotions the green light, rather than use a control.
In order to verify the experimental hypothesis, the two groups have been compared according to the Rorschach variables and afterwards such variables have been evaluated in order to understand whether they differentiated the borderline subjects with high scores of the Pd Scale of the MMPI-2 from those with low scores.
The data has been statistically analysed by means of the application of the Mann-Whitney U test for the quantitative variables and the Chi-squared test for the qualitative variables and the analysis of the multiple correspondence for the scores of the DIB scale by means of the SPSS 13.0 software.

Results

Comparison between borderline subjects and control group
The results of the Mann-Whitney U test in comparison between borderline patients and control group showed that there are significant differences (p<.05) for 8 quantitative variables out of 12 (Table 1).
Table 1: Comparison between borderline subjects and control group for the Rorschach quantitative variables.
The results of the Chi-square test showed the presence of significant differences (p<.05) for 4 qualitative variables out of 5 (Table 2).
Table 2: Comparison between borderline subjects and control group for the Rorschach qualitative variables.
Borderline subjects received lower scores in comparison to the control group in the EA and D score and negative scores in the Adj D score, in which the control group received a medium positive score instead. Borderline patients proved to be less capable in the organization of their own already scarce resources, which have to be contrasted with the requests coming from the external environment.
The control of the behavioural responsiveness for the other group can be influenced by the excessive requests of the environment in a specific moment, whereas borderline subjects have generally fewer resources and the management of the stress is however not very adequate. Borderline subjects are less capable of postponing reactions to the impulse (D index) and to carry out behaviours, which were deliberately undertaken; they receive higher scores in the sum of pure responses (C+T+C’) and in the qualitative variables E3, E4, E5; so, they seem unable to insert some aspects of rational control and of orientation of the sentimental experience.
Furthermore, they have significantly higher scores in the C%, and therefore they seem more inclined to “release” the feelings, rather than to control them.
The group of borderline patients received significantly lower scores in the X+%, Xu% and in the E2: such results indicate that borderline individuals have scarce abilities to modulate the sentimental experience. Such behaviour seems to be connected to a more atypical way to conceive reality, as it presents an unconventional response modality to the environmental stimuli (Xu%, E2).
The control group has significantly higher scores for the FC%, as they present a socially accepted and appropriate affectivity together with a more adequate and conscious rational control.
A greater impulsiveness in the borderline subject is characterized in the Rorschach test by a tendency to act without planning one’s own actions, without a rational and conscious evaluation of consequences and with a great involvement in the sentimental situation leading to the inability to modulate it. In other words, they react without a planning and a rational evaluation of the response to an emotionally relevant stimulus of the environment.
The variables, which are the objects of this study, follow the interpretative system of Exner [4] and they refer to the following clusters (Figure 1): the area of the “cognitive functioning” to which the sub-areas “mediation” and “elements of control and resources” and the area of “affectivity” belong.
Figure 1: Analysis of the variables with respect to clusters identified by Exner. Comparison between borderline subjects and control group.
Taking into account the meaning of these areas, it can be noticed that borderline subjects have lower tolerance towards stress and fewer available resources for self-control compared to the group of non-patients, with the difficulty to intentionally develop preordained behaviours: the thought has an unconventional modality and there is a scarce modulation of the sentimental experience, which is often explosive and scarcely adjustable in an adequate and socially accepted way.
Comparison between borderline subjects with high and low Pd
The results, which were achieved in the Mann-Whitney U test in comparison between borderline patients and high and low Pd, showed significant differences between the two groups for the variable C% that is more represented in the borderline subjects (Table 3).
Table 3: Comparison between Borderline patients with high and low Pd for the quantitative variables in the Rorschach test.
A single significance was highlighted in the Chi-squared test for the qualitative variables too: the variable FC<CF+C is more represented in the subjects with high Pd (Table 4). Consequently, there are no differences as concerns the elements of stress control and affectivity mediation, which are rather defective in both groups.
Table 4: Comparison between Borderline patients with high and low Pd for the qualitative variables in the Rorschach test.
However, subjects with a higher Pd showed a more explosive affectivity, a less adequate sentimental adjustment and behaviours with more intense emotional characteristics.
This study has showed that the scarce ability to modulate the sentimental experience is a basic constituent of borderline patients. The intensity, with which this affectivity is conducted, is not associated to the presence/absence of control factors (which are scarce in both subgroups) as constituents of the trait of individual personality.
In the analysis of the multiple correspondences, which was conducted in the sub-areas of DIB (affectivity, impulsive behaviours, interpersonal relationships, psychosis and adjustment), two dimensions have been identified. They result more structurally associated to each other in comparison with other psychopathologic dimensions: the impulsive behaviours and the affectivity.
Taking into account Exner’s clusters, some differences among subjects with high and low Pd have been individuated, in regard with the field of affectivity, which appears to be more explosive in the subjects with high Pd, whereas there are no significant differences among the subjects in the other two fields.

Conclusion

The study of impulsiveness takes on great importance both for the comprehension of the psychological functioning of the individual and for the prediction and the control of critical behaviours. It also aims to reduce the possible difficulties of the clinical intervention.
The literary empirical acknowledgment, which concerns the dimension of impulsiveness, often derives from samples of patients who suffer from the Borderline Personality Disorder [18,19,20,26,27].
The results of this study showed that in the Rorschach test BDP patients prove to be actually more impulsive compared to normal subjects and less capable to control their own responsiveness on the personality level, by showing fewer abilities to plan and modulate the emotional response compared to the control group.
For this reason, the evaluation by means of the Rorschach test has been useful to differentiate a group of impulsive subjects from a control group of non-patients. However, it has not been possible to detect impulsive subjects, qualitative and quantitative differences in the dimension of impulsiveness within the experimental group and consequently to identify the subjects, who proved to have greater possibilities to act impulsively in the evaluation with MMPI-2.
The Rorschach test is able to highlight the emotional dysregulation as a meta-representative distinguishing deficit, which in this study enables to identify patients suffering from BDP, who proved to have greater possibilities to act impulsively with aggressive behaviours.
The explosive affectivity, which is more likely translated into the development of psychopathic conducts, could depend on the fact that the subjects, who were never involved in interpersonal relationships facilitating the acquisition of meta-representative abilities, or who were exposed to a domestic environment, where the only modality to experience attachment was the inhibition of such processes, have grater possibilities to develop an unsafe attachment and to show scarce reflective abilities, by removing every inhibition towards violent and criminal activities. First and foremost, is the ability to imagine the mental state of the potential victim, which is an essential element to avoid situations that may intentionally cause damage.
The personal story of the patient and the environment where he lives has to be considered of crucial importance, in order to promote the expression of impulsiveness in psychopathic behaviours. The inadequacy of the child-care context might predispose the development of the meta-representative deficit, which could make the subject more vulnerable and influenced by repeated frustrating environmental stimuli in adulthood [28,29,30,31].

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