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CHAPTER FIFTEEN: Mastery, aggression, and narcissism

Aleksandrowicz, Dov R.; Aleksandrowicz, Malca Karnac Books ePub

“[The will to power …] is the primeval tendency of the protoplasm.”

—(Nietzsche, 1901)

“There's gold, and it's haunting and haunting; it's luring me on as of old;

Yet it isn't the gold that I am wanting, so much as just finding the gold.”

—(Service, 2001)

Ori, a two-and-a-half-year-old toddler, tries very hard to join some pieces of Lego in a manner known only to himself. He is visibly frustrated by the difficulty and angrily rejects offers of help, saying, “Not that!” Finally he succeeds in putting together a sort of a landing platform, which he raises in a triumphal gesture, his face beaming with pleasure, and announces proudly: “My Auntie Ettie 'teached' me!”

What is the motivational force driving Ori's efforts? What drive release provides the source of his joy? These seemingly simplequestions pose a challenge to the psychoanalytic theory of drives. Exploratory behaviour, manipulation of the physical as well as the social environment, practicing skills for their own sake: all these seem to form a life-long continuum of an urge to master one's own body as well as the environment. Like Ori, we all invest occasionally considerable effort into these activities and derive joy or frustration from success or failure.

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CHAPTER THIRTEEN: Shahar: art therapy of a boy with Attention Deficit Hyperactivity Conduct Disorder

Aleksandrowicz, Dov R.; Aleksandrowicz, Malca Karnac Books ePub

Hyperactive children are prone to be also impulsive and aggressive, especially if the home environment does not provide both adequate limit-setting and emotional support. The problems of behavioural maladjustment of such children are frequent and occasionally serious enough to justify a distinct diagnostic category, namely Attention Deficit Hyperactivity Conduct Disorder (ADHCD). We have already mentioned in Chapter Six that such a diagnosis should not automatically imply that the child presents the features of an antisocial personality, and it should be applied sparingly. Children with ADHD are frustrated by their developmental impairments (it should be remembered that many children with attention deficit present also other impairments) and angry, like most other devel-opmentally handicapped children. In most cases, however, children with ADHD have an internalized sense of social values (in other words, an integrated super-ego) and a capacity to form affectionate relations, both in the family and outside of it. Their main difficulty is not inadequate socialization but impairment of drive inhibition, affect dyscontrol, and impulsivity. Such children can deriveconsiderable therapeutic benefit from “developmentally informed” psychotherapy, supplemented by parental guidance, in addition to any other therapeutic modality, as described in Chapter Nine.

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CHAPTER EIGHT: Diagnosis of developmental deviations

Aleksandrowicz, Dov R.; Aleksandrowicz, Malca Karnac Books ePub

The diagnosis of a developmental deviation may be obvious, as in the case of a hyperactive child, or it may be subtle, as in impairment of working memory in an adult. The problem may be apparent to the patient, his parents, or even a casual observer, or its identification may require professional expertise and specialized instruments. The age of the subject and his developmental stage determine the diagnostic procedure. In most cases, a detailed history is indispensable; a family history may often be helpful, since genetic factors may play a role, as we have already mentioned.

We will examine the diagnostic procedures according to age: infancy and toddlerhood, childhood, and adulthood.

We will first discuss the subject of risk factors for developmental irregularity. Such risk factors are the domain of obstetrics and of neonatology and are much too numerous to review here; we will mention only a few common ones, some of which we have encountered ourselves. As a rule, any condition that can adversely influence the pregnancy may represent a risk factor for the development of thechild. Such conditions include maternal diabetes (a very common unfavourable influence on the developing foetus), malnutrition, infections, especially viral infections, exposure to radiation, many prescription drugs, heavy smoking, and most substances of abuse, especially alcohol and opiates. Paternal exposure to alcohol or ionizing radiation is also likely to have an adverse effect (Abel, 2004; Morgan, 2003). Foetal factors comprise anything that can adversely influence the development or maturation of the foetal brain, including inborn errors of metabolism (e.g., hypothyroidism or phenylke-tonuria), cardiovascular malformations interfering with brain blood supply, neonatal prematurity, a small-for-age neonate, heavy medication during labour, foetal anoxia, and neonatal jaundice.

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CHAPTER TWELVE: Psychoanalysis of a patient with borderline personality disorder and minimal encephalopathy: Mr. G., the “Great White Hunter”

Aleksandrowicz, Dov R.; Aleksandrowicz, Malca Karnac Books ePub

The issue of possible innate or acquired biological determinants in personality formation and in psychopathology is particularly relevant in cases of BPD. This diagnostic category comprises various clinical entities with some common and characteristic features (Gunderson, 2008; Gunderson & Singer, 1975). One of these features is an impairment or weakness of the integrative functions of the ego, such as repression, affect control, drive inhibition, or reality testing under stress (O. F. Kernberg, 1984). Such functions depend on effective operation of the brain, and it is therefore understandable that numerous investigators assumed that conditions that interfere with the optimal functioning of the brain might contribute to the formation of a borderline personality. More advanced techniques for the exploration of the structure and function of the living brain have confirmed that assumption. (We have listed the relevant publications in Chapter Three.) Over the last decade, researchers have shown increasing interest in psychotherapy of BPD and in the evolution of therapeutic modalities designed for that purpose (Gunderson, 2008), such as Dialectical Behaviour Therapy (Shearin & Linehan, 1994), Transference-Focused Therapy (O. F. Kernberg, Yeomans, Clarkin & Levy, 2008), and mentalization-based psychotherapy (Bateman, 2009).Here we describe a “developmentally informed” psychoanalysis of a young man diagnosed as suffering from Borderline Personality Disorder and presumably from a subclinical form of encepha-lopathy, and we discuss the factors that seemed to have facilitated a favourable outcome.

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CHAPTER SIX: Coping with maladaptive development

Aleksandrowicz, Dov R.; Aleksandrowicz, Malca Karnac Books ePub

Both children and adults whose development was less than optimal adopt different defensive manoeuvres to minimize the resulting distress and to maintain reasonably gratifying social relationships. There is considerable overlap between those manoeuvres and what we call “defence mechanisms”, but there is also a basic difference.

“Defence mechanism” is a term coined by Freud and elaborated by Anna Freud (A. Freud, 1936). It refers to psychic functions (and more specifically unconscious ego functions) whose ultimate goal is to prevent the subject from acting upon “forbidden” impulses, i.e., impulses (most often sexual or aggressive) contrary to the subject's own moral values and to his self-image (or his ideal self-image, i.e., how he wants to be). Those inhibitory devices arise originally from internalization of parental injunctions and parental values and reflect the society's moral code. The feature common to all mechanisms of defence is that they achieve their aim by keeping forbidden wishes out of consciousness, by repressing them.

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